NGOẠI KHOA CƠ SỞ

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NGOI KHOA C Smc lcTrangLi ni u

Phn I: ngoi khoa c sLch s pht trin ngoi khoa.......................................................... Nhng nguyn tc ngoi khoa c bn............................................ V khun trong ngoi khoa............................................................. i cng gy t................................................................................ Gy m............................................................................................... Cn bng nc, in gii................................................................ Sc..................................................................................................... Cp cu ngng tim phi.......................................................... S lin vt thng .......................................................................... Vn chuyn ngi b thng............................................................... C nh tm thi gy xng............................................................... Cm mu tm thi.............................................................................. Chun b trc m v chm sc bnh nhn sau m. Phn II: triu chng hc ngoi khoa Triu chng hc c quan vn ng K thut v cc nguyn tc thm khm c quan vn ng.............. i cng gy xng...................................................... i cng sai khp.................................................................... Khm chi trn................................................... Khm khung chu v chi di............................................... Triu chng hc c quan tiu ho, tit niu - sinh dc Triu chng hc v thm khm bnh thc qun...........................

TrangPhng php khm bng trong ngoi khoa.................................. Hi chng tc rut........................................................................ Triu chng chy mu ng tiu ho............................................. Hi chng chy mu trong............................................................ Hi chng vng da tc mt....................... Hi chng vim phc mc......................................................... Triu chng hc c quan tit niu - sinh dc.................................... Khm xt c quan tit niu - sinh dc... Triu chng hc thn kinh Triu chng tn thng dy thn kinh ngoi vi......................... Cc phng php chn on bnh l ct sng - tu sng.............. . Khm chn thng s no............................................................... Triu chng hc ngoi khoa mt s bnh cc c quan vng c, ngc v mch mu Thm khm v triu chng hc khi u vng c............................ Triu chng hc v cc phng php thm khm tuyn v......... Thm khm v triu chng hc chn thng ngc kn v vt thng ngc Thm khm v triu chng hc bnh mch mu ngoi vi................ Ti liu tham kho 309

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Phn I

Ngoi khoa c s

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LCH S PHT TRIN NGOI KHOA1. Lch s ngoi khoa. Ngoi khoa c mt b dy lch s v s pht trin nh ngy nay l nh s ng gp to ln ca nhiu lnh vc. thi tin c, thut ng "ngoi khoa" khng ch l cc phng php iu tr bnh m cn l cc bin php thc hin cc nghi l (cng qu thn, l siu thot). Vo khong 4000 nm trc cng nguyn, ngi c i bit cch tht v khu buc, cm mu vt thng. T 3000 nm trc cng nguyn, ngi Ai Cp bit s dng nhng loi ch c ch to t rut ng vt khu vt thng v cha gy xng, khoan s gii thot "thn kinh" cho ngi bnh. Vo thi k La M c i, Hippocrate (ngi Hi Lp, sinh nm th 460 trc cng nguyn) xut bn hn 70 cun sch y hc v gy xng, sai khp v nhng bnh cn iu tr ngoi khoa. Trong thi k ca cc nn vn minh c i, Hippocrate bit dng nc un si ngui v ru ra cc vt thng, c nh gy cha gy xng, nn chnh cha sai khp, p nhit t cc bi tr v cm mu bng cc di st nung , chch tho m iu tr cc p xe... Trong cun sch "Corpus Hippocratum", ng m t cc c im ca thot v, bnh lot d dy. Nm 1478, Aulus Cornelius Celsus - nh bch khoa ton th ngi La M na u th k th nht trc cng nguyn m t tnh trng nhim trng vi 4 c im: "sng, nng, , au, v mt s phng php iu tr ngoi khoa. thi k ny, nh danh y Hi Lp Herophile (sinh nm th 320 trc cng nguyn) tin hnh phu tch t thi nghin cu v gii phu ngi. Erasistrate (sinh nm th 310 trc cng nguyn) xut phng php cha tc rut v thot v nght bng m bng. Clauduis Galen (sinh vo nm th 130 trc cng nguyn) bit luc dng c trc khi s dng cho phu thut, s dng ch tht mch mu, cha cc vt thng c, thn kinh, mch mu, gy xng, sai khp v chch b mu, m ln, kh, b nghin cu v gii phu. A.C.Celsus (na u ca cng nguyn) bit cch tht buc mch mu, cha vt thng bng, dng bng v gim cha vt thng. Hoa (sinh nm 190 sau cng nguyn) dng bt gy t m vt thng, ly mi tn, m bng, khoan s, thin hon... Mc d ngoi khoa c tch ra thnh mt chuyn ngnh ca y hc t rt sm (khong 200 nm trc cng nguyn) nhng khng th pht trin c trong sut thi k trung c do s thng tr ca o gio v do Gii phu hc - mn khoa hc nn tng ca ngoi khoa vn cha pht trin. T nm 1540, nh t c tho thun v phm vi hnh ngh m cc phu thut vin khng phi lm ngh ct tc v nhng ngi th ct tc cng ch c php cha rng. Phi n nhng thp k u ca th k XVIII, chuyn ngnh ngoi khoa mi chnh thc c x hi cng nhn. Vo nm 1800, George III cng nhn trng i hc Ngoi khoa Hong Gia Lun n. Php, ngy 12 thng 12 nm 1731, vua Lui th 15 ph chun thnh lp Hi ngoi khoa. Ngy 2 thng 7 nm 1748, Vin Hn lm phu thut ca nh vua Php c thnh lp. Chng trnh o to v ngoi khoa c Pierre Joseph Desault (1744 - 1795) xy dng. 12

Vo XIX, ngoi khoa c nhng bc tin v s pht trin ng k, lm tin cho s pht trin vt bc ca ngoi khoa trong th k XX. Nc ta, t th k XIV n th k th XVIII, vo cc thi i nh L, Trn, L c nhng bi thuc y hc c truyn cha gy xng, vim ty phn mm. Tu Tnh, v danh y th k th XIV dng cao dn iu tr cc vt thng do dao chm, cc bi thuc cha bng, tr di, b ti vt thng, vt bng. Hi Thng Ln ng (1720 - 1791) c nhng bi thuc ung, thuc ra, thuc dng ti ch iu tr cc thng tch do b nh, b thng (cc vt t, vt chm), cc vt bng. 2. Gy m v kh trng. Trc khi c cc pht minh v tit trng, kh khun, th t l cc vt thng b nhim khun v tnh trng t vong do nhim khun rt cao gy nh hng ln n kt qu phu thut trong nhiu th k. + Vo nm 1840, bc s sn khoa ngi Hungari Ignaz Semmelweis v Oliver Wendell tin hnh kh trng bung v mi trng xung quanh bng vi v kh trng tay ngi bng dung dch clo. + Vic ng dng phng php gy m trong phu thut vo nm 1840 c coi l pht minh v i nht trong lch s ca y hc. Vo nm 1842, bc s Crawford W. Long (ngi Georgia) s dng phng php gy m te ct b nhng khi u nh trn da. Nm 1844, H.Wells nghin cu s dng protoxydazot gy m. Nm 1898, Augurt Bier xut phng php gy t ty sng. Nm 1947, J.Y. Simpson (ngi Anh) s dng cloroform gy m v dng cocain gy t t nm 1884. Nm 1904, Eichnom s dng novocain gy t ti ch. Vic Jame Young Simpson cng b phng php gy m trong phu thut m ra mt k nguyn mi cho s pht trin ca ngoi khoa. + Mc d knh lp v knh hin vi c Leuenhook (1632 - 1723) pht minh t nhng th k trc, nhng mi ti th k XIX mi c nhng pht hin v vi sinh vt. Nm 1864, nh khoa hc ngi php, Louis Pasteur pht trin l thuyt mm bnh v xut phng php dng nhit tit khun. + Joseph Listera (sinh nm 1827 Essex) l ngi c cng pht trin v ng dng cc nguyn l kh trng trong thc hnh ngoi khoa. Quy trnh kh trng bng cch nhng dng c phu thut vo dung dch axt carboxylic v xt hi nc kh trng mi trng trong phng m c Lister cng b vo nm 1867. T nm 1881, phng php kh khun bng cc ni hi vi p sut cao c p dng kh rng ri. William Halsted xut s dng gng tay cao su dng trong phu thut t nm 1890. Nm 1994, Jgnaz Phillip Smelwis (ngi Hunggary) xut: cn ra sch bn v ngn tay bng dung dch clorua vi trc khi phu thut v git sch cc vi, dng c c s dng trong phu thut

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NHNG NGUYN TC NGOI KHOA C BN1. V trng trong ngoi khoa V trng trong ngoi khoa bao gm tt c cc vic gim ti a nguy c nhim trng phu thut. C 3 tc nhn lin quan n cng vic ny l: phng m, bnh nhn v kp m.1.1. Phng m:

+ Phng m phi c kch thc ti thiu l 6m 6m. Phi c thng kh tt, dng kh phi i qua b phn lc gi li cc vi khun v nm bn ngoi. p lc khng kh trong phng m cn hi cao hn bn ngoi trnh bi v vi khun t ngoi trn vo. Tt c ca ca phng m c ng kn. + Phng tin dng c trong phng m: - Cc dng c hu trng khi mang vo trng m phi c bc trong bao v trng. - Tt c cc dng c v phng tin dng phng m phi c kh trng.1.2. Bnh nhn:

Phn loi phu thut v trng hay hu trng l da vo tnh trng nhim vi khun sn c ti trng m trn c th bnh nhn. Chun b da vng m ca bnh nhn: gim nhim trng vt m. + Nn cho bnh nhn tm vi cht x phng khng khun vo m trc ngy m. C th t mt ming gc v trng ln vng da nh m v bng li, ming gc ny s c b ra khi bnh nhn nm trn bn m. Phi co lng vng da nh m nhng nn thc hin ti phng m ngay trc khi tin hnh th thut, nn dng kem ty lng hoc dao co in trnh lm xy xt da. + St trng da bnh nhn trc khi rch da: St trng da theo ng vng trn i rng dn t vng nh rch da ra ngoi, khng bao gi a ming gc st trng t vng ngoi vi tr li ch vt nh rch da. Ming gc dng ri phi b i, khng c chm tr li dung dch st trng.1.3. Kp m:

+ Ra tay trc m: Phi ra tay ngay trc khi m t ngn n khuu bng dung dch st trng. + eo khu trang: Trong khi m mi nhn vin phi mang khu trang, bao trm c ming v mi ngn c cc cht bn ra t hi th v ming khi ni. + i gng tay: Gng tay phu thut c tc dng kp: Bo v bnh nhn b nhim trng t tay phu thut vin v ngc li bo v phu thut vin khng b ly nhim cc bnh ca bnh nhn qua ng mu. + Mc o m: Qun o m ca phu thut vin c tc dng d phng vi khun t da phu thut vin truyn vo bnh nhn. Vi phi l loi khng thm nc trnh vi khun c th truyn t mt ny sang mt kia ca o. + Tri khn m: Chc nng chnh ca khn tri vt m l khu tr v bo v khu vc v trng vng m..

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+ Di chuyn trong phng m: Cc thnh vin kp m ch c php di chuyn t vng v trng ti vng v trng. Nu cn phi thay i v tr th phi theo nguyn tc lng quay vo lng v mt quay vo mt. + a dng c: Cn phi rt tinh t chng n c tay ca phu thut vin mt cch an ton v t th hot ng c ngay. Khi dng xong, phi t dng c v tr ph hp sn sng s dng ln tip sau. 2. Cc thao tc phu thut. Thut ng phu thut (surgery) c ngun gc t ting Hy Lp l cheirergon, c ngha l cng vic ca bn tay. Mt phu thut vin lun phi nh rng: nu khng ht sc cn thn th bn tay ca mnh c th gy nn nhng hu qu ng tic cho ngi bnh. 3. Kim v ch khu phu thut.3.1. Kim v km kp kim khu phu thut:3.1.1. Kim khu phu thut:

Kim phu thut c thit k dn si ch xuyn qua t chc sao cho d dng v t gy tn thng t chc nht, c nhiu c to, di v cong khc nhau. N c ba thnh phn chnh l l kim, thn kim v u kim. + L kim: C th l m, kn hoc rp khun. + Thn kim: C th thng hoc cong. + Mi kim: C th l loi mi ct, mi thon nhn hoc mi t. Mi ct c dng khu xuyn qua cc t chc chc nh da. Mi thon nhn c dng nhng t chc mm, d b rch nh c, rut. Cn mi t c dng khu cc t chc d b nt nh gan; thn.3.1.2. Km kp kim phu thut:

Km kp kim phu thut phi bo m gi kim chc chn, gip kim xuyn qua t chc chnh xc v phi hp nhp nhng c vi dng c kim, ng thi phi khng lm tn thng n cu trc ca kim cng nh ch khu.3.2. Ch khu phu thut:

Nn chn loi ch nh nht c bn thch hp vi t chc cn khu.3.2.1. Cc loi ch t tiu:

Thi gian t tiu ca ch trong t chc ph thuc vo loi vt liu ch to si ch v mi trng t chc ni t mi khu. + Ch catgut: c lm t rut ca gia sc c sng hoc cu. Thi gian t tiu ca catgut thng l khong 10 ngy. Catgut chromic (trong thnh phn c thm mui chromium) c thi gian t tiu chm hn (khong 20 ngy). + Ch polyglycolic acid (ch Dexon): loi ch t tiu tng hp. Thi gian t tiu sau m khong 60 - 90 ngy. + Ch polyglyconate (ch Maxon): l loi ch t tiu n si, c an ton v dai ca mi buc tt nht so vi cc loi ch t tiu tng hp khc. N thng c dng khu cc t chc phn mm, thc qun, rut, kh qun. 15

+ Ch polyglactic acid (ch Vicryl): l loi ch bn tng hp tng t ch polyglycolic acid nhng dai hi km hn. Thi gian t tiu sau m khong 60 ngy. + Ch polydioxanone: l loi ch n si t tiu tng hp c dai rt cao, thi gian t tiu lu, t gy phn ng t chc. Tuy nhin n li hi cng v kh iu khin.3.2.2. Cc loi ch khng tiu:

+ Ch t (Silk): l loi ch protein ly t con tm. N c dai cao, d iu khin v to nt buc rt tt. Mc d l loi ch khng tiu nhng ch t vn c th thoi ho trong t chc cc mc khc nhau. + Ch polyester: l loi ch bn tng hp c dai rt cao. nt buc m bo an ton, ch polyester cn c tht nt t nht nm ln so vi hai ln i vi ch thp v ba ln i vi cc loi ch t. + Ch nylon: l loi ch tng hp n si hoc bn, c dai cao v rt trn. N c th thoi ho v t tiu trong khong 2 nm sau m, v vy dai b gim dn theo thi gian. Do rt trn nn n d xuyn qua t chc, t gy phn ng, nhng khi buc phi tht nhiu nt m bo an ton mi buc. + Ch polypropylene: l loi ch tng hp n si. N kh trn nn d i xuyn v t gy phn ng trong t chc. Ch polypropylene thng c dng trong khu ni mch mu, khu vt trong da... + Ch thp khng g: c lm t hp kim st ngho carbon, c th l si n hoc bn. N l loi ch chc nht v t gy phn ng nht nn thng c dng khu cc dy chng, cn, xng.3.3. Cc bin php k thut khc khu v ng t chc:

Hin nay c mt s bin php k thut khc c p dng ngy cng rng ri trong phu thut gip vic khu v ng cc t chc trong c th mt cch nhanh chng v an ton.3.3.1. Ghim phu thut: 3.3.2. Cc cht keo dnh phu thut: 3.3.3. Bng dnh da:

4. Cc ng thng v dn lu phu thut.4.1. Cc loi ng thng v ng dn lu phu thut (bng 1):4.1.1. Cc ng thng ng tiu ho:

+ Cc ng thng d dy t qua mi hoc mm: thng dng gim p d dy v rut non (khi b tc rut), a thuc hoc cht dinh dng vo ng tiu ho khi bnh nhn khng t nut c (b hn m, tn thng vng hu hng...), ra d dy (chy mu ng tiu ho trn, cp cu ng c thuc ng ung...). Hu ht cc ng ny u c di cn quang nm dc thn ng d dng xc nh khi chp X quang. + Cc ng thng hng trng qua mi: thng dng a thuc hoc cht nui dng vo ng tiu ho, gim p rut non... C loi ng dng nui dng (ng Dobhoff) hoc gim p rut non (ng Cantor, Gowan, Miller-Abbott, Baker-Nelson...). + Cc ng thng ng mt: 16

- Cc ng thng ng mt qua mi: ch yu ht gim p ng mt trong cc trng hp tng p lc ng mt. Thng dng loi ng Silastic mm c mt nng. - Cc ng thng ng mt kiu ch T: thng dng dn lu ng mt sau m ng mt ch, ghp gan c ni ng mt chnh... Cc ng thng ch T thng c t vo ng mt v a ra ngoi qua thnh bng trc, in hnh l ng Kehr. + Cc ng thng trc trng: thng dng cho bnh nhn nm lit ging b chy phn thng xuyn hoc c vt thng vng hu mn sinh dc d phng tnh trng m lot da hoc nhim vt thng. C nhiu loi thng trc trng c bng hoc khng c bng u. + Cc ng thng trong m thng ng tiu ho: - Cc ng thng trong m thng d dy, hng trng, manh trng qua thnh bng trc.4.1.2. Cc catheter tit niu:

+ Catheter dn lu bng quang trn xng mu a qua thnh bng trc: thng l mt nng, c bng u hoc u c hnh nm. + Catheter c bng u (catheter Foley) c dt vo bng quang qua niu o. + Cc catheter dn lu niu qun v ng dn lu thn: c nhiu loi khc nhau.4.1.3. Cc ng dn lu lng ngc:

Cc ng dn lu lng ngc c dng gii thot cc cht dch t khoang mng phi hoc trung tht. Chng thng c ng knh ln (20 - 36 Fr), u c nhiu l, c vch cn quang chy sut chiu di ca ng.MT S LOI CATHETER DNG TRONG NGOI KHOA

A - Catheter niu o u t, c 1 l B - Catheter niu o Robinson C - Catheter niu o c u kiu ng so D - Catheter Coud u bu dc v tht ngng E - Catheter Malecot niu o t gi c 4 cnh F - Catheter Malecot niu o t gi c 2 cnh G - Dn lu Pezzer t gi, m u H4.2. Dn lu trongmt nhnh bm bng (i) - Catheter kiu Foley c phu thut: v mt nhnh dn lu (ii) I. Catheter kiu Foley ba nhnh, mt nhnh bm bng (i), dn lu (ii) v mt nhnh ti ra bng quang d

mt nhnh phng tc (iii)

Hnh 1 : Mt s loi catheter dng trong phu thut.

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V KHUN TRONG NGOI KHOAV khun l mt nguyn tc, mt ch hng u ca ngnh Y t ni chung v ca ngnh ngoi khoa ni ring, n c ngha thnh bi trong cng tc ngoi khoa. Thut ng v khun bao hm hai lnh vc: + Tit trng (stevilisatio) l cc bin php tiu dit mi hnh thi ca vi khun bao gm c nha bo. + Kh trng (desinfectio) l ch tiu dit vi khun dng thc vt. 1. Cc tc nhn c s dng tit trng, kh trng.1.1. Cc dung dch ho cht:

Ho cht tit khun t c hiu qu v khng c ho cht no c th cng mt lc dit tt c cc vi sinh vt. N c th dit vi loi vi sinh vt ny nhng li khng th dit c cc loi vi sinh vt khc. Cc ho cht thng c s dng kh khun trong ngoi khoa gm: + Cn (alcol): C tc dng duy tr s kh khun ca mt vt sau khi vt c kh khun bng phng php khc, n cn c dng st khun trn da v t gy hi da. Thi gian kh khun cn thit ca cn l 20 pht, nng s dng st khun l 700. Bt li ca cn l: khng dit c bo t, lm kh da, khng lm mt tc dng ca c t, lm hng dng c bng cht do, lm han g dng c st, khng ty c du m, tc dng ca cn gim i khi b bc hi hoc pha long. + Dung dch it (iod): Ngi ta pha dung dch cn iod dng st khun l 2% iod trong cn 700. Vi loi cn iod ny s b kh chm li v khng lm chy da. Thi gian kh khun l 15 - 20 pht. Bt li: n c th gy kch ng da, nu m c c th gy chy da; c th lm mt mu v n mn kim loi. + Dung dch oxy gi (eau oxygene): C tc dng tt vi cc vi khun ym kh, c s dng ra cc vt thng nhim bn khi gp cc vt bn, mu, m dung dch s si bt, n cn c tc dng cm mu v lm co u cc mao mch nh. Khng c dng dung oxy gi cho cc vt thng ang ln t chc ht. + Cc hp cht amoni - NH4: Cc hp cht amoni NH4 dng kh khun cc dng c kim loi nhn sc, dng c bng cht do. Bt li ca dung dch ny l khng dit c nha bo, khng c tc dng khi dng c cn dnh x phng, du m. + Dung dch Wescodyne: L dung dch hu hiu tit khun v n c th dit c c nha bo. Dung dch ny cn c s dng kh khun sn v tng phng m. + Dung dch Cidex: c mu vng, c s dng kh trng dng c m, c bit l cc dng c m ni soi. + Cc hp cht c clo: Dung dch sodium hypochlorite l dung dch nc vi trong c clo dng ty u cht thi c nhim khun. 2. Tit trng bng nhit cao. Tit trng bng nhit cao c 2 cch l hi nng kh v nng m. + Hi nng kh: 18

- t dng c st bng cn: Phng php ny t c s dng v s lm hng dng c nhng n c u im l tit trng hon ho v nhanh chng. - T sy kh: l mt ci t bng thp c hnh khi hp ch nht, v dy c lp cch nhit v chu c p lc. H thng cnh t c lp giong cao su chu nhit, pha trn t c nhit k, c rle nhit, ng h o thi gian v cng tc in. Trong lng t c cc ngn xp dng c, pha y t l h thng bp in v qut gi. Khi bt cng tc in, cc bp in hot ng, h thng qut a hi nng vo lng t. Khi sc nng trong lng t t c mc quy nh (160 - 1800C) th rle nhit t ng ngt bp in. Khi nhit h di mc quy nh th rle t ng ng v bp in li hot ng. Khi thi gian duy tr th t c tt. + Hi nng m: - Phng php un si: Phng php ny do nhit khng cao (1000C) nn mt s nha bo khng b dit, nn khng th tit trng mt cch tuyt i c, do trc khi luc dng c m phi ra sch ri ngm vo dung dch ho cht t nht 15 - 20 pht ri mi em luc. Ni chung y ch l mt gii php tnh th trong iu kin thiu thn v phng tin phu thut hay trong ngoi khoa d chin. - Phng php ch si: l nguyn l hot ng ca cc ni hp d chin c qun i cc nc p dng trong iu kin chin tranh. Cu to ca ni hp d chin nh mt ch si: ngn di nc, ngn trn xp dng c. Thnh ni hp l nhm hay thp dy, chu c lc, vung c c vn cht vo thnh ni, trn vung c van x hi, un bng ci. u im ca loi ny l c th a c nhit ln cao trn 1000C, c th dit c c nha bo. Nhc im l kh khng ch c nhit , hp c t dng c, nhim mi trng. - Ni hp m hin i autoclave (auto claring cold): Nguyn l hot ng: Da trn nguyn l bin in nng thnh nhit nng v nhit nng thnh cng nng lm tng p sut ni nc nhm a nhit ln cao theo mun kh trng dng c phu thut. V cu to ni hp m antoclave l mt ni hnh tr, thnh c 2 lp cch bit v chu c p sut ln. Di y ni l h thng bp in, pha trn l mt khoang cha nc, khoang ny c mt phu nc vo. Phu ny c mt van, khi y nc ti mc quy nh phi vn cht van li. Khoang cha dng c c mt van x hi nc nng vo. Np ni c mt ng h o p lc, mt rle nhit v c cc nm vn gi cht np ni vi thnh ni. Khi un si nc, nc bc hi nhng khng thot ra c nn p sut c tng dn v nhit cng v th tng theo, ta c: 1 kg/cm2 (1 atmotphe) = 1200C. 2 kg/cm2 (2 atmotphe) = 1340C. 3 kg/cm2 (3 atmotphe) = 1450C. Khi hp ta thng rle p lc mc ti thiu l 1 kg/cm2 v ti a mc 1,5 - 2 kg/cm2. Sau khi ng h p lc t ti 1kg/cm2 ta m van x hi nng trn vo khoang dng c, lc p lc s st gim nhng do ta vn tip tc duy tr bp in nn p lc trong bung dng c li tng dn. Khi tng ti con s 1,5 - 2 kg/cm2 th ni li t ng ngt in. C nh vy ta duy tr 40 - 60 pht l c. Sau khi hp xong phi tho van x hi nc trong bung dng c x ra ht mi c m ni nu khng s rt nguy him ng thi m bo dng c c kh. - Phng php Tyndall: L phng php un cch thy 50 - 550C mi ngy 1 gi hoc 60 - 800 trong 30 pht trong 3 ngy lin tip s dit c c vi khun v nha bo. Phng php ny dng tit khun cc dung 19

dch c cha albumin, cc dng c cht do v mt s dung dch c bit cy khun. u im ca phng php nng m: tiu dit c cc vi khun v nha bo trong mt thi gian ngn; tit khun c nhiu dng c v vt dng khc nhau; d kim sot c nhit . Nhc im: nu s dng khng ng, khng thnh tho d gy tai nn nguy him. 3. Kim tra vic tit trng. C th kim tra vic tit trng bng chng nghim ho hc v chng nghim vi khun. Thng qua s kim tra c cht lng my mc, kim tra c chnh xc ca p k v nhit k, kim tra c hiu qu tit trng dng c. + Chng nghim ho hc: - Hn hp axit benzoic vi mt lng bng hai ht ng v sulfat km vi mt lng bng ht tm, trn u cho vo ng thy tinh, nt kn vo bung hp. Hn hp ny s nng chy nhit 1210C. - Hn hp tecpin 100g v tm metyl 1 gam cng trn ln cho vo ng nghim. Chng s nng chy nhit 1170C. - Dng loi mc ho hc vit ln mnh giy mt k hiu no y a vo trong ng nghim ri vo bung hp. Cng thc mc: Coban chlorur : 20g. Axit chlohydric 30% : 10ml Nc ct : 88ml. Tt c cho vo l lc u. Hp xong ta thy k hiu trn giy hin ln l c. + Chng nghim vi khun: Dng hn dch nha bo v hi subtilis (c kh nng chu c sc nng ngang vi nha bo un vn) t vo gia cc hp dng c sy. Sau khi hp sy em typ vi khun ny i cy, nu khng thy mc l c. 4. Kh trng - tit trng.4.1. Kh trng, ty u :

Thng thng kh trng, ty u ngi ta s dng cc dung dch ho cht. Dng c trc khi kh trng phi c ra sch, chn loi ho cht thch hp vi cht liu dng c v loi vi khun cn phi kh. Phi ch ti thi gian cn thit kh khun. Dng c cao su, cht do hay dng hi formol. Dng c thy tinh th luc.... Vi cc my ht, my gy m c th dng hi formol, dung dch sidex... Vi mi trng phng m dng n cc tm, hi formol, nu c iu kin th dng fil lc vi khun thng kh phng m.4.2. Tit trng:

tit trng thng thng dng hi nng kh v m. + Dng c kim loi: c th dng hi nng kh 160 - 1800C trong vng 40 - 60 pht, c th dng hi nng m trong vng 30 pht. + vi: ch s dng hi nng m. Nu gi 1 lp vi th cn phi hp 1210C trong vng 15 pht. Nu gi vi 2 lp th cn phi hp 1210C trong vng 30 pht. trong hp st c l th cn phi hp 1210C trong vng 40 - 60 pht. 20

+ Gng tay cao su hp 1210C trong vng 15 pht. + Dng c thy tinh: hp m. + Dng c cao su: hp m. + Mt s loi dung dch c bit, cht do hp bng phng php Tyndall.

21

I CNG GY T1. nh ngha Gy t l mt phng php v cm s dng phng tin l, ho hc lm mt cm gic trn mt vng nht nh ca c th, vn duy tr thc ca bnh nhn. 2. Phn loi Gy t c chia thnh hai phng php: + Gy t ti ch (local anesthesia). + Gy t vng (regional anesthesia).2.1. Gy t ti ch:

Gy t ti ch l phng php dng cc tc nhn vt l - ha hc tc ng trc tip ln nhng nhnh tn cng ca thn kinh ngoi vi. Phng php ny bao gm: + Gy t b mt (surface anesthesia): thc hin bng cch nh, phun, bi thuc t ln b mt nim mc. Phng php ny thng dng trong cc phu thut mt, tai, mi, hng, ni soi, rng ming. + Tim ngm (infiltration anesthesia): cn gi l phng php Visnepxki, thc hin bng cch tim thuc t theo tng lp t chc. Ch s dng cho cc trng hp m nh, m nng, chch rch p xe... + Gy lnh: - Phun cc loi thuc m bc hi nhanh ln mt da (klen): dng trong chch tho m p xe, mn, nht... - Lm lnh bng nc : l phng php c in, s dng trong cc trng hp ct on chi bnh nhn c th trng rt km, khng s dng c cc phng php v cm khc. Cch thc hin: t mt gar khong 10cm pha trn v tr s m sau khi chm vng ri ngm chi trong b nc : . Chi trn 90 pht. . Chi di 150 pht.2.2. Gy t vng (regional anesthesia):

Gy t vng l phng php dng thuc t tc dng trc tip ln cc ng dn truyn thn kinh (thn, m ri, r thn kinh) qua lm mt cm gic mt vng tng ng do thn kinh chi phi. Gy t vng bao gm: + Gy t m ri thn kinh c. + Gy t m ri thn kinh cnh tay. + Gy t ngoi mng cng. + Gy t di mng nhn (gy t ty sng). + Gy t tnh mch. + Gy t trong xng. 22

3. Tnh cht chung ca cc thuc t. Theo Eccler thuc t ngn chn s dn truyn xung ng bng cch ngn cn cc ion Na + qua mng t bo thn kinh, lm chng khng kh cc c. + Cng , thi gian tim tng (latency), thi gian tc dng ca thuc t (duration) ph thuc vo: - Loi thuc t. - Liu lng (nhiu hay t). - Dng n thun hay pha vi thuc co mch. - Nng thuc t c s dng (cao hay thp). + S nhy cm ca cc si thn kinh vi thuc t ph thuc vo ng knh ca n. Cc si c kch thc nh tc dng trc, kch thc ln tc dng sau theo th t. - Si thc vt. - Si cm gic (nng, lnh, au, xc gic). + S hi phc ca cc si s theo chiu ngc li. + Cc thuc t ch yu b phn hy gan, mt phn t chc bi cc men c hiu cho tng loi thuc. Sn phm phn hy ca thuc o thi qua thn, phi, ch mt t l rt nh thi nguyn cht (khong 5%). 4. Cc thuc t. 4.1. Phn loi: C hai cch phn loi:4.1.1. Theo ngun gc.

+ T nhin: cocain. + Tng hp: chim hu ht cc thuc t hin nay.4.1.2. Theo cng thc ho hc:

+ Loi ester: cocain, novocain. + Loi amid: lidocain, marcain... Do tnh cht dc l ca n, mi loi thuc t u c liu ti a. Khi s dng nn dng liu lng hn ch v thch hp ty theo la tui, tnh trng ton thn bnh nhn. Liu c th gim i nu ch cn gim au m khng cn lit vn ng. 5. Ch nh v phn ch nh.5.1. Ch nh:

Ch nh dng cho tt c cc trng hp phn ch nh gy m; cc trng hp th trng bnh nhn yu, nu gy m s c nhiu bin chng, tin lng xu.5.2. Phn ch nh:

+ Bnh nhn khng ng gy t. + Phn ng vi thuc t. + Nhim trng vng gy t. + Bnh nhn b bnh tm - thn kinh. + Bnh nhn c tm l khng n nh, lo s. + Bnh nhn suy gan. 23

+ Bnh l ng mu chy mu. + Bnh nhn m trn din tch qu rng (phi dng liu ln, d ng c). + Tr em di 5 tui. 6. Bin chng.6.1. Ng c:

Tai bin ch yu do sai st v k thut nh tim thuc trc tip vo mch mu, tim qu liu, vo cc khu vc giu mch mu (tng sinh mn, c t cung...) hoc thuc t ngm ngay vo mu (t vng hu hng, thanh ph qun...).6.2. D ng:

+ Triu chng: ni mn, nga, ph ton thn, huyt p tt, nn ma. 7. Chun b bnh nhn gy t. + Khm bnh nhn trc khi gy t: pht hin tin s d ng, phn ng thuc t, cc bnh phn ch nh ca gy t. + Chun b bnh nhn: bnh nhn nhn n trc 6 gi. Tim thuc tin m: lm cho bnh nhn trn tnh lo s. + Bnh nhn nm trong lc gy t. + Dung dch m c thng c hn dung dch long, tc tim cng nhanh cng d gy c. Nhng tai bin i khi dn ti t vong l mt lng ln thuc t vo nhanh trong mu. Bi vy phi rt thn trng khi gy t ng tit niu, mi, hng. + Vim ty: so x cng, ngn cn thuc t khuch tn, do tc dng ca thuc t b hn ch. + Trc khi tin hnh phu thut: phi kim tra hiu lc ca thuc t, phi i mt thi gian t 5 - 15 pht t mi c hiu lc. + Chun b sn sng cc phng tin cp cu: xy, my h hp nhn to, ng ni kh qun. Tin hnh cc th nghim (test) bo m an ton (ht kim tra xem c mu khng...) v m bo v khun tuyt i.

24

GY M1. nh ngha. Gy m l phng php v cm nhm mc ch lm mt tm thi thc cm gic, cc phn x, bng cc thuc m tc ng trn thn kinh trung ng. 2. C ch. Nu hiu c c ch gic ng th ngi ta s gii thch c nhng tc dng khc nhau ca cc thuc gy ng cc mc : + Ton b c th. + H thng thn kinh, khi coi h thng ny hot ng nh mt thc th xc nh. + Sau cng mc nh nht l t bo, thm ch c cc thnh phn cu to ca t bo.2.1. mc t bo: 2.1.1. S thay i v l - ho hc:

Claude Bernord nhn thy tt c cc t bo thc vt cng nh ng vt u c s thay i v hnh dng ca i thc bo ngay khi chng chu tc dng ca thuc gy m. iu ny dn n s hn ch ton b hot ng ca nguyn sinh cht din ra theo bn cht v hnh thc th hin ca n. Di knh hin vi, ngi ta c th nhn thy bng mt thng s bin i cht ny tng ng vi s thay i dng keo trong lng t bo. S ng vn thnh phn lipid ca nguyn sinh cht t bo nhng ch cho s ng vn ca thnh phn protid di tc dng ca thuc gy m v iu ny din ra mt cch kh ph bin. Tuy nhin s ng vn thnh phn protid ny li tr v trng thi ban u trc cc thnh phn lipid. Trong thc t, s thay i ny dn n hin tng tng thnh phn lipid m hu qu l lm tng nht ca huyt tng. Cui cng hin tng ny lm cn tr hot ng ca cc ion trong t bo, iu ny gii thch s thay i hot ng ca t bo, bt k chc nng ca t bo l nh th no.2.1.2. S thay i v ho hc:

Bn cnh nhng s thay i v l - ho hc, cn c nhng thay i thun tu v mt ho hc. Nhng s thay i ny gii thch mt phn hin tng gim hot ng ca t bo, trong cc hin tng cnh tranh v i khng ho hc l l do ca vic gim hoc cn tr hot ng ca mt vi h thng men c bn. Mt v d in hnh l hin tng c ch cc men hexokinaza do nhng thuc h bacbituric, t dn n vic gluxit chuyn ho thnh triose ch khng phi l hexose nh khi khng dng thuc.2.1.3. S c ch:

Mc d c nhiu c ch to ra s c ch nhng kt qu u l vic lm gim s tiu th oxy t bo. Trong mt s trng hp, iu ny l tc dng ph xy ra trong gy m, nhng trong mt s trng hp khc, y li l tc dng tc th ca thuc gy m. Tuy nhin, r rng l hin tng thiu oxy t bo vi t cch l nguyn nhn hay hu qu ca gy m lm thay i gii hn sinh l ca i sng t bo. i vi bc s chuyn khoa, gy m c ngha l lm gim n mc thp nht lng tiu th oxy m t bo c cung cp. 25

2.2. Mc ton b c th:

Cn phi xc nh v tr tc dng chn lc ca nhng thuc gy m ti vng th li ca thn no. Cc th nghim chng minh: s tc ng qua li gia hnh no v i no iu ho tnh trng thc v ng. Di tc dng ca thuc gy m, hiu in th chn lc ti vng ny cng thay i so vi ban u, mc d trc khng c s thay i in no ti vng v no. Kt qu l ngi ta c th lm gim nhng hin tng ban u xc nh hot ng ca thn no v hnh no qua qu trnh sinh ho v ho hc c ni ti phn trc, iu ny din ra trc tt c cc tc dng ca thuc gy m. 3. Cc giai on ca gy m (theo Guedel).3.1. Nghin cu lm sng:

t lu, gy m ng ngha vi vic to ra gic ng mong mun, cng ging gic ng bnh thng cng tt. + Trn lm sng nghin cu trn mt ngi trng thnh kho mnh v gy m n thun bng ether v c theo di da trn cc yu t sau: - Nhng phn x v trng lc c. - Vn ng h hp. - S thay i v tim mch. - Biu hin ca da. + Trng lc c: c duy tr bi phn x nhn cm bn th. Phn x ny gim r u giai on III v s bin mt cui giai on ny. iu ny lm mm, bt u l c mt v cui cng l cc c tht khi t ti giai on nhim c. Khi dng gy m, trng lc c s din ra theo chiu ngc li. + Phn x: Nhng nghin cu v phn x trong cuc gy m l nn tng c th hiu bit su hn v gy m. Tin trnh ca nhng phn x ny l tng dn, chng bin mt theo mt th t nht nh v li xut hin theo th t ngc li khi cuc gy m kt thc. - Cc phn x nut, nn bin mt dn dn cui giai on th II (hoc giai on kch thch). - Phn x thanh qun v ng np thanh mn mt i mun hn, vo gia giai on III (giai on m phu thut). iu ny dn n gim v sau l mt phn x ho ca ph qun. Cc phn x ph qun v thanh qun l rt quan trng, chng quyt nh n s lng cc tai bin v tai nn khi gy m nng. Giai on an ton ca gy m phu thut l sau khi cc phn x ny bin mt. - Cc phn x tit dch chi phi hot ng ca cc tuyn nc mt, m hi, nc bt v ph qun s mt i u giai on III. - Cc phn x mt l d theo di nht: phn x mi mt mt i mun hn ( mc 2 ca giai on III). 26

Vic gii thch v s bin mt ca cc phn x mt thng l kh khi s dng phi hp thuc, do hin tng giao thoa tc dng ca chng trn h thn kinh giao cm v ph giao cm. + Cc biu hin h hp: Cc biu hin ny c nh gi thng qua nhp v bin ca c ng c th. S u n ca th ra v ht vo, khng c s ngt qung gia 2 th ny l biu hin ca giai on m phu thut. Giai on th hn lon vi nhp tim v bin khng u xut hin trc giai on ny. Hin tng suy th, c bit l ht vo rt ngn sau mt giai on ngng th, th hin s bt u ca giai on nhim c. + Biu hin v tun hon: u tin, biu hin ca h tun hon l nhp tim nhanh khng u, sau u nhng vn cn kh nhanh, huyt p ng mch tr v bnh thng sau khi tng nh. giai on nhim c xut hin hin tng suy tun hon vi mch nhanh, yu v khng u, th hin mt s try mch ngoi bin. Mt giai on tng huyt p ngn xut hin (c l do hin tng ng CO2) sau da tr nn nht nht, lnh, tm ti, tuy vn cn nhn thy tun hon mao mch. + Biu hin ngoi da: Khi gy m, da hng, kh v m, nhng trong giai on nhim c da nht nht, tm ti nh v lnh, nht l u chi. Da trn nhng biu hin ny, Guedel xc nh 4 giai on ca gy m.3.2. Bn giai on ca gy m (theo Guedel):3.2.1. Giai on I (Giai on ngm thuc hoc gim au):

+ Bnh nhn bt tnh dn dn. + S tp trung thc ca bnh nhn tr nn yu dn. + Bnh nhn cm thy mi th xung quanh chuyn ng, nhng vn nh c. + Mch khng u, nhp tim trong khong 110 - 150 ln/pht, huyt p ng mch tng. + Cc biu hin ngoi da bnh thng. + Trng lc c khng thay i. + H hp ri lon, th ra lu hn ht vo. + in no th hin bnh nhn cn tnh.3.2.2. Giai on II (Giai on kch thch):

+ Tng tt c cc phn x, y l giai on nguy him ca gy m. + Khi s dng ether, bnh nhn thng nn v hin tng ny ch mt i cui giai on kch thch. Cc phn x thanh qun v kh qun vn cn, c th dn ti ph thanh qun hoc kh qun, e da n thiu oxy cho ngi bnh. + Thuc tin m l rt cn thit hn ch hin tng ny. + Biu hin da vn bnh thng, cc biu hin v tim mch v h hp cng nh giai on trc, th nhanh v nhp tim nhanh khng u. + Mt thc v cm gic, tng vn ng, th hin rng cc trung tm ty b kch thch khng ng b vi cc trung tm v no. + ng t co nh, mt chuyn ng, trng lc c vn nhn tng nh. 27

3.2.3. Giai on III (Giai on phu thut), chia ra 4 mc :

+ Mc III1: - Nhn cu c ng, ng t co. - Mt phn x nut. - Mt phn x mi mt. - H hp u c khi nhp th chm. - Mch, huyt p ng mch bnh thng. + Mc III2: - Nhn cu bt ng, ng t co. - Phn x hng, phn x nut mt. - H hp u v su. - Mch + huyt p ng mch bnh thng. + Mc III3: - H hp nng (lit c bng, lit dn cc c lin sn, hot ng c honh bnh thng). - ng t gin nh. - Phn x gic mc mt, mch tng nhanh, huyt p ng mch gim. + Mc III4: - H hp nng khng u (cc c lin sn lit hon ton, hot ng c honh gim dn). - ng t gin to. - Mt phn x vi nh sng. - Mch tng nhanh, huyt p ng mch gim hn. Thy nhng du hiu mc III4, i hi phi ngng s dng ether ngay lp tc. 3.2.4. Giai on IV (Giai on nhim c thuc m): Hot ng ca cc c h hp lng ngc gim v dng li, ch cn c honh hot ng yu vi nhng khong ngh khi ht vo, ko di dn ra v ngt qung tng hi. ng t gin ht c, mch nh kh bt, khng u, huyt p ng mch gim nhiu v kt. Tun hon mao mch gim, da t mu hng sang nht nht, tm ti, sau t ngt ngng h hp, ngng tun hon, biu hin da tm ti, khng cn mch bn, mch cnh, khng nghe c nhp tim, khng cn chy mu ti vng phu thut, ng t gin ti a, gin cc c tht.Trng lc c

Cc phn xTit dch Nut, nn

H hpNhp Bin

Tun honMch Huyt

Da

ng t

Cc

giai on gy m

Giai on I (giai on ngm thuc hoc gim + au)

+

tng N Bnh + Khng u v Tng khi ht vo hanhBnh thng thng Bnh thng dn

28

Trng lc c

Cc phn x+ (5) (6)

H hpKhng u v tng Tng dn

Tun honNh trn Tng

DaBnh thng

ng t

Giai on IIgiai on (giai on Cc gythch) m kch +

Gin

(1) Giai on III Mc III1 Mc III2 Mc III3

(2) + -

(3)

(4)

(7)

(8)

(9)

(10)

(11)

(12)

(13) Co Co Gin

Nhanh v n nhNh trn Nh trn nh thng thng B Bnh Nh trn B Bnh Nh trn Nh trn nh thng thng

Nh trnCn bng v giNh trn Bnh th Bnh th

Mc III4

-

Gim khng Yu, nhanh, u Nht nht, Chm dn nht l khi ht khng u Gimlnh, tm ti Gin to vo Khng n nh, hn n, ngng th sau khi ht vo v ngng hn Ri rc Tt Nh trn

Giai on IV (giai on nhim c) -

Gin to

Ngay khi dng thuc m, tt c cc du hiu ca gy m xut hin tr li theo trt t o ngc nhng vic o thi ether nhanh hn nhiu so vi vic bo ho. Trong khong 5 - 10 pht, bnh nhn loi thi mt na lng ether ngm vo mu, lng cn li s o thi trong khong 12 gi. Nhng du hiu trn c th d dng thy bnh nhn gy m bng ether n thun v khng c tin m. Ngy nay ngi ta thng phi hp thuc tng tc dng mong mun nhng khng lm tng tc hi ca chng. 4. Phn loi gy m. Ty theo ng vo c th ca thuc m ngi ta chia ra lm 3 loi:4.1. Gy m qua ng h hp: 4.2. Gy m qua cc ng khc:

+ Gy m qua ng tnh mch: + Gy m qua ng trc trng: + Gy m qua ng bp tht: 4.3. Gy m phi hp: + Dng cc thuc m khc nhau qua 1 ng hoc nhiu ng khc nhau vo c th bnh nhn gy m. V d: dng thiopental khi m qua ng tnh mch, sau duy tr m bng thuc m ng h hp nh ether, halothane... 29

Gy m phi hp bao gm c nhng phng php dng thuc m phi hp vi cc thuc gim au, thuc gin c, thuc c tc dng c bit i vi chc phn ca cc c quan khc nhau ca c th nh cc thuc lit hch, c ch thn kinh, gim au, gim au trung ng, an thn trn tnh... 5. Thuc tin m. + L thuc dng cho bnh nhn trc khi gy m hoc gy t lm cc phu thut t nh n ln nhm mc ch: - An thn trn tnh, gy ng, gim au. - Gim chuyn ho c bn v cc kch thch, phn x gim tit. - Nng cao ngng nhn cm gic au. - Trung ho v ngn nga cc tc dng xu ca thuc t, m. Dng thuc tin m tt v hp l l iu kin tin quyt v s dng thuc trong gy m. - Khi khm bnh nhn gy m cn c bit lu : - Tnh trng ca c quan h hp, tun hon, thn, gan. - Tui v gii (tnh trng thai nghn nu c). - Cc bnh km theo. - Bnh nhn nhn n ung c bao lu (t nht l 6 gi mi an ton). - Mc lo lng ca ngi bnh.

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CN BNG NC, IN GII1. Cn bng nc.1.1. Cn bng nc:

Chc nng chnh ca nc l mt dung mi cho cc h thng sinh hc. Lng nc trong c th con ngi ph thuc vo tui v gii. + Nc c phn b theo tng khu vc. Khu vc trong t bo gi l khoang ni bo v khu vc ngoi t bo gi l khoang ngoi bo. Khu vc ngoi bo li c chia thnh khu vc ni mch (dch trong mch mu), khu vc k (dch gian bo) v khu vc t bo trao i (dch d dy-rut, dch mt, dch no ty, nc tiu, thy tinh dch, dch bao hot dch). Nc rt cn thit v phi c cung cp y cho c th. Nc c a vo bng ng n ung. Ngoi ra cn ngun nc ni sinh t qu trnh oxy ho thc n. + Dch trong mch khong 4 lt nhng vn chuyn rt nhanh: - Mt ngy mu qua tim khong 7000 lt: 4000 - 5000 lt vo gian bo, t bo sau li tr li mao mch. - Tc tun hon ca nc rt ln, 73% lng nc trong mt pht chuyn t lng mch vo gian bo v ngc li (nh s chnh lch p lc thy tnh trong ng-tnh mch tn cng v p lc thm thu). - Dch t ng tiu ho trong 24 gi gm: nc bt 1,5 lt; dch d dy 2,2 lt; dch rut 3 lt; dch mt 0,7 lt; dch ty 0,7 lt. Dch qua thnh rut c hp th vo mu, cn li 100 ml theo phn ra ngoi. - Qua thn: mt ngy c 900 lt mu qua thn to nn 180 lt nc tiu u v 178 lt c ti hp thu ng thn (99%) cn 1,5 - 2 lt nc tiu (1%). + Bnh thng lng nc vo v lng nc ra cn bng nhau. Lng nc mt ti thiu trong 24 gi ngi ln khong 1700 ml, trong 480 ml mt qua ng th (kh tnh c), 100 ml qua phn, cn li qua ng nc tiu.Bng 1.1: Lng nc trong c th lin quan gia tui v gii.S sinh 1 tui 10-15 tui 60% (nam) 79% 65% 50% (n) 50 - 46% (n) Trn 50 tui 60 - 52% (nam)

Bng 1.2: Lng nc trung bnh trong ton b c th v s phn b thanh nin kho mnh.Phn b Nc ton b c th Nc ni bo Nc ngoi bo Nc trong c th (ml/kg) 600 330 270 % Trng lng c th 60,0 33,0 27,0 % Nc trong c th 100,0 55,0 45,0

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Trong lng mch (th tch huyt tng) Khong gian bo huyt)* M lin kt** Sn** Xng** Trao i qua t bo*** (bch

45 120 45 45 45 15

4,5 12,0 4,5 4,5 4,5 1,5

7,5 20,0 7,5 7,5 7,5 2,5

* Bao gm 25% phn b nhanh ca cc m lin kt c. ** Khong 75% m lin kt v xng khng o c bng cht ch th. *** c o thng qua s chuyn vn tch cc ca cc cht vo t bo c th. Bng 1.3: Nc do oxy ho t thc n.Cht Cht bo Hydratcacbon Protein S lng 100g 100g 100g Nc t oxy ho 107 ml 45 ml 41 ml

Bng 1.4: Cn bng nc hng ngy ngi ln.Cn bng nc - Nc a vo di dng dung dch (nc ung v sp) - Nc a vo di dng thc n c v st Nc vo - Nc do oxy ho Tng lng nc vo hng ngy (1) - Nc mt qua nc tiu - Nc mt qua da Nc ra - Nc mt qua phi - Nc mt qua phn Tng lng nc mt hng ngy (2) S lng 1000 - 1500 ml 700 ml 300 ml 2000 - 2500 ml (3) 1000-1500 ml 500 ml 400 ml 100 ml 2000-2500 ml

Bng 1.5: Nhu cu b sung nc ti thiu ph thuc vo tnh trng lm sng ngi ln.

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Nhu cu b sung nc thm thu t do hng ngy - Nhit tng thm 1oC - Tit m hi bnh thng - Mt m hi nhiu, st cao - Tng thng kh - Tng thng kh trong mi trng rt kh - Vt thng h v cc khoang trong c th (v d: phu thut ko di ti 15 h)

S lng (lt) 0,1 - 0,3 0,5 1,0 - 1,5 0,5 1,0 - 1,5 0,5 - 3,0

1.2. Ri lon cn bng nc:

C hai loi ri lon cn bng nc c bn: mt nc v tha nc. Da vo natri ngoi bo ngi ta c th phn bit mt nc v tha nc nhc trng, ng trng hoc u trng. - Mt nc nhc trng: thiu dch km theo vi thiu natri. Do gim p lc thm thu ca khoang ngoi bo dn n gim nc trong khoang ngoi bo v tng nc trong khoang ni bo. - Mt nc ng trng: thiu nc vi tng p lc thm thu huyt tng v gim th tch nc ngoi bo. Do s khuch tn nc m th tch ni bo gim, dn ti thm thu ca dch ni bo tng ln. - Tha nc ng trng: tha nc v natri. thm thu huyt tng bnh thng, th tch ngoi bo tng v th tch ni bo bnh thng. - Tha nc u trng: tha nc v natri, khi thm thu huyt tng v th tch ngoi bo tng ln. Do s khuch tn, th tch ni bo gim i, thm thu ca dch ni bo tng ln.Bng 1.6: Kt qu xt nghim trong ri lon cn bng nc.Ri lon Protein ton phn Natri (mmol/l) (g/l) Hb (mmol/l) S lng hng cu Hematocrit (%) (tr/mm3) Nam:40-48 N: 36-42 Nam:4,5-6,1 N: 4,1-5,3

Gii hn bnh thng 65-82 Mt nc nhc trng Mt nc ng trng Mt nc u trng Tha nc nhc trng Tha nc ng trng Tha nc u

Nam: 8,7-11,2 132-152 N: 7,4-9,9 BT BT

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trng

Nu mt nc ng trng do mt mu th lng protein ton phn, s lng hng cu, Hb, hematocrit bnh thng hoc thp. Nu mt nc ng trng do mt huyt tng th protein ton phn bnh thng hoc gim.Bng 1.7: Nguyn nhn, triu chng mt nc.Ri lon Nguyn nhn Triu chng - Mt mi, chng mt, nn, gim trng lc, try mch, st, chut rt. - Th , mch nhanh.

- B natri khng do nn, a chy, ra m hi. Mt nc nhc trng - Tng mt natri do suy thng thn, ct b thng thn, iu tr li tiu ko di, a chy, r tiu ho. - Mt nc ng trng do a chy, nn. - R tiu ho, li tiu. - Dn lu dch c trng, vim mng bng, Mt nc ng bng, nhim c thuc ng v monoxite trng cacbon (CO). - Say nng. (1) hi nhiu. Mt nc - Tng khng kh. u trng - Bnh thn mn tnh. - Suy thn cp giai on a niu. - i tho nht. - Li tiu thm thu. (2) - Lng nc vo khng hoc do mt m

- Kht. - Mt mi. - Chng mt. - Try mch. - Nn, gim trng lc. - Chut rt. - Mch nhanh. (3) - Kht. - St. - Da kh. - Bn chn. - M sng. - Hn m.

Bng 1.8: Nguyn nhn, triu chng tha nc.Ri lon Nguyn nhn Triu chng - Mt mi, bun nn, nn. - Kh th, l m, mt thc. - Ph. - Trn dch. - Kh th.

- a vo qu mc dch khng c mui. Tha nc nhc - Ra d dy bng nc thng. trng - Tng hot ng ca ADH. Tha nc ng - Truyn qu nhiu dch ng trng trong trng giai on thiu v v niu. - Suy tim, hi chng thn h. - Tng ur mu mn tnh, vim cu thn cp.

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- X gan, mt protein do bnh l rut non. - a vo qu mc mui. - Hot ng qu mc v thng thn trong Tha nc u hi chng Conn, hi chng Cushing, dng trng nhiu steroide. - Hi chng gi mui do no. - Ung nc bin sau m tu. Nn, a chy, huyt p dao ng, ph phi, hong lon, thay i huyt p tnh mch trung tm.

2. Cn bng in gii. in gii l nhng ion mang in tch dng v m (cation v anion).Bng 2.1: in gii trong dch c th.in gii Na+ K+ (1) Ca++ Mg++ CaHCO3H2PO4 SO-2 Acid hu c Protein pH Huyt tng 114 4 (2) 2,5 1 103 25 1 0,5 4 2 7,4 (mmol/l) Dch gian bo 143 4 (3) 1,3 0,7 115 28 1 0,5 5 20 49

ml/kg/pht, di ngng ny th s gin mch no ti a v s sng ca t bo no ph thuc trc tip vo thi gian thiu mu no. T bo no l t bo c bit nht trong c th, khi tn thng th khng c ti to v b p nh cc t bo khc. Trong iu kin bnh thng kh nng chu ng thiu oxy ca no ti a l 5 pht. Khong thi gian ny cn gi l giai on cht lm sng v vic cp cu nhm cung cp li mu v oxy cho no phi c tin hnh trong giai on ny mi c th cu sng c bnh nhn. Qu thi gian ny, cc t bo no b tn thng khng cn kh nng hi phc v bnh nhn chuyn sang giai on cht sinh vt hay cht no. Trong mt s trng hp c bit, kh nng chu ng thiu oxy no c th ko di hn nh: ngng tim trong iu kin h thn nhit (m vi tun hon ngoi c th - h thn nhit, ngng tim ngoi tri bng tuyt, cht ui trong nc lnh...), ngng tim m trc c s dng cc thuc lm gim tiu th oxy no nh bacbituric, tr s sinh... 3. Mc ch ca vic cp cu. Trong iu kin nhanh nht c th, cung cp c mu cng vi oxy n cho t bo no, nht l trong vng 5 pht u k t lc ngng tim. Chnh v vy, vic cp cu ngng tim-phi cn tin hnh ti ch, khn trng v ng k thut. 4. Triu chng chn on. Da vo 3 triu chng c bn sau: + Mt thc: c xc nh khi bnh nhn gi hi khng c p ng tr li, khng c phn x thc tnh. + Ngng th: xc nh khi lng ngc v bng bnh nhn hon ton khng c c ng th. + Ngng tim: khi mt mch cnh v mt mch bn. Ngoi ra bnh nhn cn c cc triu chng khc nh: tm nht, gin ng t v mt phn x ng t vi nh sng, nu bnh nhn ang c phu thut s thy mu vt m tm en v ngng chy.5. Cp cu ngng tim - phi c bn trong iu kin khng c trang b. 5.1. Khai thng ng th cho bnh nhn: Bnh nhn c t nm nga trn nn cng, u v c t th n ti a, mt quay v mt bn. S d phi lm nh vy v khi ngng tim, cc trng lc c mt i khin cho xng hm di v gc li ri xung chn lp ng th ca nn nhn cn tr ng tc h hp nhn to. Ngi cp cu dng tay m ming bnh nhn ra, dng cc ngn tay mc sch m di v d vt nu nh c th ly c. Vi cc d vt su v kh ly, khng nn c ly d vt v lm mt thi gian v c th y d vt vo su thm hoc gy tc hon ton ng th. C th p dng nghim php Heimlich lm bt cc d vt ng th ra ngoi. Nghim php Heimlich c tin hnh nh sau: Ngi cp cu m sc nn nhn ln t pha sau, mt bn tay thu li thnh nm t ngay di mi c ca nn nhn, bn tay th 2 t chng ln bn tay th nht, m sc bnh nhn ln sao cho nm tay thc mnh vo thng v hng v pha lng ngc ca bnh nhn. Nu nn nhn qu to ln khng th sc ln c th t nn nhn nm nga trn nn cng, ngi cp cu ngi ci trn ngi nn nhn, hai bn tay t chng ln nhau trn vng thng v ca nn nhn thc mnh v pha ngc. Nguyn l ca nghim php l lm tng p lc trong lng ngc mt cch t ngt. Nhng khng nn lm nghim php ny khi d dy y v c th gy tro ngc, cng khng nn lm c nhiu ln nu khng ly c d vt v s lm mt thi gian. Vi tr em, c th cm 2 chn dc ngc bnh nhn ri dng tay v mnh vo vng gia 2 xng b vai cng c th lm bt c d vt ra ngoi.

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5.2. Thi ngt cho bnh nhn:

C th chn k thut thi ming-ming hoc ming - mi. Thng thng thi ming - ming c hiu qu hn, ngi cp cu dng 1 bn tay t ln trn bnh nhn n nga u bnh nhn ra sau ng thi dng ngn tr v ngn ci kp mi bnh nhn li, cc ngn tay ca bn tay th 2 va nng hm di ca bnh nhn ln trn ra trc ng thi m ming bnh nhn ra, ngi cp cu sau khi ht su p cht ming vo ming nn nhn ri thi ht khng kh d tr qua ming vo phi ca nn nhn. Nu nn nhn qu to ln, c th p dng thi ming-mi, ngi cp cu va dng bn tay va nng xng hm di ca bnh nhn ln trn ra trc va khp ming bnh nhn li, bn tay th hai t ln trn nn nhn n nga u nn nhn ra sau, sau khi ht su p cht ming vo mi nn nhn ri thi ht khng kh d tr qua mi vo phi. Tn s thi nn t 12 - 15 ln/pht. Nu lm ng k thut, vi mi ln thi nh vy, s thy lng ngc bnh nhn n vng ln. Nu lm khng ng k thut s thy lng ngc bnh nhn khng n theo nhp th ng thi thy bng bnh nhn to dn ln theo tng nhp thi hoc khng kh ph ra ngay trn mt bnh nhn. ng tc thi ngt gip a khng kh cng vi oxy vo trong phi nn nhn, ng tc th ra th ng sau khi ngng thi khng kh vo gip khng kh trong phi thot ra ngoi mang theo CO2.5.3. p tim ngoi lng ngc:

Ngi cp cu chn v tr thch hp mt bn bnh nhn, mt bn tay t dc theo chnh gia 1/2 di ca xng c bnh nhn, bn tay th hai t vung gc ln bn tay th nht, dng lc ca hai tay, vai v thn mnh p vung gc xung lng ngc ca bnh nhn sao cho xng c ln xung t 4 - 5 cm, sau nhc tay ln m tip tc nhp p th hai, tn s ln khong 80 - 100 ln/pht. Vi mi nhp p tim ng k thut s phi bt c ng mch bn hoc ng mch cnh ny. Phi p nh vy th mi c th lm tng mu ln vng tun hon nh c lc p trc tip ln tim kt hp vi lm thay i p lc trong lng ngc. ng tc ny s a mu t tht phi ln trao i kh phi, a mu t tht tri ln tun hon vnh v tun hon no, cn mu s th ng tr v nh khi ngng p khin tim gin ra v p lc trong lng ngc gim xung. Hai ng tc p tim v thi ngt phi c thc hin xen k vi nhau mt cch nhp nhng, c th thi mt ln ri p tim 5 ln hoc thi 2 - 3 ln ri p tim 15 ln. Cch th hai tt hn v to c p lc tng mu cao hn nhng khin ngi cp cu chng mt hn.5.4. Nh th no l cp cu ngng tim-phi c bn c hiu qu:

l khi vic cp cu t c mc ch cung cp c mu v oxy n cho tun hon no, tun hon vnh cng nh t chc t bo. Biu hin lm sng l nim mc mi bnh nhn m v hng tr li, ng t co li nu thi gian thiu oxy no cha lu v cn kh nng hi phc. Cng tt hn nu nh c cc du hiu ca s sng nh: th tr li, tim p li, thc tnh tr li... Cn lu l ch cc du hiu cung cp c oxy cho t chc t bo (mi m hng tr li) m cha c du hiu tn thng nng n t chc no (ng t co li). V vy cn kin tr cp cu, ng thi gi cc i cp cu y t hoc va cp cu va vn chuyn bnh nhn n mt c s y t gn nht. 6. K thut cp cu ngng tim - phi c bn tuyn qun y n v.6.1. Khai thng ng th:

K thut khai thng ng th khng c g khc so vi phn trn, nn nhn cn c t nm nga trn ging cng, nu l ging m cn t mt ming g mng di lng bnh nhn. Cn c my ht ht m di, km m ming, panh gp d vt...

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6.2. H hp nhn to:

Bnh nhn c khai thng ng th, ngi cp cu dng masque p kht ln mi v ming ca nn nhn, masque ny c ni vi bng bp. Cn bp bng cho bnh nhn khong 20 nhp/pht, th tch mi ln bp vo khong10 - 15 ml/kg. Tt nht l bp bng ni vi ngun oxy vi lu lng 6 8 lt/pht.6.3. p tim ngoi lng ngc:

Ging nh khi cp cu khng c phng tin; ng tc p tim v thi ngt cn xen k vi nhau mt cch nhp nhng nh phn trn.6.4. Dng thuc trong cp cu ngng tim-phi:

+ Thuc u tay l adrenalin ng ng 1mg/1ml, thuc kch thch th th adrenergic trn h thn kinh t ng ca tim (c bit l nt xoang) lm cho tim p li. Liu dng l 1mg cho 1 ln tim, nhc li 5 pht mt ln nu nh tim cha p li, c th tng liu ln 3mg cho mt ln tim nu nh dng liu 1mg khng c hiu qu. ng tim thuc tt nht l tim vo tnh mch, c bit tim vo tnh mch trung tm v l con ng nhanh nht a thuc ti nt xoang. Nu tim vo tnh mch ngoi vi cn chn tnh mch cnh ngoi, tnh mch u hoc tnh mch nn cnh tay. Liu adrenalin cn pha trong 20 ml huyt thanh mn 0,9% v c tim nhanh vo tnh mch, khi tim vo tnh mch cnh tay cn nng cao cnh tay ln, nu t c mt dy truyn tnh mch th sau khi tim thuc vo dy truyn cn nng cao chi th v cho dch truyn chy nhanh ln vi mc ch lm cho thuc v tun hon trung tm nhanh hn. Khng s dng cc tnh mch chi di v t hiu qu. Con ng d phng a thuc vo khi cha tim c thuc vo tnh mch, l tim thuc vo kh qun bnh nhn. Liu dng theo ng ny cn cao hn l 5mg adrenalin pha trong 5ml huyt thanh mn 0,9%. V tr tim l khe sn gip-nhn, va chc kim va ht nh bm tim n khi thy khng kh trn vo trong lng bm tim mt cch d dng chng t mi kim nm trong lng kh qun, bm nhanh thuc vo, sau khi rt kim ra, bnh nhn phi c thng kh v p tim ngay. Nh ng tc thng kh, thuc c a vo ph nang ri ngm sang mng ph nang - mao mch vo tun hon phi ri nh ng tc p tim v tim lm tim p li. Khng nn nhc li vic tim thuc vo kh qun qu nhiu ln v lm ngp nc phi bnh nhn. Con ng cui cng a thuc vo khi cc con ng trn khng thc hin c hoc khng c hiu qu l tim thuc vo bung tim. Cn chn kim tim di 7 - 10cm c th chc ti bung tim, kim mnh c 18 - 20Gauge hn ch tn thng c tim. V tr tim l khoang lin sn 4 - 5 st cnh xng c bn tri, st b trn xng sn di trnh mng phi v b mch thn kinh lin sn. Hng kim l t di ln trn, t ngoi vo trong, t trc ra sau, va chc va ht nh bm tim n khi mu tro vo bm tim mt cch d dng chng t mi kim nm trong bung tim th bm nhanh thuc vo. Sau khi rt kim ra bnh nhn cn c p tim v thng kh ngay. + Cc thuc khc: - Cc thuc kim mu ch thc s cn thit khi tim p li v c huyt p, nhng khi cp cu hi sinh ko di c th s dng vi liu 1mEq HCO3- cho 1kg cn nng cho 30 pht cp cu . - Ca++ gy tn thng t bo nn hin ch dng cho cc trng hp ngng tim do h Ca++ mu hoc ng c cc thuc c ch Ca++. - Cc thuc chng rung tht v lon nhp tim nh lidocain dng vi liu 1,5mg/kg, bretylium 4,5mg/kg khi c ch nh. 52

- Truyn dch khi phc khi lng tun hon ch c ngha quyt nh trong trng hp nguyn nhn ngng tim l do mt mu v dch th cp tnh. Cn tuyt i a s cc trng hp khc, ch cn truyn 200 - 300ml huyt thanh mn 0,9% trong sut qu trnh cp cu, ch yu l gi mt ng tnh mch chc chn a thuc vo c th.6.5. Ph rung bng sc in:

Rung tht l tnh trng cc th c tim rung ln mt cch hn lon, khng cn kh nng tng mu i nui c th v c coi l ngng tun hon. Ph rung bng sc in l dng dng in c hiu in th thp nhng c cng ln phng qua trc ca tim, nhm xo sch cc pht xung hn lon, khi phc li tnh t ng bnh thng ca h thn kinh tim. Rung tht biu hin trn in tim l mt phc b QRS m thay bng cc sng ln nhn, nu bin > 7mm ( o trnh ngoi vi) l rung tht bin ln thng p ng tt vi sc in, nu < 7mm l rung tht bin nh, p ng km vi sc in, cn kin tr p tim v thng kh giu oxy chuyn rung tht bin nh thnh rung tht bin ln, ph rung s hiu qu hn. Liu sc in thng thng l: - Ln 1 : 200j - Ln 2 : 200j - Ln 3 : 300j - Ln 4 : 360j nu cha ph c rung tht. Hin nay, cc my ph rung bn t ng rt ph bin trn th gii, n cho php t pht hin rung tht v phng xung in. Cc th h my mi thay dng in c xung hnh sin kinh in bng dng in 2 pha (biphasic) dng nng lng thp hn, t gy tn thng c tim hn.6.6. Khi nim v trng thi sau hi sinh v hi sinh tim-phi- no:

Mc d c cp cu sm v tt, tim p li nhng bnh nhn s c tin lng xu nu trn nn bnh l mn tnh giai on cui. Nu ngng tim - phi trn ngi trc kho mnh, sau tnh trng thiu oxy nng n ko di nh vy, mc d tim p li nhng tnh trng bnh nhn vn cn rt nng, c bit l do tnh trng thiu oxy no ko di. Cc bnh nhn ny cn c theo di iu tr ti cc khoa iu tr tch cc nhm gi cho huyt ng n nh, cung cp oxy y . Vic hi sc no ch yu l cung cp oxy cng vi p lc ti mu no tha ng, duy tr tnh n nh ca ni mi nh ng mu, p lc thm thu mu, pH, paO2, paCO2 trong gii hn bnh thng, s dng cc bin php lm gim tiu th oxy no c tnh cht bo v no nh bacbituric, h thn nhit va phi (350C). Nh vy, nu tuyn n v, sau khi cp cu tim p li, bnh nhn cn c chuyn ln tuyn trn hoc mi tuyn trn xung cp cu ty trng hp c th. 7. Khi no ngng cp cu. Nu p dng ng, y cc bin php cp cu nh trn, khng c iu kin vn chuyn hoc gi tuyn trn chi vin, trong vng 30 pht m ng t khng co li, tim khng p li th cho php ngng cp cu v bnh nhn t vong. Cn lu cc trng hp ngng tim - phi trong iu kin c bit nu phi cp cu kin tr hn vn c th cu sng bnh nhn.

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S LIN VT THNGNghim nh Phn

1. i cng. Vt thng l cc thng tn gy rch, t da hoc nim mc v cc phn khc ca c th. S lin vt thng l mt qu trnh phc hi c bn trong bnh l ngoi khoa, ph thuc vo nhiu yu t, mc , tnh cht thng tn, sc chng ca c th v cch x tr. Din bin ca vt thng tri qua 2 qu trnh: lin vt thng k u v lin vt thng k hai. 2. lin vt thng k u. Khi vt thng gn sch, c x tr sm v ng nguyn tc, ng k thut, c khu kn k u, hai b ming vt thng p st vo nhau, khng b vim nhim, khng c hoi t t chc. Cht t huyt ng 2 mp vt thng c tc dng nh keo: kt dnh. Cc m bo, nguyn bo si, bch cu tp trung lp y khe gia 2 mp vt thng v m ht c hnh thnh. Qu trnh tng hp cht collagen do nguyn bo si c tin hnh t ngy th hai sau khi b thng, t cao im ngy th nm, th by sau khi b thng. Qu trnh m ho lp biu b hoc lp nim mc hon thnh trong 6 n 8 ngy, nh vy vt thng lin ngay k u. Mc lin chc ca 2 mp v vt thng cng t kt qu cao ngy th 5, th 7. 54

3. Lin vt thng k hai. Khi vt thng tn thng nhiu t chc, hai b ming vt thng cch xa nhau, b nhim khun th qu trnh lin vt thng s din bin di hn, nu th tch thng tn ln th c th phi huy ng cc ngun d tr n bo v v ti to vt thng. Qu trnh ny tri qua 3 giai on sinh hc.3.1. Giai on vim (Giai on t tiu, giai on d ho, giai on tim):

Giai on vim din ra trong 5 ngy u vi cc triu chng c nh danh y c i Celsus (25 trc CN-45 sau CN) m t: ", nng, xng, au". V sinh bnh hc th hin bng: ri lon cc b tun hon mu do cc kch thch gy ra t vt thng. Vi gi sau khi b thng c s thm nhp cc bch cu a nhn, cc i thc bo (bch cu n nhn v cc t bo thuc h thng li ni m). Chng tit ra cc men phn hy cc t bo b thng tn thnh cc phn t ln ri tiu ho chng. Cc i thc bo bi tit cht lactat v cc yu t iu chnh s tng sinh v kh nng tng hp ca cc nguyn bo si, cc nguyn bo si di chuyn ti t 1 n 3 ngy sau khi b thng, s phn chia nguyn bo si t ngy th 2 n ngy th 6 sau khi b thng. Trong giai on vim c s tng sn cht mucopolysaccarit do cc nguyn bo si tit ra ti vt thng. Khi c cc t bo vim xm nhp. Lng hexosamin ton phn tng cao v cc biu hin dng tnh d sc (merachromasia) t ngy th 1 v t nh cao ngy th 5, th 6 sau khi b thng. Khi m cc si collagen bt u hnh thnh v th hin r v ho t chc. Trong giai on vim ny cc t bo b thng tn tit ra nhng cht sinh hc: leukotoxin (lm tng tnh thm thnh mch, lm bch cu chuyn ng qua thnh mch), necrosin (men tiu cc m hoi t), cc yu t kch ng bch cu Cc t bo chuyn bit cn tit ra fibronectin c nh hng n c ch khng ti ch ca vt thng i vi cc t bo b tiu hy v cc cht ngoi lai. C s tng nng histamin do cc t bo bn v cc t bo i kim tit ra. Trong giai on ny, mi trng vt thng toan ho, pH: 5,4 - 7. T ngy th 2 n ngy th 4 xut hin hin tng tn to mch mu.3.2. Giai on tng sinh (Giai on ng ho, giai on collagen):

Bt u t ngy th 6 n khi vt thng lin khi hon ton.3.2.1. V mt sinh hc:

Cc mm mao mch c mc ln thnh cc quai mao mch c ni mc tng i dy, pht trin mc thng ln v song song vi nhau t cc t bo lin kt tr, a s l nguyn m bo v m bo (histioblast, histiocyt) ri n cc bch cu a nhn trung tnh, bch cu i toan, cc tng bo, cc nguyn bo si. Gia cc t bo lin kt v cc quai mao mch c cc si keo v cc cht cn bn (dch qunh gm nc 80 - 90%, cht m 7 - 15%, cht mucopolysaccarit 3%).3.2.2. M ht:

Gm cc t bo lin kt non mi c phn chia, cc t, si lin kt v cht c bn (c cha nhiu glucoaminoglycan). + Cc thnh phn ca m lin kt u c nhim v sinh hc trong vic ti to t chc, t l tng sinh cc i thc bo v nguyn bo si l s phn nh ca sc khng v kh nng ti to thun li ca vt thng. Vic ngng tng sinh ca nguyn bo si l do mt ca chng trong vt thng quyt nh; mt ca chng cao nht tun l th t. + Cc nguyn bo si c chc nng tng hp cc phn t to keo protocollagen v tit chng vo cht cn bn ca m lin kt. Cc t collagen c to thnh do qu trnh trng hp cc phn t 55

protocollagen, lc u c phn b thnh mt li hn n gia cc quai mch v cc t bo. Sau c nh hng thnh 2 lp: - Lp nng: xp dc thng ng so vi nn vt thng. - Lp su: xp song song vi nn vt thng. Khi nh hng xong v tr, cc t collagen pht trin v hp vi nhau thnh cc si collagen nh cc mucopolysaccarit ca cht cn bn tr thnh bn dai v khng ho tan. Ty theo tnh cht m b thng tn m c mt s chuyn bit ho cc nguyn bo si: nguyn bo si c (myofibroblast), nguyn bo sn (chondroblast), nguyn bo xng (osteoblast), s sp xp cc t v si collagen cng ph thuc vo tnh cht m. S tng hp cht collagen ca nguyn bo si i hi cc iu kin sau: mi trng hi axit v c cht kh v c phn p oxy 10 - 20 torre. S tng hp cc cht glycoaminoglycan c tin hnh ti vt thng cng vi s tng hp cht collagen t ngy th 2 n ngy th 16 sau khi b thng. Qu trnh tng hp collagen t dng nguyn sinh u tin n dng hon chnh cui cng ngy th 40 - 50. + M ht l hng ro khng; cc t bo lin kt gi vai tr i qun dit cc vi khun. + Hin tng biu m ho t cc t bo biu m ca lp biu b tng sinh s lan ph, che kn din m ht v vt thng thnh so. Nu m ht khng c che ph bi lp biu m th vic tin trin lin so ca vt thng s khng thun li, ko di, m ht s gi, tr thnh mt khi x chc (fibrocyte), cc quai mch mu gim dn, cc si collagen x ho.3.3. Giai on ti to t chc (Giai on ti lp m collagen):

L qu trnh ti to t chc so mi hnh thnh trong c s ti lp v s gim bt m to keo, s to li m x thnh lp m m. + Cht collagen c ti xy dng bng cc qu trnh phn nh mc cao nht vo thi gian 40 - 60 ngy sau khi b thng c sp xp mt cch c th t, nh hng v kt hp cht ch vi cht glycoaminoglycan thnh cc b m to keo v s gim dn trong t chc so. Thi k ny tng ng vi cc triu chng lm sng. Trong thi gian u th tch ca so ln ra (ngy th 25 n 50 sau khi thnh so), so hi chc, dy, b mt so cao hn mt da, so dnh vo cc t chc ln cn, t di ng (2 - 3 thng u). Nu theo di s thy sau l thi k so co. + Dn dn cc quai mao mch trong so gim v s lng, c s to li m x vi s xut hin t chc m trong so, cc nguyn bo si cn rt t, cc b x tr nn dt v mng. Thi k ny tng ng vi trng thi so khng co na khi theo di lm sng. Lp m m c hnh thnh; tnh n hi c phc hi, so tr thnh mm mi di ng c. Qu trnh phc hi cm gic theo thi gian: t 3 thng tr i c xu hng phc hi xc gic. Trong nm u c th phc hi 95% cm gic au. Cui nm th hai phc hi cm gic nhit. Sau 6 thng n 1 nm so s tin trin theo hng n nh hoc hng bnh l. + So n nh: cc b si collagen c phn b c trt t sp xp theo cc hng dc, nghing nht nh c s pht trin ca cc t bo m xen k gia cc b si, lm cho tnh di ng v tnh bn c hc ca so c hnh thnh. + So ph i: do s pht trin khng n nh, khng bnh thng ca cht to keo v m x. So tr nn dy chc, gy cm gic cng, cao hn mt da bnh thng, t di ng, din so thu hp li so 56

vi khi im (30% - 40%). C nhiu kh nng t khi sau 3 - 4 thng tin trin. Nu phu thut ly so i th thng t ti pht. + So li: do s pht trin khng n nh, khng bnh thng ca cht to keo v m x. So li pht trin to, dy, chc, cng mu, tm , nga, c khi au, khng th t khi, khi pht trin th c tnh cht lan sang cc t chc da ln cn. Trn c th c so li th cc ni c so u pht trin thnh so li (bnh so li). Nguyn nhn gy so li n nay vn cha xc nh c r rt. V tin trin, so li khng t khi m c su hng pht trin, t l ti pht cao sau m v iu tr (ti trn 40 - 50%). + So b lot lu lin: do qu trnh biu m ho khng hon chnh, t cc m m ht khng c ph kn, hoc t cc so bng lin nhng b chn thng ph, b cng nt. Tin trin ca lot ko di nhiu nm c th b thoi ho ung th. + So b ung th ho: thi gian chuyn sang c tnh c th ngn (vi tun), nhng thng rt di (vi nm n hng chc nm). Thng gp th ung th biu m dng biu b, t gp th ung th biu m t bo y. Trn lm sng thy vt lot c y sn si, cng, b ca lot ni g cao, c nhng nt sn trn nh. Tin trin dai dng, ko di, lot tit dch hi, thng b nhim khun, c khi thy nhng k nt m so. + So co ko: do qu trnh tng sinh cc nguyn bo si c, cc si to keo, dn ti mt qu trnh gim cc th c, hnh thnh cc di x di so, di lp cn. Qu trnh co ko c th ch do so da n thun hoc c th co ko c lp cn, gn, c, bao khp, dy chng, do cc di x di so gy nn. So co ko khng hi phc li c. + So dnh: khi c mt din m ht rng cc phn ca c th tip gip nhau, khi thay bng khng tch nhau ra, m c thnh mt khi. Din m ht pht trin thnh mt khi chung v c biu m che ph khi hnh thnh so, nn cc phn c th ny dnh vo nhau. 4. iu tr. + X tr vt thng k u: nhm cm mu, chng nhim khun, gim au, d phng v iu tr cc bin chng cp tnh do cc vt thng gy ra. + S cu vt thng: bng b, cm mu, c nh, vn chuyn v tuyn iu tr. + Ti tuyn iu tr: khm ti ch v ton thn, chng sc, thay bng x tr phu thut k u vt thng ng nguyn tc v ng k thut. Bt ng chi th c vng b thng. - Ty theo tnh cht, v tr v mc tn thng m ra chin thut v k thut x tr khc nhau. - Khi vt thng ht giai on vim nhim v loi b sch cc t chc hoi t, ty theo kch thc v tnh cht ca giai on ti to t chc m quyt nh khp kn ming vt thng bng khu kn k hai hoc ghp da cc loi. Cn ch nui dng v tng cng sc khng ton thn. Cn theo di din bin ti ch v ton thn trong qu trnh iu tr vt thng mau lnh, hn ch nhng bin chng v di chng sau ny.

VN CHUYN NGI B THNGNghim nh Phn.

57

1. i cng. Vn chuyn ngi b thng (gi tt l chuyn thng) nhm m bo a ngi b thng t ni b thng v ti c c s y t v qun y c kh nng cu cha tt nht. Trn bc thang iu tr, vic chuyn thng thc hin theo tuyn. Khi c cc iu kin cho php v theo cc ch dn quy nh trong cc quy nh chuyn mn, c th t chc chuyn thng vt tuyn v cc c s iu tr c kh nng x tr thch hp nht, theo tnh cht chuyn khoa ca vt thng. Vn chuyn ngi b thng l mt ni dung cng tc rt quan trng, c nh hng trc tip n tnh mng nn nhn v n kt qu iu tr. 2. Nguyn tc.2.1. Cu cha lin tc:

Vi cc nn nhn, nht l i vi cc nn nhn nng, c chuyn ti tuyn iu tr c cht lng th ti mi tuyn, phi tin hnh cc bin php khn cp cn thit, c th tip tc vn chuyn nn nhn nng v ti tuyn iu tr c cht lng, m tnh trng ton thn ca nn nhn khng b xu i, p ng hai yu cu: nhanh chng v an ton. Tranh th vn chuyn sm c cc nn nhn nng n cc c s iu tr thch hp s c hiu qu tt v mt iu tr v tin lng. Trn ng vn chuyn cn tin hnh cc bin php bo m an ton v sn sc chu o. Cc cn b y t, lm cng tc h tng, cc nhn vin lm cng tc chuyn thng, phi ng dng cc bin php cp cu v bo v sinh mng ca nn nhn trn ng vn chuyn.2.2. Cng tc chuyn thng phi kt hp cht ch vi cng tc chn lc, phn loi nn nhn:

Phi u tin vn chuyn cc nn nhn c chy mu trong, c gar cc chi, vt thng thu bng, trn kh mng phi m hoc kiu van, vt thng vng u, c, c ri lon h hp, sc nng, vt thng b nhim cht c ho hc, cht phng x. Khng vn chuyn cc nn nhn ang hp hi, cc nn nhn ny phi c cp cu v x tr cho n nh ri mi chuyn v tuyn sau. Phi la chn nhng phng tin chuyn thng thch hp vi tnh trng bnh l cc tn thng. Vi cc nn nhn nh c th khi c sau cu cha trong mt thi gian ngn th a v cc trm x a phng, cc n v qun y hoc iu tr ngoi tr. 3. Chuyn ngi b thng bng tay khng. c tin hnh ngoi trn a hoc ni xy ra tai nn a ngi b thng ra ngoi khu vc nguy him n mt ni tng i an ton trong khi ch i chuyn v pha sau. Vn chuyn ngi b thng bng tay khng thng do mt ngi lm, v vy thng khng th chuyn c i xa.3.1. t ngi b thng ln i v l nghing (hnh1):

+ t ngi b thng nm nghing thng. + Y t nm nghing sau lng ngi b nhn v cng mt hng vi ngi b di co, chn trn dui thng.

v bn khng b thng, thng, mt chn

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+ t ngi b thng nm trn chn co ca y t, mo chu ca ngi b thng t st vo mt trong i ca y t, tay trn ca y t m ngang nch ngi b thng, ko st vo ngi mnh. + L nghing lt a ngi b thng v pha sau. Hnh 1 Khi l nghing, chn co ngi b thng khng c ng m phi nhc theo tng bc ca tay di v p ca chn trn di chuyn. 3.2. B cng ngi b thng trn lng (hnh2): Hnh 2 + t ngi b thng nm nghing v mt bn. Hnh 2 + Y t b tip cn ngi b thng, p st lng mnh vo ngc ngi b thng. + Cho ngi b thng m vo c y t, y t dng hai chn qup vo chn ngi b thng. + Y t chuyn t t th nm nghing sang nm sp, khi chuyn dng tay tm vo qun ngi b thng v dng 2 chn ko 2 chn ngi b thng ln, ri b theo t th b thp. Khi b ch dng mt chn p t cho ngi b thng khi b lc l hoc lt u 2 bn chn v 2 tay.3.3. Cng ngi b thng trn lng:

ng tc tuy n gin nhng khng i c xa v ngi cng rt mi.3.4. Du ngi b thng:

Ch p dng vi ngi b thng nh, i c.3.5. Vc ngi b thng trn vai.

C th thc hin i vi ngi b thng nh, khng t i c.3.6. B ngi b thng.

ng tc ny n gin nhng cng ch i c mt on ngn, v ngi b rt chng mt. 4. Chuyn ngi b thng bng cng. y l cch vn chuyn ph bin nht ho tuyn cng nh ni xy ra tai nn t trc n nay.4.1. Cc loi cng:

+ Cng bt khing tay (hnh3):

Hnh 3

+ Cng tre hnh thuyn (hnh 4):

59

Hnh 4

+ Cng chng (hnh 5):

Hnh 5

+ Cng vng ay (hnh 6):

Hnh 6

+ Cng vng bt (hnh 7):

Hnh 7 4.2. Cch cng ngi b thng (hnh 8):

60

Hnh 8

+ t ngi b thng ln cng (dng 2 ngi): - t cng bn cnh ngi b thng, cha lng n cng. - 2 ti thng qu bn cnh ngi b thng v pha i din vi cng. - Lun tay ngi b thng nhc t t v t ln cng. - Buc dy cng. + Cng ngi b thng: Mi ti thng c mt chic gy chng cao khong 1,40m - 1,50m, c chc u trn n cng khi cn ngh hoc i vai. - Khi cng trn ng bng: 2 ti thng cn trnh i u bc cng khi lc l. - Khi cng ln ng dc: gi cho n cng thng bng hoc u ngi b thng hi cao hn chn. - Khi cng ln dc: phi cho u i trc. - Khi cng xung dc: phi cho u i sau.

C NH TM THI GY XNGNghim nh Phn.

1. i cng + Gy xng c th l gy xng h hoc gy xng kn, do nhiu nguyn nhn gy nn nh: v kh, ti nn giao thng, tai nn lao ng + Xng thng b gy v thnh nhiu mnh, c th b mt tng on xng, cc on xng b di lch. + Gy xng cng phc tp th tn thng phn mm cng rng ln. + u xng sc nhn ti gy lm cho mch mu, thn kinh d b tn thng. + Nu khng c s cu, cp cu kp thi c th a n nhng tai bin v bin chng nh: - Sc do mt mu v au n, nht l do gy cc xng ln. - Gy thm tn thng mi do cc u xng gy gy nn. 61

- Nhim khun vt thng. C nh tm thi gy xng l mt trong nhng k thut c bn v quan trng hn ch nhng tai bin v bin chng trn. 2. Mc ch. + Gi cho gy xng c tng i yn tnh, ngi b thng c vn chuyn an ton v cc tuyn phu thut khn cp hoc c bn pha sau. + Gp phn phng v hn ch c nhng tai bin, bin chng trn do gy xng gy ra. 3. Nguyn tc. + Phi gim au tt trc khi tin hnh bng b c nh chi gy khng c nng nhc, bng b, c nh chi gy nu cha c gim au. + Np phi c nh c c khp trn v khp di gy, buc chc chn vo chi. + Nu chi gy b di lch, bin dng ln, sau khi gim au tht tt, c th nh nhng ko chnh li trc chi gim bt bin dng, gim bt nguy c thng tn phn mm do cc u xng gy gy ra v to iu kin thun li c nh tm thi gy. + Khng t np cng st vo chi m phi lt bng bng m, gc Khi c nh khng cn ci qun o ngi b thng, v qun o c tc dng tng cng m lt cho np. 4. Cc loi np thng dng.4.1. Np tre:

c dng ph bin v thun tin tuyn x v i i. C 4 b np tre cho chi trn, chi di theo quy cch sau: + B np cho cng tay: gm c 2 np, rng 5 cm, dy 0,5 - 0,7 cm, np trc di 30 cm, np sau di 35 cm. + B np cho cnh tay: gm c 2 np: - Np trong: di 20 cm, rng 5 cm, dy 0,5 - 0,7 cm. - Np ngoi: di 35 cm, rng 5 cm, dy 0,5 - 0,7 cm. + B np cho cng chn: gm 2 np hoc 3 np, mi np di 60 cm, rng 5 - 6 cm, dy 0,8 - 1 cm + B np cho i:8 cm

Hnh 9: B np cho i

Gm 3 np: - Np sau: i t trn mo chu n qu gt chn di 100 cm, rng 7 cm - 8 cm, dy 0,8 cm - 1 cm. - Np ngoi: i t h nch n qu b ngoi bn chn, di 120 cm, rng 7 cm - 8 cm, dy 0,8 cm - 1 cm. 62

8 cm

8 cm

- Np trong : i t bn n qu b trong bn chn di 80cm, rng 7 cm - 8cm, dy 0,8 cm - 1cm. Cc kch thc trn ch l trung bnh, khi s dng, nu cn phi ct bt cho ph hp vi tng chi th ca ngi b thng. Cc np c bc trc bng bng m hoc giy xp cun bng x, trn ton b chiu di, bt kn 2 u.4.2. Np Crame:

Hnh 10: Np Crame

L loi np lm bng si km, b un c, hnh bc thang c nhiu kch thc thch hp cho tng on chi. S dng np Crame cng cn c cc kch thc v cng cn bc lt bng gc nh vi np tre. Trong tnh hung khn cp m khng c np chun b sn, c th s dng cc phng tin ty ng nh cnh cy, gy g, sng hng, cng c th c nh chi trn vo thn hoc buc chi di gy vo chi lnh. Trn th gii cn c nhiu loi np nh: np li, np T - mt, np Diteric, np cht do bm hi, rt thun tin nhng t ph hp vi hon cnh kinh t, kh hu v iu kin chin u nc ta. 5. C nh tm thi mt s gy xng ln.5.1. C nh tm thi gy xng cng tay: 5.1.1. C nh bng np tre:

+ t np ngn mt trc cng tay i t np khuu n khp ngn bn. + t np di mt sau cng tay, i qu mm khuu, i xng vi np mt trc. + Buc 2 Hnh 11: C nh gy xng Hnh 12: C nh gy xng on c nh 2 cng tay bng np tre. cng tay bng np Crame. np vo bn tay v cng tay. on th nht bn tay v c tay, on th 2 di v trn khp khuu. + Dng bng cun treo cng tay t th gp 900.5.1.2. C nh bng np Crame:

+ t 1 np Crame st mt sau cng tay v cnh tay i t gia cnh tay ti khp bn tay, ngn tay (cng tay gp 900). 63

+ Bng vng xon t bn tay ln ti gia cnh tay c nh cng tay vo np. + Dng khn tam gic hoc 1 vng bng treo cng tay.5.2. C nh tm thi gy xng cnh tay: 5.2.1. C nh bng np tre:

+ Mt trong cnh tay t 1 np u nch, u di st np khuu. + Mt ngoi cnh tay t 1 np u vai nch, u di qu khp khuu. + C nh np 2 on: on 1 v khp vai, on 2 trn v di + Dng bng tam gic treo cng tay vi cnh tay v cun 1 vi vng bng vo thn.5.2.2. C nh bng np Crame:

trn ln ti h trn qu khp 1/3 trn cnh tay khp khuu. vung gc 900 buc cnh tayHnh 13: C nh gy xng cnh tay bng np tre.

+ t cng tay vung gc vi cnh tay t th na sp v cnh tay st vo thn vi 1 cun bng hoc bng lt nch. + Un np Crame theo t th ca chi i t c tay vng qua mt ngoi cnh tay ri un ra sau lng ti mt sau xng b vai bn chi lnh. + Dng 1 cun bng buc u trn vi u di ca np, di bng i trc v sau thn. + C nh np vo chi v vo thn ngi bng nhng vng bng cun.Hnh 14: C nh gy xng cnh tay bng np Crame.

64

5.3. C nh tm thi gy xng cng chn:5.3.1. C nh bng np tre:

Hnh 15: C nh tm thi gy xng cng chn bng np tre.

+ t 2 np mt trong v mt ngoi chi gy, i t gia i ti qu c chn. Nu c np th 3 th t mt sau cng chn. + Bng c nh np vo chi bn c chn, di v trn khp gi, gia i.5.3.2. C nh bng np Crame:

Hnh 16: C nh tm thi gy xng cng chn bng np Crame.

+ t mt np mt sau i t gia i n gt chn ri b cho vung gc vi bn chn ra ti cc ngn chn. + t bng m ri bng c nh np nh trn.5.4. C nh tm thi gy xng i:5.4.1. C nh bng np tre:

Hnh 17: C nh tm thi gy xng i bng np tre.

Dng 3 np c nh nh sau: - Np mt ngoi i t h nch n qu gt chn. - Np mt trong i t bn n qu gt chn. - Np mt sau i t trn mo chu n qu gt chn. - Bng c nh np vo chi bn chn, c chn, 1/3 trn cng chn, trn gi, bn, bng v di nch. - Trc khi vn chuyn: buc chi gy c nh vo chi lnh c chn, u gi v i.5.4.2. C nh bng np Crame:

65

Cn c 3 np: + Np mt sau i t mo chu n gt chn th b gp vung gc vi gan bn chn. + Np mt trong t bn ti b trong ca bn chn, c th b cong np p vo gan bn chn. + Np mt ngoi t h nch ti b ngoi ca bn chn th b gp 900 vo ti b trong m ly bn chn v np mt sau. C 3 np, nht l np sau phi un st chi v lt bng m ri cun thm bng gc. + Bng vng xon hoc bng tng on c nh ging np tre.5.5. C nh tm thi gy xng khc:

Bao gm c nh tm thi gy xng bn tay, ngn tay, khp c tay, xng n, xng chu, xng chu v cc tn thng ct sng, vng hm mt, vng s no, (Tham kho ti liu: "Nm k thut cp cu v chuyn thng ho tuyn" Nh xut bn Qun i nhn dn - H Ni, nm 1994).

CM MU TM THINghim nh Phn.

1. i cng. Tt c cc vt thng (VT) u t nhiu c chy mu. Vt thng lm tn thng mch mu e da n chc nng sng ca ngi b thng c gi l vt thng mch mu. Vt thng mch mu l mt loi vt thng nng. V th cm mu tm thi nhanh v tt l rt quan trng v cn thit cu sng tnh mng ngi b thng cng nh hn ch nhng bin chng v sau. Khi gp mt trng hp b vt thng chy mu ngoi, cn phi bnh tnh cm mu, c bin php x tr khn trng v thch hp. 2. Mc ch. + Nhanh chng lm ngng chy mu hn ch mt mu (v mt nhiu mu s gy sc nng cho ngi b thng). + Lm ngng chy mu nhng phi thc hin ng nguyn tc, ng k thut th mi bo tn c chi th, bo tn c tnh mng ngi b thng. 3. Nguyn tc.3.1. Khn trng, nhanh chng lm ngng chy mu:

Nu x tr chm th mu chy ra cng nhiu. Khi tn thng nhng ng mch ln, mu pht thnh tia v mnh th cng phi khn trng cm mu, nu khng s d c nguy c a n sc v t vong do mt mu.3.2. X tr ng ch nh, ng k thut theo tnh cht ca VT:

Ty theo tng vt thng v tnh cht chy mu vt thng m chn bin php v k thut cm mu tm thi cho thch hp, khng lm mt cch ty tin, thiu thn trng hoc sai k thut (nht l khi t gar) s gy nguy him n tnh mng ngi b thng. 4. Phn bit tnh cht chy mu. Cn c vo mch mu b tn thng m phn chia thnh 3 loi: 66

4.1. Chy mu mao mch:

Mu chy ra t nhng mch rt nh, quan st mt vt thng thy mu chy dn ra chm trn b mt VT v mu t cm sau mt thi gian ngn khong vi pht.4.2. Chy mu tnh mch:

Ti VT mu chy ri r, mu sm, khng thnh tia mnh, cc mu hnh thnh nhanh chng v bt cc tnh mch b tn thng li. Nu tn thng cc tnh mch ln nh: tnh mch cnh, tnh mch ch, tnh mch di n th s gy nn nhng chy mu t nguy him.4.3. Chy mu ng mch:

Khi quan st VT thy mu chy phun thnh tia, theo nhp p ca tim, hoc tro qua ming vt thng ra ngoi nh mch nc n t y ging ln, hoc nhn thy mu thm t m ra bng v qun o; mu mu ti. Lng mu chy ty theo loi ng mch b tn thng. Trong thc t, mt vt thng him c chy mu n thun mao mch, tnh mch hoc ng mch m thng phi hp c ng mch v tnh mch b tn thng. V vy, khi gp mt trng hp chy mu quan trng cn phi nhanh chng xc nh tnh cht: chy mu ng mch, tnh mch hay phi hp nhanh chng quyt nh bin php cm mu thch hp v cn thit. 5. Cc bin php cm mu tm thi.5.1. Gp chi ti a:

Khi chi b gp mnh, ng mch cng b gp v p bi cc khi c bao quanh lm cho mu ngng chy. Ch p dng gp chi ti a cm mu tm thi vi nhng vt thng khng c gy xng km theo.5.2. n ng mch:

Dng ngn tay n cht vo ng mch trn ng i ca n t tim n vt thng. Ty theo mc tn thng v v tr n m dng ngn tay hoc c nm tay n ng mch.5.3. Bng p:

L phng php bng vi cc vng bng xit tng i cht, p mnh vo cc b phn b tn thng; to iu kin thun li cho vic hnh thnh mu cc cm mu. Bin php bng p thch hp vi cc vt thng khng c thng tn mch mu ln.5.4. Bng chn:

+ L bng p c vt chn ln cc v tr n ng mch. Con chn c t trn ng i ca ng mch, gia vt thng v tim, cng st vt thng cng tt, sau bng c nh con chn bng nhiu vng bng xit tng i cht theo kiu vng trn hoc vng s 8. + Hai yu cu c bn ca bng chn l: - t con chn ng trn ng i ca ng mch. - Cc vng bng c nh con chn phi xit tng i cht.

67

5.5. Bng t nt:

L cch bng p c dng thm bc gc nht nt vo vt thng. Bin php ny thch hp vi cc vt thng chy mu ng mch su, gia cc k xng, vt thng vng c, vng chu.5.6. Dng kp cm mu:

p dng i vi vt thng rng, th kp ti ch ri chuyn thng binh5.7. Khu mp vt thng:

nng. Kp xong v tuyn sau. dngkh:

Sau khi nht gc cht vo vt thng, khu gh cht 2 mp vt thng li.5.8. Vn gar trong vt thng ho

kim

ch

Gar l bin php cm mu tm thi bng dy cao su hoc dy vi xon cht vo on chi, lm ngng s lu thng mu t pha trn xung pha di ca chi. Mt gar thc hin ng yu cu k thut s ct t hon ton s lu thng ca mu t trn xung v ngc li. Mt gar khng lu qu 1 n 2 gi, nu qu c th s lm hoi t on chi pha di gar. Nu phi ch i th c 30 pht phi ni lng gar mt ln. + Ch nh t gar: Hnh 18: Cc im chnh n - Vt thng b ct chi t nhin, hoc chi th b t ng mch trn c th. gn la. a) ng mch i. d) ng mch cnh. b) ng mch nch. e) ng mch - Chi b gip nt qu nhiu bit chc khng th bo c) ng mch di n. cnh tay. tn c. - Vt thng tn thng mch mu p dng nhng bin php cm mu tm thi trn m khng c kt qu. - Vt thng chy mu t chi trong chin u c lit; khn trng m qun y cn phi x tr nhanh chng khi khng c iu kin lm bng chn. - Vt thng m ngi b thng v ng i khng bit cch bng chn, bt buc phi t gar. - Buc gar khi ni xy ra tai nn gn trung tm phu thut. - Buc gar tm thi trong mt thi gian ngn m x tr vt thng. - Buc gar khi b rn c cn. + Nguyn tc t gar: - Gar phi t st ngay pha trn vt thng v l ra ngoi. Tuyt i khng ng qun, tay o hoc vt g che lp gar. - Nhanh chng chuyn nhng thng binh c gar v tuyn sau. Trn ng vn chuyn phi ni gar 30 pht mt ln v khng gar lu qu 3 - 4 gi. - Phi chp hnh trit nhng quy nh v gar l: . C phiu ghi r ngy, gi t gar, h tn ngi t gar... 68

. C k hiu bng di ci vo ti o trn bn tri. . Phiu chuyn thng c gar cn ghi ch ng theo mu quy nh. + Cch t gar: - n ng mch pha trn vt thng tm thi cm mu. - Lt vi hoc gc ch nh t gar hoc dng ngay ng qun, ng tay o lt. - t gar v xon dn (nu l dy vi), b tay n ng mch ri va xon va theo di mch di hoc theo di mu chy vt thng. Nu mch ngng p hoc mu ngng chy l c. Khi xon va cht th c nh que xon. Nu l dy cao su th ch cn cun nhiu vng tng i cht ri buc c nh. - Bng p vt thng v lm cc th tc hnh chnh cn thit. + Cch ni gar: Ni gar l cho mu xung nui dng on chi di gar. - Nhng trng hp khng ni gar: . Khi chi b hoi t, khi gar qu lu (qu 4 gi). . Khi chi b ct t nhin. . Khi on chi di gar c du hiu hoi t, hoi th. . Khi b rn c cn. Cn li cc trng hp khc phi thc hin ni gar 30 pht mt ln. - Th t ni gar: . Ngi ph n ng mch pha trn gar . Ngi chnh ni dy gar, rt t t, va ni va theo di sc mt thng binh, tnh hnh mu chy vt thng, mch v mu sc on chi di gar. . gar ni khong t 4 - 5 pht. Trong khi ni nu: Thy mu chy mnh vt thng th phi n li ng mch cho tt ( pha gc chi). Nu thy sc mt thng binh thay i t ngt tm ti hoc nht nht phi t gar li ngay. Ch : Khi t li dy gar, khng t ch c m nhch ln hoc nhch xung mt t khi gy ln da tht v thiu mu ko di ch t gar. Nu ni gar m quan st thy khng chy mu vt thng na th khng cn tht li gar na nhng vn dy gar ti ch v sn sng buc li nu chy mu li. + Cch tho gar. Tho gar thay th bng mt bin php cm mu khc. Tin hnh nh sau: - D phng sc do tho gar cho thng binh: . Phong b gc chi: novocain 0,25% 50 - 100 - 150ml ty theo v tr. . Tim cafein 0,25 1 ng vo bp tht. . Truyn tnh mch huyt thanh ngt v sinh t B1, C nu c iu kin. - Mt ngi n ng mch, mt ngi tho gar t t, nh nhng. - Thay gar bng mt bin php cm mu khc nh bng p, bng chn, kp hoc tht ng mch... nu cn thy chy mu nhiu.

69

Khi tho gar phi theo di mu chy ti vt thng, mch, nhit , huyt p, sc mt ngi b thng. Nu thy c hin tng sc nhim c do tho gar th phi nhanh chng t li gar ngay v tin hnh chng sc tch cc.

CHUN B TRC M V CHM SC BNH NHN SAU MV Huy Nng

Phu thut l mt phng php iu tr, n gy ra sang chn c nh hng nht nh ti c th bnh nhn. bnh nhn chu ng c cuc m cn thit phi chun b chu o v tinh thn v th cht cho bnh nhn. Mt khc phu thut cng c th gy ra cc bin chng, do vy phi bit phng pht hin v iu tr kp thi nhng bin chng sau m. Thy thuc cn phi thy r vic chun b bnh nhn trc m v chm sc bnh nhn sau m l cng vic gp phn quan trng vo thnh cng ca cuc m. 1. Chun b trc m.1.1. Thi k trc m:

Thi k trc m l thi k c tnh t khi bnh nhn vo vin n khi c m. Thi k trc m c chia ra 2 giai on: + Giai on chn on: chn on xc nh bnh, nh gi chc nng ca cc c quan trong c th v ch nh m. + Giai on chun b trc m: Giai on ny c th di hoc ngn ph thuc vo mc phu thut: m cp cu hoc m phin, vo tnh trng bnh nhn, mc v tnh cht ca cuc phu thut (i phu, trung phu, hoc tiu phu). Th d: m cp cu vim rut tha cp, thng lot d dy-t trng, tc rut, cha ngoi d con v... Khi qu trnh chun b phi tin hnh nhanh chng, m cng nhanh cng tt v tnh mng bnh nhn ang b e da. Chun b bnh nhn m ct phi do qu trnh m mng phi vi biu hin ca nhim trng c th chun b m trong vng 10 n 30 ngy lm cho tnh trng bnh nhn tt dn ln v tnh trng nhim trng gim i. Vi nhng bnh l c tnh th vic chun b bnh nhn v thm khm trc m cn phi khn trng hn na.1.2. Nhim v ca thi k trc m:

Nhim v ch yu ca thi k trc m l lm gim ti a cc bin chng nguy him ca cuc m. Chun b m mt cch c h thng, nh gi tnh trng bnh nhn phng cc bin chng trong m v sau m. Phu thut vin cn nh: phi chun b m chu o trong phm vi c th hn ch thp nht cc ri ro ca cuc m. Trc khi phu thut cn tnh xem lng mu mt trong m v kh nng b tr thch nghi ca c th bnh nhn. Mc thiu mu cp tnh cng nh s ri lon lng mu lu hnh do mt mu ph thuc vo s lng mu mt v s thch nghi ca tng c th bnh nhn.1.3. Cc bc tin hnh trc m:

Cn thn trng v tin hnh cc bin php phng cc bin chng v ri ro, bao gm cc bc c th sau: 70

+ Chn on xc nh bnh, ch nh phng php m ng, chn phng php phu thut v phng php v cm ph hp. + Xc nh cc bin chng c th xy ra v cc bnh l km theo ca bnh nhn. + nh gi tnh trng chung ca bnh nhn, nh gi chc nng v tn thng thc th ca cc c quan. + Tin hnh cc bin php iu tr nng cao th trng, iu tr cc bnh km theo v cc bin chng c th xy ra. + Nng cao kh nng thch nghi ca h thng min dch ca c th. + p dng cc bin php lm gim nguy c cc bin chng phu thut, gim nguy c nhim trng. gii quyt cc nhim v trn phi da vo c im c th tng bnh nhn, triu chng ca bnh v thi gian ko di ca cuc m. Do phi chun b m c th cho tng trng hp vi tng loi phu thut v vi tng loi bnh l. V d: phi ra d dy i vi bnh nhn hp mn v, tht tho i vi phu thut i trng... Vi tnh trng chung ca bnh nhn phi tin hnh theo nguyn tc chung: chun b tm l trc m, cho thuc ng, v sinh c nhn v v sinh vng m, n nhng thc n d tiu v giu vitamin ngay trc hm m... C th dng a sinh t vi bnh nhn suy mn, i vi bnh nhn hp mn v phi truyn dch, truyn m nng c th trc m.1.4. nh gi cc h thng c quan: 1.4.1. H thng thn kinh:

Quan tm ti gic ng ca bnh nhn. Nu bnh nhn mt ng, lo lng... phi cho bnh nhn dng thuc an thn hoc thuc ng. Ngi thy thuc cn phi gii thch bnh nhn an tm v tin tng vo s thnh cng ca cuc m.1.4.2. H thng tim mch:

Bnh tim mch l nguyn nhn chnh gy t vong v bin chng phu thut. Khi c biu hin bnh l tim mch phi khm chuyn khoa tim mch, ch tin hnh phu thut khi khng c chng ch nh v tim mch. Nhng bnh nhn c bnh l tim mch phi c iu tr n nh theo kin chuyn khoa.1.4.3. Xt nghim mu:

Xt nghim mu rt quan trng. Nu t l HST < 25%- 40% th khng c tin hnh m v nu m s xut hin bin chng trong m: shock, thiu mu, hoc bin chng sau m: chm lin so, nhim trng vt m... Thng thng phi tin hnh truyn mu trc m vi s lng 250ml - 500ml cho nhng trng hp bnh nhn thiu mu t l HST t 60% - 65%. Ngoi ra cn kt hp b sung cc loi vitamin nhm B, vin st.1.4.4. H thng h hp:

Bin chng h hp sau m gp t 5-10% cc trng hp, suy h hp cp tnh l nguyn nhn trc tip gy t vong 25% s bnh nhn t vong do phu thut. Do giai on trc m phi iu tr khi cc bnh vim ph qun mn v cp, cc vim nhim ng h hp. phng cc bin chng h hp trc, trong v sau m cn dng thuc iu tr v kt hp vi l liu php.1.4.5. H thng tiu ho:

+ Rng ming: Sau khi m vic v sinh rng ming thng hn ch nn d dn ti vim hng, mi, tai... cho nn cn thit phi v sinh rng ming, c bit cc trng hp vim hng, su rng cn phi c iu tr n nh. 71

+ i trng: i vi phu thut i trng cn c ch n cao m, giu vitamin, d tiu; ty giun sn v tht tho. + Gan: phi thm khm lm sng v siu m, xt nghim nh gi chc nng gan trc m. + Ty: cn phi xc nh cc bnh l vim ty cp hoc mn.1.4.6. H thng tit niu:

Yu cu bt buc phi kim tra chc nng thn, xt nghim nc tiu.1.4.7. H thng min dch:

+ Xt nghim mu: khi c vim nhim th s lng bch cu v bch cu ht tng cao, khi truyn mu trc m th t l bch cu ht tng cao t 6 n 8 ln. Bnh nhn gy yu, suy mn s c t l protid mu thp. Sau m t l protid mu gim do cc nguyn nhn: chn thng, au n, mt mu, nh hng thuc m, thuc t, st cao, do bnh nhn thng phi nhn n 3 - 4 ngy sau m v do cc bin chng sau m khc. Do vy, i vi cc bnh nhn ny trc m nn truyn mu, huyt tng, cc dch thay th mu (cc aminopeptid, cc axitamin...). + Vi cc bnh nhn bo bu th cn c ch n thp nng lng. c bit vi cc bnh truyn nhim, nht l thi k bnh (v d nh bnh cm) th d c bin chng sau m, cn phi kt hp thuc vi cc bin php khc nh xng hng... + Phi thm khm bnh nhn ton din trc m vi ba ngy, chng ch nh m phin khi bnh nhn c hnh kinh v c nguy c chy mu cao sau m.1.4.8. H thng ni tit:

Kim tra xc nh bnh l i ng, suy thng thn... Ngoi ra cn phi khm da liu nu c bnh l ngoi da nh: eczema, vim da lin cu, t cu th phi iu tr khi trc khi m. 2. Chm sc sau m.2.1. Thi k sau m :

Thi k sau m l thi gian c tnh t thi im kt thc cuc m ko di n khi bnh nhn hi phc kh nng lao ng. Thi k sau m chia lm 3 giai on: + Giai on u: giai on ngay sau m ko di 3 - 5 ngy. + Giai on 2: ko di thm 2 - 3 tun sau m n khi bnh nhn c ra vin. + Giai on 3: xa hn, ko di n khi bnh nhn phc hi kh nng lao ng, i lm vic c.2.2. Nhng nhim v ca thi k sau m:

+ D phng, pht hin v iu tr cc bin chng sau m. + Tng cng kh nng qu trnh lin so. + Phc hi kh nng lao ng. D phng tt nht cc bin chng sau m bao gm: thc hin chun b trc m chu o, iu tr tt cc bnh v bin chng.2.3. Cc bc tin hnh:

+ Bt ng sau m kt hp vi l liu php, phng n tc m, di, ng kh o. + Tng lu thng tun hon phng cc bin chng nhi huyt mch mu, huyt tc m. + Vn ng chng lit rut sau m v cho n sm hp l. 72

2.4. Tnh trng bnh nhn sau m:

+ Ngi ta chia ra 2 loi tin trin sau m: - Khng c bin chng: tin trin sau m bnh thng, thun li khng c biu hin ri lon c quan, h c quan. - C bin chng: khi c th bnh nhn c nhng phn ng li vi cc chn thng ca cuc m, xut hin cc ri lon ln v chc nng ca cc c quan v h c quan. + Ri lon chuyn ho ng: thng gp 90% cc trng hp c biu hin tng ng mu, c ng nc tiu. Cc bin php v cm khng nh hng n hin tng tng ng trong mu. Tng ng mu ko di 3 - 4 ngy ngay sau m, sau gim dn, v tr v bnh thng. + Ri lon chuyn ho m: Biu hin tng nit d trong mu, gim protid mu, tng t l globulin so vi albumin mu. Gim s lng m trong huyt tng, h protid mu gp tt c cc bnh nhn. Hin tng ny tr v bnh thng sau m 5-6 ngy. mt s bnh nhn nng, m ln th protid mu tr v bnh thng chm hn t 15 n 30 ngy sau m, do phi truyn mu v m sau m. + Ri lon chuyn ho nc v in gii sau m: Bnh nhn c biu hin mt nc v thiu nc (nc tiu hng ngy theo thn t 1 - 1,5 lt, nc mt qua phi 400 ml v m hi qua da khong 1 lt). Sau m ra m hi nhiu, th nhanh, st... dn n tnh trng mt nc do cc nguyn nhn ngoi thn. phng thiu, mt nc sau m th giai on chun b m phi tin hnh a mt lng nc vo c th khng di 3 lt ngy bng cc ng ung, tim truyn ; phng ri lon in gii cn truyn dch ringerlactat. + Cc bin i thnh phn mu sau m bao gm: - Tng s lng bch cu 11.000 - 12.000/mm3 mu, gim lymphocid v eosin. Hin tng ny xut hin ngay sau m. Vi m trung phu thut c s tng bch cu trong 4-5 ngy sau gim dn v tr v bnh thng sau 9 - 10 ngy. Tng s lng bch cu vi mc ln thng gp khi c biu hin nhim trng vt m, vim phi. - Gim s lng hng cu: gp 5 - 7% cuc m trung phu v 10 - 20% cuc m i phu. Gim s lng hng cu v HST gp ngay sau m v ko di 4 - 6 ngy sau m, khi m ln s ko di lu hn. Nguyn nhn do mt mu trong m, gim s lng dch. Hi phc HST sau m ph thuc vo tnh cht cuc m t 10 ngy n 1,5 - 2 thng sau m, do cn truyn mu sau m. - Gim s lng thrombocid ngay sau m v ko di 4 - 5 ngy, sau m 9-10 ngy c th tr v bnh thng. - Gim kh nng ng mu gp 65 - 70% cc trng hp do tng nht ca mu, tng prothrombin. - Nhng ngy u sau m thng thy d tr kim gim n cui ngy 2 - 3 th tr v bnh thng. Sau m thng c hin tng toan mu do chn thng ca cuc m v do bnh nhn nhn n sau m, sau s ht hin tng gim d tr kim. Hin tng mt b toan mu sau m biu hin bnh nhn c cc triu chng: bun nn, nn, trng bng, au u, mt ng, mt mi. Do sau m nn cho n sm, truyn glucoza kt hp dng insulin phng hin tng toan mu sau m. + Nhim c: nguyn nhn do tiu hy t chc vt m do cn gim sang chn, thao tc m phi nh nhng. 73

2.5. Hi sc tch cc giai on sau m:

+ Vn ng sm ti ging bnh, cho n sm v l liu, th dc liu php. Kinh nghim lm sng: phng bin chng sau m cn vn ng sm lm lu thng mu, tng nhanh kh nng lin so. Vn ng sm bao gm tr mnh, xoa bp ngay ti ging bnh v ngay sau m bnh nhn th su, ho khc. Vo chiu ngy th 2 sau m phin c th cho bnh nhn ng dy c. Chng ch nh vn ng sm i vi cc trng hp nhim trng cp tnh, vim phi nng, suy tim. + Cho n sm: phng toan mu v b sung nng lng cho c th. Cn kim tra tnh trng chung ca bnh nhn, tnh cht cuc m, chc nng ca ng tiu ha v ch n king ph hp vi tng trng hp bnh nhn c th. Phu thut bng cn cho n sm sau khi c trung tin.2.6. Bin chng sau m, cc bin php phng v iu tr:

+ pht hin bin chng sau m cn ch n vic kim tra thng xuyn bnh nhn sau m theo y lnh mt cch nghim tc, cht ch, t m: - Mch, nhit v nhp th. - Tnh trng da v nim mc. - Kim tra vt m, cm gic bnh nhn ti vt m, mu thm bng, khi c ng dn lu cn lu s lng dch v cht lng dch qua sonde bng v sonde d dy. - nh gi thm khm ton din t m, tun t theo h c quan t u n chn, t ton thn n ti ch bng nhn, s, g, nghe. + Cc bin chng ch yu ca h thn kinh: - au sau m: Triu chng ny gp tt c cc bnh nhn ph thuc vo tng trng hp c th, mc v cng au ph thuc vo tnh cht mc cuc m, v kh nng chu ng ca tng bnh nhn. phng bin chng ny th cn thn trng bnh nhn nm theo t th gii phu, th su, dng thuc gim au sau m 1 - 2 ln/ngy. Dng thuc gy nghin phi thn trng. - Sc mun sau m: phng nn chun b m tt, chn phng php v cm thch hp v theo di cht ch sau m. - Mt ng sau m: l bin chng sau m do cm gic au n, c t, tnh trng tm thn kinh ca bnh nhn sau m. X tr c th dng thuc an thn, thuc ng v iu tr bnh chnh. - Ri lon tm thn sau m: Tt c cc bin chng trn u nh hng n qu trnh lin so sau m, nh hng n n ung v tm sinh l bnh nhn sau m. Tm li cc bin chng thn kinh sau m bao gm: au, shock, mt ng, ri lon tm thn. phng cc bin chng phi tin hnh t giai on chun b m, gim nhim trng, tng cng sc khng ca c th. + Bin chng v tim mch: - Cc bin chng v tim mch xut hin sm ngay sau m thm ch ngay trong m. Nguyn nhn do mt mu, lit rut, nhim trng, ri lon chuyn ha nc in gii, suy dinh dng, nhim c hoc do gy m. Do sau m cn truyn dch, b in gii, th oxy h tr v tng cng tun hon mao mch. 74

iu tr ri lon tun hon: dng cc thuc tr tim, truyn huyt thanh ngt, gim s ng tun hon. - Huyt khi: ch yu gp tnh mch chi di (tnh mch i), tnh mch chu, thng gp n, ngi cao tui v bnh nhn ung th. Huyt khi sau m hay gp bnh nhn bo bu, ri lon chuyn ha v bnh nhn c bnh l nhi huyt mch mu. Biu hin lm sng ca huyt khi: au chi di, ph n, tm ti, st c th km theo huyt tc ng mch phi. phng huyt khi, giai on chun b m phi lm cc xt nghim mu v dng thuc chng ng trc m. + Bin chng phi: Bao gm: vim ph qun, vim phi thy, vim mng phi, gin ph qun, vim ph qun - phi. + Bin chng v cc c quan sinh dc - tit niu t gp hn bao gm: - Thiu niu. - V niu. - Vim i, b thn. + Bin chng c quan c phu thut: - Chy mu, mu t sau m. - Bc, x r ming ni. - Vim phc mc sau m. - Tc rut sm hoc mun. - Nhim trng vt m, toc vt m. Chun b bnh nhn trc m v chm sc bnh nhn sau m l cng vic quan trng nhm ch ng ngn nga cc bin chng sau m, n ph thuc vo nhiu yu t: c a ca tng bnh nhn, v bnh l, v mc nng nh ca bnh, v mc ca cuc m v ph thuc vo tnh hung m cp cu hay m phin. Cn phi nm vng cc nguyn tc v chm sc, theo di phng v pht hin cc bin chng m bo chc chn cho s thnh cng ca cuc m.

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