1. 1. BNH VIN NHI NG 2 PHC IU TR NHI KHOA 2013 (Xut bn ln th t c sa cha, b sung) Ch bin: TS.BS. H MNH TUN NH XUT BN Y HC Chi nhnh Thnh ph H Ch Minh 2013 Xut bn ln th 1 - 2004 Xut bn ln th 2 - 2006 Xut bn ln th 3 - 2008 Xut bn ln th 4 - 2013 BNH VIN NHI NG 2 a ch: 14 L T Trng Phng Bn Ngh Qun I Thnh ph H Ch Minh Website: www.benhviennhi.org.vn
2. 2. BAN BIN SON Ch bin: TS.BS. H MNH TUN ..................................................... Gim c Bnh vin Hiu nh: BS. CKII. TRNH HU TNG...................... Trng phng K Hoch Tng Hp BS. CKI. NGUYN ANH TUN.................................Phng K Hoch Tng Hp Trnh by: TRN TUN ANH .....................................................Phng K Hoch Tng Hp T NGUYT ANH ....................................................Phng K Hoch Tng Hp LU TH M DUYN................................................Phng K Hoch Tng Hp ON TH M LINH .................................................Phng K Hoch Tng Hp NGUYN QUNH NH............................................Phng K Hoch Tng Hp NGUYN LNG HUYN TRN............................Phng K Hoch Tng Hp CNG TC VIN BS.CKI TRN C NGUYN ANH ThS.BS. NGUYN TH KIM ANH BS.CKI TRN ANH BS.CKI. V QUC BO BS. HUNH TH NGC BCH BS.CKII. PHM L THANH BNH BS. LU THANH BNH ThS.BS NGUYN THNH DANH BS.CKII HUNH TRNG DN BS.CKI NGUYN TH M DIP TS.BS ON TH NGC DIP BS NGUYN THU DUNG BS.CKI. PHM MAI NG BS.CKII. NGUYN VN NG BS.CKI BI VN ThS .BS. NGUYN TH LONG GIANG ThS BS. L HNG H ThS.BS. NGUYN THANH HI BS.CKII NGUYN TH THU HU TS BS. TRN TH MNG HIP BS.CKII. NGUYN THIN HONG TS.BS. PHM TH MINH HNG ThS.BS. TRN QUNH HNG BS.CKI. CAO NGC HNG BS.CKII. NG TH KIM HUYN BS. V HONG KHOA BS. HUNH TH THY KIU BS.CKI. PHM TUN KHI ThS.BS. NGUYN TH MAI LAN PGS.TS.BS. NGUYN TH THANH LAN ThS BS. GIANG TRN PHNG LINH BS.CKI. HONG NGUYN LC BS.CKI. NGUYN VN LC ThS.BS. TRN TH THU LOAN ThS.BS. TRNG B LU ThS.BS. NGUYN HUY LUN BS.CKI. HUNH KHC LUN BS.CKI. NGUYN TH HNG LOAN ThS.BS. MAI QUANG HUNH MAI BS.CKII QUCH NGC MINH ThS.BS. NGUYN TRN NAM BS.CKI INH TH CM NHUNG BS.CKI.NGUYN HUNH BO NGN ThS .BS.TRN TH KIM NGN ThS.BS. TNG L CHU NGC BS.CKII. NGUYN MINH NGC Ths.BS. NGUYN TH KIM NHI BS.CKI. V HIP PHT BS. DNG NGC PHI
3. 3. BS. NGUYN NH QUI BS.CKII. HONG NGC QU ThS.BS. HUNH TH V QUNH BS.CKII. PHM TH MINH RNG ThS.BS. TNG THANH SN ThS.BS. THCH L TN TS BS.CKII.PHM TH NGC TUYT BS.CKI L TH THO BS.CKII NGUYN TH THANH BS. HUNH MINH THM BS.CKI. NGUYN TH HNG TH BS.CKI NGUYN TNG THI ThS.BS. H TH KIM THOA ThS.BS. PHAN THNH TH ThS.BS. HUNH MINH THU BS.CKI. PHM MINH THU BS.CKI. NGUYN TH THANH THY BS. TRN TH THY ThS.BS. HONG TH DIM THY BS.CKI. L TH THANH THY BS.CKI THI THANH THY BS. NGUYN TH THU THY ThS .BS. NG TH THU THY ThS.BS. BI NGUYN OAN TH BS.CKI. CAO MINH THC ThS.BS. TRNG M HNH TRM BS.CKI PHAN TH THU TRANG BS.CKI. L NGUYN NHT TRUNG BS.CKI LU NH TR BS. CKII. TRNH HU TNG BS. NGUYN CM T BS.CKII NGUYN TH BCH TUYT BS.CKI. NGUYN NH VN TS.BS.CKII. L TH KHNH VN BS. TRN TH KIM VN BS.CKI V TH VN BS.CKI. TRN THU VN ThS.BS. CHU VIT ThS.BS. NGUYN MINH TR VIT BS.CKI. H L VIT ThS.BS. NGUYN DIU VINH BS. NGUYN HU THY VY T NGHIN CU KHOA HC & Y HC CHNG C 1. BS.CKII. TRNH HU TNG 2. BS.CKI. H L VIT 3. BS.CKI L NGUYN NHT TRUNG 4. ThS.BS NGUYN TRN NAM
4. 4. LI NI U Trong thin nin k mi t u th k 21, vi s tin b vt bc ca khoa hc k thut trn mi lnh vc ngnh ngh nh tin hc, y hc, khoa hc c bn cng vi nhng thnh tu t c trong nghin cu v vi sinh hc, sinh l bnh hc, min dch hc, c bit l di truyn hc em li nhiu tin b to ln cho ngnh Y, m Nhi khoa l ngnh c tn hng nhng ng dng ny trong vic chn on cc bnh l bm sinh di truyn. c im ca chuyn ngnh Nhi khoa l phi chy ua vi thi gian, phi x tr chnh xc trong mi tnh hung; mt sai st d rt nh s em li nhng hu qu v cng nghim trng v nh hng n c mt th h tng lai. Phc iu tr ca Bnh vin l mt trong ba ti liu quan trng khng th thiu nh gi cht lng hot ng theo tiu chun qun l cht lng ISO 9001:2008 m Bnh vin Nhi ng 2 c t chc Intertek cng nhn trong nm 2011 va qua. Sau ba ln xut bn, Phc iu tr Bnh vin Nhi ng 2 - 2013, n bn ln th t ny, c vit li v chnh sa hon thin hn, theo hng tip cn v p dng y hc chng c trong chn on v iu tr. y l cng trnh tp hp tr tu ca tp th cc Bc s ca Bnh vin Nhi ng 2, vi s hp tc tham gia ca cc Ging vin B Mn Nhi i hc Y Dc Tp. H Ch Minh v i hc Y khoa Phm Ngc Thch Tp. H Ch Minh, Phc c cp nht nhng kin thc mi. Chng ti cng xin chn thnh cm n TTND.BS.Bch Vn Cam (nguyn Trng khi Hi sc Cp cu BV Nhi ng 1), PGS.TS.BS.Phm Th Minh Hng (Ph Trng khoa Y, Ph Ch nhim BM Nhi i hc Y Dc Tp. H Ch Minh), TTT.PGS.TS.BS.V Minh Phc (Ch nhim BM Nhi i hc Y Dc Tp. H Ch Minh) dnh thi gian qu bu xem v gp cho Phc iu tr ca bnh vin chng ti. Hy vng tp sch nh ny s l ngi bn ng hnh, lun lun gn b vi cc Bc s, Sinh vin y khoa trong cng tc chuyn mn hng ngy. n bn ln th t ny c bin son vi nhiu n lc, cp nhp ha cc kn thc mi mt cch thn trng, nhng chc chn cn nhiu sai st. Rt mong s gp ca Qu ng nghip, ln n hnh sau c hon thin hn. Tp. H Ch Minh, ngy 04 thng 09 nm 2013 GIM C BNH VIN TTT.TS.BS.H MNH TUN
5. 5. 1 MC LC LI NI U 1. CHNG I: Tng qutCc triu chng v hi chng 1. St tr em 2. St ko di cha r nguyn nhn tr em 3. Tip cn chn on i 4. Co git tr em 5. Gan to 6. Lch to 7. Hch to 8. Tiu mu 9. Tiu c tr em 10. Ngt 11. au ngc 12. au khp 13. au u tr em - au u Migrain 14. Ho-Ho ko di 15. Ho ra mu 16. Tip cn th rt, kh kh 17. Hi chng yu lit tr em 18. Hi chng tng p lc ni s 19. au bng cp tnh 20. au bng mn tnh 21. To bn 2. CHNG II: Hi sc Cp cu Tai nn Ng c 22. Cp cu h hp, tun hon c bn v nng cao 23. Suy h hp cp tr em 24. Hi chng nguy kch h hp cp 25. Ph phi cp 26. D vt ng th 27. Sc 28. Sc phn v v cc phn ng d ng khc 29. Ri lon nc - in gii 30. Ri lon kim - toan 31. Hn m 32. Suy gan cp - Hn m gan
6. 6. 2 33. H ng huyt 34. H calci mu 35. Ngt nc 36. Rn cn 37. Ong t 38. in git 39. X tr a chn thng tr em 40. Ng c cp tr em 41. Ng c acetaminophen 42. Ng c thuc tr su ry 43. Ng c thuc dit c (paraquat) 44. Ng c thuc gy nghin 45. Ng c salicylates 3. CHNG III: S sinh 46. Hng dn chung chuyn vin an ton tr s sinh c vn cp cu ni ngoi khoa 47. Nhim trng huyt s sinh 48. Suy h hp s sinh 49. Vim phi s sinh 50. Xut huyt no mng no s sinh 51. Vim mng no vi trng s sinh 52. Vng da tng Bilirubin gin tip 53. Vng da tng Bilirubin trc tip 54. Co git s sinh 55. H ng huyt s sinh 56. Chm sc s sinh cc non thng 57. Dinh dng tnh mch ton phn s sinh 58. Nhim trng bo thai 59. Ri lon in gii s sinh 60. Lon sn ph qun phi 61. Vim rut hoi t s sinh 4. CHNG IV: H hp 62. Vim ph qun 63. Vim thanh qun cp 64. Suyn 65. Kh th thanh qun 66. Vim tiu ph qun
7. 7. 3 67. Vim phi 68. Vim phi ht . 69. Ap xe phi 70. Trn dch mng phi 71. Trn kh mng phi 72. Trn m mng phi 73. Soi ph qun chn on bng ng soi mm tr em 5. CHNG V: Tim mch 74. Suy tim 75. Cn tm 76. Cao huyt p nng 77. Cao p phi 78. Cc bnh tim bm sinh khng tm khng c shunt tri - phi 79. Cc bnh tim bm sinh khng tm vi shunt tri - phi 80. Bnh c tim 81. Thp khp cp 82. Bnh vim ng mch Takayasu 83. Bnh Kawasaki 84. Trn dch mng tim 85. Vim ni tm mc nhim trng 86. Nhp nhanh kch pht trn tht 87. Nhp nhanh tht 88. Nhp chm 89. Vim khp dng thp thiu nin 90. t t do nguyn nhn tim mch tr em 6. CHNG VI: Tiu ha 91. Tiu chy cp 92. Tiu chy ko di 93. Vim lot d dy t trng do nhim Helicobacter pylori 94. Tro ngc d dy thc qun 95. Xut huyt tiu ha 96. Vim ty cp 97. Bnh l vim rut mn (Crohn, Vim lot i trng) 98. Nhim k sinh trng ng rut 99. i ti din 100. Tng p ca 101. Ni soi tiu ha: ch nh, chun b BN
8. 8. 4 102. Vim gan 103. Hi chng l 104. Bnh gan mn 105. Teo ng mt 106. Vng da mt 7. CHNG VII: Thn kinh 107. Bnh nhc c 108. Hi chng Guillain Barr 109. ng kinh 110. Vim no ty hu nhim 111. Teo c ty sng (SMA) 8. CHNG VIII: Thn 112. Hi chng thn h 113. Vim cu thn cp hu nhim trng 114. Nhim trng tiu 115. Vim thn Lupus tr em 116. Ban xut huyt dng thp 117. Tn thng thn cp 118. iu tr bo tn suy thn mn 119. Hi chng tn huyt ur huyt cao 120. Tiu dm khi ng 9. CHNG IX: Ni tit 121. Suy gip 122. Cng gip 123. Tiu ng tr em 124. Nhim toan Ceton trong tiu ng 125. i tho nht 126. Suy thng thn 127. Dy th sm 10. CHNG X: Huyt hc 128. Thiu mu 129. Thiu mu thiu st 130. Thiu mu huyt tn min dch 131. Thalassemia 132. Hemophilia 133. Xut huyt gim tiu cu min dch 134. Suy ty
9. 9. 5 135. Hi chng thc bo mu 136. Truyn ch phm ca mu. Tai bin truyn mu 11. CHNG XI: Bnh truyn nhim 137. Vim mng no m 138. Nhim no m cu ti cp 139. Vim mng no v khun 140. Vim no cp 141. Bnh tay chn ming 142. Bnh thng hn 143. Bnh ho g 144. Bnh thy u 145. Bnh quai b 146. Bnh Rubella 147. Vim gan siu vi 148. Cm 149. Nhim Cytomegalo virus 150. Nhim Epstein Bar virus 151. Si 152. Nhim HIV/AIDS 153. St rt 154. St xut huyt Dengue 12. CHNG XII: Bnh l da 155. Vim da d ng 156. Bnh chm tr em 157. Nhim trng da v m mm 158. Vim m t bo 159. Hi chng Stevens Johnson v hoi t thng b nhim c 13. CHNG XIII: Dinh dng 160. Thiu Vitamine A 161. Bnh ci xng do thiu vitamin D 162. Bo ph tr em 163. Bing n 164. Nui n qua ng thng d dy 165. Dinh dng qua tnh mch 166. Ch n iu tr 14. CHNG XIV: Bnh chuyn ha
10. 10. 6 167. Bnh l chuyn ha bm sinh tr em 15. CHNG XV: Pht trin sc khe 168. Mt s ri lon tm l thng gp tr em 169. Lch tim chng 170. Phn ng sau tim chng 16 . CHNG XVI: Chuyn khoa l 172. Vim hng 173. Vim amidan 174. Vim nu ming herpes 175. Vim xoang 176. Vim ty lan ta vng sn ming 177. Vim tai gia cp tr em 178. Vim kt mc 179. Vim lot gic mc do siu vi 180. Vim lot gic mc do vi khun 181. Vim lot gic mc do nm 182. Chp lo 184. c thy tinh th bm sinh 185. Chm sc rng tr em v phng nga su rng 17. PH LC 186. Liu lng cc thuc dng trong hi sc nhi 187. Liu lng khng sinh dng trong suy thn 188. Trang b ti cp cu 189. Hng s sinh hc theo la tui 190. Cc bng, biu pht trin chiu cao, cn nng l tng, din tch da,.... TI LIU THAM KHO
11. 11. TI LIU THAM KHO 1. A guide to Neonatal Intensive Care, 1992. 2. A Practical Guide to Pediatric Intensive Care, 1990, 3rd ed. 3. Adult and pediatric Urology, 1996, 3rd ed. 4. American Academy of Pediatrics Committee on Children with Disabilities, 2001, The pediatricians role in the diagnosis and management of autistic spectrum disorder in children, Pediatrics, 107:85. 5. Annne H. Rowley, Standford T. Shulman, 2007, Kawasaki Disease. Nelson Textbook of Pediatrics18th ed.Saunders Elservier: pp 1.036 1.042. 6. Angelika Kindermann, Ana I. Lopes. Helicobacter pylori Infection in Pediatrics. Helicobacter 2009, 14:52-57 7. Bi ging nhi khoa i hc Y Dc Thnh ph H Ch Minh, 2005. 8. Bi ging nhi khoa i hc Y Dc Y H Ni 2004. 9. Bnh hc Tai Mi hng GS.TS Ng Ngc Liu 10.Beck CE, Nathan Pc, Parkin Pc, et al, 2005, Corticosteroids versus intravenous immune globulin for the treatment of acute immune thrombocytopenic purpura in children: a systematic review and meta-analysis of randomized controlled trials, J Pediatr, 147(4), p. 521-527. 11.Bolger W.E., Kennedy D.W., Changing concept in chronic sinusitis Hospital Practice, 1992, 30: 20-28. 12.Britis guidelines for the management of pleural infection in children. 2005, Thorax, 60(suppl I),10.1136. 13.British Thoracic Society Guidelines for Management of Community Acquired Pneumonia in Children: Update 2011. 14.Blood Disease of Infancy and Childhood, 1995, Mosby. 15.Cc sang thng m mm vng ming Tr Em, b mn Rng Tr Em Khoa Rng Hm Mt i Hc Y Dc. 16.Cc bnh d ng da do thuc nng, cc hi chng Stevens-Johnson, Lyell, Dress v qun l iu tr, Hen v Min dch d ng, phn 3, AFVP, TpHCM 01 06/11/2010. 17.Cardiovascular Therapeutics, 1996, W. B. Saunders. 18.Cindy Neunert, Wendy Lim, Mark Crowther, 2010, Clinical guideline update on Immune thrombocytopenia: an evidence based practice guideline developed by the American Society of Hematology. 19.C Philip Steuber, 2011, Treatment and prognosis of immune (idiopathic) thrombocytopenic purpura in children. 20.Chris P.J, 2007, Identification and evaluation of children with autism spectrum disorders, Pediatrics, 120:1183-1215. 21.Clinical Hematology,2002, 10th ed, Williams and Wilkins. 22.Clinical Manual of Emergency Pediatrics, 1997, 3rd ed, McGraw-Hill. 23.Clinical Pediatric Gastroenterology, 1998, Churchill Livingtone, U.U.A. 24.Clinical Pediatric Neurology, 1997, 3rd ed, W.B Saundezs.
12. 12. 25.Current Emergency Diagnosis and Treatment, 2004, 3rd ed, Appleton and Lange, Stanford. 26.Current Pediatric Diagnosis and Treatment, 2008, 14th ed, Appleton and Lange, Stanford. 27.Dengue Haemorrhagic Fever: Diagnosis, Treatment, Prevention and Control, 1997, Revise 2002, WHO, Geneva. 28.Drew Provan, Roberto Stasi, Adrian C. Newland et al, 2010, International consensus report on the investigation and management of primary immune thrombocytopenia, Blood, Volume 115, Number 2 29.Danna Tauber, 2008, Abnormalities of the pleural space. Pediatric respiratory medicine- Mosby Elsevier, 2nd ed, 989-97. 30.Emergency Medicine, 2000, 5th ed, Mc GrawHill. 31.Endocrinology and metabolism, 1999, 3rd ed, Mc GrawHill. 32.Essential Haematology, 2001. 33.Essentials of Pediatric Intensive Care, 1990. 34.Evidence Based Pediatrics and Child Health, 2004, BMJ Book. 35.Fishmans Pulmonary diseases and Disorders, 1998, 3rd ed, MC GrawHill. 36.Foundations of Respiratory care, 1992, D.J. Pierson, R.M. Kacmarek, Chuchill Livingstone. 37.Gates G.A, Muntz H.R, Gaylis B.G, 1992, Adenodectomy and otitis media, Annals of Otolaryngology, Rhinology and Laryngology, 101: 24-32. 38.Gastroenterology, 1997, W.B. Saunders Company. 39.Gold BD, Colletti RB, Abbott M, et al, 2000, North American Society for Pediatric Gastroenterology and Nutrition. Helicobacter pylori infection in children: recommendations for diagnosis and treatment. J Pediatr Gastroenterol Nutr, 31:4907. 40.Glenna B. Winnie, 2007, Pleurisy, Pleural effusions,and Empyema, Nelson, 18th edition 41.Gio trnh nhn khoa B mn Mt i hc Y dc Tp.HCM. 42.Giorgina MV, Nedim H, 2006, Biliary atresia and neonatal disorders of the bile ducts. Pediatric Gastrointestinal and Liver Disease, 59: 870-879 43.GINA Report, Global Strategy for Asthma Management and Prevention - 2009 44.Guideline on the Management of Asthma 2009 - British Thoracic Society 45.Handbook of pediatrics, 2004, Appleton and Lange. 46.Handbook of Advanced Pediatric Life Support, 2000, 2nd ed, Mosby. 47.Heart Disease: A textbook of Cardiovascular Medicine, 2001, 6th ed, W.B. Saunders. 48.Heart Diseases in Infant, Children and Adolescents, 1995, 5th ed, William and Wilkins. 49.Hematology of Infancy and childhood, 2003, 6th ed, W.B. Saunders Company. 50.Immunologic Disorders in Infants and Children, 1996, 4th ed, Saunders, Philadelphia.
13. 13. 51.Integrated management of Childhood Illness, 1999, Model IMCI Handbook, WHO. 52.Janet S. Soul, Intracranial Hemorrhage and Periventricular Leukomalacia, Manual of Neonatal Care, 6th ed, Lippincott Williams & Wilkins 53. Jane W. Newburger, Masato Takahashi , 2008, Kawasaki Disease, In Moss and Adams Heart disease in Infants, Children, and Adolescents including the Fetus and Young Adult 7th Ed. Lippincott Williams and Wilkins: pp 1.242-1.256 54. Jane W. Newburger, Masato Takahashi, Michael A. Gerber, 2004, Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Statement for Health Professionals From the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association, Circulation, 110: pp 2747-2771. 55.J.M. Saudubray. Maladies du metabolisme. Precis de Pediatrie -1996-Doin edit Kendigs Disorders of the Respiratory Tract in children 2006 56.Kendig s Disorders of the Respiratory tract in children, 1998, W B Saunders Company, Philadelphia 57.L. Arturo Batres Benjamin D. Gold, 2006, Helicobacter pylori infection, Burg: Current Pediatric Therapy, 18th ed. 58.Linda S. de Vries, 2006 Mosby, Intracranial Hemorrhage, Fanaroff and Martin's Neonatal-Perinatal Medicine, 8th ed, . 59.Lisa M. Adcock, Clinical manifestations and diagnosis of intraventricular hemorrhage in the newborn, UptoDate 19.2 60.Lisa M. Adcock, Management and complications of intraventricular hemorrhage in the newborn, UptoDate 19.2 61.M. L. Casselbrant, E. M. Mandel, 1996, Acute and Chronic Otitis Media, Pediatric otolaryngology to the general otolaryngologist, 239-247. 62.Malfertheiner P, Mgraud F, OMorain C, et al, 2007, Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report, Gut , 56:77281. 63.Management of the child with a serious infection of severe malnutrition: Severe persistent diarrhea, 1997, WHO. 64.Manual of endocrinology and metabolism, 1998, 2nd ed, London Little Brown. 65.Manual of Neonatal Care, 6th Edition, 2008 66.Manual of Pediatric Hematology and Oncology 2010 67.Mark Montgomery, 2006, Disorder of pleura, Kendigs. 68.Mark B.D., 2007, Adverse Reactions to Drugs, Kliegman, Nelson Textbook of Pediatrics, 18th Edition, Chapter 151. 69.Manual of Meatbolic Paediatrics, 2004, Schattauer. 70.Nhn khoa lm sng i hc Y H Ni . 71.Neonatology, 2004, 5th Edition. 72.Neonatal- Perinatal Medicine, Diseases of Fetus and Infant, 8th Edition, 2007. 73.Neonatal Decision Making, Edition, 1993. 74.Nhi Khoa , 2006, Nh xut bn y hc, chi nhnh TP H Ch Minh
14. 14. 75.Otolaryngology HNS, 4th Ed.Volum 4. 76.Phc iu tr Bnh Tai Mi Hng , BV Tai Mi Hng 77.Phc iu tr nhi khoa Bnh vin Nhi ng 1,2009 78.P. De Lonlay. Urgences metaboliques neonatales. Encyclopedie chirurgico- medicale. 2012. 4-049-K-30. 79.Pediatric Otolarygorogy Cotolaryngology Cummieng , 2004. 80.Pediatric Dosage Handbook, 2001, 7th ed. 81.Pediatric Emergency Medicine, 1996, 1st ed, McGrawHill. 82.Pediatric Gastrointestinal Disease, 2004, 2nd ed, Mosby, USA. 83.Pediatric Nephrology, 1999, 4th ed, Lippincott William and Wilkins. 84.Pediatric cardiovascular medicine, 2000, 1st ed, Churchill Livingstone. 85.Principles of internal medicine, 1998, Harrison. 86.Principles of Neurology, 1998. 87.Rowland M, Bourke B, Drumm B. Gastritis, 2004, Helicobacter pylori and peptic ulcer disease, Pediatric gastrointestinal disease: pathophysiology, diagnosis, management, 4th edition. 88.Sang thng cht lot vng ming BS V c Tuyn b mn Bnh Hc Ming 89.Samra S. Blanchard Steven J. Czinn, 2007, Peptic Ulcer Disease in Children, Kliegman: Nelson Textbook of Pediatrics, 18th ed. 90.Stephanie HA, 2006, Approach to neonatal cholestasis, Uptodate 19.2 91.Stevens-Johnson syndrome and toxic epidermal necrolysis - UpToDate 18.3 92.Textbook of Pediatrics , 2010, Nelson, 19th ed. 93.Textbook of Pediatric Infectious Diseases, 1998, 4th ed, W.B. Saunders Company. 94.The Expert Panel Report 3 (EPR3) Full Report 2007: Guidelines for the Diagnosis and Management of Asthma (National Heart, Lung, and Blood Institute) 95.The Pediatric Cardiology, 1997, 2nd ed, Mosby. 96.The Science and Practice of Pediatric Cardiology, 1998, 2nd ed, William and Wilkins. 97.Toxicologic Emergencies, 1990, 4th ed. 98.Up to date 2011, Pediatric respiratory medicine- Mosby Elsevier, Second edition, 2008, 989-97. 99.V. Reid. Sutton, Overview of the evaluation of inborn errors of metabolism in children, Up-to- date 2012. 100. Vicky LN, 2006, Neonatal hepatitis, Pediatric Gastrointestinal and Liver Disease; 58: 852-868 101. Virginia M, Deborah KF, 2004, Guideline for the evaluation of cholestatic jaundice in infants: recommendations of the North American Society for pediatric gastroenterology, hepatology and nutrition, J of Ped Gastroentero Nutr;39: 115- 128.
15. 15. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 1 AU BNG CP I. I CNG: 1. nh ngha: au bng cp l triu chng au vng bng, thng xy ra t ngt. y l mt l do rt thng gp a tr n khm ti bnh vin. au bng cp l mt triu chng khng c hiu v lin quan n rt nhiu nguyn nhn. Mc d nhiu nguyn nhn ca au bng cp l lnh tnh, nhng mt s i hi phi chn on v iu tr kp thi hn ch bin chng v t vong. 2. Nguyn nhn: - H tiu ha: vim d dy rut, vim rut tha, vim hch mc treo, vim phc mc, vim ti tha Meckel, vim rut, to bn, chn thng bng, tc rut, ng c thc phm. lot d dy, bt dung np lactose. - Cc ri lon h gan lch ng mt: vim gan, vim ti mt, si mt, nhi mu lch, V lch, vim ty - H tit niu sinh dc: nhim trng ng niu, si niu, au bng kinh, hi chng Mittelschmerz, bnh vim vng chu, da xy thai, thai ngoi t cung, xon tinh hon, xon bung trng - Ri lon chuyn ha: Nhim ketoacid trn bnh nhn tiu ng, h ng huyt, Porphyrin niu, suy thng thn cp - Ri lon huyt hc: Thiu hng cu lim, hi chng tn huyt u-r mu cao, ban xut huyt Henoch- Schnlein. - Thuc v c t: Erythromycin, Salicylates, ng c ch, c t cn trng. - Nguyn nhn phi: Vim phi, trn dch mng phi vng honh. - Nguyn nhn khc: au bng do cn co tht rut tr nh, au bng chc nng, vim hng, ph mch mu thn kinh. II. LM SNG: 1. Hi bnh s: - Tui: l mt cha kha quan trng lng gi nguyn nhn. Tn sut bnh v triu chng thay i rt nhiu theo la tui (bng). - Kiu au: tr nh thng khng th miu t chnh xc bng li triu chng v v tr au. Tuy nhin, trn bt k tr no b au vng h chu phi u phi nghi ng vim rut tha. - Chn thng gn y: cn hi k tr (nu c), ngi gi tr v cc tnh hung mi b chn thng trong thi gian khong vi ngy tr li. - Yu t gim au: au tng cn thng c ngun gc i trng, gim au sau khi nn thng c nguyn nhn quanh on d dy rut non. - Triu chng i km: + Tiu chy hay gp trong vim d dy rut, ng c thc n. au bng, tiu chy, trong phn c mu hng ngh n nguyn nhn vim, nhim trng tiu ha, lng rut. au bng km b trung, i tin c th do tc rut. + Thay i tnh cht i tiu nh: tiu lt nht, tiu kh, nc tiu hi gi nhim trng tiu.
16. 16. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 2 + Ho, th nhanh, au ngc ch im mt tn thng trong lng ngc. + Kht nhiu, tiu nhiu gi tiu ng. + au khp, pht ban: ban xut huyt Henoch-Schnlein. + Tin s ph khoa: tr gi tui v thnh nin, cn khai thc tin cn ph khoa: chu k kinh, huyt trng, sinh hot tnh dc v s dng cc bin php nga thai. au khi u t ngt gia chu k trong khong thi gian ngn gi hi chng Mittelschmerz. au bng km huyt trng c th do bnh l vim vng chu. au bng km mt kinh c th do thai ngoi t cung, da xy thai. + Tin s sc khe: nn tm hiu tin s cc ln nhp vin v cc t bnh quan trng trc y nh: phu thut (c th dng loi tr mt vi nguyn nhn, nhng cng c th lm tng nguy c cc nguyn nhn khc nh tt rut do dnh,), au nhiu ln tng t (gi mt bnh l ti din). + Thuc ang dng: mt s thuc c th gy au bng (lit k phn nguyn nhn). 2. Triu chng thc th: - Sinh hiu: St l du ch im tnh trng vim hay nhim trng. Mch nhanh, huyt p h gi bnh l lm gim th tch mu lu thng. Huyt p tng c th gp trong ban xut huyt Henoch-Schnle hay hi chng tn huyt u r mu cao. Nhp th Kussmaul c th gp trong nhim ketoacid trn bnh nhn tiu ng. - Khm bng: Quan st bng di chuyn theo nhp nh. Sau ngh tr dng mt ngn tay ch vng au nhiu nht trn bng. Khm tm cc v tr au c bit (h chu phi,), cc khi hay tng to ra, du khng, gng cng bng. - Khm trc trng v vng chu: Khm trc trng cung cp nhiu thng tin hu ch v trng lc c vng, khi u, phn, mu trong phn. Khm b phn sinh dc ngoi, trn b trai, c th pht hin bt thng dng vt hay tinh hon; trn b gi, dch m o, teo m o hay mng trinh khng l. - Khm tm cc du hiu khc: Vng da gi tn huyt, bnh l gan mt. Du Murphy (+) nghi ng vim ti mt. Ban xut huyt km au khp gi ban xut huyt Henoch-Scholein. III. CN LM SNG: Cc xt nghim cn lm sng c thc hin ty thuc vo triu chng v du hiu ca bnh nhn. - Huyt : nh gi tnh trng thiu mu, nhim trng. - Tng phn tch nc tiu: c th gip pht hin tnh trng nhim trng niu, si v cc bt thng khc: mu, m niu cao, - Siu m: khi nghi ng lng rut. - Chp bng ng: nu ngh n nguyn nhn tt rut, thng tng rng. - X-quang ngc: c ch loi tr vim phi. IV. CHN ON:
17. 17. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 3 Hu ht cc au bng cp c th c chn on da trn hi bnh s cn thn, thm khm lm sng v thc hin mt s cn lm sng c bn. V. IU TR: iu tr ty thuc nguyn nhn au bng cp. Cn trnh s dng thuc gim au khi nguyn nhn au bng cp cn cha r rng v s lm kh khn trong theo di din tin bnh. Lu lng gi lm sng au b ng bn tri au b ng vng gia sang bn ph i Ch n thng To bn Xo n bu ng trng/tinh hon HC Mittenschmerz Tm d u ch n thng, ngc i Vim ru t tha Xo n bu ng trng/tinh hon Vim h ch m c treo HC Mittenschmerz Ng c thc n Vim d dy ru t B nh l vim vng ch u Thai ngoi t cung Ban xu t huy t Henoch-Schnlein H i chng tn huy t u-r huy t cao Vim ru t Ban xu t huy t Henoch-Schnlein H i chng tn huy t u-r mu cao Vim d dy - ru t S i th n Ch n thng th n Nhi m trng ti u Ru t xoay b t ton L ng ru t Xo n ru t Cn tn huy t h ng c u li m Nhi u ngi trong nh cng m c b nh Ho t ng tnh d c Da xanh / ban xu t huy t Phn c mu Ti u ra mu D u t c ngh n H i v theo di c c D u chng thi u mu h ng c u hnh li m Nhi m trng ti u Vim h ng Vim d dy ru t Vim h ch m c treo Vim ph i Vim ru t tha B nh l vim vng ch u c c c c c c c c c khng S t khng khng khng khng khng khng khng khng khng khng
18. 18. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 1 AU U TR EM I. I CNG - au u la tri u ch ng rt thng g p trong thc hanh y khoa. - Ty l hin mc au u tre em khoang 11% tui n trng 5-15 tui. - Theo i nh nghia, au u la cam giac au vung u va cam giac au nay khng co s phn b theo cac vung cam giac thn kinh . au u co th la tri u ch ng cua rt nhiu b nh ly khac nhau, tai h thn kinh hay bnh toan thn , t b nh n ng cn cp c u n b nh khng n ng. II. TIP CN MT TRNG HP AU U - Khai thac y u va chinh xac b nh s , tin cn. - c tinh cua cn au u : au t ng cn hay lin tuc , vi tri au, thi gian au, au u co theo nhi p ma ch hay khng , cac tri u ch ng kem theo , yu t lam tng va giam au - Thm kham: 1. Du hi u sinh tn: - Thn nhi t: co st khng? - Mach, huyt ap: mach nhanh hay chm , huyt ap tng hay giam ? Nhng cn nhi p tim nhanh , HA tng, au u d di kem va m hi gi y pheochromocytoma . Nhip tim chm , huyt ap tng kem ri loa n nhi p th gi y hi ch ng tng ap lc ni so. - H hp: cac bnh ly gy CO2 gy au u. 2. Thm kham tng quat : chu y anh gia cn nng nh sut cn g i y b nh ac tinh , b nh ma n tinh keo dai , kham vung u, m t, c, rngtim cac sang thng da gi y nhom bnh da thn kinh, nghe m thi vung c 3. Kham thn kinh: - anh gia phat trin tm thn, v n ng. - o vong u: t t u nho, nao ung thuy.. - Du thn kinh khu tru - Du mang nao: c gng, Kernig, Bruzinski. - Cac xet nghim cn lm sang: tuy theo nguyn nhn: + Choc do dich nao tuy: nghi ng vim mang nao, vim nao.. + CT-scan sonao: chi inh khi: au u n ng, khi phat t ngt. au u din tin n ng dn ho c khng in hinh. Du thn kinh khu tru . Nghi ng tng ap lc ni so. Nghi ng tn thng choan ch. Nghi ng b nh ly ma ch mau nao : nhi mau nao , xut huyt nao, xut huyt di nh n Co gi t.
19. 19. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 2 au u sau chn thng. CT-scan cung cp rt it thng tin trong nhng sang thng vung h sau . Tuy nguyn nhn ma ngi thy thuc co chi i nh bm thuc can quang hay khng . + MRI sonao : cho hinh anh chi tit hn CT -scan, c bi t nhng sang thng vim, b nh ly ma ch mau nho , sang thng vung h sau. + Cng hng t ma ch mau (MRA, MRV), chup mach mau (DSA): phinh ng mach nao, di dang mach mau nao, thuyn tc mach mau.. + EEG: khng co chi i nh trong trng hp au u . Tuy nhin khoang 1% b nh nhn co cn au u la biu hi n duy nht cua b nh ng kinh . Trong trng hp nay EEG la tiu chun chn oan. III. PHN LOI AU U Theo Hi p Hi au u th gii 1988, au u gm 2 nhom: 1. au u nguyn phat: khng lin quan n b nh ly tai i tai la i hay b nh sinh co th xac inh, tri u ch ng chu yu la au u, khng co mt tn thng nao khac,din tin man tinh co nhng t cp, gm 3 loai thng gp: - au u migraine - au u cng c - au u tng cum (him g p tre em) 2. au u th phat : la triu chng au u biu hi n cp tinh , ban cp hay man tinh kem vi cac bnh ly khac , trong trng hp nay ngi thy thuc phai tim ra nguyn nhn iu tri . Cac nhom nguyn nhn thng gp: - Nhom gy tng ap lc ni so : chn thng so nao, xut huyt nao , phu nao, nao ung thuy, u nao, abcess nao, nang mang nh n.. - Nhom giam ap lc ni so : sau t VP shunt, sau choc do tuy sng , ro dich nao tuy sau v san so - Nhom bnh mang nao : vim mang nao , xut huyt khoang di nh n , di mang c ng - Nhom bnh mach mau : vim ma ch mau , tai bin ma ch mau , di dang ng tinh mach - Nhom bnh ly xng , m mm: t da u , mt, mui, xoang, tai, rng, hu hong, khp thai dng ham.. - B nh ly nhim trung: nhim trung, nhim siu vi
20. 20. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 3 AU U MIGRAIN I. I CNG: Migraine la b nh au u thng g p ,din tin t ng t va keo dai sut i . Ty l mc b nh tng dn theo tui , n chim u th . B nh co tinh gia inh , tuy khng nguy him nhng anh hng n i sng b nh nhn. II. PHN LOI: Co 2 loai chinh - Migraine co tin tri u (kinh in hay th mt ): biu hi n mt nh am im choi sang, ban manh.. - Migraine khng co tin tri u: th thng thng III. C TINH CN AU MIGRAIN - Thng au na u co th lan hai bn , t ng cn, theo nhi p ma ch , cng tng dn va d di. - Kem theo s anh sang, sting ng, bun nn va oi - c bit tre em , hi ch ng co th khng hoan chinh va chi co tri u ch ng lin quan n h thn kinh t chu ( Migrain th bung ) hay thay i tinh tra ng tinh thn ( cn ln ln cp) - Mt s hi ch ng chu ky cung c phn loa i nh Migrain: + Cn chong m t ki ch phat lanh tinh + Cac t nn oi co tinh chu ky + Migraine vi biu hi n li t c v n nhan IV. IU TR 1. iu tri ct cn: - Thuc giam au: Acetaminophen, NSAIDs nh Ibuprofen - Thuc chng nn: Domperidone, Metoclopramide - Thuc c hi u: Ergotamine - Thuc an thn : nhom Benzodiazepine co thi gian tac dung ngn , nm nghi ngi trong phong ti, yn tinh. 2. iu tri ng a cn : him khi chi i nh tre em , chi s dung khi s cn nhiu: trn 3 cn mi thang , gm thuc chng trm cam ba vong , -blockers, c ch canxi , Sodium valproate, Topiramate 3. Tranh cac yu t khi phat cn: - Th c n (chocolate, bt ngot, tyramine, nitrate, ru, bia) - Sinh hoa t, n ung, nghi ngi iu . - Gii ha n dung caffeine, cac thuc kich thich, vitamin A - Tranh cac cng thng v mt tm ly. - Tranh cac thuc dan mach.
21. 21. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 1 HO HO KO DI I. I CNG: 1. nh ngha: - Ho l phn x bo v ng th quan trng, gip: + Tng xut d vt ng th + H tr lm sch thong ng th + Tr khe mnh cng c th ho, trung bnh 10 ln/ngy + Th th ho nm : Biu m ng h hp trn v ng h hp di (gim dn) Ngoi tm mc Thc qun C honh D dy ng tai ngoi Do , ho c th l biu hin ca bnh l ti hoc ngoi ng h hp Cc tn thng mc tiu ph qun hoc ph nang c th rt t hoc khng gy ho - Ho ko di l ho lin tc trn 4 tun. 2. Nguyn nhn: - Bt thng bm sinh ng h hp: + Tt ch thanh qun + D kh thc qun + Mm sn thanh kh ph qun: nguyn pht hay th pht + Bt thng bm sinh ph qun hay phi + U trung tht + Tim bm sinh km tng lu lng mu ln phi - Nhim trng: + Nhim siu vi ti din + Nhim Clamydia, Mycoplasma, + Ho g + Nhim nm - Bnh phi to m (Dn ph qun va p xe phi): + Cystic fibrosis + D vt ng th b qun + Suy gim min dch; bm sinh hoc mc phi - D ng: + Suyn + Suyn dng ho + Vim mi vn mch hay d ng
22. 22. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 2 - Hi chng ht: + Ri lon chc nng nut + B khi ng + Tro ngc d dy thc qun + D vt ng th - Tc nhn vt l hay ha hc: + Ht thuc th ng hay ch ng + nhim mi trng + Ho do tm l hay thi quen + Do thuc: c ch men chuyn II. LM SNG: 1. Bnh s: - Tui v tnh hung khi pht: + Ho bt u ngay sau sinh: d tt bm sinh ng h hp? hi chng ht (d kh ph qun, khe thanh qun (laryngeal cleft), bnh l thn kinh)?, nhim trng mn tnh (x nang phi, ri lon vn ng lng chuyn)? + Hi chng xm nhp: D vt ng th? + Sau t vim phi nng: do tn thng ng th nng? dn ph qun? + Sau nhim trng h hp trn: c th ho do thi quen hoc tm l - Tnh cht cn ho: + Suyn: ho kch pht mn tnh, khi pht sau gng sc, khng kh lnh, khi ng, tip xc d nguyn + Bnh l kh qun hoc ng th gn (v d nh: mm sn ng th, vim thanh kh ph qun, vim thanh qun co tht (spasmodic croup), d vt ): ho nh ch sa hoc ho lanh lnh (brassy cough) + Ho tng cn (staccato) tr nh nhi: c th do nhim Clamydia trachomatis + Ho nh ting ngng ku v khng ho khi ng: ho do tm l hoc thi quen + Ho c m ko di: cn loi tr dn ph qun, x nang phi, nhim trng mn tnh, suy gim min dch, bt thng bm sinh, hen, d vt. - Thi gian v yu t khi pht cn ho: + Suyn: ho sau khi tip xc vi cc yu t khi pht hen in hnh, nng ln khi ng + Ho do bnh l mi: nng hn trong khi ang thay i t th + Dn ph qun: ho khc m nhiu vo bui sng + Ho sau khi nut: hi chng ht? (nguyn pht hoc do d kh thc qun, bt thng vng thanh qun) + Ho trong vng 1 gi sau ba n hoc nng hn khi nm nga; tro ngc d dy thc qun? + Ho ban ngy, nng hn trong gi i hc, mt khi ng; ho do tm l - Cc triu chng lin quan:
23. 23. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 3 + Kh th + Ho mu + St ko di + Chm ln + St cn + Bnh l thn kinh - Tin cn s dng thuc - Tin cn gia nh - Mi trng sng 2. Triu chng thc th: Cn lu : - Tng trng - nh gi pht trin th cht - Mc suy h hp - Nghe phi - Khm tai mi hng - Khm tim - Khm thn kinh - Sang thng da - Du hiu ca cc hi chng di truyn III. CN LM SNG 1. X-Quang ngc: X-Quang ngc n c him khi cho chn on xc nh, m ch gip gi nguyn nhn v cho hng la chn cc cn lm sng ph hp tip theo. - Nghi ng d vt: cho chp quang thng th ht vo v th ra - XQuang ngc bnh thng: trong trng hp ho do thi quen. Tuy nhin, cng c th c trong trng hp d vt, hen, bnh x nang phi giai on sm, dn ph qun - Dy thnh ph qun 2 bn, c hoc khng km tng thng kh: vim nhim lan ta 2 bn, hen, x nang phi, vim ph qun ti din, hi chng ht, ri lon vn ng lng chuyn - Dy thnh ph qun 2 bn km tn thng ng c mt hoc nhiu phn thy phi: vim ng th lan ta (nh trong hen, vim ph qun ti din, ri lon vn ng lng chuyn, bnh x nang phi). Thm nhim thng thy thy gia phi phi. - Bt i xng thng kh hoc ti mu: do tc nghn mt phn ng h hp (d vt, mch mu chn p, hp ph qun) - Thm nhim thy gia phi phi: thng thy trong nhng bnh l gy tc nghn ng th.
24. 24. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 4 - Dy quanh ph qun i km vi tn thng dng li, nt xut pht t rn phi: dn ph qun - Hch rn phi: thng thy trong lao hoc nhim nm - Rng trung tht - Din tim bt thng - Bt thng mng phi 2. o chc nng h hp 3. Ni soi ph qun 4. o pH thc qun 5. Chp hnh xoang 6. IDR 7. Th nghim d ng IV. CHN ON HO KO DI 1. Tt c tr ho ko di phi c: - Hi bnh s mt cch chi tit - Thm khm lm sng k - Chp X quang ngc - o chc nng h hp: nu c iu kin - V cc xt nghim khc ty vo gi lm sng trong tng trng hp c th 2. Thng thng, qua cc bc trn, c th phn loi ho ko di thnh 2 nhm: - Ho c hiu (c bnh l nguyn nhn) - Ho khng c hiu (khng c bng chng ca bnh l nguyn nhn) Cc nguyn nhn gy ho c hiu thng biu hin cc triu chng sau: - Ho c m, c th l m m hoc khng: lun l du hiu bnh l - Kh kh - Hi chng xm nhp - Xquang phi hoc chc nng h hp bt thng - C bnh l tim mch, bnh thn kinh c - Chm ln, n kh, hay ho mu Ho khng c hiu: Nu khng c cc triu chng trn, Xquang ngc v chc nng h hp bnh thng, nn ngh n cc nguyn nhn gy ho khng c hiu. Mt s chn on c th l: hen dng ho, ho ko di sau mt t nhim siu vi ng h hp, tng ngng nhy cm ca th th ho, ri lon chc nng (bao gm ho do thi quen v tic). Nu triu chng ho gy kh chu cho bnh nhn, c th ngh n chn on hen v cho iu tr th. Nu khng p ng, phi ngng iu tr. Gia nh cn phi c tham vn v theo di pht hin kp thi cc triu chng nng.
25. 25. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 5 Tri u chng xu t hi n sau h i chng xm nh p Ho c m Ho k ch pht Ho sau khi n Ho t sau sinh Ho nh ti ng s a Ho nh ti ng ng ng ku, m t khi ng Ho khan, lin t c Ho ti n tri n, s t cn, s t Ho mu C a d ng, n ng hn khi n m nghing Ch y m i sau, vim m i d ng D v t Vim ph qu n dai d ng, d v t, vim ph i ti pht, x nang ph i, r i lo n v n ng lng chuy n, suy gi m mi n d ch Ho g H i chng ht (r i lo n nu t, d kh thc qu n) B t thng b m sinh, d kh thc qu n, khe thanh qu n, b nh l th n kinh, x nang ph i, r i lo n v n ng lng chuy n M m s n kh / ph qu n, d v t Ho do thi quen, tm l B nh ph i m k Nhi m trng m n (lao, d v t b qun, nhi m n m, k sinh trng) Dn ph qu n,b nh ph i t o hang (lao ph i, apxe ph i), suy tim huy t, b nh s t, d v t, b nh l m ch mu ph i, r i lo n ng mu,u i u tr th Xquang c - ngc, soi ph qu n Test m hi, CT ngc, Xquang ngc, CT ngc, xt nghi m nh gi chc n ng lng chuy n, c y m, nh gi mi n d chC y virus, PCR, huy t thanh ch n on Xquang thc qu n c n quang Test m hi, xquang thc qu n c n quang, soi ph qu n, nh gi mi n d ch Soi ph qu n, Xquang ngc, CT ngc Quan st, lo i tr nhng nguyn nhn khc, i u tr th o chc n ng h h p, CT ngc, d u n mi n d ch, sinh thi t ph i Xquang ngc th ng, soi ph qu n, IDR Xt nghi m c hi u theo tng nguyn nhn Ho khng c hi u, hay tr kh e m nh Gy kh ch u Cn nh c i u tr hen th Dng thu c 2-4 tu n Khng p ng Ngng i u tr Quan st v theo di Khng gy kh ch u Ho khng quan tr ng nh gi l i, quan st s xu t hi n cc tri u chng mi, theo di C i thi n Ngng i u tr i u tr l i n u tai pht C Kh kh, d ng Cc tri u chng gi ho c hi u Lm sng Ch n on c thHen Xc nh ch n anTh nghi m d ng, o chc n ng h h p, i u tr th Khng
26. 26. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 6 V. THUC IU TR HO V ho l phn x c li nn a s cc trng hp khng cn s dng thuc iu tr ho. Vn quan trng l xc nh v iu tr nguyn nhn. 1. iu tr nguyn nhn 2. iu tr triu chng ho: gm 2 nhm thuc - H tr ho: gip ho c hiu qu hn + Acetylcysteine + Carbocysteine + Bromhexine + Guaifenesine + Nc mui u trng + Cc syrup tho dc: hu nh v hi cho tr Ch nh: khi ho c m Chng ch nh: (ty tng loi thuc c th) - Chng ho: kim sot v ngn chn cn ho + Codein + Dextromethorphan + Khng histamine Ch nh: Ho khan lm bnh nhn kh chu, mt mi, mt ng Chng ch nh: hen suyn, suy h hp
27. 27. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 1 HO RA MU I. I CNG: 1. nh ngha: Bnh ho ra mu l khc nh ra mu hoc l c s xut hin ca mu trong m. Tr nh thng nut m ca chng. V vy, bnh ho ra mu rt t c pht hin tr nh hn 6 tui tr khi xut huyt nhiu (th nng). ngi ln, mc nguy cp ca bnh ho ra mu c phn lai theo lng mu c khc ra. Trong Nhi khoa, bnh nhn mc bnh ho ra mu khng c phn lai nh vy. Do , nh gi lm sng l cng c ban u m ngi bc s c trong vic nhn nh mc nguy cp ca bnh ho ra mu tr em. 2. Nguyn nhn: a. Nhim trng: - Vi khun: p xe phi, lao, nm, nhim bo t nm, bnh nm cocidioides - Virus. HIV b. Hi chng vim mch: - Phc hp min dch trung gian: Ban xut huyt Henoch-Schonlein - Hi chng vim mch trung gian min dch: u ht Wegenner,s, vim a ng mch - Bnh min dich khc: st phi khng r nguyn nhn, bnh ban h thng, bnh nm qut d ng, hi chng Goodpasture. c. Bnh tim bm sinh: Suy tim huyt, Khng c ng mch hay tnh mch phi. d. D dng phi, u phi, u mch mu, gin mao mch, bt thng ng tnh mch phi. e. U tn sinh: u tuyn, u nh dng t bo a bc, u c tnh, phnh ng mch ph qun. f. Tc tnh mch ca g. D vt ng th h. Chn thng: tin cn chn thng, rch dy thanh m, m kh qun, ht ra ng th i. Do thuc: thuc khng vim, thuc dit cn trng. j. Hi chng Ehlers-Danlos k. Khng r nguyn nhn II. CHN ON 1. Lu 2. Xt nghim gip chn on: Trc tin nn xc nh v tr ngun chy mu l h tiu ha hay phn trn hoc phn di ca h h hp. Trong ho ra mu, mu c mu ti (bright red) hoc mu st g st, c th c bt kh v ln vi m. pH l kim (pH>7). Cc triu chng bao gm ho ra mu hoc hng ging c thc. Tr ln c th phn nn v s lo lng i vi phn gia ngc. iu ny c th gip xc nh v tr chy mu.
28. 28. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 2 Ngc li, trong bnh nn ra mu, mu thng c mu thm (crimson) hoc nu vi mu sc ging nh b caph, c th cha nhng mu thc n. pH l acid (pH14 ngy sau chy mu Theo di Siu m tim Nghi ng xut huyt phi Hay ho ra mu Chy mu mi Khm li Bt thng Bnh thng C th bnh tim Xt nghim hi chng thn XN IPH (-) C bnh Hng iu tr Kim tra chy mu cc tng
29. 29. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 3 - Nhng pht hin lin quan: + Vt mu trong m pht sinh t vim m nim mc thng l biu hin ca bnh vim kh-ph qun. + St hoc n lnh c km theo m m ngh n bnh vim phi + m c mi hi c kh nng b abscess phi + Vic s dng dc phm bt hp php (c bit l ht cocaine) v nhng thuc gy tn hi cho chc nng ca tiu cu hoc gy ra hin tng gim tiu cu nn c lu . + Bnh huyt niu gi mt bnh vim mch thn-phi nh l hi chng Goodpasture hoc bnh vim u ht Wegener. + Vt thm bm vng ngc hoc c (chn thng), gin mao mch hoc u mch mu (gi cc d tt ng v tnh mch), hoc clubbing (gi v bnh phi cp tnh, cc d tt h thng ng v tnh mch phi, hoc bnh tim bm sinh). + Chy mu trong khoang ming hoc phn mi - hu hoc mt rng c th l c cho trng hp ht phi vt th l vo phi. Nu bnh vim phi tn ti th vic xem xt h h hp s cho thy nhng du hiu ca s ngng t. - X- Quang: + Chp X quang vng ngc: pht hin cc thm nhim vng nhu m hoc vng ph nang, s vi ha (cho thy bnh lao phi). + Nhng vt th l gy phn quang, hoc hin tng mt th tch phi l biu hin ca s tc nghn ni ph qun, hoc bnh gin ph qun. Tuy nhin, mt phn ba s tr em mc bnh ho ra mu s c kt qu X quang bnh thng. + Chp ct lp (CT scan) c hoc khng c tng tng phn (phn quang) c th gip xc nh nhng d tt v ng h hp v mch mu. y l s kim nh la chn hnh nh ti u ca nhu m trong phi. + Vic chp ng mch nn c xem xt nu c nghi ng v s tn ti ca cc d tt mch mu cho d kt qu CT scan l m tnh. - Huyt : + nh gi ban u nn m huyt cu v tiu cu lai tr bnh Willebrand + (vascular hemophilia: xut huyt mch mu) + Nu c hai hoc nhiu ln chy mu nn lmCreatine trong huyt thanh, BUN (blood urea nitrogen), TPTNT + ANA (antinuclear antibody), ANCA, xt nghim m hi, cc khng th mng nn khng tiu cu, cy vi trng (pht trin), nm, virus v AFB (acid-fast bacilli) phi c lu . - Soi ph qun: + Soi ph qun linh ng: gip xc nh vng chy mu, tm nguyn nhn chy mu + Soi ph qun khng linh ng: la chn cho trng hp c vt th l hoc chy mu nhiu. - Sinh thit phi: c xem xt cho nhng tr xut huyt ph nang din rng, thm ch nu nghin cu huyt thanh hc i vi nhng ri lan do dng thuc tng min dch (ANCA,
30. 30. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 4 ANA, cc khng th mng nn khng tiu cu) cho thy kt qu m tnh, cng nh c nhng trng hp pht bnh do dng thuc tng min dch vi kt qu huyt thanh m tnh.
31. 31. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 1 NGT (SYNCOPE) I. NH NGHA Ngt l tnh trng mt tri gic & mt kim sot t th t ngt, thong qua trong thi gian ngn do gim ti mu no v thng hi phc t nhin sau . II. NHNG C IM TRONG BNH S GI NGUYN NHN NGT Bng 1: c im trong bnh s gi nguyn nhn ngt Nhng s kin trc cn ngt Nguyn nhn gy ngt Thuc h p, h ng huyt au n, xc ng C ng u v c Gng sc Gng sc chi trn H huyt p, h ng huyt Ngt do thn kinh ph v, tng thng kh Tng nhy cm xoang cnh Tc nghn ng ra ca tht, Takayasu Hi chng nh cp mu ca mch vnh Kiu xut hin t ngt Nhanh, c tin triu T t Bnh l thn kinh (ng kinh), ri lon nhp tim Bnh l thn kinh, ngt do thn kinh ph v Tng thng kh, h ng huyt T th lc ngt Ngi dy ng lu T th bt k H huyt p t th Ngt do thn kinh ph v Ri lon nhp tim, bnh l thn kinh, h ng huyt, tng thng kh Hi phc sau ngt Chm Nhanh Bnh l thn kinh Tt c nguyn nhn khc Nhng bin c i km Tiu tiu khng t ch, cn li, chn thng Bnh l thn kinh III. NGUYN NHN Nguyn nhn gy ngt tr em rt a dng (Bng 2).
32. 32. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 2 Khc vi ngi ln a s ngt l do nguyn nhn tim mch, tr em ngt thng do ri lon h thn kinh thc vt, ch yu ngt do thn kinh tim (neurocardiogenic syncope). Ngt tr em him khi l du hiu bo trc nguy c t t, ngoi tr nu tr c bnh l nn cn phi kim tra.
33. 33. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 3 Bng 2: NGUYN NHN NGT TR EM Ri lon kim sot huyt p do phn x thn kinh Ngt do thn kinh ph v Ngt do xoang cnh Ngt do ho, ht hi Ngt do kch thch ng h hp Ngt do tng p lc trong lng ngc (nng vt nng) Ngt do au dy thn kinh thit hu Ngt do kch thch ng tiu ho (nut, i tiu, hi chng tro ngc d dy thc qun) Ngt do kch thch ng tit niu (i tiu) Ri lon kim sot huyt p do t th H huyt p t th v cn H huyt p t th do thuc Ri lon nguyn pht do suy yu h thn kinh t ng Th pht sau bnh l thn kinh Ri lon nhp tim nguyn pht Ri lon chc nng nt xoang (bao gm c hi chng nhp nhanh nhp chm) Bnh l h thng dn truyn nh tht Nhp nhanh kch pht trn tht (bao gm nhp xon nh) Hi chng QT di Ri lon chc nng h thng to nhp nhn to, nhp tim nhanh do my to nhp, hi chng my to nhp. Bnh l tim mch hoc tim phi Bnh van tim (hp ng mch ch, ng mch phi, van hai l) U nhy nh tri Nhi mu c tim cp tnh Bnh c tim tc nghn Bnh mng ngoi tim / chn tim cp Hi chng nh cp mu ca ng mch di n Vim ng mch Takayasu Thuyn tc phi Tng p phi nguyn pht Bnh l mch mu no, thn kinh, tm thn Bnh tc nghn mch mu no (nh cp mu trong no) Bnh l h thn kinh trung ng (ng kinh, xut huyt di mng nhn, cn ng thong qua, no ng thy) Ri lon tm thn (cn hong s, hysteria) NHNG NGUYN NHN KHC (ri lon chuyn ha, ni tit) Tng thng kh (gim CO2 mu) H ng huyt Gim th tch tun hon (thiu mu, bnh Addison, u ty thng thn) Gim oxy mu
34. 34. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 4 KHNG R NGUYN NHN IV. CHN ON 1. Bnh s: Cc thng tin cn khai thc: - Trc cn: + Kiu xut hin (t ngt, t t) + Hon cnh (thi tit nng nc, trong phng kn, hot ng gng sc, i, mt, au n, xc ng mnh, c ng u c, ho, rn, gi ca ba n cui, nhim siu vi h hp trong vng 24 gi trc khi c cn ngt) + T th lc xy ra ngt (ngi dy, ng lu, t th bt k, t th nm nga sau b gi tro ngc d dy thc qun, t th bt k) + Tin triu (hi hp, tim p nhanh, au ngc, lo o, v m hi, t rn, l ln, lit tay chn hoc mt, m mt, nhc u, lo lng, ng) Trong cn: thi gian ngt, gng - git, tiu tiu khng t ch, tm hoc xanh ti? Sau cn: hi phc tri gic nhanh hay chm, qun nhng g xy ra, ri lon tri gic, du thn kinh nh v, au c? - Tin cn: + Bn thn: Mt/nhiu cn ngt, c im tng cn? Bnh l tim mch, bnh l no hoc thn kinh, ng kinh, migraine? Ri lon tm l? Ct dy thn kinh giao cm, thiu mu, tiu ng, giang mai, bnh rng ng ty, thoi ho dng bt Thuc s dng? + Gia nh: ngt, co git, ic hoc t t? 2. Khm: Xc nh tnh trng ngt c bit ch : sinh hiu; nh gi cn thn tnh trng tim & thn kinh Khm lm sng a s bnh thng. Test chn on c la chn ty vo bnh s v kt qu khm lm sng. - Test lm sng: Tilt Table Testing + Ch nh: Nu c nhiu cn ngt ti pht, hoc nguyn nhn cha chc chn. Ngt thn kinh tim in hnh: xy ra t th ng hoc ngi. Tin triu, thay i nhp tim v huyt p. + K thut: Bnh nhn: nhn i, t sn ng truyn tnh mch Dng c phi c khi thc hin test: monitor theo di nhp tim; ECG; huyt p k Thuc : Isoproterenol, dung dch in gii + Tin hnh: lc sng sm, trong 1 phng yn tnh, bnh nhn nhn i.
35. 35. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 5 Bc 1: bnh nhn nm nga u ngang khong 10 -30. Bc 2: chuyn sang t th u cao 600 trong 60 pht (s dng bn c kh nng t c t th thch hp trong vng 1 pht). Theo di nhp tim, HA lin tc trn monitor, khi thy bnh nhn bt u c triu chng t bnh nhn tr li t th u thp. Nu vn cha c triu chng : lp li test ln 2 v truyn TM Isoproterenol liu 0.02 -2 g/kg/pht. + nh gi kt qu dng tnh: Khi c h huyt p / nhp tim chm, khng cn bnh nhn phi ngt. Khi c tin triu (bun nn, chng mt, ri lon th lc) + huyt p gim t 20 30 mmHg so vi huyt p trc , hoc thp hn tr s ti thiu ca HAmax t 50 90 mmHg, hoc nhp tim di 60-90 nhp /pht. Cc test nh gi h thn kinh thc vt: xoa xoang cnh, n nhn cu, nghim php Valsalva, phn x ln, c th thc hin trong lc lm test tilt table. Xt nghim: - ECG: quan trng, c bit trong cn ngt gip pht hin ri lon nhp, QT ko di? - Gi c bt thng cu trc tim? - XQuang tim phi thng, siu m tim. - Dextrostix, Glycemie, Ion mu, thng bng kim toan. - EEG: nu c biu hin tn thng no lan ta hay co git. - o nng catecholamine trong mu trc v sau khi bnh nhn b ngt. V. IU TR - Tr b ngt cn c theo di st tnh trng h hp v huyt ng hc: + Nu huyt ng hc n nh, theo di st bnh nhi, trc mt cha cn iu tr g c bit, nhng phi tm nguyn nhn nga ti pht. + Nu huyt ng hc b nh hng, hi sc h hp tim mch phi thc hin khn cp, nhng trc tin phi loi tr nguyn nhn ri lon nhp. - Xc nh iu tr tu thuc vo s ln ngt, nguyn nhn v c ch bnh sinh ca ngt, cng nh nguy c i vi bnh nhn. + Nguyn nhn do tim hoc khng do tim: iu tr c hiu nguyn nhn gy ngt. + Bnh nhn b cng ph v c th iu tr bng kch thch giao cm tc dng di, him khi phi to nhp vnh vin. + Nguyn nhn gy ngt tr em a s do ri lon h thn kinh thc vt. Ngt thn kinh tim (neurocardiogenic syncope) ni chung khng nguy him v thng p ng vi iu tr bng thuc.
36. 36. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 6 IU TR NGT THN KINH TIM Cc phng thc iu tr sau y c th c chn phi hp, ty vo c ch bnh sinh gy ngt. 1. Tng ti dch: l ch yu, thng p ng tt, khng cn can thip no khc. thiu nin thng cn t 3- 4 lt /ngy (lng dch thch hp nht l bao nhiu vn cha r). Nn s dng dch giu in gii v cc loi thc ung dng trong th thao. Trnh dng thc ung cha caffein v chng c tc dng tng t Isoproterenol, c th lm tng phn x thc vt bt thng. Cng khng nn dng thc ung giu nng lng v giu lipid, v d sa nguyn kem. Nu tng lng dch khng hiu qu, cn phi hp thm mui hoc Fludrocortisone. (Flurocortisone phng nga c ngt n 90%). Tuy nhin, iu tr phi hp nh trn d a n ri lon in gii, do cn theo di st ion mu (nng Na+ v K+ c duy tr tt, nhng nng Natribicarbonate thng tng). 2. Thuc chn : tc dng ngn tht co bp qu mnh, ng thi c tc dng c ch Epinephrine trong tun hon, y c th l yu t trung ng gy phn x bt thng, km vi nhp tim nhanh. Thuc chn c th nga ngt ti pht tr em. 3. Disopyramide: c tc dng anticholinergic, gip ngn nga chm nhp tim trong giai on c ch tim, v c tc dng tng khng lc ngoi bin. Thuc c th gy lon nhp, khong QT ko di, c th dn n cung ng tht, v c tc dng inotrope (-). 4. - Adrenergic agonist: Epinephrine & Pseudoepherine c tc dng kch thch giao cm trc tip tng trng lc tnh mch ngn tnh trng dn mch v mu tnh mch, ng thi c tc dng co ng mch lm tng khng lc ngoi bin. Thuc c hiu qu trong nhng trng hp ngt do gim trng lc tnh mch. 5. c ch thu nhn serotonin: Fluoxetine hydrochloride (Prozac) v Setralin hydrochloride (Zloft), c s dng cho bnh nhn ngt khng p ng vi cc thuc khc. Tc dng ph: bun nn, tiu chy, nhc u & mt ng. 6. My to nhp: l iu tr cui cng bnh nhn ngt ti pht nhiu ln, khng p ng vi thuc iu tr. Tuy nhin vn cn nhiu tranh ci.
37. 37. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 7 LU TIP CN CHN ON NGT TR EM (EPS: Electrophysiologic study; ETT: Exercise tolerance test; LFTs: liver function test) Bnh s & khm LSNguyn nhn Thn kinh ? Khng gi nguyn nhn tim hay thn kinh Thn kinh Nguyn nhn Tim? Hi chn Thn kinh? EEG, CT/ MRI TK tim Tilt table test Chuyn ho Ng c Thai k Tm l Ion , Glycemie LFTs XN c cht RL nhp Tc nghn ECG Holter ETT Echo +/- EPS ECG Holter ETT Echo +/- Cath/ EPS
38. 38. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 1 ST KO DI CHA R NGUYN NHN TR EM I. I CNG: 1. nh ngha: St cha r nguyn nhn (st CRNN) l st ko di m nguyn nhn khng xc nh c sau 3 tun iu tr ngoi tr hoc sau 1 tun iu tr ni tr. 2. Nguyn nhn: Gm 5 nhm: a. Nhim khun: l nguyn nhn hng u, chim 40-60%, thng tr < 6 tui - Vi khun: nguyn nhn thng gp l lao, thng hn, Mycoplasma pneumoniae,. - Virus: nguyn nhn thng gp l Ebteinsbar virus, Cytomegalovirus, HIV, Adenovirus, virus vim gan A, B,C. - K sinh trng: st rt, amip, toxoplasma, u trng di chuyn ni tng (Toxocara).. - Xon khun: nguyn nhn thng gp l leptospira, giang mai. - Nm: Candida, Aspergillus.,.. b. Bnh t min: thng tr > 6 tui, l nguyn nhn ng hng th hai, chim t 7 20%, vim khp dng thp thiu nin v lupus l 2 nguyn nhn thng gp nht. c. Bnh l c tnh: chim mt t l nh trong hu ht cc nghin cu, t 1,5 6%. Bnh bch cu cp l bnh c tnh ph bin nht tr em, k tip l lymphoma v neuroblastoma. d. Nguyn nhn khc: bnh Kawasaki, hi chng thc bo mu, i tho nht nguyn nhn trung ng hoc do thn, st do thuc, st do trung tm di i, st chu k, thuyn tc phi, thuyn tc tnh mch, ng c gip, vim rut mn, bnh l di truyn c tnh gia nh (ri lon vn ng gia nh, tng immunoglobulin D, tng triglyceride mu), e. Khng tm thy nguyn nhn (25 67%): Tuy nhin, hu ht bnh nhn ny c tng trng tt v st c th bin mt sau vi thng hoc vi nm. II. LM SNG: 1. Bnh s: - St: st t khi no, mc st, kiu st. - Tui: + Tr < 6 tui: thng gp nhim khun ng h hp, nhim khun ng tiu, p xe, vim xng ty, lao, vim khp mn, bch cu cp. + Tr v thnh nin: thng gp vim rut mn, bnh t min, lymphoma. - Triu chng c bit: + au xng, khp: gi bnh bch cu cp, vim xng ty. + au bng, nhng triu chng than phin v d dy rut: gi thng hn, p xe trong bng, bnh mo co (do nhim Bartonella henselae), vim rut mn. + Ung nhiu, tiu nhiu: gi i tho nht. - Tin s:
39. 39. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 2 + Tip xc ng vt, n hi sn sng: nhim Toxoplasma, nhim Leptospira, nhim Bartonella henselae, + Ung sa khng tit trng: nhim Brucella. + n vng dch t st rt, tip xc ngi b lao. + Dng thuc (ung, bi): khng sinh (c bit l nhm beta-lactam, imipenem/cilastin, minocycline), phenothiazine, epinephrine v hp cht c lin quan, nhm anticholinergic (antihistamin, atropine, thuc chng trm cm), haloperidol, antidopaminergic. + Chng nga. + Phu thut: tng nguy c p-xe trong bng. + Chng tc v di truyn: st a Trung Hi gia nh, hi chng tng IgD ngi chu u, ... 2. Triu chng thc th: - Thm khm ton din, ly sinh hiu. - nh gi s tng trng Ch : - Mt: + Vim kt mc: bnh Kawasaki, nhim Leptospira + Khng c nc mt v mt phn x mng mt: ri lon vn ng gia nh - Tm cc sang thng ngoi da: + Chm xut huyt trong vim ni tm mc, nhim khun huyt, nhim virus hoc rickettsia. + Dt hng ban gi bnh lupus. + Hng ban nt c th gp trong bnh nhim khun, vim khp dng thp thiu nin, vim rut mn, bnh c tnh. + Sang thng dng nt sn trong bnh mo co. III. CN LM SNG: Cc xt nghim tm nguyn nhn c lm da vo bnh s, thm khm lm sng nh hng n nguyn nhn . Nu khng nh hng c nguyn nhn c th lm theo trnh t sau: - Bc 1: + Huyt hc: Cng thc mu, pht mu ngoi bin, k sinh trng st rt, VS + Sinh ha: CRP, ure, cratinine mu, SGOT, SGPT, ion mu, in di m mu, tng phn tch nc tiu. + Vi sinh: Test nhanh HIV, Widal, test nhanh khng nguyn st rt (nu c yu t dch t), cy mu (vi khun thng v k kh), cy nc tiu. + X quang phi - Bc 2: Da vo kt qu bc 1 (VS, CRP, in di m), c th nh hng 2 nhm nguyn nhn:
40. 40. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 3 + C hi chng vim: cc nhm nguyn nhn thng gp l bnh nhim khun, bnh l vim, bnh c tnh. + Khng c hi chng vim: cc nguyn nhn c th l gi st, do thuc, i tho nht, ri lon chc nng vng i th, ri lon vn ng gia nh hoc nguyn nhn khc. Cc xt nghim ngh tip theo ty theo hng nguyn nhn: - C hi chng vim: + Procalcitonine. + Huyt thanh chn on hoc PCR: EBV, CMV. + Huyt thanh chn on nhim Mycoplasma, Toxoplasma, nm, Bartonella, + Xt nghim min dch: ANA, RF, anti dsDNA, LE cell, C3, C4, b 6 khng th, ANCA. + nh lng IgG, IgA, IgM nu tr c nhim trng ti din hoc ko di. Nu thp: nghi ng suy gim min dch. Nu tng: gi suy gim min dch nhnh khc ca h thng min dch, nhim trng mn tnh hoc bnh t min + nh lng IgE: nu c chng c ca d ng hoc hi chng tng Ig E + nh lng IgD: nu bnh nhn c st ngt qung hay st chu k + Cy mu: nhiu ln nu hng ti nguyn nhn nhim khun , ch tm nm, vi khun k kh. + IDR + BK m/dch d dy, PCR lao trong m/dch d dy + Soi, cy phn (nu phn lng) + Chc d ty sng + Siu m bng (tm p-xe, u, hch) + ECG v siu m tim nu cy mu dng tnh v nghi ng vim ni tm mc CT u, ngc, bng (tm p-xe, u, hch), MRI, scintigraphie xng, PET scan (positron emission tomography) + Ty + Sinh thit hch, hoc sinh thit tn thng qua da nu c chng c lin quan n c quan c hiu no + Ni soi v sinh thit + Xt nghim khc: ty theo trng hp (chc d mng bng, mng phi, ) - Khng c hi chng vim: + thm thu mu + CT scan s no IV. IU TR - iu tr ty nguyn nhn. - iu tr triu chng v nng tng trng.
41. 41. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 4 - Nn trnh iu tr theo kinh nghim thuc khng vim hay khng sinh ton thn bnh nhn st CRNN. TIP CN ST CHA R NGUYN NHN St cha r nguyn nhn Hi bnh Thm khm ton din Hng chn on Cha c hng chn on Khng cn lm XN XN c hiu Chn on xc nh iu tr Theo di din tin Xt nghim - Huyt - VS, Fibrine, CRP, procalcitonine - 10 thng s nc tiu, cy nc tiu - Chp phi - IDR Cha c chn on C hi chng vim Khng hi chng vim Bnh nhim khun: cy mu, CDTS, huyt thanh , Xq vm hng, siu m bng, siu m tim, scintigrahy xng Bnh t min: ANA, RF, anti dsDNA, LE cell, C3, C4, b 6 khng th, ANCA Bnh mu/c tnh: Siu m bng v chu, ty , scanner ngc bng, sinh thit hch, Catecholamine nc tiu Khc: ion mu, p lc thm thu mu , CT no, Do thuc
42. 42. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 1 ST TR EM I. I CNG 1. nh ngha: - St khi nhit hu mn > 38C hay nhit nch > 37,5C. 2. Nguyn nhn: - St c th l hu qu ca nhim khun (vi khun, virus, k sinh trng, nm), bnh c tnh, bnh t min, bnh chuyn ha, bnh di truyn, s dng thuc, va mt s trng hp, khng r nguyn nhn. II. LM SNG: 1. Hi bnh: - c im ca st: + S ngy st + Nhit khi st + Lin tc hay khng + C tnh chu k hay khng + p ng vi thuc h st hay khng - Triu chng i km: + H hp, TMH: ho, s mi, au hng, au tai, + Tiu ha: i, tiu chy, to bn, au bng, + Tit niu: tiu kh, tiu nhc, tiu mu, ... + Thn kinh: au u, co git, yu lit, ... - Dch t: + Nhng ngi xung quanh c bnh g? + C sc vt nh? C b sc vt cn? + Du lch t vng dch t v? - Tin cn: phu thut, chch nga gn y , s dng thuc, bnh sn c (suy gim min dch, tn thng c quan mn tnh, suy dinh dng, ), nhng t nhim khun ti din, 2. Triu chng thc th: khm ton di n III. CN LM SNG: - Thng qui: huyt - Chuyn bit (ty theo nguyn nhn nghi n ): CRP, Procalcitonine, cy mu , NS1Ag, huyt thanh chn on tac nhn gy b nh , 10 thng s nc tiu v cy nc tiu, cy phn, chc d ty sng, X quang phi, siu m bng, siu m tim IV. IU TR 1. Muc tiu: - H nhit
43. 43. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 2 - iu tr nguyn nhn - iu tr bin chng 2. H nhit: - Phng phap v t ly : cho b nh nhn m c thoang mat , lau mt bng nc m (khng lau mt bng cn v cn c th hp thu qua da v phi gy ng c ), cho b nh nhn ung nhiu nc, ni thng thong. - Thuc h nhit khi tre b t r t , kh chu hoc khi thn nhit > 39oC ho c > 38oC nu tr c tin cn bnh tim mch, vim phi hay st co git: + Acetaminophen: 10 15 mg/kg, ung hoc t hu mn ho c truyn tinh mch, mi 4 6 gi (tng liu: 60 mg/kg/ngy). + Hoc Ibuprofen: 10 mg/kg ung mi 6 8 gi. Khng dung nu nghi ng st xut huyt, ri loa n ng mau, b nh ly th n, tiu hoa, + Dantrolene 1 mg/kg TM khi st c tnh xy ra sau gy m. 3. iu tr nguyn nhn: iu tr c hiu ty nguyn nhn gy st; St v nhim khun khng ng nghia vi nhau nn khng sinh khng nn c ch nh rng ri v vic iu tr khng sinh theo kinh nghim cng cn phi trnh. 4. iu tr bin chng co git (phc x tr co git) V. TIU CHUN NHP VIN: Nn cho nh p vi n khi tre: - Thuc nhm nguy c cao : di 2 thng tui hoc c bnh ly nn (ct lach, b nh tim bm sinh, b nh phi ma n tinh, b nh ac tinh, suy giam min di ch,). - C v mt nhim trng, nhim c hoc ri lon tri gic, co git. - C ban xut huyt, VI. HNG DN CHO THN NHN - Cch x tr khi tr b st v st co git ti nh. - Cc du hiu bnh nng cn khm li ngay.
44. 44. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 3 ST N THUN TR < 36 THNG Tr < 3 thng Tr 3 thng 36 thng Tc nhn - thng l siu vi (40 60%) - Vi khun thng gp: Streptococcus nhm B v Listeria monocytogenes (nhim khun huyt v vim mng no khi pht mun) Salmonella (vim rut) Escherichia coli (nhim khun tiu) Neisseria meningitidis, Streptococcus pneumoniae, v Haemophilus influenzae type b (nhim khun huyt v vim mng no) Staphylococcus aureus (nhim khun xng khp) - thng l siu vi (cn ch y bnh st xut huyt v bnh tay chn ming) - Vi khun thng gp: S. pneumoniae chim 90% cas cy mu (+) N. meningitidis Salmonella H. influenzae type b Lm sng St tr < 3 thng tui khng bao gi l du hiu tm thng; 10 15% tr < 3 thng tui st c tng trng tt b nhim khun nng. Cc bnh cnh lm sng thng gp: - nhim khun huyt - vim mng no - vim i b thn - vim rut - vim xng ty xng - vim khp m - vim tai gia - vim phi - vim rn - vim v - cc nhim khun da v m mm khc. Khong 30% tr 3 thng 3 tui st m khng tm thy nhim khun; Cc bnh cnh lm sng do nhim vi khun thng gp: - nhim khun huyt (khng xc nh c ng vo) - vim phi - vim np thanh qun - vim tai gia - vim h hp trn - vim rut - nhim khun tiu - vim m t bo - vim ngoi tm mc - vim xng ty xng - vim khp m - vim mng no Cn lm sng Xt nghim ban u: - huyt - CRP - cy mu - 10 thng s nc tiu v cy nc tiu Khi tr c v khng khe : chc Xt nghim ban u: - huyt - 10 thng s nc tiu Khi c du hiu nhim trng, nhim c: - CRP - cy mu
45. 45. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 4 d ty sng (trc khi s dng khng sinh) Khi c nguyn nhn nghi ng: lm xt nghim c hiu (KSTSR, chp phi, cy phn, siu m, ) - cy nc tiu - chc d ty sng - chp phi Khi c nguyn nhn nghi ng: lm xt nghim c hiu (KSTSR, siu m, NS1Ag, ELISA Dengue, ) iu tr iu tr ban u: - khi c tnh trng nhim trng, nhim c - hoc khi BC >15.000 hoc < 5.000 - hoc khi CRP > 40 mg/l Vi: - Ceftriaxone: 50 mg/kg/liu mi 24 gi, nu dch no ty bnh thng, hay 100 mg/kg/liu mi 24 gi, nu bch cu dch no ty tng - hay Cefotaxime: 50 mg/kg/6gi kt hp vi: Ampicillin: 50 mg/kg/6 gi iu tr c hiu: ty kt qu cn lm sng v din tin iu tr ban u: khng sinh ty thuc chn on, lm sng MT S BNH L NHIM KHUN NNG C TH GP NHNG C A C BIT B ST N THUN C A NGUY C BNH L Khng suy gim min dch S sinh (40C) Vim mng no, nhim khun huyt , vim phi, say nng, st xut huyt th no St + xut huyt da Nhim khun huyt v vim mng no do Neisseria meningitides, H. influenzae type b, v Streptococcus
46. 46. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 5 pneumoniae Suy gim min dch Bnh tim bm sinh Vim ni tm mc; abcs no do shunt phi - tri Ct lch Nhim khun huyt v vim mng no do N. meningitides, H. influenzae type b, v S. pneumoniae AIDS Nhim khun do S. pneumoniae, H. influenzae type b, v Salmonella KT trung ng Staphylococcus aureus, coagulase-negative Staphylococci, Candida Bnh c tnh Nhim khun huyt do vi khun gram m ng rut, S. aureus, v coagulase-negative Staphylococci; Nhim nm huyt do Candida v Aspergillus Hng cu lim Nhim khun huyt, vim phi v vim mng no do S. pneumoniae, vim xng ty xng do Salmonella v Staphylococcus aureus Thiu b th/properdin Nhim khun huyt do N. meningitidis Agammaglobulinemia Nhim khun huyt, nhim khun xoang v phi
47. 47. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 1 TO BN I. I CNG - To bn l bnh rt thng gp tr em, chim 3% - 5% tng s tr khm ngoi tr. - T l mc bnh: 1% - 30%. - Tui thng gp: trc khi i hc v tn sut mc bnh ngang nhau gia nam v n. II. NGUYN NHN: - Cn phn bit 2 th to bn: chc nng v thc th. 1. To bn chc nng: >90% trng hp to bn tr em l to bn chc nng - L tnh trng i tiu khng ht, tiu khng thng xuyn, kh khn khi i tiu ko di khng km theo bt thng gii phu hc hoc sinh ha. - y l th to bn thng gp nht tr em. - 3 giai on tr d b to bn: giai on n dm, giai on tr tp i toilet, giai on tr bt u i hc. - Cc yu t gy to bn chc nng: + Tr t chi i tiu: Do au: d hu mn, kch thch quanh hu mn, lm dng tnh dc, tr. C : thay i mi trng sng nh chuyn trng, i du lch. + i tiu khng ng cch. + Mt cn bng cm xc. + Chm pht trin tr tu. + Tr khng c tp thi quen i tiu ng cch. + Ch n khng hp l: thiu nc, tri cy, rau c, cht x + Tin s gia nh b to bn. 2. To bn thc th: Chim < 5% tng s tr to bn - Tr chm tiu phn su (> 48 gi sau sinh), c th do: + Tc rut, tc rut phn su, Hirschprung, Tc rut c nng (non thng, nhim trng huyt, suy h hp, vim phi, ri lon in gii), i trng tri nh (thng gp tr c m b tiu ng thai k), M dng thuc trc sanh (MgSO4, thuc phin ), Suy gip (tr vng da ko di, co git, h thn thit). - Ri lon ni tit, ri lon chuyn ha: + H kali mu, H hoc tng canxi mu, Suy gip, Tiu ng, U ty thng thn (Pheochromocytoma), a niu, Amyloidosis, Ri lon chuyn ha porphyrin, Ri lon tch t lipid. - Bnh l thn kinh: + Lit no, Thot v ty, mng ty, Chn thng ty, Khng c xng cng, Chng ct ngang ty, U x thn kinh, Chng yu c, Hi chng Guillaine-
48. 48. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 2 Barre, Lon sn thn kinh, Ri lon thn kinh thc vt c tnh gia nh, Ri lon h ph giao cm mc phi. III. TIU CHUN CHN ON: Theo Multinational Working Teams to Develop Criteria for Functional Disorders (Rome III) 1. Tr s sinh v tr nh: c t nht 2 trong cc tiu chun sau ko di t nht 1 thng: - i tiu 2 ln/tun. - t nht 1 ln i tiu khng t ch sau giai on tr tp i toilet. - Tin s ng phn qu mc. - Tin s au hoc kh khn khi i tiu do phn cng. - Hin din khi phn to trong trc trng. - Tin s c khi phn to gy tc nghn toilet. 2. Tr t 4 -18 tui: t nht 2 trong cc tiu chun sau ko di t nht 2 thng: - i tiu 2 ln/tun. - t nht 1 ln i tiu khng t ch/tun. - Tin s ng phn qu mc. - Tin s au hoc kh khn khi i tiu do phn cng. - Hin din khi phn to trong trc trng. - Tin s c khi phn to gy tc nghn toilet. IV. LM SNG - Tm triu chng bt thng ty sng: gim cm gic v vn ng, l hu mn rng, tiu khng t ch, mt phn x c bu, tng sc t da, bi tc vng cng ct. - Tm bt thng gii phu hc vng hu mn trc trng: mng chn hu mn v tr cao, hu mn lc ch pha trc, hu mn cm lc ch vo m o hoc vo v tr gia bu v l hu mn bnh thng. - Thm trc trng: + To bn c nng: lng trc trng cha y phn. + Du hiu gi bnh Hirschprung: ng hu mn hp, lng trc trng trng, chng bng v chm ln tr nh. - Tm mu n/ phn tr nh nghi bt dung np sa. - Triu chng vim rut: tng trng xu, tiu mu, bng chng. V. CN LM SNG - Xem xt thc hin nu nghi ng c nguyn nhn gy to bn hoc to bn chc nng tht bi iu tr. 1. Hnh nh - Chp i trng cn quang vi barium pht hin bnh Hirschprung: tr nh c to bn nng trong giai on s sinh, tr chm tiu phn su. Nu phim i trng bnh thng, xem xt ch nh sinh thit i trng. 2. Sinh ha
49. 49. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 3 - Tng phn tch v cy nc tiu pht hin nhim trng tiu: tr c ng phn qu mc, tr a n. - Cng thc mu, huyt thanh chn on bnh celiac (IgA antibodies): tr chm ln hoc au bng ti pht. - T4, TSH tm sot suy gip: tr c ng cong tng trng i xung. - Ion / mu: tr c nguy c ri lon in gii. - o nng ch/ mu tm sot ng c ch: tr d thc, pht trin bt thng, sng trong nh c xy dng trc 1950 hoc nh mi sa, anh ch em rut c ngi b ng c ch. 3. Xt nghim khc: - o s chuyn ng ca i trng (colon transit): + Tr chm tiu phn su. + To bn nng trn 1 nm. + To bn chc nng tht bi vi iu tr ni khoa tch cc. - o p lc c tht hu mn trc trng (anorectal manometry): + Tr b to bn kh iu tr. + Hi chng gi tc rut. + Nghi Hirschprung. 4. Gii phu bnh: sinh thit i trng VI. IU TR 1. Mc tiu iu tr - T vn cho ph huynh hiu v bnh v hp tc iu tr. - Quyt nh c nn tht tho gii p ti thi im khm bnh khng. - Gii p khi phn tch t bng thuc (ng ung hoc bm hu mn). - iu tr duy tr nhm to lp v duy tr thi quen i tiu ng (tiu t nht 3 ln/tun, phn mm, v khng cm gic kh chu khi i tiu) 2. Nguyn tc iu tr - Thuc nhun trng, - Tp thi quen i tiu ng cch, - Thay i ch n - Ch theo di. 3. iu tr c th - Tr nh: + Thuc nhun trng thm thu thng dng: lactulose, sorbitol. + Polyethylene glycol khng c b sung in gii (PEG-3350, Micralax) bc u nghin cu cho hiu qu cao v an ton. + Mineral oil khng c khuyn co s dng tr nh v nguy c vim phi do ht sc (chng c 1C). + Tht tho v thuc nhun trng kch thch cng khng c khuyn co s dng (chng c 1C). - Tr ln: + T vn bnh nhi v ph huynh:
50. 50. PHAC O IEU TR BENH VIEN NHI ONG 2 2013 4 Thi quan tm n bnh. iu tr cn c s phi hp gia: bnh nhi, cha m v thy thuc. Ph huynh khng nn la mng hoc pht tr khi tr tiu phn cng. Gii thch ph huynh s cn thit v tnh an ton ca vic dng thuc nhun trng lu di. Nn c bng ghi ch qu trnh i tiu v dng thuc ca tr. Qu trnh iu tr ko di t 6 thng n nhiu nm. To bn nng: cn c s h tr ca nh trng v gio vin nh: Cho php tr i tiu khi c nhu cu. Cho php tr mc qun o thoi mi. + Phc hi nhu ng rut: Lm trng trc trng: Thuc ung: dng cho tr au khi i tiu, chn thng vng chu hoc tr khng chu bm hu mn. o Polyethylene glycol (PEG) khng in gii (PEG 3350 - Miralax): 1 1,5g/kg/ngy x 3 ngy, pha vi 10ml/kg nc ung hoc nc tr a thch. o Polyethylene glycol (PEG) b sung in gii: 25ml/kg/gi cho n khi sch phn, ti a 1000ml/kg/gi. Hoc 20ml/kg/gi x 4 gi/ngy (Chng c 2C). o Mineral oil: 15 30ml/1 nm tui, ti a 240ml/ ngy. o Thuc khc: magnesium hydroxide, magnesium citrate, lactulose, sorbitol, senna, and bisacodyl. Thuc bm hu mn: hiu qu hn ng ung. o Phosphate sodium: 30 ml cho tr 2 -