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VAI TR CA SIU M DOPPLERTIM TRONG CP CU
VIN TIM MCH VIT NAM
BS. NGUYN TUN HI
[email protected]@bachmai.edu.vn
TRNG I HC Y H NI
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I CNG
Emergency Medicine Clinics of North America, Volume 22, Issue 3, August 2004 , Pages 621-640
1980: Lnutin p dngSiu m Doppler tim cp dnglnutikhoa cpcu Hoa K.
Thmd khng xm nhp(hocxmnhptithiu), c ththchinnhiu
ln. Thng tin thu c: nhanh, chnh xc
Khng dn tri, tptrung vo mctiu
chnh Huhtcc trnghp: S 2D, +/-
phihpvi Doppler nhgi huytng
Chnonnhngtnhhung
lmsng trmtrng
nhhng
cho canthipiutrngay tckhc
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CH NH LM SNG CHNH: Pht hin dch mng tim, tm du hiu p tim
nh gi chc nng tim trong trng hp ngng tunhon
nh gi chc nng tht tri
nh gi chc nng tht phi
Pht hin phnh tch MC ngc on gn
Tnh trng thiu oxy ko di
Ti u ha iu tr: thc hin th thut di hng dnca siu m.
CH NH LM SNG
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MT S CH NH C BIT:
nh gi p lc y tht: tha dch/thiu dch
Chn on ph phi cp huyt ng hay tn thng
Ti u ha iu tr vn mch trong sc nhim khun
CH NH LM SNG
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Chn thng
Ngng tun hon
Tnh trng sc, hoc huyt ng khng n nh
au ngc
Suy h hp cp
Thiu oxy ko di, khng p ng vi iu tr
Hng dn t dn lu mng ngoi tim
TNH HUNG LM SNG
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Btnvhuytngkhng r nguyn nhnSc
Ph phicp
S Doppler cpcu+/- Cmtay
Mtcttithiu: dibsn, tmmtim
Dchmng tim (+++)p TP/NP, Gin TMCD
TP gin, kovnng
TT gim/khngvnng
Tim tngng,TMCD xp
PTIMCP
TCNGMCHPHI
SUY TIMCP:
Nhimu ctimVim ctimNhimc
GIM THTCH TRMTRNG: chy
mu trong?SC NK?
KHC?
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Siu m Doppler qua thnh ngc:
Pht hinccbtthngcutrc v chcnngtim.
Kh khn: Hnh nhqua thnh ngcm mtct
dibsn.
Siu m Doppler qua thcqun: (ch chngchnh)
Bnhnhn chnthng, achnthng
Bnhnhn sauphuthutTm kimcc lungthng trong tim
Trcscinchuynnhp: loitrhuytkhi
nhgi hotngcavan nhn to
CC HNH THC S DOPPLER
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S qua thnh ngc : u tin s 1, d thc hin, d lpli, thng tin nhanh chng
S qua thc qun > S qua thnh ngc: Chn thng ngc kn Bnh nhn thng kh nhn to Bnh nhn sau phu thut tim, v sau phu thut
chung Bnh l c nguy c gy thuyn tc t tim
LA CHN HNH THC S NO?
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Pht hin c dch mng tim v bit cch chn on
tnh trng p tim
Pht hin tnh trng gin, suy chc nng tht phi o kch thc tnh mch ch di v nhn nh
Pht hin ri lon vn ng vng ca tht tri, v
nh gi chc nng tht tri.
YU CU TI THIU
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CC YU CU V K THUTSIU M DOPPLER
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1. u d t cnh c tri: Mt ct trc dc
Mt ct trc ngang
2. u d t ti mm tim Mt ct 4 bung
Mt ct 5 bung
Mt ct 2 bung
3. Ca s d-i mi c Mt ct 4 bung
Mt ct trc ngn
4. Ca s trn hm c
MT S MT CT THNG QUY TRNSIU M QUA THNH NGC
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Mt ct
4 bung
Mm timD-i b s-n
Mt ct
trc dc
Cnh c tri
Mt ct
trc ngang
S MT S MT CT THNG QUY
Mt ct
trn hmc
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MT S MT CT THNG QUY TRNSIU M QUA THC QUN
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2D: gii phu cc bung tim, hot ng van tim TM: Chc nng tim theo p/p Techolz, b dy thnh tim
Doppler xung: Dng chy c V = 2 3 m/s. Dng o cung lng
tim, dng chy qua cc van tim.
Doppler lin tc: Dng chy c vn tc cao. Dng trong HoHL,
HoC, hot ng van nhn to, ALMP.
Doppler mu: nh gi c thay i v gii phu v huyt ng.
Doppler m c tim: nh gi chc nng tim, p lc y tht,
pht hin mt ng b
CC KIU SIU M DOPPLER
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CH NH CA CC MT CT SCHNH MTCT S NHNNH
Pht hindch Di bsnTrc dc cnh c
Nhanh nht, dtipcnnhtPhn bitdchmng tim v mng phi
ChcnngTP Trcdc cnh c4 bung t mm
nhgi vnngvngSo snh kch thcTP/TT
ChcnngTTton b
Trc dccnh c ochcnngtrn TM theo Teicholznhgi tnh trngvan hailas
Hotngvan tim Mt ctt mm nhgi ddng viDoppler mu, xung
nhgi thtch 4 bungdi bsn, TMC di
Thay itheo h hpcaTMC dinhgi thtch TT cuitm trng
Sc/Ttp Dib sn,Trc dc cnh c
nhgi MC, mng phi, dch bng
BnhMC cp Trcdc cnh ccao, 2 bung tmm, trn hm c
Gin MC ln (> 40 mm)Tch nimcMC ln, quai MC, MCxung
Ngngtim Dibsn Nhanh nht(di10 giy): Dch, v tmthu, gimngTP
Emerg Med Clin N Am 29 (2011) 759787
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Dd
Ds
Phngphp Teicholz
Phngphp Simpson
NH GI CHC NNG TM THU THT TRI
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Nh tri Din tch Th tch
Dng chy qua van hai l Sng E, A v t l E/A Thi gian gim tc sng E
Dng chy qua TM phi Sng S, D, Ap
Doppler m qua vng van hai l
NGHIN CU V HUYT NG
nhgi p lcythttri
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Dng chy qua van hai l:
E/A > 2(BT >1)
DT < 130 ms (BT > 150 ms)
Dng chyqua tnhmchphi: dApdAm > 20 ms(BT < 0)
Vntclan truyndng yqua van hai l:
Em /Vp > 2,5 (BT < 1,5) Vntcvng van hai l:
Em/Ea > 15(BT < 8)
NHNG THNG S CH RA TNH TRNG TNGP LC Y THT TRI
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p lc tht tri
p lc nh tri
0
E A Dng chy qua van hai l
Dng chy quaTM phiApDT
79+-26 cm/s 48+-22 cm/s
184+-24 ms 19+-4 cm/s
E/A =1,7+-0,6
A p su
DT
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TM chdi:K < 11.5 mm/m2
xp> 50%
BN bthadch:p lcycaop lcnhphi= 15 mmHg
TM chdi:K > 11.5 mm/m2
xp< 50%
BN khng bthadch:p lcythpp lcnhphi= 5 mmHg
P LC Y TIM PHI
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TNH MCH CH DI
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TNH HUNG LM SNG
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VAI TR PHT HIN CA SIU M: Ri lon chc nng tht tri
Ri lon y tht:
Gim th tch tun hon
Ri lon chc nng tht phi
Bin chng van tim cp tnh p tim cp do TDMNT
SC, TT P
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RI LON CHC NNG THT TRI
NGUYN NHN:
Hichngvnh cp
Gimthtch tunhon nghim trng
Rilonnhpkhng kimsot c
Tnthngctim khng do thiumu ccb
Vim ctim cp
Cpcungngtunhon ko di
Thiuoxy trmtrng, toan mu trmtrng
Do thuc: qu liuchnb ta, chncanxi
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RI LON CHC NNG TM THU THT TRI
THNG S SIU M DOPPLER:
Phn stngmu thttri (EF): Teicholz, Simpson
Cung lngtim (CO, CI): CI = 2,54,2 l/ph/m2
Chschcnngctim (Tei index): TI < 0,4
Chcnng EF
Bnh thng 55%
Gimnh 4554%
Gimva 3044%
Gimnng < 30 %
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RI LON Y THT TRI
NGUYN NHN:
Mtthtch tunhon do nn, xuthuyt, achy
Ti phn blidchtrong lng mch: scphnv, sc
nhimtrng, tngp lctrong lngngc
Mtthtch tunhon vo khoang th3: ph ton
thn, cchng.
Phihpgiagimchcnngtm thu/rilony
tht: NMCT cp
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GIM TH TCH TUN HON
THNG S SIU M DOPPLER:
Kch thctim: nh, tngng.
ChsE/A qua van hai l: E/A < 1
K TM chdithay itrn 50% khi h hp
A.Chenzbraun, Emergency Echocardiography, 2009
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TRONG THC HNH LM SNG:
Trcmtbnhnhn ttp, E/A c vai tr quan trng:
E/A < 1: BN c gimthtch tunhon (ngay ckhi c phihpRL chcnngthttri).
E/A > 1: t khnnghn.
E/E: c gi trtrong nhgi p lcythttri
Hnch: Khng nhgi cchnh xc khi:
Nhptim qu nhanh hocqu chm Rung nh
E/A thay itheo tui
Bnhvan hai l
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TthuytpGimcung lngtim
E/A < 1 hocE/E < 8
PLC Y TT
E/A > 1 v/hocE/E = 8 - 15
E/A >> 1 v/hocE/E > 15
DT < 140 ms
GIM THTCH TUN
HON
PLC Y TT
PLC Y TT
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P TIM CP
THNG S SIU M :
Chnondchmng tim: khongtrngsiu m
Chnontnh trngp tim trn siu m:
Duhiuxpthtphi, nhphi
TM chdigin, khng thay itheo h hp
Thay isng E van hai l > 20% theo h hp
Slng KTSA(sau TSTT th TTr)
ctnhlngdch
T < 10 mm < 300 mlVA 1020 mm 300700 ml
NHIU > 20 mm > 700 ml
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TDMT t
TDMT va
TDMT nhiu
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1. Siu m tim hng dn chc dn lu mng ngoi tim
- u d siu m t di b sn hoc mm tim,
gip xc nh v tr chnh xc v hng i ca catheter.2. Siu m cn m c thc hin khi:
Dch mu ng
Nghi ng kim chc i qua vch tim vo trong bung tim.
S dng NaCl 9 + 0, 5ml khng kh to bt cn m, bmqua kim chc d trong khi t u d siu m:nu bt cn
m khng xut hin trong khoang mng ngoi tim m xut hintrong bung tim:chc qu su vo trong bung tim:nhnhng rt kim, dng th thut, hi sc tch cc:chuyn
phng phu thut m mng tim ti thiu.
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BNH CNH LM SNG:
Thiu oxy khng p ng vi iu tr, khng c km
theo bnh l ti tim v phi.
Cn tm tn ti l bu dc vi shunt phi - tri
PHNG THC SIU M:
S cn m qua thnh ngc
S qua thc qun
THIU OXY
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BNH CNH LM SNG:
Ph phi cp ko r nguyn nhn, au ngc, ngt
Tm ting thi mi xut hin, hoc ting van nhn to
CC THNG S SIU M DOPPLER:
Dng h van tim trn Doppler mu
Tht tri: tng ng
Tng p lc MP, TP c th gin, gim ng
Chnh p qua van o trn Doppler lin tc
Nguyn nhn: thng phi lm S qua thc qun
BNH L CP CU CA VAN TIM
NGUYN NHN
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NGUYN NHN:
Van t nhin
H van hai l cp do:
t dy chng ct c t pht/do vim NTMNK
Thng l van
Bin chng cp ca NMCT
H van MC cp do:
Vim ni tm mc nhim khun
Tch thnh MC Stanford A, chn thng
Van nhn to Van c hc: Tc nghn van do cc mu ng, pannus,
si. H cnh van
Van sinh hc: H cnh van. Thoi ha van. Si van.
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tdy
chngVHL
Hvan MC
do si
HcnhVHL
chc
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NH GI CHC NNG VAN NHN TO
THNG S SIU M:
Doppler mu: nhgi dng hqua van nhn to
Doppler lin tc:
Chnh p trung bnh qua van
Thigian bn gimp lc(PHT)
Dintch lvan hiudng
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NH GI CHC NNG VAN NHN TO
GII HN BNH THNG:
Van ngmchchnhn to
Van hai l nhn to
Vntctia(m/s)
Chnh p trung bnh(mmHg)
Dintch lvan(pt lin tc: cm2 )
1,44 530 1 - 3
Vntctia(m/s)
Chnh p trung bnh(mmHg)
PHT(ms)
1,22 18 60 - 160
AU NGC V HI CHNG VNH CP
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CH NH SIU M CP CU:
Khng c s tng hp gia lm sng, T v cc du n sinhhc.
T hoc cc du n sinh hc khng r rng khng nh hay
loi tr HC vnh cp.
au ngc cp + huyt ng khng n nh
VAI TR CA S CP CU:
Chn on v tr ri lon vn ng vng
nh gi mc nng: RL vng nng, EF gim
Pht hin cc bin chng c hc, hoc bnh phi hp
AU NGC V HI CHNG VNH CP
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tctcl
trcVHL
Thngvchlin tht
Vthnh t
do thttriA.Chenzbraun, Emergency Echocardiography, 2009
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VAI TR CA SIU M:
Pht hin:
Tch thnh MC: v tr, lan rng
Huyt khi trong lng MC Lot thnh MC
Cc thng s khc:
Mc gin ca MC
Mc h ch (Stanford A)
Dch mng tim, dch mng phi
HI CHNG MC CP
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European Journal of Echocardiography (2009) 10, i31i39
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VAI TR PHT HIN CA SIU M:
Ch cn S cm tay.
Pht hin nhanh nhng nguyn nhn c th gii quyt
BN c ngng hot ng in hc tim:
Tc mch phi
p tim cp
Trn kh mng phi p lc
Mt th tch tun hon (v phnh MC, chy mu nng)
TRONG V SAU HI SINH TIM PHI
BS HSTP
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BS.cpcuHSTP yu cuS cpcu
TiptcHSTP
Btmy SChunbud
Dng5s khi
cy. cu
Btuiutrchiu
NgngHSTP
TiptcHSTP
Yu cudngp tim, nhgi nhanh
Dchmng tim, thtphi, thttri
tud vo mtctdibsntud thcqun(BN tng)
Dchmng tim va: p timTP gin, gimng: TcmchphiTT nh, tngng: GimV tunhon
TT gin, gimng: RLCN TT nng
Bs.cpcuhisinh tim phi BS. siu m tim
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Siu m Doppler tim trong cp cu:
Nhanh chng thc hin
Khng cn my S nhiu chc nng (ch cn S cmtay)
Khng cn kho st t m
C hiu qu rt cao:
Cu tnh mng bnh nhn
Trnh sai lm khi cp cu
Yu cu:
Cn c o to
KT LUN
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