Tài liệu ôn tập cho kỳ thi tuyển viên chức ngành y tế năm 2017 giao trinh gay me gay te i flie 3

NHUN G TIE {)eHU-XN-Q-u-6-c-TE---V-E--kNl6*N~-------7~~-ITRONG GAY ME HOI

sue

JVI~/Clieu hoac t(lp:

d

Trinh bay duoc tdm quan trong va muc tieu cua nhiing tieu chudn quoc

1.

v~ an toan trong gay me h6i sire.

Trinh bay duoc nhiing tieu chudn tong quilt v~ an toan trong gay me h6i

2.

sue.
J.

Trinh bay dirac nhiing quy dinh

C1;l

thi vean

{a

an trong gay me h6i sire.

l.D~ICUONG
Ml)C

tieu cua nhfrng tieu chu~n quoc tS v~ an toan trong gay me hbi sire la

d~ huong d~n, giup
quan

eta chuyen gia gay me, cac hoi chuyen nganh, nhirng nguoi

1y cac benh vien va chinh phu cac nuoc trong viec cai tien chftt hrong va an

toan trong cong tac gay me h6i sue.
D&i voi mot s&chuyen gia gay me, nhfrng tieu chuan nay la muc tieu phai
huang toi trong tuong 1ai,trong khi d&i voi nhirng chuyen gia gay me khac
chung ta dil duoc xay dung d~y dl\ rbi va duQ'c coi nhu 1a npixng khuySn eao

et~

thvc hi~n. NhiIng tieu chu~n quan tn,mg nhftt lien quan dSn con nguai gay me.
Cae d\mg .C\lki~m bao (monitoring) gifr mQt ph~n quan trQng cho SlJan toan cua
gay me vi 1anhUng phuong ti~n

rna rQng cho nhUng k9 nang

lam sang hem la d~

thay thS cho nhUng k9 nang fty.
Nhung tieu ehu~n t6i thiSu co thS ling d\lng duQ'ctrong nhfrng ca gay me
co kS ho~ch truac til vi~c danh gia b~nh nhan dSn giai cto~n h6i tinh. Tuy nhien

c~n hiSu r~ng nhfrng bi~n phap cftp Clm Iuon Iuon phai duQ'c thlJc hi~n

Uti

tien

trong tinh hu6ng kh~n cftp. NhUng khuyen cao them d.n duQ'c thvc hi~n khi
phuong ti~n va kha nang dao t~o cho phep: nhfrng tieu chu~n vai khuySn cao

63


va cuoi cling la nlnrng tieu chuan duoc khuyen khich ap dung.
C~n noi tnroc rang nhirng tieu chuan nay c~n phai diroc xem xet lai khi
trong thirc hanh va ky thuat co sir tien bo.

2. NHUNG TIEU CHuAN TONG QUAT
2.1. Dja

vi ngh~

nghi~p

Thuc hien vo cam la mot cong viec sinh nr trong cham soc sire khoe co
ban va xirng dang duoc chia se nhfrng tai nguyen tuong xirng hien co.Chung ta
khuyen cao manh me rang Bac si gay me phai duoc huong luyen d~y du va phai
duoc xac nhan la chuyen gia y t~ co dll qUYSnhan ve Him sang va hanh chinh.

o

nai nao rna vo cam diroc thirc hien boi mot nguoi khac thi can duoc khuyen cao
rnanh me rang nguoi gay me ~y phai duQ'c hu~n lUY9nm<)t ca.ch thich dang,
duQ'c xac nh~n, dieu khi~n va giam sat boi m9t chuyen gia y t~ co d~y du tu
cach va kha nang chuyen mon vS gay me.
2.2

TB chrrc

ngh~ nghi~p

Cac chuyen gia gay me nen h9P thanh t6 chu'c 0 cac vung, dia phuong hay
c~p qu6c gia d~ dua ra nhUng tieu chw1n hanh nghS, giam sat cong tac hu~n
luy~n, dao t(;10liefl tl,lc, c~p chUng chi, xac nh~n va thuc d~y cho cong tac gay me
nhu'm<)t chuyen nghanh dQc l~p. Cac t6 chuc nay c~n lien k~t v6i cae t6 chtl'C
gay me khac trong vling, trong nuac hay qu6c t~.
2.3. Hu~n luy~n, chung chi va

X3C

nh~n

Phai co du thai glan va phuang ti~n danh cho cong tac dao t(;10,ea dao t(;10
ban d~u va dao t(;10lien t\lC d~ dam bao r~ng nguai gay me d(;1tduQ'c d~y du va
duy tri duQ'c tieu chu~n thong th(;1ove khi~n thuc, thanh th(;1ovS th\1'c hanh. C~p
chUng chi chinh thuc vS dao t(;10va xac nh~n d~ hanh nghS la cong vi~c c~n lam.
2.4 Ghi chep va th6ng

ke

C~n ghi chep nhfrng chi ti~t 1a di~n ti~n cua mQt cUQcgay me va luu trfr

chung vai h6 sa b~nh an. Ghi chep bao g6m ca nhfrng danh gia truac m6 va
nhfrng di~n ti~n sau m6. Nhfrng ea nhan, cac khoa - bQ mon, cac hQi gay me dja
64


phuong va toan quoc nen thu tn?p cllc aln(i~n-cf~ tao ~91 thuariIoi cho S\Itf~~i

,

j

bQ vi: an toan, hiru hieu, tinh hieu qua va phil hop cua g~y me.
I

i
I

2.5. Rit soat
Nhirng t6 chirc cap vien, cap vung va cap quoc gia phai duoc thi~t lap d~
!

'

cho phep viec ra soat lien tuc cong tac thirc hanh gay me. Nhlrng buoi thao luan
co tinh each rieng nr voi dong nghiep v~ nhimg vfm d~ qhuyen mon, nhtmg ca lam
,

,"'\

sang can thuc hien dinh ky, deu ~.

baa

'1

)

?

"

Can phat trien nhtrng itochirc, nhirng qui trinh de

dam rang nhirng sai sot v~ nghe nghiep cua ca nhan vai!?p th~phai diroc nhan bi~t

va sua chira. Nhirng baa cao cac tai bi~n (khong neu dic~ danh) phai khuy~n khich
nhu Ia mQt phucmg cach huu feh trong vfm d~ nay. Phai ~o nhUng baa dron an toan
thich dang v~ m~t Iu?t phap cho tinh each bi m?t Cllanhupg tai li~u ra soat miy va

a

nm nao chua co !hi dm c6 giing th\IChi~ncho duCJc.
2.6. KhfJi hrQ'ng cong vi~c
Phai co au s6 lUCJIlgchuyen gia gay me da aUCJerhu~n luy~n d~ h9 co th~
,
!

h~mhngh~

a trinh

aQ cao, phai co thai gian danh cho ~\I phM tri~n ngh~ nghi~p,

cong tac hanh ehinh, nghien CUukhoa h9C.
2.7. Nhan Sl!
MQt nguai gay me cham soc cho mQt b~nh nha¥ va phai co m~t trong su6t
./)

thai gian vo cain - gay me, gay te ho~c an th~n c6fheo d6i va phai chiu trach
nhi~m v~ vi~c di chuy~n b~nh nhan v~ phong h6i tinh r6i chuy~n giao vi~c cham
soc b~nh nhan eho nhan vien da du9'c huck luy~n thu~n thvc. Ngum gay me con phai
chiu trach nhi~m v6i b~nh nhan trong sU6tthm gian h6i tinh va phai sfuI sang co m~t
d~ hQich~n cho d~n khi b~nh nhan tinh hoan toanoChuyen gia gay me phai dam baa
r~ng, n~u vi~c cham soc tf\ICti~p b~nh nhan truac va trong gay me duCJcgiao cho
ngum khac thi ngum nh?il trach nhi~m du9'c giao phai la ngum th\ICS\Ico kha nang
va nfun b~t du9'c thong tin lien quan d~n gay me va b~nh nhan .

6 noi

nao rna nhung tieu chu~n tren day khong th~ d~t du9'c va Bac

Sl ph~u thu?t ho~c m<)t. nguai

khac dam nh?n trach nhi~m vo dun thi

du9'c khuy~n cao m~nh me la vi~c thvc hanh va nhfrng ca gay me phiii
65

-

duVc-x-eTI1-xet-l-~-v-a-th-i-ITIT-th-mrn-g~dm;rc-ki-¬ -m-traiJ 6't-l1n)tciiuyen-gi agay":

me

d~ duoc hu~n luyen dung mire.

2.8. Phuo-ng ti~n va trang thi~t

hi

B~t cir noi nao co thirc hien gay me va cham soc benh hoi tinh d~u phai co
phuong tien va trang thiSt bi dung mire, ca v~ s6 hrong va chat hrong,
M9t danh sach nhirng trang thiSt bi khuyen dung va nhfrng goi

y xep thea thir tu

c~n them vao khi dieu kien cho phep se diroc trinh bay 0 phan phu I\lCB.
Chung toi khuyen cao manh me rang nhirng thiet bi gay me phai phu hop
voi nhfrng tieu chu~n tarn cO' quoc gia va quoc tS.
Viec cap chirng nhan chinh thirc cho mot ca nhan co kha nang sir dung
mot bo phan rieng biet cua trang thiSt bi mot each dung d~n va an toan 1a dang
khuySn khich.

3. CHAM

soc TRUaC,

TRONG, SAU GAY ME (GAY TE)

vA KlEM

BAo MONITORING
3.1. Cham soc quanh gay me, gay

te

Vi~c d~u tien va quan tr9ng nh~t trong v~n d~ cham soc quanh me (te), k~
ca v~n d~ ki~m bao h~ th6ng me va b~nh nhan, la SlJ hi~n di~n lien t\lc eua 1119t
chuyen gia gay me th?n tn;mg trong su6t thai gian 1116.

3.2. Cham soc trU'O'cmS
Chuyen gia gay me phili luqng gia b~nh nhan tru6e khi khoi me.
Chuyen gia gay me phai bao dam r~ng t~t ea cac trang thiSt

bi

c~n thi~t

d~u 0 vj tri va tinh tr?ng ho?t d9ng t6t truac khi khoi me. Nen tri~n khai nhl1ng
quy trlnh giup cho cong vi~c ki~m tra ~y duQ'cd~ dang.
Chuyen gia gay me phai ch~e eh~n la da:s£n sang co S\I trQ'giup va nguai
trq giup da:dUQ'ehu~n luy~n d~ lam ho~e co kha nang lam duqc nhfrng nhi~m vt)
e~n thiSt.

3.3. Ki~m bao trong gay me
3.3.1. S., bao hao oxy
3.3.1.1. NguBn cung cAp
KhuySn cao m?nh me: MQi b~nh nhan duQ'cgay me toan di~n c~n phai duQ'c
cho them oxy. Chuyen gia gay me phai bao dam to~mv~n cua ngu6n cung dp oxy.
66

}(hi N20 h-o~cmQt ngu6n hoi nao khac diroc sir d\lng, pnaTKi~m tra nong

dQ oxy trong khi tho VaGit nhat la trong giai doan khoi d~u cua m6i cuoc gay
me. N6ng dQ hit VaGcua oxy duoc thea doi trong m6i cuoc gay me voi mot
dung cu duoc gang voi bQ phan bao dong nong dQ oxy thap (khuyen cao manh
me). SU dung thi~t bi bao dong thi~u oxy va mot dung cu bao v~ chong lai
nguon h6n hop hoi me thieu oxy diroc khuyen cao manh me. Nen dung h~ thong
ngan ngira viec gang nh~m cac nguon hoi (khi).
3.3.1.2. Tinh trang bao hoa oxy ella b~nh nhan
Tinh trang bao hoa oxy m6 c~n duoc theo doi bang m~t m6i khi co th~
duoc, C~n chac ch~n la co du anh sang va b~nh nhan duQ'cbQc lQ du quan sat tru
khi co su d\lng mQt d\mg Ct,lki~m bao thich Ung.
Vi~c su dt,lng lien tl,lc mQt may do tinh tr~ng bao hoa oxy nhu may do
oxy-m~ch (pulse oxymetry) duQ'ckhuy~n cao m~nh me.
3.3.2. Dmrng tho- va sl! thong khi
Tinh tr~ng thong duemg tho va

Sl,l'

thong khi d~y du phai dUQ'cthea d5i

lien tl,lcb~ng cach quan sat va su dt,lng6ng nghe m6i khi co th~ duQ'c.
Noi nao co au h~ th6ng d~n hoi me thi phai thea d6i ho~t dQng cua bong dV trll.
Vi~c thea d6i lien tt,lCvai 6ng nghe truac tim, truac khi quan ho~c 6ng nghe
thlJc quan duQ'ckhuy~n cao m~nh me.
Chung toi cling khuy~n cao m~nh me vi~c
oQ va

su dl,lng lien tt,lCmay do n6ng

tpeo _QQi~Qng_CQ2-_tr_i~lLma.Il..hl@ ..dA.xac. _Qj_~.'V_Lt~i
.c!~~g eila &ng nQi khi
~~g:

~.~au_~L~~t

Khi dung may tho phai co d\mg ct,l bao dQng <sut 6ng> trong su6t thai
gian may tho.
Nen dung may do lien t\lc luc;mgkhi hit VaGho~c tho ra.

3.33. Tu~n hoan
3.3.3.1.T~n sB va nhip tim
Tinh tr~ng tu~n hoan c~n duQ'c theo d6i lien tl,lc, phai lien tl,lc b~t m~ch
(ho~c thea d6i mc:tchduQ'c ghi tren man hinh monitoring) ho~c lien t\lC nghe
ti~ng tim.Theo d6i lien t\lCt~n s6 tim vai d\lng C\ldo m~ch (vai Plethysmograph
ho~c pulse oxymeter) ho~c di~n tam d6 duQ'c khuy~n cao m~nh - nh~t thi~t phai

co may phi

rung (defibrillator).
67


---~--~J.J.l.-2.-Sv-t-1f0l--m~au
mo------~··· ---- - ~-----------~~-.~
Phai thuong xuyen quan sat lam sang xem mo co diroc

..~-- ..-~---~---

tum mau du hay khong.

Ki@mbao lien tuc voi dung cu do mach (Plethysmograph) hoac voi Capnograph
diroc khuyen cao manh.
3.3.3.3. Huyet ap
Huyet ap phai diroc xac dinh

V3.0

nhirng thai khoang thich hop (thong

thuong it nh~t la nam phut mot l~n va neu tinh trang Him sang c~n thi phai do
thuong xuyen han).
Khuyen khich viec ghi huyet ap thirong xuyen trong cac tnrong hop can thiSt.
3.3.4. Nhi~t

oQ

, Phai co phuang tien do nhiet 0(>va sir dung thirong xuyen 0 nhfrng ca co
chi dinh Him sang (vi du: gay me keo dai hoac phirc tap, tre em .... )
Khuyen cao manh: do thuong xuyen nhiet d(>cho nhirng benh nhan rna SlJ thay
dbi nhiet d(>diroc tien doan tnroc la do c6 y ho?c nghi nga.
Nen co s~n dS S11 d\lng d\lng C\ldo nhi~t d(>lien t\lCb~ng di~n tu.
3.3.5. D(} me
Thuang xuyen danh gia d(>me b~ng cac phuang ti~n lam sang khuy~n
khich do lien t\lC nbng d(>hit vao va tho ra cua N20 va cac thu6c me b6c hO'i.
3.3.6. Chu-c nang thftn kinh CO'
Nen dung may kich thich th~n kinh ngo?i bien khi S11 d\lng thu6c gian cO'
4. CHAM SOC SAU KHI GAY ME (POST-ANESTHESIA

CARE)

4.1. PhUO'Dg ti~D va DhaD sl!
T~t ca cac b~nh nhan da dugc cho thu6c me co anh huang dSn chuc nang
th~n kinh trung uang vaJhO?C m~t phan X? bao v~ c~n dugc luu giG' 0 noi da
dugc gay me ho~c chuy@nd~n nai danh rieng cho hbi tinh sau me.
4.2. Ki~m bao

MQi b~nh nhan c~n phai dugc quan sat va theo doi m(>tcach thich dang
tuy theo tinh tr?ng cua chuc nang th~n kinh, cac d~u hi~u sinh tbn, tinh tn;mg
lam sang vai Sl! chu

y d~c bi~t: d~n dQ bao hoa

oxy, Sl! thong khi, va tu~n hoim.

Cung vai Sl! theo doi v~ Him sang nen su d\lng them cac may do nhu da mo ta 0
tren. D~c bi~t nen S11 d\lng d\lng C\l do oxy m?ch (pulse oxymeter).
68


---

.-~------~------ll-

PHT) Ll)C
TRANG Bl CAN THIET-NHUNG

YEU

cAu co

BAN

D~ gay me:
Bao gom gay me tinh mach, gay me vung va gay me ho h§.p (nhfrng

ky thuat

gay

me ho hoac binh b6c hoi loai draw-over thich hop),
D~ theo doi b~nh nhan

Ong nghe
May do huyet ap
Nguon sang
Nhi~t

D~

hA

Xu

Iy duong

kS

trg b~nh nhan

ho hfip

Ong thong duong thotalrwaysj.mat na
May hut
Den soi thanh quan.cac 6ng noi khi quan
Bong tv ding (self inflating bag)
Nguon duong khi

H6 trg

tu~n hoan Kim tiem, 6ng tiem, catheter, dich truyen

Thu&c di~u tr]: Ole thuoc phil hop cho nhirng tnrong hop kh~n thong thirong
va cap ciru ho hip, tuan hoan.
NHiJ'NG YEU
D~ gay

cAu TRUNG

me

BINH (intermediate

requirements)

Nguon khi nen: 02,N20
Binh b6c hoi co khac nong d<)
H~ thong d~n hoi me

D~ theo dfii b~nh nhan

Dung cu bao dong khong du Oxy
May phan tich Oxy (Oxygen analyzer)
May do d<)bao hoa Oxy(Oxymeter)
May do CO2 (Capnometer)
ECG

f)~

hB trg

b~nh Dhan

NHUNG YEU

May pha rung

cAu TOI

UlJ(Optimal

repuirements)

D~ gay me: May gay me co trang bi nhUng b<)ph~ theo doi hoc;ttQ<)ngcua may
Gian ca
D~ then doi b~nh nhan

V S Quang tho/thong khi

Capnogaph
Do th~ tich ho h§.p
69


MA.YTHO
M I;lc tieu hoc t~p:
1. -Trinh bay duoc each phdn loai may tho, co chi hoat dong va cac bo phdn co
ban cua may tho:
2. Trinh bay duoc nhiing anh huong tren cdc co quan khi thong khi nhdn tao.
3. Trinh bay duoc cdc kiiu thong khi nhdn tao biing may tho thuong dung.
4. Trinh bay duoccac chi dinh tho may.
5. Trinh bay duac each thea doi benh nhdn tho may.
o

>

•

1. PHAN LO~I MAy THO

vA co CHE HO~ T DONG'

Co nhi~u each phan loai may tho, nhung

dQ:p

gian nh~t la ta chia lam hai

l<.~~i_la[f~.~l_~i:2~;\IIttlvaOo?i

-th~tich]
1.1. Lo~i ap sufit
May nay hoat dong tren nguyen t~c la k-9iphoi oa dat mot ap luc guy dinh

tbi lUll Im;mg ~i t6ng .vaong~.!S dichuyen. Dac oi~m co ban cua may ap sw1t la
neu h~ thong di vao benh nhan co ho chut it thi no dua den au th~ tich khi, ngoai
trtTh6 qua nhiSu, no. khong th~ oao qua tbJ th6 ra rna kllong 'au ap.lvc trong ph~
nang. Ngu
* UU
TT.
uIem:
oJ'~

- C~u t?O qon gian, ggn nh~.
- D?t t~t ea cae yeu e§u cua phuong phap oiSu tri ho help hi~n t?i n@uouqc g~n
them cac b(>ph?n di~n ttT.

* Nhu9'c aiim
- T6n oxy_ngo?i tm su dVng khi nen.
- Khi oi~u trj lau~
--,

.~.

khonE nen dung may ap su~t.
~--_

..

._~

- -_.

-.

~ .•• ~ __

•• ~ .-J

1.2. May th~tich
Cac may nay ho?t o(>ngtren nguyen t~c la ~~!]h

rillan m.Ql!bS tich kh!

~_ diIlI:Ltruac.ThS tich khi nay do tui x~p, bong, ho~c long xilanh co pit tong
70


cung c~p.1Zni-dTI'a11-irttr~Ltch-va-o-h~f.!h-nhaTI-thi-e-a0-1:1~~~~~1:~!~-::-yL~i-trhc_~---

~~ b~t d~u th1 thO'ra. Voi ca che van hanh tren nen khong th~ btl duoc khi thoat
ra ngoai neu 6ng ho, nguoc lai du sire can tang cao n6 v~n dam bao du th~ tich
quy dinh ngoai tru qua cao thi may dirng lai.

* Uu diem:
_ C6 th~ hoat dong Hiudai lien t\}c rna

f1 tfm_o~

_ C6 th~ dap irng moi tnrong hop suy ho h~p va nhat la no dap irng cac nhu cau
sinh 1ythich hop han nho cac bQ phan dien ur va cac ch~ dQtho.

* Nhuac

didm:

_ Khong bu ducc thoat khi nen cho hrong khi van benh nhan khong duo
_ D6i voi tLe sa sinh rna th~ tich
h9C cua may~,

lW.i tbuimg

11m50 - 100 ml thi cac bQ phan, ca

cung voi nhip tho cao cua tre sa sinh.

1.3. Co' ch~ ho~t dQng
Du thuQc lo?i ap su~t hay th~ tich, ,rnaY,1b9',hpat,dgng,_1heohai each:

Ib.,t

t.b6 ya~(!p_th6.
t

ThS
h6 khong d6i hoi c6 g~ng th6 eua b~nh nhan, thi hit van b~t d~u thea thai gian

quy dinh sau khi th6 ra. Do d6 thS thO' chi _~_p_"sl,lJng,kbi._b~nh
nh~IlJ~oan

..~-----toan
...
_

ng,~g th6. N~u rnu6n ap dl,mg thS th6 0 b~nh nhan C;6I1~£_q,,_g~~g_
..t~_0,ta phai
dung

tP1l9C

gialJJ:;a,ho~c thu6c ?-nth~n
d~ b~nh nhan t~p tho quen v6i may thO',
".,
'_ ,
.,_

,

nh~t la khong d~ ch6ng l~i may.
Cach ho~t dQng giup thO-doi hoi b~nh nhan con e6 g~ng tho t6i thi~u v6i
ap Ivc t6i thi~u 5 cm Hi)l H~u hSt cac 1o~imay tho d~u dap ling v6i cac c6 gkg cua
b~nh nhan. V6i ~Q_C?~ho~t dQnggi~p,!h0' 11?-.~X~p
__§g~t,d~tyeu c~u cao han vi n6 dua
th~ tich khi bfuIg ap l~~'rili~- h~ 1aphai cha bop bong ho~c pit tong v~ chuy~n.
Ngoai cac ca ch~ ho~t dQngtren, cac may th6 co th~ thiSt l?p cac lo~i tho ill nhienvQj
~Jg~ __duang_a__
cu6i_thi.thQ r'lho~c.giup thoJheo yeu c&1!rimE- dqt.

1.4. Cae bQ ph~n eO' ban ella mQt may thO'
- Ngu6n du6ng khi

- Th§ tich va t~n s6

- Ty l~ thai gian hit vaq, th6 ra (I IE)
71


~ __- B_Q_12h~1l_kh6id(mg__(Trigger)

_

- B9 phan lam frm
- Cac bo phen ~c hieu & m9t s6 may: Tho dai, tang thStich g~p doi, tho ra chu dong ...

2. vAl NET SINH

2.i. Anh

LY BENH
•

efJA THONG KHI NHAN TAO
e

hurrng tren he) hfip

Binh thirong khi tu tho,

a thi

tho vao ap luc trong long ngirc am vi th~

khong khi duoc hit vao chu dong, khi tho may - thi tho vao do may chu dong

bam khi vao nen tao ap lire duong trong long nguc,
tho

tv nhien

d~u thu dong, su phan

b6 khi

6 thi tho

ra, ca may tho va

& phe nang cua ca hai 10<;1i
G~llphu

tuoc vao dQ dan h6i cua phoi va sire can cua duong tho.
Khi tho may lam gia tang thay d6i ty l~ giira thong khi va nroi rnau. Ho
h~p nhan t<;10cling nhu khi lD& rpjy gay !~ng thong khi & vung dinh phoi nhung
.giam__
~~9_12__~
~i & vung day ph6i (tue la tang khoang ch~t & vung dinh va tang
hi~u Ung Shunt &day).
"'1hQ__
m~y_1~ITl_gi,lm
dQ ~ian n6--cu~ph6i...
2.2. Anh hU'Ong tren huy~t d(>ng

Th& may gay tang ap Ivc trong 16ng ngvc, tang the tich trong ph6i,

ta~gap

Ivc cua ph~ nang nen gay tang h~u ganh th~t phai lam tucln hoan tr&v~ giam, giam thS
_tich th§t trai (do vach lien th§t ph6ng sang trai)d§n d~n luu luqng tim gial]l.

--

.

\~~_~i __
~~_2'-may1ll6Q!d~~;Mng

-

"-~.

" -

-,-'_-

.

--~--

.

giam hru Im;mg tim,}nh.1t la._khi ap

_9__lJp_g_ki
~u _lD._&__ P_~_~~
.
2.3. Anh hU'irng tren th~n kinh trung

U'O'ng

Khi thay d6i khi mau, d~c bi~t n6ng dQ C02 trong mau lam thay d6i lUll
luqng mau nao. Khi thay d6i ImmHg cua PaC02 trong mau d9ng m<;lchse lam
thay d6i Iml/lOOg/phut cua lUll luqng mau nao. Voi PaC02 trong khoang til 20
- 60mmHg, khi PaC02 co gia tr! 26mmHg, lUll Iugng mali nao giam 35%. Trai
l<;lithay d6i Pa02 thl it thay d6i han, nhung khi Pa02 giam <50mmHg thi tang
lUll luqng mali nao. Luu luqng mall nao tang 50% khi Pa02 & 30mmHg, tang
lUll luqng mau nao d~n d~n tang thS tich mall chua trong hQP SQ nen gay tang ap
IllC -nQiSQ.

Tf) ;i 'Mm~

R"let)-L ~

If)

1-~ /AJ.)J~(V'hi

L \_~I~{ "


Vi-v-~y thCi-mayGuy' tri S\f tl1ong-Kl11t6r;-ct?c bi~ct-rrng-thung-k:ht-}a-m9l·---+--khau quan trong trong dieu tri tang ap lire noi S9 do nhieu nguyen nhan khac
nhau, nhung tho may cling lam thay d6i hru hrong mau nao, d?c biet tbQ_PE~J

lam can
tro tuan hoan
tro v~-.----.til -.-~_,----.-.'-he tinh mach
0 d~u, vi vay ~_p_hQrlgc~n
~1
"----------. ~-~-__ . ----- --~-.-.,-----~--...,'-

---------....__

...

..

...

g~u

cao 10- 30°,
tranh kich thich ho, c~.
..'
.
.

2.4. A.nh huong cac

CO'

quan khac

- D6i voi gan: tho may lam ~iam lUll luang mau d~n_ga1).

- Than: tho may lam giam lUll luang mall d~n than, giam hru hrong mau d~n c~u
than do hien nrong tai phan b6 mau, d~n d~n giam luang lll:!ac tieu, gLam_,!9
.~

thai C~ILVa

mroc nr do gay gill mu6i va mroc.

3. cAc KIEV THONG
3.1. Thong khi

CO'

KHI NHAN T~O

THUONG DiJNG

hoc co ki~m soat (CMV)

3.1.1 Ki~u tho' chuyen tir,lhO' ra thanh JhO' viw

"I=:

~':]
t5 i\[

Ki~u tho nay duoc chuy~n til thi tho raecua may tho) thanh thi tho van
(cua benh nhan)§gll mot khoangthai_gian_c<2_9.!nh.V6i kieu tho nay, th~__
tichkhi
hru thong va l~n s6 c6 ~.

nen

!boI)__g khi philt khon_g__
d6i cho

~_nh_nh_a_tu.~6

t~ tho dua_c.
Vai ki~u tho nay phai co cai d?t gioi h?n ~p l\fc duang tho d~ tranh eh~n
,

thuang phoi do ap l\fc.
3.1.2. Ki~u thO' theo

tY r~thiri

gian thO-v~lOva thO' ra(I1E)

N~u cai ki~u tho giam liE se lam giam ap llJc trong l6ng ng\fc, giam
Pa02, tang khoang ch~t sinh 1y, tang PaC02, tang hi~u ling shunt. Do bom khi
van ng~ri lam phan b6 kh6ng d6ng d~u trong ph~ nang .

.Yl v~y ~ang
cai liE 1a 12
---~~-3.1.3. Ki~u thO' dai (SIGH)
Ml}e dich tranh bi~n chUng xep .!?lilli,h6i phlJc l(jlib€ mat ph~ nang vai
ch~t ding b~ m?t SUr}Jhactant,lam tang dung tich c?n chlie nang trong qua trinh
tho may. eli chu ky 100 l~n tho eho ki~u tho dai d~ tang Vt len 1,5 - 2 l~n tranh
duqc xyp ph6i.

3.1.4. Ki~u thO' PEEP
73


s-, IbC \<-fil1·;D
-~--

~~.

-~-~hong-thU'ffng-ca1-d~t-PEEp e-mireS ='15-em mroc. -N~t1-eai--quaeao-gay-giam lUll luang tim, tang ty V/Q va ch~n thuang ph6i do

up hrc.

Chi dinh tho PEEP khi (pa02<60mm-fuk nhu cfru phai tang Fi02 100 han
0,5 trong thai gian han 12 gio, thirong g?P trong hoi chUng suy ho h~p c~p t!.~n
,

,

trien, trong soc nang.
Ch6ng chi dinh tuang d6i ella PEEP khi thi~u khi>i__lm;mg
tu&n hoan, khi
ph~ thung, chan thuQ11gS9 naG c~p.
3.1.5. Ki~u thO-thong khi ap l\fc dirong lien tuc (CPAP)
Day la kieu tu' tho nhung 6 trong mot h~ thong co fu?Jyc luon cao han ap
LtJcc~a khi. gUY~!1
~hu

ki~u tho PEEP nhung it anh huong huyet dong, it gay chan

thuang phoi do ap hrc, khi tho CP AP co th~ khong c£ind?t n(>ikhi quan,
tang cong tho, co ho http ch6ng suy, kho kin khi va d~ chuang bung.

~gay

3.2. Thong khi ki~m soat -

hB trg

(A/C)

Ki~u tho nay may tho thuang Sh~ d(>ng kh&i pha~ ho~t d(>ng tho vao,
IJhl!pg n.fuJ. benh nhan co tho' van g~ng suc va tao nen _ch._efll:l
ap duang th6 nr -0,5
d~n -O,2cm mroc hoac tao nen di chuycn dong khi tlr~i ~ 10ml trong h~ thong
day tho vao, luc do b(>phan nhan cam/bang ap hrc hoac hru luongjthi may thO'
se £_hitt'dongthO'van thea nb~pth.a_~nh__nlllin(ki~uTrigger).

1:Y~-d~ it anh huang

huy~t d(>ngcung'nhu ho http, tang Pa02, ty V/Q it

bi thay d6i do co ho~t dong <;'~la
cC?'Jto~!~r·
~~

N~u b~nh nhan th6 g~ng suc nhanh se phat d(mg may th6 thea va

~o nen thong khi khoang ch~t cilng nhu lam cO' ho http nhanh chong suy ki~t.
3.3. Thong khi ki~m smit ng~t quang dc3ng thi(SIMV)

V oi ki~u thO'nay thong thucmg phill_ th6 cua may trung voi th_aidi§lTI b~t
dfru nhip thO' van clla b~nQ_!1hanho?c tranh ch6ng len nhip th6 VaGcua b~nh
nhein, vi th~ tranh tang qua Ian Vt.

VU di~m: lam giam ap ItJc duang thO'trung binh, giam ch~n thuang ph6i
do ap ItJc va cho phep dung them ki~u thO'PEEP ap Ivc cao han, phan
74

b6 khi


trong pfi61 t6t flan do

Tr5TSn-a6i

\11Q~t g-ay~suYTu-h6-h~p;-b~nh--nh-aFl-tllea-i----rB-a-i----

han, it t6n thuoc an than, dan co va d~ cai may tho.
3.4. Thong khi

h6 trQ' tho' vao ho~c h6 irg ap 11!c(PSV)

Ch~ dQ PSV giup benh nhan hit vao b~ng ap 1vc, may ph at dong tho nho
sir gang sire tho vao cua benh nhan. May tho cung cap du dong khi va khi dong
khi tho vao giam den mire cai d~t truce thi may se chuyen chu ky tho vao thanh
tho ra va ap hrc duong tho giam tro lai d€n rmrc ban d~u.
- Vu di~m: tang Vt, giam cong tho.
3.5. Thong khi ki€m soat ap ll}'c(PCV)
KiSu tho nay 1110 nen dong khi tho vilo giam d~n, kbi

ap luc

duang tho

tang va dong khi dUng khi ap luc dat '[oi muc dinh cua gia tri cai dat tnroc.
_ Nhuoc di~m: Vt khong c6 dinh rna thay d6i thea de>dim h6i cua phoi va thanh
nguc, d~ gay giam thong khi ph€ nang.

3.6. Thong khi h6 tro tU'qng x.rn__g(PAV)
Ki~u tho nay tao ra ap h,IC ty l~ voi sir gang sire hit vao cua b~nh nhfm,
b~nh nhfm hit vao cang m~nh may sinh ap Ivc dmg cao.

4. CHi DJNH THO MAy, THEO DOl VA CHAM SOC
4.1. M~t

s6 thong s6 g
- Vt <5mllkg
- Dung tich s6ng <25mllkg
- T~n s6 <10 l~n ho~c >35 l~nJphut
- Tho vao g~ng suc <25cm nuoc
- Pa02<60mmHg voi Fi02<60%
- PaC02 >60mmHg va pH <7,35
4.2. Mc)t

sa trU'O'nghgp

Cl}

th~

4.2.1. Giam thong khi ph~ nang
- Ibn thuang th~n kinh_tr~1}gJ!QIlg

- Tem thuang th~n kinh ngo_§.ivi gay _lietco h6_h~p

_B~Bh_12h~iva COPD,

tlnh tr~ng co gi~t toan th~ nhu _dgng kinh, l:l9!l..y_ap

4.2.2. Giam oxy mau n~ng do shunt trong ph&i
75


M\lC tieu hoc t~p:

1.. Trinh bay duoc aijc azim giai phdu lien quan

adn gay

te tuy song

2. Trinh bay duac cac chi dinh, chong chi dinh cua gay te tuy song.
3.. Neu duoc noi dung chudn bi dung cu.phuong tien, thu6c va benh nhdn

ad gay

,

te tuy song
4.. Trinh bay duoc kjJ thudt gay te tuy song
5.. Trinh bay duoc cac bidn chung va huang xU-tri cac blin chung thong thuong
,

cua gay tli tuy song.
1.D~icuong
Gay te tuy song CTTS) hi phtrong phap gay te vung, duoc thirc hien bang
each dua mot li€u thu6c te vao trong dich nao tuy, thu6c te se ire ch~ co h6i phuc
d~n truyen cua cac r€ than kinh, ~~<::_r€ Jl)~Dki@ nay khong duoc bao boc boi
IQp.yQ.IlgQa,_i_1h~I}_k!_1!h
va ~i~p~uc vai thu6c. te trong dich nao tuY.
''f{'t.)j;;.c.l;>-:iL/

,--;

nfn.l L~[::I",ti?:

d_'6)~'-H;~5p_ ;._.:'.~II ''ft;

(,~-,

uri';L/"

,

,

2. Vai net ve d~c diem ghii phau lien quan den gay te tuy song
2.1. C()t s6ng

C<)ts6ng cong hinh <;h_fr_.S
keo deli tu 16 ch§m d~n mom cling. 'G6m 33 d6t
s6ng hqp l~i vai nhau (7 d6t s6ng c6, 12 d6t s6ng ngl!c, 5 d6t s6ng th~t lung, 5
d6t s6ng cung, 4 d6t s6ng C\1t)t~o thanh 4 do~n cong khac nhau: c6 cong ra

truac, ngllc cong ra sau, th~t lung cong ra truac, do~n cling 16i ra sau (hinh 1).
Cac di~m cong nh§.t cua c<)ts6ng cling la ch6 v~m d<)ng d€ nh§.t nen d~
chQc kim khi gay teo
C§.1l.t~Q.m6i~d6Ls.6ng_.haQ~.g9rp:
Than d6t s6ng, 16 d6t s6ng, mom ngang,
mom gai, cung d6t s6ng, mom khap tren va duai.
Gifra 2 d6t s6ng k€ nhau ~o thanh khe lien d6t, khe nay r<)nghay h~p la
thea tlmg do~. Mom gai g~ nhu nk

ngang

a do~

th~t hmg nen thu?n lqi cho vi~c

chQc tuy s6ng. Cac vling khac mom gai n&mch~ch xu6ng nen kho chQC.
78

tuy


202. Cac day ch~ng va mang
Til' ngoai

VaG

nao

trong gom co:

- Da, t6 chirc duoi da.
_ Day chang tren gai (thirong hep va xo hoa

a ngiroi gia).

- Day chang lien gai.
_ Day chang vang (day chang nay thirong cling, keo dai ill vung c6 d~n cQt song th~t

hITl~)'Khi ,chQc VaG 410 sire dill manh va do la dau hieu

nhan biet khi choc

. J '':._'~~'''''~.
1 ~H"[~\
..l.l

_ Mang cling va mang nhen sat phia trong day chang vang.
- Mang nuoi ap sat tuy song.

eOt.... sfin··
Sf

co

DOt ,seing

th.t

l~Itng

CQt sang th~ng, nghieng

79

qua

no.


M~t e~t doc ella eQt sang

2.3. Cac khoang
2.3.1. Khoang ngoai mang cung
La khoang ao, gioi han phia tnroc la mang cling, phi a sau la day chang
yang, chua nhiSu lQ__chY_c.Ji~Jl
..J.<.~t,Jl1Q:,JTI9_ch__mau, Khoang ngoai mang cling la
mot khoang ~6,~_p)vc
am.
...... - - ~
...~
"

,~

....

..

2.3.2. Khoang duoi nh~n

80


---Bao

quaM tufs6ng,

_nam -gifra m~mg

n:n~nVam~mgnuo-t-:-ihfmg-v6Tphfa----

tren qua cac nao that. Trong khoang nay ,?~~~~.{§--!!b_~lJ~ki.u!1
illiliJlilQJ!!Y·
('\1 h.l~tr"tb' /to.o
2.4. Dich nao tuy
';6 - '
,,\uv'~.,:;-·
1\lIC~~v i1< (,0.1)
,

.

t) il!;

'fl.-Cft{ .

{zC~

_ Dich nao tuy duoc san xuat tir dam
r6i.•..... rnang mach
cuanao th~.
_....
. '_

-_

,-

, '~""'"

..'

'-_"'"

-~:"

tuy theo 16 Luska ra b~ mat nao va qua 16 Magelis xuong tuy s6ng. Dich nao tuy
duoc h~p thu

a cac nhung

,

.. '

._.,_

mao cua mang nhen.
. -_" ,-

_'-.,.....

..._....,."... ....._ ,.__,.

,._._'_~... ~

a

- SO_lug~g khoang )~--.~_o-- IS0mL tjrc kh_Q~Ilg_?J!1_lj_!& tre sa
sinhIa
_ ..
'"

I,!OJ.)

-f--··---'--------··\

tlm1lkg,\.. '
....-----..~

\f..s_ l(~;__'_l ~,:~~~ ~7 w'

r1t~:'~/'ifJ;~~~···/;I

~(

F

'-"

'( dtA.J_'i,:,

.:-2.,;,...,./

- Ty trong thay dbi tir 1,003 - 1,009, pH khoang 7,39 - 7,5.

- Thanh ph~n: Glucose tir 40 - 80mg/dl, proteine tir 15 - 45mg/dl, Na+ nr 140 150mEq/l, K+ 2.8mEq/1.

2.5. Tu)' sang
- Tuy song lien tuc tir nao qua 16 chamxuong 6PKs6ng, thuong ket thuc tai LJ ·2,
3. Chi dinh

va chang

chi dinh

3.1. Chi dinh
- Ph§.u thu~t ~\l~gcl1Jgi: Ngang

r6n tra xu611gvi d\l nhu
>0 '",

,••. " •• ,.:. ••• ,.",.,..;_.,

•• , ...

''",.J.._......,.,,'''''''~

c~t ru(>tthua.

- Cae phfru thu~t s~n phV khoa: C~t tu cung, c~t u nang bu6ng trlmg, thong voi
tfLrng, mb 1§ythai.:.
- Cac phfru thu~t chi du6i: Chinh hinh, m?-ch mau, c~t cvt, ghep da ...
- Cac phfru thu~t t.i~tni~u: C~t nQi soi u xa ti~n li~t tuy~n qua ni~u d?-o,soi bang
quang, soi ni~u quan, ngay ca soi th~n.
- Cac phfl.uthu~ttfulgsinh man trvc trimg:Nang tuy~n Bartholin, nUth~u man, tri...

3.2. Chang chi dinh
3.2.1. Chang chi dinh tuy~t dBi
- B~nh nhan

tu ch6i.

- Thi~u kh6i ]m;mg tu~n hoan chua btl dil, s6c.
- R6i 1o~ndong mau ho~c dang dung tb1l6c cb6ng dong.
- Nhiem trung t~i ch6 ch9C, nhiem khu~n huy~t.
81

:':

, ••

:

:J,.-:'

--- --

B a~t
- ~ --=-__
__thin
liang

.,. ill';all~ma.JU1_Qng
;"
lT1 ~
' ~ dliqC.gIaLp
trh;!.
e~cbQC_tlLy.song_

- Benh tim nang.
- Tang ap hrc !1_(>i
SQ.

- Di imgthuoc te
3.2.2. Chong chi djnh nrong d8i
- Dau d~u va cot song.
- VH~mxirong khop, ung thu di can vao xuong.
- Benh mach vanh, nh6i mau co tim.
- Xa mach mau nao.
- Cao huyet ap nang hoac huyet ap qua th~p.
-

-.

- Tre em qua nho kho thirc hien.
4. Co' eh~ me d1}ngciia thu6e te va hoat d(>ngciia thu6e te trong djch nao tuy
4.1. CO'eh~ tile dung ella thu6c
- Thai gian

te

dS thu6c te ngam vao t6 clnrc th
cling nhanh trong vong 5 d~n lQ..pbill: &1usau khi tiem thuoc (tuy lo~ithu6c te).
Khi thu6c te bam vao tuy s6ng m(>tph~n thu6c te ng~m vao tily s6ng,m(>t
ph~n thu6c te ng~m vao cac r~ th~n kinh tu do him li~t day than kinh cam
giac,li~t day th~n kinh v?n d(>ngva lam day th~n kinh giao cam.
4.2. Ho~t d{}ngeua thu8-c te trong dieh nao tuy
Thu6c te bam vao dich nao tuy tuan thea qui Iu?t chung cua hai ch~t long
hoa van nhau,m?t d(>thu6c cang cao,khu~ch tan dmg tang va y~u_t6 quy€t di~h

Q-.day-l~Ltn;>.ngJg.__.
L,/!

tJll}J_huQcco tfJIQngjillhqn

4i_£h_PAQ_tu_y
thi:

+ Khi ta d?t d~u b~nh nhan th~p thi thu6c d6n nhiSu v~ phia d~u b~nh nh<1nva
nguQ'c l?i .

+ "NilLth1J.f>c
co tY_trqis:l:u)._~g__t~y
thi khi ta d?t d~u b~nh nhan th~p
thi thu6c d6n nhiSu vS phia chan b~nh nhan va nguQ'c l?i .
';,)
/

- ~t\l_JQlJQc co JY_1rgng_bkg clj_cb_n~Q_tllY
thi khi ta d?t b~nh nhan n&m ngfra
ngang th1 thu6c se Ian dan sang hai ben.

82


·~.

!i2;ry-r.;
,,~/,,\."f}
"-~.
-/\;'::,j ~H;
~Y}O

\}t)

,)

a!.J..'l {r}~J ....'-' -.--_
D~f}..

:1

",

_ Dung dich thu6~c~t--e~c-'o~t"'-y~t~ro~.
n~g~<OH9q8~a~7QC-duQ'c g9i laty-tn;mg-thfrp-;->-~-~
1.009 goi la ty trong cao, nam trong gioi han tren duoc goi la d~ng trong. Tuy
nhien di~u nay con phu thuoc van trong luong cua dich nao tuy

a m6i d. the.

_ Mirc
d9_yiotJhQigi2\!lte phu thuoc van
lieu luong- thuoc te va n}mg do _9ung dich
.....~ -.~-.--._ ~.~~_'-~',-_:~
.. _, ..

..

.\--..
t:»

thuoc teo

_Pbam vi vung.te cao hay thap lien quan d~n Y.L~~~~E_9C
_9Ova tu_th~J?~h nhan.
5. Ky thu~t
5.1. Chu~n bi b~nh nhan

5.1.1. T.J!!.hJll_~-n

Chu§n bi benh nhan

mb giong

nhu cac tnrong hQ'Pmo khac

Gay te tuy song la ky thuat doi hoi SlJ hQ'Ptac t6t cua benh nhan. Do do

h~_L~l!'~_
c~n _!bi~·

viec tn19_oJ1i,gi.MJhi~.hcho benh nhan la
5.1.2. l:ruy~{Ldi-cbtnr
te

C~n phai lam truY~Il duemg nnh m~ch mQt cach h~ th6ng truac khi ti~n
hanh gay teo Truy~n dich truac co 2 mvc dich:

_Bu l?i dich rna b~nh nhan con thi~u tnIac

mb do nhin

an, u6ng ho~c m~t nua-c.

_ Chufm bi bli kh6i lUQ'llgtu~n hoan do gian m?ch sau khi gay teo
Thong thucmg IUQ'llgdich nay tU:&~ ~--5-~11k&ungdich tinh th~ d~ng truang.
5.2. ChuAn

hi

phtrO'ng ti~n va thuBc dung

5.2.1. Cac phlfO'ng ti~n hBi SITC c~p

ClfU

Bong ambu, m~t n? th6 OXY,den d~t nQi khi quan, bng nQi khi quan cae

sb,

eanuyn Guedel, may theo doi, may th6 (n~u eo di~u ki~n).

2.2. Chu~n

hi

thu6c

_ Cac thubc e~p clm: Atropine, ephedrine, dimedron, adrenaline, dopamine ...
_ Cae thube gay me: Thubc me, gian ca, giam dau
_ Cae thube gay te: Xylocaine 5%, pethidine, mareaine 0.50/0,fentanyl...
_ Cae dich truy~n: Dung dich tinh th~, dung dich keo.
5.2.3. Dl}ng Cl}gay

te tuy

sang

83

~--

~t '
;.. S-ang L:;:'b
.~
k
"
;_. ~ (\ 1:0/
-- ----- Kh--~y-~::7_:~_ng_
gorn:
0, orn.tiern. cac.co, ep sat-trurrg,GGFllGu.@-I:foo7-I-O-----r

'"

1%, con trang hoac betadin, povidine ...
- Kim choc tuy song cac s6 25G, 27G, 29G. Kim cang nho thi cang han che
diroc t6n thirong t6 chirc va mat dich nao tuy. Cac kim tir 27G - 29G phai co
kim d~n duong.
5.3. TU' th~ b~nh nhan

Thuong co 2 tir th~:
- Tu th~ ngoi:
DS benh nhan ngoi cong lung, hai tay chong vao hai d~u g6i,d~u cui t6i da
earn ti vao nguc.hai chan du6i thang tren ban.
Ttr th~ nay co thS d€ xac dinh cac khe dot song han nhung thl.JQug __g~Y.-tlJLhuy~t
_~phoac cam giac kho chiu cho benh nhan, thuong danh cho nhirng nguoi map.
- Tu th~ nam nghieng cong lung:
Dat benh nhan n~m nghieng,lung sat mep ban m6,m?t ph~ng hrng vuong

goc veri m?t ban m6.Hai d~u g6i ap sat viw b\mg hai tay om hai d~u g6i,d~u cui
t6i da c~m ti vao ngl,Ic.
Thuang danh cho cac b~nh nhan gia y~u dS tranh tl,lthuy~t ap, ng~t, xiu, k116 chiu ....
Low poinl
Nil
!e

Creslol
ilHIll)

)
'-.../

c

Nam


.-

i

'itt' ..:.\rf'Y~l

Tn' th~ n~m nghieng

Tll' th~ ng6i

S, 4. each xac dinh vi tri choc
Thuong choc van khe giira 2 d6t song do vay

vi tri

choc se phu thuoc van

phau thuat cao hay thap. Thong thirong choc tir L2-3 dSn L4-5, duong n6i hai gai
,-'

'....

chau truce tren cua xuong chau thuong di qua !.:4-S,.?_sau
do dung ngon tay chuyen
dich len tren se thay khe L3-4 va L2-3·

Nguoc lai co the xac dinh nr tren xuong bang lfiy moe g6c suon, lung ke
:

xuong se tirong dirong voi LI-2 rbi xac dinh tro xuong.

S. 5. Sat trung

__- ~;J~.:
c
rtf! c:!.U -- r:J!)
s

~1,q

r:

«>

Dung ~QD."~Ltrung-o~i
__

khan 10 len tren.

vung choc kim 2 dSn 3 l~n, sau do lau kho va phu

00 \{)~
..--J tn·::

;'

_

\..J({~/

.r;

"oN"~

r-

6~

v

•

~'C~·V,,-i
'''''

,.:;,6. Ch<,>ctuy sang
Nguoi chQc tily s6ng: Beo khftu trang, rua tay, m~c a~, di gang. Co hai
duang chQc: DuOng chQc gifra
(hinh
chQc ben: Vi tri
chQc cach
oo o_o
__o~-_o 6) va duemg
.~_-=-:- __ -=-~_
duemg gifra L,.5_:_ 2cm, @rOng kim van dUOng gifra, len tren, ra trua . Gay te t(;li
/

__

0-

__

ch6
vung chQc b~ng rxyl~cain{O,5
~._
u

- -1%.j
--'

,

Dung kim 18G d~n duOng, d~t kim vuong goc v6i m~t ph~ng lung dS
chQc kim qua da,chQc sau tu 1 - 2cm.

,
:_;A ci),~,

,-

F),\:J

85


"',

bcutansous tissue

Interenir

• s,"

.. >

\

,.-:'S"

\

nent

~amentumflavum

..

..
Spinous process

Duirng choc gifra
- Dung kim tuy song lu6n qua kim d~n duong 3 - 5cm (v_~_LkimJ11-LQ1)g
len
tI~T1_k_bj_p_~!Jh_.n. h_~tUl~ ..m, ~~!__kiI!l_.I!~!!l_Il.gb_i~P.Kl__Q_~Ilb_®_?T1
ng9i) rut nong kim
n~u thay dich nao tuy chay ra nrc la kim da

a trong

khoang duoi nhen (kim cang

be thi ,- dich nao tuy chay ra cang cham).
- Dung born tiern c6 thu6c gay te da l~y s~n,J~p vao d~u kim gay te tuy
song .Khi l~p bom tiern phai c6 dinh ch~c chan vi tri kim.khong
vao sau hem hoac

rut kim

diroc day kim

ra.

-TillQ_G_khLb_Q1U_thu6..~_N phai b_~_LL~tixem c6 dich nao tuy chay ra khong,
neu c6 thi ti~n hanh born thu6c te.khi born thi
-Khi born h~t li@u thuoc thi phai

QQm."~_!~_Y..~_9._~_~!~y.

rut nhanh

dong thai ca kim va born tiern

ra va bang kin lai .
Lieu thuoc te bom vao tuy song

tuy thea

li@uluqng cho tirng benh nhan r6i rut

kim bang kin l~i. T6c dQ bam thu6cE:IQ_giay
cho m6i mililit~dung
dich
thu6c teo
---.::::__:__~"-.-'---'-'----- ,_
-.,...--.,:",;:,,-,-.-.,,~-

- Khi dung kim 25G chQc tuy s6ng thi kh6ng c~n dung kim d~n duOng.
\~(6. Cac bi€n chu'ng va cach

xu tri

86


r"

<:
.

'~¥, ,,'

--6--=-1:--n-iencn.rDglilii ch<}c tuy-sBng
6.1.1. Th§t bai
Khong choc diroc do voi hoa, thoai hoa C9t song, gu, veo. Co th~ chuyen
sang choc duong ben hoac chuyen qua phirong phap vo cam khac.

6.1.2. Choc vao cac r~ thin kinh
Khi ti~n hanh choc, benh nhan co th€ thay dau choi, gi~t chan mot ben

hoac ca hai ben. Ta rut kim ra va choc chb khac.
6.1.3. Choc vao mach mau
N~u kim co mau chay ra, ta doi mot luc n~u mau loang d~n va trong tro
lai thi ta tiern thuoc. N~u mau tiSp tuc chay thi

rut kim

ra va choc chb khac,

6.2. Sau khi choc tuy sang
6.2.1. Tut huyet ap va mach ch~m
Do tac dung ire che giao cam gay gian mach, neu LrC ch~ vao th~n kinh

giao cam chi phoi tim se gay nhip cham va lam Wt huy~t ap.
- f)~ phong:

Tru~~n
truQC2.S:J19_<;:.
__t1!y_~Q_I)g_kh_Q~I}g50Q_d~D
1OOOm_! dUl.l_g_g_ighJ~acl
0.9%
:,..--_._."-+~'---'~
-,-_----_ .._-----------._-}c tJ

hQ~C._g_Yllg_c;lj~h.ril"lgt:r
lac:t~t.
- f)i~u trj:

N~u tl,1thuy~t ap thi ke cao 2 chan dS cai thi~n tu~n hoan tra v~, ho~c
dung ephedrine 5 - 10mg tiem tTnh m?ch co th€ l~p l?i n~u c~n.

BLl dich tinh th~ 500 - 1000ml theo huy~t ap ho~c dich keo (Gelofusine,
6%-10%).

HEA

Atropine (0,5 - Img) n~u m?ch ch~m. NSu huySt ap chua len co th~

dung adrenaline.

2.2. BuBn non

va non

Thong thuOng do tvt huySt ap ho?c do thay d6i ap h,rc n9i S9 ho?c tac
dvng phV cua thu6c (h9 morphine).

Xu

tri: nang huySt ap b~ng bu dich va ephedrine

(QIjl!:lp~r'!D,atropine ...).
87

ho?c thu6c ch6ng non


~---

_. 2-;3;-Nh uc-d~u _--Dau d&u xu~t hien sau 24 - 48 gio, do rach mang cimg lam m~t dich nao
tuy. ~_guiri.Jri:_tubjhay bi nhiSu hon.
l~~~r:~ong_p.I2i!~g_ ki_!!lcan.g_o!lU-kclP_gJ6t, khi choc phai dS vat kim khong
c~t dirt mang cimg rong dS tranh ro ri dich nao tuy.
''7'

T£~y~!!._gi~h__!!:gQc
dS bao dam khoi hrong tu&n hoan,

t.ii)

, 'r-i'.. " ." ~-·~.~-r~~1·

(~~_~_l!__

",,'_J

N~m p§.t._Q.9Il_g_@i_giuOng,
~

__
.hl~hjhich,

r ;~:'

c, "

1
f)v'

Q1L9j~h. dung thu6c giam dan,

~afe_ine,.200-400mg,tiem tinh mach, neu khong do co thS l?p lai sau 3 gio hoac uong,
~_'fr.f'i)\o..!.(-1CHft
.../
n(l

pO,J\.Ct r;..\.J;':

{J

fJd'L \;.-;"r

..,I

Dung phuong phap ~at£h;_

Bang each lay khoang 10 - 20ml mau

cua benh nhan rbi bam van ch6 choc kim vao khoang ngoai mang cung d~ bit 16
thung khong cho dich nao tuy thoat ra ngoai.
2.4. Bi ti~u
Thong thuang do tic d\mg phV cua thu6c te va nh~t Ia thu6c h<;>morphine. Thu6c lam

tful:g!!:y'9TIKbl~_gC!!~~!.g~
t~g.quang, va

t:£<::. s:he.QW!!.TQLc,®gg~y

Xu tri:

ChuOm nong, dung thu6c prostigmine,
('z ~ ;·~t~;_.. b6f ....
tt: '( i~oh~{'~u:5 -c}.t·_l~~~r:/E:' f~8).-~~;(.._")·'"1
xy10caine vao bang quang.

bUt~i.

d?t 6ng thong ti~u va bam
·'1}~0..

;;6,1 ',~::::~-:_' ~.", ;~:::\ '~~!;-'U:{~'

2.5. Dau ehB chQc vung IU'ng

- Do t6n thuong day ch~ng ho?c t6 chue da, duai da.
- DS phong: Ch<;>ckim nho, tranh ch<;>cnhiSu 1&n.
- Di~u tri: Dung thu6c giam dau va an th&n nhu tren.
2.6. Cac bi~n chung thfin kinh
- T6n thuang

m<)t hay nhi@u r~ th&n kinh gay hi9n tu,gng 10C;1ncam ho~c tang

cam giac dau, h<)i chUng duoi ngga, viem mang nao - nao do nhi~m trung, co thS
bj li9t do t6n thuang tuy hay do thu6c te ho?c do t1,1mall chen ep vao th&n kinh.
- Di@u tri: Dung thu6c giam dau, an th~n n~u nh~. Co h<)i chUng nhi~m trimg
phai dung khang sinh, n~u bi chen ep phai m6 d~ giai phong chen ep.

88


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9._.......
am
Q~L(thu6c--;ky-thrr?-r)---va-t6~
_,..-_ 15~~'yQ~I[!lA~-m:y-~
..--- ~--- ....._-~--......-.--~- ......-.~--.......p----'~
trong cac chi dinh chong chi dinh.
l

F<:."\

2.7. ThO-y~u ho~c ngirng thO- (~{h~- qTL

CUV

qUJ;<,

v

t

- Nguyen nhan:
Do gay te qua cao.qua li~u thuoc te,d?t benh nhan sai tu th~ .

- Xu tri:
H6 http nhan tao ngay voi oxy 1OO%,chuy~nphuong phap gay me.
Trong tnrong hop nhe.cho 'benh nhan tho oxy hoac h6 tro h6 http .
N~u 6n dinh kh6ng can d?t noi khi quan.
~<

i

i

~

hilif b:::u'

Ht: cl~lni ~ rf)a~i-J ViLe CC/f/'Lf_lV
rfuU;'J

vaD

rYla,cl)

7K
Vn[i~~ ,

TLd Nft .

I\I6h i>

4; .,;;,

NJ.uJ!( c1-2i£

89