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NGO OOC CAP • • I O A l CUCTNG X u tri ngo doc cap b a o gom : N h om C ac bien p h ap hdi s u e va dieu trj cac trieu ch irn g Bao gom : - C ap c u u ban dau - Hoi benh, kham , dinh h u o n g chan doan, lap ke hoach va th u c hien ke hoa ch dieu trj - C ac bien phap d ieu tri h6 tro toan dien N h om C ac bien p h a p ch d n g doc dac hieu Bao gom : - Han che hap thu - Tang dao thai d o c chat - T hu oc giai d o c d a c hieu Khi benh nhan (B N ) da co trieu c h u n g , u u tien c ^ c bien phap (n h o m 1) va th u o c giai doc dac hieu (neu co) Khi BN den s d m c h u a co trieu c h u n g thi u u tien cac bien p p (nhom 2) li x u ’ TR i c y T H £ C lp c u u ban d au hay on djnh cac c h u c nang s6 n g cua BN (u u tien sd 1) N h ie m vy: tie p x iic v d i BN, tron g vong vai ba p h iit dau tien, xac d jnh va th u c hien cac bien phap can tien hanh nha m bao dam tin h m ang va on djnh tra n g thai BN (kh o n g de BN chet dang tham k h a m ) V ie c xac djnh d u o c th u c hien b ln g : n hin BN, s d m ach va lay goi BN C a c tin h huong can giai q u y e t nga y th u o c ve he c o quan song con: ho hap, tu a n hoan va th a n kinh a H o h a p D o c chat co the g a y suy ho hap qua cac c o che sau: u c che th a n kinh tru n g u o n g gay th d cham , n g u n g th d (heroin, m o rp h in , G a rd e n a l va cac th u o c ngu, an th an); gay liet c o toan than bao gom c o ho hap (ngo dpc p h o s p h o hu'u co , te tro d o to xin - ca n o c ); gay ton th u o n g phoi doc chat (P araqua t) hoac sac, th ie u o xy d o n th u a n hay he thong T uy tin h huo ng can can th ie p kjp th d i - M yc d ich can th ie p n h lm : khai thong d u d n g th d , bao dam th o n g khi, th d oxy de bao dam tin h trang oxy hoa m au - C a c bien p p can thiep : n g u a co, th d oxy, hut d d m dai, dat ca n u n M ayo, d a t noi quan, m d quan, thoi ngat, bop b on g am bu, th d may, dung cac th u o c g ian phe q u a n b T u a n h o a n C o tin h tra n g can x ir tri cap: loan nhjp va tgt huye t ap (H A ) 156 H u o n g d a n c h A n b o A n vA b i £ u t r i b £ n h N I KHOA - Loan nhip: + N hip cham d ira i 60 chu ki/phu t: atro pin 0,5m g tTnh m ach (TM ), n h lc lai ch o den m ach > 60 la n/p hut hoa c tong lieu - 2m g N eu nhip cham khong cai thien, thu’O’ng kem v a i tu t huye t ap truyen adrena lin TM ,2 (jg /kg /p h u t, dieu chinh lieu th e o dap irng + N hip nhanh: ghi dien tim va xlp tri th e o loai loan nhip: nhanh that, rung that, x o ln dinh: soc dien khip rung; nhanh xoang, nhanh tren that: tim va dieu tri cac ngu yen nhan (VD: m a t nipac, thieu oxy, kich th ich ), digoxin, - Truy m ach - tut HA: giam th e tich , soc phan ve gian m ach, vie m c a tim nhiem doc, + T ru a c het xac dinh co giam the tich tuan hoan khong; neu co tru ye n dich D a t c a th e te r tTnh m ach trung tam de th e o doi ap ly c tTnh m ach trung tam (A LTM TT) va dieu chinh dich truye n Neu giam the tich long m ach th o a t m ach m at huyet tu a n g can truye n d un g dich keo: hu ye t tu a n g , dich truyen thay the huyet tu’a n g (vi du H a este ril, H em ohes, ) + Khi da loai trip giam the tich va A LTM T T > 5cm n u a c m a van tut H A thi cho th u o c van m ach: dopam in (5-15pg/kg/phut); neu tut H A viem c a tim nhiem doc: dobutam in: bat dau 10pg /kg/ph ut, tang lieu neu c h u a dap m oi lan co the tang - pg /kg/ph ut cho den dat ket qua hoac dat 40pg/kg/phut L in g, + Neu tu t H A gian m ach giam tru’a n g I lpc m ach: d un g n o d re n a lin , b i t dau 0,05pg/kg/phut, dieu chinh th e o dap i>ng, phoi h a p v a i cac th u o c van m ach khac: thu’a n g la d o b u ta m in neu co suy tim, neu khong co d o b u ta m in co the phoi h a p v a i d op am in hoa c adrena lin c Than kin h C o giat hay hon m e la hai trang thai m a nhieu doc chat gay va can d u a c dieu tri kip th a i: - C o giat: ca t c a n gia t bang cac loai th u o c v a i lieu hieu qua la phai c i t d u a c c a n giat, khon g phai lieu toi da tron g cac d im e dien + S e duxen ong 10m g tiem TM (tre em tiem 1/3 den m ot ni>a ong ) n h lc lai ch o den c i t d u a c can giat Sau tru ye n TM hoa c tiem b lp tri khong che c a n giat + T h io p e n ta l lo 1g; tie m TM - 4m g/kg, n h lc lai cho den c i t c a n giat; d u y tri 2m g/kg/gicr Dieu chinh de dat lieu t h lp n h lt m a c a n giat khong tai phat + N eu co giat keo dai hay tai phat, co the thay th u o c tri b ln g G a rd e n a l vie n 0,1 g uong ti> den 20 v ie n /n g a y tu y th e o m ipc + Kinh ngh iem tai T rung ta m C h ong doc, Benh vien B ach M ai: be tu o i co gia t hoa c h it bao ve thu'C vat, d u a c tru ye n th io p e n ta l 6g/5 g ia m a i khong che d u a c c a n giat S a u ch u ye n m yd a zo la m va p ro pofol de tra n h vie m gan lieu cao th iop ental C hau d im e clpu song m a kh o n g co b i t clp di ch im g nao Hai BN ngo doc hoa chat bao ve th irc va t co co giat keo dai da phai d un g G a rd e n a l keo dai hang thang, lieu cao nha t 2g/ngay, giam dan sau thang xuo n g vie n /n g a y BN tip ngipng th u o c va len can co giat tai phat, m p t BN tip vo n g va BN lai lai tiep tu c d im e d ieu tri n h ie u th a n g sau - H on me: + G lu co se lpu t r u w ig 30% 50m l TM , kem vitam in B1 200m g + N a lo xo n ,4m g TM ch a m de loai trip qua lieu heroin + B ao dam ho hap cho n g tut lira i, hit phai djch tra o n g ira c C h in d o an a H o i b en h K h oang 95% chan doan n gu yen nhan ngo doc la hdi benh; can kien tri hoi n g u a i benh, n g ira i nha, nhieu lan, de n lm d u a c th o n g tin trun g th u c Y e u cau n g u a i nha m ang den va t chipng nghi gay doc (do an uong, vo Ip, bao bi th uoc, hoa c h a t ) se rat h u u ich ch o vie c chan d oa n d o c c h it H i / c h e tSc d u n g - G iai 400 Truy tim mach, tirvong III D ie u TR| - Kiem soat du’a n g th a : t u the nam nghieng an toan, chon g tut lu a i, lam sach d a m dai - D a m bao ho hap (oxy, bop bong, dat noi quan tin h tran g ho hap), dam bao tuan hoan, u am cho benh nhan - H on me: kie m so a t d u a n g th a , dam bao ho hap - T y t huye t ap: dat c a th e te r tin h m ach trung tam , bu du djch, tru y e n djch, d un g th u o c van m ach ThSm kham n nh ch o n g de pha t hien cac bien c h im g - C h ong du’a n g m au: cho benh nhan an du, truye n g lu co se u’u tru a n g ket h a p tiem vitam in B1 200m g/ngay - G iu’ am cho b en h nhan - D ie u trj cac tin h tra n g ch a n th u a n g ket hap - D ie u trj ca c b ien c h u n g : tieu c a van, suy than, nhiem trun g, roi loan n u a c dien giai - T ru ’a n g h a p b en h nhan uong ru a u khon g ro nguon goc, ru a u n g u a i dan tu nau, ruo'u lau, ru a u gia hoa c kho n g ro loai ru a u : can th e o doi sat lam sang ket h a p kh o a n g tro n g th a m thau (nong ru a u neu co the) va m au d on g m ach + N eu lam sang cai th ie n , khoa ng tham thau va m au b in h th u a n g thi benh nhan hoi phuc 162 H u C n g d A n c h A n o o A n vA o ifu t r i bEnh NO i khoa + Neu lam sang chu a co gi dac biet ngoai cac dau hieu cua ngo doc ethanol, khoang tham th£u tang nhu’ng mau binh thu’O’ng: can theo doi tiep + N eu lam sang co dau hieu nhiem toan chuye n hoa nang (trong la cta t va ceton ch i t3ng nhe ho3c khong tang), bat th ira n g ve n hin (n h in m a ) hoac ton thu’a n g ca c c a quan (d a c bie t than kinh, than, tim m ach) thi can n g h i ta i ngo doc cac ru g u khac (dac biet m e th a n o l) va glycol Lpc m au (H D ) rat huru ich tru’a n g h a p IV phCng benh - G iai th ich, g ia o due cho benh nhan va gia d inh ve tac hai cua rira u , lactat, cong thi>c m au, dong m au, X q u a n g tim phoi - T on g phan tich n ira c tieu, ceton nieu - X e t n gh iem kh&c: ch u p C T scan so nao, sieu am bung, dien tim - C a c xet ngh iem kh a c quye t dinh tu y th u o c th e o lam sang t A i l ie u t h a m k h A o E d w ard J , K a th e rin e M , Lau rie B G (2 0 ), “E th a n o l”, C lin ica l toxico lo g y, PP 605-612, WB S a u n d e rs com pany N a tio n al p o iso n s c e n tre (2 ), “E th a n o l”, Toxinz, o n lin e ve rsio n , N e w Z e a la n d NGO DOC KHI CARBON MONOXIDE (CO) I DAI CIFONG - K hi C O (carb on m onoxid): la san pham chay khong hoan toan cua cac chat co c h ira carbon N guon nhiem bien nha t la s ir dung cac nhien lieu co carbon (than, cui, xang, d au ) de dot (bep, lo s u d i, chay dong c o ) d n o i th o n g kh i kem (phong kin, khu v u c it lu’u th o n g khi) - CO: khon g m au, khon g m ui, khong vi, khuech tan m anh, khon g gay kich th ich, co ti xap xi ti khong - CO la gay n g a t he thong, gay giam kha nang van ch uye n oxy den te bao, giam co bop c o tim , roi loan c h irc nang te bao, ire che co bop c o tim - N ong H bC O gay doc: > 12% N go doc xuat hien nhanh va th u ’O’ng gay tip vong nhanh chong Di c h u n g than kin h -ta m than nang ne xuat vien chiem to i 4-40% T h a i nhi, n g u o i cao tuoi, n g u o i co benh li m ach vanh, m ach m au nao nguy c o bi ngo doc nang hon II c h A n o o A n C h an d o an xac djnh a N g u o n k h i d o c N h u tren, bien la d o t than, cui, chay dong c o tron g phong kin b L am s an g - K h o i dau: trie u c h irn g th u o n g khong dac hieu: dau dau, m et m oi, cho n g m at, buon non, n hin m a, roi loan hanh vi kem th e o ca m gia c sang khoai - Than kinh: + N ang co the co hon m e, co giat, hon m e tang tru o n g lu c co , th o i g ian va m ire hon m e rat thay doi, xuat huye t vo n g m ac, dau hieu ngoai thap + M ot so benh nhan hon m e co the hoi phu c nhanh chong, so kh a c cai thien th o a n g qua va khong hoan toan, nang len a tu a n th ir hai va de lai di c h irn g than kinh - ta m than + Di c h irn g : m at vo, van d on g bat th u o n g , tang tru o n g lu c, P a rkin so n , giam tri n h o , giam tap trung - Tim m ach: loan nhip (ch ie m - 6% ), co the tu t huye t ap, phu phoi cap hdn hop N g u d i bi benh m ach vanh tru d c cd th e dau n g u c, nhoi m au c o tim D ie n tim : th ie u m au co' tim , thay doi T, ST, loan nhip tim - T o n th u o n g co : C K ta ng, th o a t dich khoa ng ke, giam th e tic h long m ach, n u d e tieu sam m au, va it dan - M u c nang tren lam sang: + Nhe: dau dau, b uo n non, chdn g m at, non + V u a : dau n g u c kh o tap chung, n hin m d , kho th d g ln g s ire nhe m ach nhanh, th d nhanh, hoai tir co , th a t dieu H i / P n g d A n c h A n d o A n vA o i£ u t r i b £ nh N P i k h o a 164 + Nang: dau n g u c, hoi hop, m at dinh h u o n g , co giat, hon m e, roi loan nhip tim , tu t huye t ap, thieu m au c o tim , p ho ng da c X e t n g h ie m D o H bC O b ln g p h u o n g phap m ach (C O -o xim e te r) H b C O £ 15% la ch a n d oa n ngo doc Phuom g phap do bao hoa oxy m au dong m ach b ln g p h u o n g phap m ach (p u lse oxim e ter, S p 2) phan anh sai ket qua S p vi c h i pha t hien d u g c H b 2, khong phat hien d u g c H b C O va nha m H bC O la H b nen ket qua S p tang gia tao so v g i th u c te - D inh lu g n g H bC O b ln g q ua ng ke: ti le H bC O £ 15% (lay m au d o n g m ach hoa c tin h m ach) Tuy nhien, H bC O giam nhanh sau benh nhan d u g c d u a khoi n o i n hiem d o c va d u g c thcr oxy lieu cao, can lay m au cang s g m ca n g to t sau benh nhan den vien C h an d o an phan biet - N go d o c nhe: phan b ie t v o i cam cum - N go doc v u a va nang: phan biet v o i dau t h lt n g u c khong on dinh, hon m e, co gia t cac nguyen nhan khac - C hu y: neu ngo d o c d o hit phai khoi chay, c ln phat hien ca c ngo doc, ton th u o n g khac kem theo n h u ngo d p c cyanu a, h it phai h o i nong, m eth e m o g lo b in , hit phai ca c kh i g a y k ic h u n g d u o n g ho hap C h an d o an bien c h u n g - S uy ho h ip : xe t n gh iem m au - T on th u o n g nao th ie u oxy, nhoi m au nao, hon m e keo dai, th o a i hoa m ye lin (chup cpng h u d n g tu so nao) - N hoi m au c o tim : dien tim - Toan ch u ye n hoa, tieu c o van, suy than C a c x e t n g h ie m , th a m giu p chan an , dan h g ia, dieu trj va th e o doi - C ong th u c m au - Ure, cre a tinin, d u d n g m au, dien giai do, CK, C K M B , am yla se, m au d on g m ach, la ctat m au - D ie n tim , X q u a n g phoi, dien nao - C hup c i t |p p so nao danh gia phu nao, nhoi m au nao, cong h u d n g tu g iu p c h in doan nhoi mau nao, th o a i hoa m yelin - Test th u thai v d i phu n u tu o i sinh de, th e o doi tim thai neu benh nhan co thai III b i£ u TR! G iam h ip thu - N h anh chon g m d rpng cu a , lam th o a n g khi, d u a benh nhan kh o i n o i n h ie m d o c (lu u y dam bao an to&n cho n g u d i cap cu u ) - N eu benh nhan th d yeu, n g u n g th d : ho h ip nhan ta o b ln g p h u o n g tie n hien co tai cho (co the ho hap nhan tao tru e tiep), cung cap oxy 100% cang s d m cang to t neu co d ie u kien B ien phap hdi s u e - K hai th o n g d u d n g th d , ho trg ho hap can: N K Q , th d may - D ie u tri chon g co giat, hon m e - T u t huye t ap, dat catheter, th u o c van m ach - D ieu tri to a n ch u ye n hoa, tieu c o van, suy than - D ieu tri khac NGO DOC CAP BARBITURIC • • I D AI C lP a N G - B a rbitu ric la th u o c co ta c dung an than, gay ngu, gay m e, dieu tri dong kinh va tin h tran g co giat Loai thu’d n g gay ngo d o c la loai b a rb itu ric cham bien nha t d l£ p h e n o b a rb ita l (G arden al) - C o che gay ngo doc: d c che he Than kinh trung u o n g , ta c dong len re ce p to r b a rb itu t d nao, lam tang G A B A Lieu cao, g a y tu t huye t ap d c che tru e tiep c o tim , g ia m tru o n g lu c he giao cam - B enh nhan th u d n g uong de tu tu V i vay, benh nhan uong v d i so lu g n g nhieu va uong v d i nhieu loai thuoc khac, nen tre n lam sang th u d n g gap benh nhan tro n g tin h tran g nang, p h u c tap, nhieu bien c h u n g va co ngu y c o t u vong - T h u c te hay g a p n g o d o c cap d benh nhan co tien s u roi loan ta m than, dong kinh, nghien m a tu y ii c h An o o An C h an d o a n xac djn h a Trieu c h irn g n g o d o c - N go dgc b a rb itu ric ta c d un g cham (G ardenal): hon m e yen tinh, g ia m phan xa gan x u o n g , khon g co dau than kinh khu tru, d on g tu co, phan xa anh sang, giai doan m uon thi dong tu gian Suy ho hap (th d yeu hoa c n g u n g th d kie u u c che ho hap hoac sac phoi, vie m phoi) T ruy m ach, roi loan dieu hoa than nhiet: sot ca o ho a c than nhiet b X e t n g h ie m d o c c h a t - T im G a rd e n a l tro n g d ich da day, n u d e tieu (dinh tin h ), xet ngh iem m au (dinh lu g n g ) C h an doan m u c - N go doc G a rd e n a l nang: hon m e - 4, nong G ard e n a l m au > m g% - M u c nhe: hon m e - 2, nong G a rd e n a l m au < 4m g% C h an d o an phan b ie t - Hon m e n h u n g n g u ye n nhan khac: + B enh li than kinh tru n g u o n g (tai bien m ach nao, vie m nao ) + Sot ret ac tinh + Ha d u d n g m au, to a n ceton dai th a o d u d n g - H on m e th u o c an th a n khac: + N h om o p io id (m o rp h in , heroin): benh nhan tinh sau tie m n a lo xo n ,4m g tin h m ach ( n h lc lai neu can) + N h om b e n z o d ia z e p in (d iaze pam , clo n a ze p a m , b ro m a ze p a m ): benh nhan tinh sau tiem flu m a z e n il (A n e xa te ) ,2 m g tin h m ach ( n h ic lai neu can: m g /2 gid ) 196 H u Ong d An chAn d o An v A d i £ u t r i b En h N oi k h o a C han doan n g u y e n nhan - T hu’o n g tu t u ho a c uong qua lieu th u o c hoa c uong nham III.O l£ U TR| B enh nhan tinh - R u a da day (neu c h u a ru a d tu ye n tru d c ): - lit b ln g n u o c sach co pha m uoi (5gr/l) - A n tip o is - B m h oa c th a n hoat: lieu ban dau 0,5 - g/kg, ket h o p S o rb ito l lieu g a p doi B enh nhan hon m e - D a t ong noi q ua n co bong chen, th o n g nhan ta o (b o p bong ho a c th d m ay) - N eu tut h u ye t ap: tru ye n NaCI 0,9% : 0 m l tron g - g id N eu hu ye t ap van tut, tien hanh d§t ca th e te r tin h m ach tru n g tam , A L T M T T (ap lu c tin h m ach trun g ta m ), tru y e n dich th e o ALTM TT, phoi h o p v d i th u o c van m ach (d o p a m in , n o d re n a lin ) - D a m bao ho hap, tu a n hoan m d i tien hanh ru a da day T h an h o a t da li§u - G iup tang thai tru ba rb itu te , ap dung benh nhan nang da d u o c d a t noi kh i q ua n va khong co dieu kien b e m au: lieu ban dau n h u tre n (0,5 - gam /kg), sau ,5 g a m /kg , kem m ot lu o n g sorbitol gap doi; toi da lan cach g id , n gh i 12 g id cho benh nhan an, d un g lien tu c va th e o doi cho td i benh nhan cai th ie n ve lam sang va xet ngh iem hoa c co ta c d un g phu (non, tru d n g bung, mat nhu dong ruot) can p i n g u n g B enh nhan co ta o bon can tang lieu S o rb ito l va th e o doi sat, benh nh^n tieu chay can g ia m lieu S o rb ito l hoa c tam n g u n g va th e o doi L a i tieu c u d n g b u c va ki§m hoa n u d e tieu (xem th e m bai B enh nhan ngo d o c cap) giup t§ng thai tru barbiturat - Truyen: + N atri clo ru a 0,9% : 0 m l/2 g id + 2g kali + G lu co se 5% : 0 m l/2 g id + B ica rb o n a t natri: 1,4% m oi 0 m l/2 g id + 2g kali, nha m tri pH nieu £ + K a liclorid pha va o cac chai dich va bu th e m neu can (phai th e o doi kali m au va bu du kali) Loc ng o th an C h i dinh BN ngo doc nang: hon m e giai doan - (co roi loan: suy ho hap, tu t hu ye t ap roi loan than nhiet) - T n nhan tao: th e o n g h ie n c u u cua T rung ta m C h o n g d o c sau g id b e m au (H D ) nong b a rb itu ric m au giam 60% - T rong tru d n g h a p benh nhan hon m e sau, tu t huye t ap can ch a y th a n nhan ta o b in g p h u o n g phap sieu b e tin h m ach - tin h m ach lien tu c ( C W H ) D ie u trj h6 t r g - C hong boi nhiem : kha n g sin h th ic h hap - C hong dong: d u ng lo ve n o x neu khon g co chon g ch i dinh - V ie m phoi h it d d m dai, c h a t non: vo rung, dan lu u tu the, hut d d m , co th e noi soi phe q u a n bam ru a hut d d m neu nang, ket h o p dieu trj vie m phoi n h u th u d n g quy - D a m bao dinh d u d n g 30 - K C a l/kg /n g a y, ve sinh ch o n g loet, vat li tri lieu H IV uong d An c h An d o An v A o i £u tri b £n h NOi khoa 197 phCng benh C an de p ho ng m ot tro n g cac bien c h u n g sau: - V iem phoi, xep phoi, loet m uc, viem loet giac m ac - T i c m ach huye t khoi - S uy than c ip tie u c a van - B e tran h cac bien c h u n g tren can cham soc tot benh nhan, th a y doi t u the benh nhan lan/n gay ket ho-p v a i li lieu phap ho h ip , dung khan g sinh can, chon g dong d u phong dung Lovenox: ong 20m g, tiem d u o i da ong/ngay T uy nhien, dieu tri tich c u c b in g bai nieu tich c u e phoi h a p loc m au giup benh nhan chon g hoi tinh la cach phong bien c h u n g tot nhat - Benh nhan can d u a c tu v in va kham chuyen khoa tam than sau vien t A i l ie u t h a m k h A o D avid C L ee (2006), “S e d a tive - H ypnotics", G o ld fra n k's T o xico lo g ic E m e rg e n cie s, 8th edition, M cG w - Hill, PP 1099 - 1111 P O IS IN D E X ® M a n a g e m e n ts (2010), "B a rb itu te s - L o n g A ctin g ", M IC R O M E D E X ® 1.0 (H e a lth ca re S e ries), T h o m s o n R euters NGO DOC CAP ACETAMINOPHEN (PARACETAMOL) • • I D A I CU’O’NG - P a ce ta m o l la m ot th u o c giam dau, sot d im e sip dung rong rai nhat H ien tren thi tru a n g co rat nhieu loai biet du’O’c khac co chipa paracetam ol D a y la m ot th u o c noi ch u n g an toan, nhung dung qua lieu co th e gay ngo doc, chu yeu la gay hoai tip te b a o gan va d o c v o i than - C o che gay ngo doc: b in h th u a n g khoa ng tren 5-90% a ce ta m in o p h e n ch u ye n hoa a gan theo d u a n g g lu co ro n yl va sulfat hoa d u o i tac dung cua e nzym cyto cro m P th a n h san pham khong doc 5-15% du>ac ch u ye n hoa N A P Q I (N -a c e ty l-p -a m in o p h e n o l) co ta c dung d o c n h u n g lai bi gluta thion bat hoa t th a n h m e rca p ta t, cystein khong doc Khi uong q u a lieu a ce ta m in o p h e n , ch a t chuyen hoa doc la N A P Q I tang len, v u o t qua kha nang trun g hoa cua g lu ta th io n gay d o c v a i gan, thgn li c h An d o An C h an doan xac djnh • Hoi benh: co hai tru a n g hap - U ong m pt lieu gay ngo doc: benh nhan uong p a ce ta m o l v a i lieu ngo d o c £ 140m g/kg, a ngucri nghien ru a u , suy dinh d u a n g , x a gan, dang dung cac th u o c kh a c doc v a i gan th i co the ngo doc vcri lieu thap han - U ong q u a lieu dieu tri lap lai nhieu lan, cung co the gay ngo doc: uong £ lan, m oi lan > 4g khoa ng th a i gian > gia • Trieu chipng: chia lam giai doan th e o th a i gian - G iai doan (0,5 -24 g ia ): nga y sau uong: th u a n g khon g co trie u chipng + B uon non, non + V a m o hoi, kho chiu + C o th e tang AST, ALT + K ham lam sang thay b in h th u a n g - G iai doan 2: 24-72 g ia + C han an, buon non, non + AST, A L T ta n g cao, b iliru b in tang, th a i gian P T keo dai, chipc nang th a n giam - G iai doan 3: (72 - 96 g ia ): + S uy gan: vang da, roi loan dong m au, benh nao gan, hon m e gan dan den tip vong + S uy th a n cap: co the phoi h a p v a i suy gan + S uy da tang - G iai doan (tu -1 ngay): neu benh nhan song thi c h u c nang gan hoi ph u c hoan toan khon g fle lai x a hoa • X e t nghiem : - D o c chat: H itcJ n g d An chAn o o An vA ei£u t r i b En h NOi khoa Do thj Rumack-Matthew K hong co nguy c a ngo doc D u a n g khuyen cao tri benh T ake le v e l at le a s t h o u rs p o s s ig e n s io n Thdi gian tir uong den lay m au xet nghiem (gid) 199 H 200 uong d An ch An bo An v A o i £ u t r i b En h NP i khoa + D in h tinh: p a ce ta m o l du’a n g tin h djch da day hoa c n u a c tieu, c h i ch o biet benh nhan co uong paracetam ol + Dinh lu g n g paracetam ol m au, xac dinh nguy c a ngo doc hau het cac tru a n g hop quyet dinh v>ec chi dinh hoac ket thuc dieu tri dac hieu: lay m au vao th a i diem khoang 4-24 g ia sau uong Lay mau sam h a n ket qua khong co y nghla, lay m uon h a n co the nong da am tinh Neu ket qua khong ro ngp doc nen lay lan sau g ia (trong tru’a n g h a p hap thu cham ), sau doi chieu v a i thi R um ack - Matthew - X et ngh iem m au, n u a c tieu: ure, d u a n g , cre a tinin, dien giai, AST, ALT, dong m 6u c a ban xet nghiem loai tru vie m gan cac ngu yen nhan khac Tong phan tic h n u a c tieu - C h an doan h inh anh: X q u a n g tim phoi, sieu am o bung - X et ngh iem khac: tu y th e o tin h tran g benh nhan C h an doan bien c h u n g - S uy gan cap: benh li nao benh gan (roi loan y th u c , hon m e, phu nao), roi loan dong m au tieu cau giam , N H tang, lactat tang, d u a n g huyet, album in g ia m , - C h ay m au: roi loan dong m au suy gan - S uy than cap C h an d o an phan biet - V iem gan, suy gan, hon m e gan vie m gan virus, nghien r u a u va cac n g u ye n n h ^n khac III D I^ U TR| O n d jn h b e n h n h a n • X u tri cap c u u on d jnh tin h tran g benh nhan: ap dung th e o n gu yen t i c ch u n g , x u tri cac tin h trang nang (n h u suy ho hap, tu t huye t a p ) • Loai bo c h it doc: - G ay non: neu benh nhan m a i uong p a ce ta m o l vong gia - R u’a da day: benh nhan m a i uong tron g vong gia - T n hoat: sau benh nhan d u a c gay non hoac ru a da day D ung lieu g/kg, ket h a p von S o rbito l lieu tu a n g d u a n g • T h u o c giai doc: - N - a ce tylcyste in (M u co m yst, A c e m u c ) - C hi djnh: + B enh nhan uong p a ce ta m o l lieu t 140 m g/kg tron g vo n g 72 g ia , m en gan c h u a tang, c h u a co hoa c khon g co xet n gh iem nong p a ce ta m o l m au + U ong qua lieu dieu trj lap lai nhieu lan co nong p a c e ta m o l > m c g /m l hoa c m en gan t3ng + B enh nhan nghi uong qua lieu p a ce ta m o l n h u n g khon g ro lieu, den tro n g vo n g 72 g ia m en gan c h u a tang + B enh nhan co nong dp p a ce ta m o l a tre n d u a n g kh u ye n ca o d ieu trj cu a thj + B enh nhan uong q u a lieu p a ce ta m o l (> g /2 g ia ), den m uon, b at ke nong paracetam ol n h u n g co vie m gan hoa c suy gan, khon g loai tru d u a c ngo doc p a ce ta m o l - Lieu dung: + B enh nhan c h u a co bieu hien viem gan: + N -a ce tylcy ste in d an g uong lieu ban dau: 140 m g/kg, cac lieu sau m g /k g /la n , g ia /la n (17 lieu) + N -a ce tylcy ste in d an g tru ye n tin h m ach: lieu ban dau m g/kg, tru y e n tro n g 60 phut, lieu tiep theo 50m g/kg, tru ye n tron g g ia , lieu tri 100m g/kg tru ye n tro n g 16 gia H u Ong dAn chAn o o An v a o i £ u t r i b En h NOi khoa 201 - T h a i gia n dung: + D ung td i p a ce ta m o l m au am tin h va m en gan khon g tang + T ru’a n g h a p khon g co xet nghiem nong do: dung ta i du lieu n h u tren, enzym gan lam lai khong tang N eu e n zym gan ta n g th i dung tiep lieu tri den e n zym b inh th u a n g + B enh nhan co bieu hien viem gan, suy gan: dung tu’a n g t y n h u tren va keo dai cho den het viem gan -C a c h dung: + P N -a ce tylcy ste in d an g uong th a n h dung dich 5% , co th e ch o th e m nu’a c qua de d§ uong K hoang cach g iu a cac lieu la g ia , neu benh nhan non sau m a i uong th u o c th i uong lai lieu sau g ia Neu benh nhan m a i d im e dung than hoat th i van uong th u o c b inh thu’ang + C h ong non tic h eye: tru d c benh nhan uong th u o c can dung th u o c chon g non cho benh nhan: co the P rim peran 10m g x ong tiem tin h m ach, neu van non thi cho benh nhan uong cham tu n g it m ot hoa c nho gio t ch a m q u a ong th o n g da day (benh nhan khon g tinh), tiem nhac lai hoac am inazin 25m g x 1/2-1 ong tiem bap + N eu benh nhan non sau uong, n h ic lai lieu sau g id - C ac bien p p dieu tri khac: + Bu n u d e , d ien giai + B enh nhan an kem non nhieu: chong non, truye n d u d n g g lu o se 10-20% de nuoi d u d n g + V iem gan: d ieu tri hd tra th e o nguyen tac chung + S uy than cap: dieu tri th e o ngu yen t i c chung - T he o doi: xe t n g h ie m e n zym gan, c h u c nang than T h e o doi v ie c d u n g N -a c e ty lc y s te in T in h tran g non cua b en h nhan, benh nhan cd d u a c dung dung lieu hay khdng; theo doi cac xet nghiem (n h u tren) IV PHONG BENH - K huyen benh nhan kh d n g lam dung paracetam ol, than tro n g vi cd nhieu loai che pham khac cung c h u a p a ce ta m o l - N en than tron g d un g p a ce ta m o l cho cac benh nhan ngh ien ru a u , cd benh gan, dang dieu tri thuoc doc v d i gan, b en h nhan suy dinh d u a n g - V d i benh nhan tu tu , kh a m va dieu trj th e o ch uye n khoa tam than de tra n h ngo doc tai dien t A i l ie u t h a m k h A o A n th o n ie A n k e r (2 0 ), "A ce ta m in o p h e n e ", C lin ica l T oxicology W B S a u n d e rs C om pany, PP -27 K e n t R O ls o n (20 ), “A c e ta m in o p h e n e ”, P o iso n in g and D rug o ve rd o se 5th edition, Me G raw H ill-L A N G E , e le c tro n ic versio n P O IS IN D E X ® M a n a g e m e n ts (2010), “A c e ta m in o p h e n ”, M IC R O M E D E X ® 1.0 (H e a lth ca re S eries), T h o m s o n R e ute rs R o b e rt G , K e n n e th E (2006), ‘A c e ta m in o p h e n e ”, G o ld fra n k ’s M a n u a l o f T o xico lo g ic E m e rg e n cie s, 8th e d ition, M e G w Hill, PP 523-543 NGO DOC CAP ROTUNDIN • • D AI C im N G - R otun din du’O’c chiet xuat tu cu b inh voi v d i phan ch in h la L te tra h y d ro p a lm a tin co tac dung an than, giam dau, gay ngu La th u o c co an toan cao, nhien neu uong qua lieu co the gay nhieu bien ch u n g - Lieu gay ngu tu 30 - 90m g, lieu giam dau 60 - 120m g, toi da co th e d un g to i 480 m g/nga y Lieu ngp doc c h u a co tai ligu nao noi ch in h xac la bao nhieu Tuy nhien, th e o ng h ie n c u u cua chun g toi benh nhan uong 0 m g /2 g io da gay n h u n g bien doi ve dien tim li chAn An C h an d o an xac djnh a H o i b en h p h a t h ie n b en h n h an cd u o n g ro tu n d in b Trieu c h irn g lam san g - T n kinh: u c che th a n kinh trung u o n g , giam y th u c , nang d in den hon m e, m ot so it benh nhan kich th ich - H o h ip : u c che ho h ip , vie m phoi sac - Tim m ach: hau het deu co cac roi loan tren dien tim , th u o n g gap nha t la S T chen h len, T am ho§c pha, QTc keo dai, co the gap nhip cham , xoang hoa c nhanh xoan g, b lo ck n h i that, tu t h u ye t ap - Tieu hoa: buon non, non, co the gay vie m gan n h u n g chu yeu la g a p o b en h nhan dieu tri keo dai c X e t n g h ie m - D o c chat: tim rotu ndin tro n g dich da day, n u o c tieu D jn h lu o n g ro tu n d in tro n g m au b in g s ic ki long khoi - D ie n tim : ghi dien tim luc va o vien va luc vien, co bat th u o n g ve d ien tim can th e o doi dien tim m oi - g io b in g m onitor C h an doan phan biet - V o i cac loai th u o c ngu va an than khac: xe t nghiem doc chat - P han biet v o i cac n gu yen nhan khac gay hon me III D I^U TRI - T uan thu cac b u o c cap c u u on djnh benh nhan neu benh nhan tro n g tin h tra n g nang - K hong co th u o c giai doc d a c hieu - H an che hap thu + G ay non neu den so m , tinh hoan toan + N eu da co roi loan y th u c : ru a da day sau dat noi q ua n (N K Q ) co bong chen , vcn lucm g n u o c ru a toi da tu - lit H uong d An c h An d o An v A o i £u t r i b£n h NOi khoa 203 + T h a n hoat g/kg, uong m ot lan kem th u o c tay + T h u o c ta y sorbitol: - 2g/kg - H oi s u e + B ao dam ho hap: benh nhan co roi loan y th u c: dat benh nhan nam tu the ngh ieng an toan, tranh tut lu d i, hut d o m dai, th o o xy neu can + N eu co hon m e, suy ho hap: tien hanh dat NKQ , th d m ay CMV + T ruyen dich: tang c u d n g thai tru chat doc, dung natri clo ru a 0,9% ; g lu co se 5% + N uoi d u d n g , ve sinh c o the, chon g loet + T h e o doi dien tim , vien QTc co xu h u d n g giam trd ve bin h th u d n g t A i l ie u t h a m k h A o H Tr H u n g B H T h u ; P.Due (2002), “N g o d o c ro tu n d in ”, H oi th a o tap huan ngo doc toan quo c lan th u 3, Ha Long F e ld h a u s K M , H o ro w itz R S, D a rt R C e ta l (1993), “L ife -th re a te n in g to x ic ity fro m te tra h yd ro p a lm a tin e (T P H ) in an h e rb a l m e d ic in e product", Vet H um an Toxicol, 35, PP 329 H o ro w itz R S , D a rt RC , H u rb u t K et al (1994), “A c u te h e p a titis a s s o c ia te d w ith a Chinese h e rb a l product, Jin B u H u a n ”, N orth A m e rica n C o n g re ss o f C lin ica l Toxicology Lai C K & C h an A Y W (1999), “ T etrahydropalm atine p o is o n in g : d ia g n o s e s o f n ine a d u lt o ve rdose b a se on to x ic o lo g y s c re e n s b y H P L C w ith d io d e a rra y d e te ctio n a n d g a s c h ro m a to g p h y-m a ss s p e c tro m e try ”, C lin C h em , 45, PP 229 - 236 P O IS IN D E X ® M a n a g e m e n ts (2010), "T e trahydropa lm atine", M IC R O M E D E X 1.0 (H ealth care S e ries), T h o m s o n R euters O liv e r LH , N eal Al et al (1998), “H e rb a l p re p a tio n s", G o ld fra n k 's T o xico lo g ic e m e rgencies, 6m edition, A p p le to n & lange, PP 12.22 - 1.241 NGO DOC NAM DOC • • • I G IQ I THIEU - C ac loai nam cfoc co doc tin h khac Tuy nhien, th u c te tre n lam sang phan lam hai loai loai nam gay ngo doc s d m (bieu hien tron g vong g id dau sau an) va loai gay ngo d o c m uon (bieu hien sau an - 40 g id ) C h an d oa n ban dau chu yeu d u a va o benh canh lam sang sau an nam - T ru d n g h o p ngo d o c s d m de phat hien, ch i dieu tri trieu c h u n g va ho tr o day du benh nhan thudng song T ru d n g h o p ngo doc m uon de b| bo sot hoa c chu q ua n dieu trj kh o n g tic h cue, khong day du, th u d n g nang va tu vong cao - N go doc nam th u d n g xay vao m ua xuan, he, th u d n g n g u d i dan tu hai va an cac loai n im m oc hoang dai Tren ca n u d e d cac khu v u c ru n g nui deu co cac vu ngo d o c tap the, gia d inh v d i nhieu n g u d i ngo doc nang va tu vong, nguyen nhan th u d n g la nam luc (loai gay n g o d o c cham ) li c h An d o An C h an d o an xac djnh a N g o d o c c h a m > gid1(lo a i n g u y hiem ) Do nam luc hay nam doc xanh den - A m a n ita p h a llo id e s ho a c nam doc t r in g - A m a n ita vem a, chua am atoxin X u at hien m uon sau an - 40 g id (th u d n g la 12 g id ) - G iai doan I: trieu c h u n g xuat hien - 24 g id sau an nam gom : dau bung, non, buon non, tieu chay, m at n u d e dien giai C o the nang tu o n g tu n h u ta - G iai doan II: xuat hien 24 - 48 g id tiep theo + C ac trieu c h u n g tieu hoa th u ye n giam hoac het, benh nhan va th a y th u o c de chu quan, n gh i benh khoi Ton th u o n g cac tang, dac biet la gan dang bat dau - G iai d oa n III: xu a t hien - nga y sau + V iem gan nang dan (ALT, AST, b ilirub in tang cao) va dan td i suy g a n to i cap (roi loan dong mau, g iam tieu cau, hon m e gan, tu vong), suy than va cac tang khac • X e t nghiem , th a m do: - C ac xet n gh iem danh gia vie m gan, suy gan, than, d on g m au, c o n g th u c m au, ton th u a n g cac tang khac - Test nhanh doc chat: ep nam tu o i lay n u d e va nho len m ie n g g ia y th a m , lam kh o (tranh lam nong va tran h anh n ln g m at trd i), nho m ot giot acid clo h yd ric dac len vj tri co djch nam , neu nam co am atoxin thi vj tri nho gio t se xu a t hien m au xanh lam L u u y, dong th d i lam c h u n g so sanh (nho acid len m ieng giay d vj tri khon g co djch nam ) Test co the d u o n g tin h gia b L o a i g a y n g p d o c n h a n h < g/'d X u a t hien nga y sau an, tro n g vong g id va keo dai vai g id T u y thuQC loai nam , co th e thay H u Ong d An c h An o o An v A o i £u tri b £n h NO ik h o a 205 • H oi c h u n g d isu lfira m (do an nam m u c - C oprinus a tra m e n ta riu s, c h u a co p rin va uong ru g u ): - C h i xa y benh nhan an nam va uong ru g u C a c trie u c h u n g xu a t hien 0,5 - g id sau uong ru g u (tru d c do, tro n g vong - 72 g id trd lai benh nhan co an nam ) - C am g ia c b o c hoa, buon non, non, nhip tim nhanh • Roi loan y th u c , ao g ia c va kich th ich (nam hay nam m at trd i - A m a n ita m u scaria, nam m un trang hay nam tan da bao - A m a n ita p a n th e ria , c h u a ib o te n ic acid va m u scim o l) T rong vong 0,5 - g id sau an nam : - N g u d i Idn th u d n g noi bat la chon g m at, kho chju, lo m o , sang; tre em th u d n g noi bat la noi nhieu, la het, ao giac, kich th ic h kho chju, rung giat co, co giat • Hoi c h u n g m u sca rin ic (do nam m u kh ia - Inocybe p a to u illa rd ii, c h u a m uscarin): - X u a t hien tro n g vo n g 0,5 - g id sau an va keo dai vai gid - Tang tiet n u d e bot, va m o hoi, chay n u d e m at, non, tieu chay, m ach cham , tu t huye t ap, co dong tu , co th a t va tang tie t p h e quan K hong co hoi c h u n g nicotinic • Trieu c h u n g ong tieu hoa (nam phien den chan vang - A g a ric u s x a n th o d e rm is, doc to c h u a ro), xuat hien tro n g kh o a n g m o t vai g id sau an: - D au quan bung, b uo n non, non, tieu chay cac m u c tu nhe den nang, co th e m a t n u d e dien giai - Test nhanh: nho d u n g dich kiem (co the KO H hoac N aO H ) len m u hoa c than cay nam thi nhanh chong th a y ch u ye n m au vang Chan doan phan biet - Benh s u an nam cu n g b en h canh th u d n g giup chan d oa n n h u n g co m o t so tru d n g h g p gan giong ngo doc nam - N go doc th u c p h a m ca c ngu yen nhan khac (V D ta hoa c cac vi khu a n khac): ch i co trieu c h u n g tieu hoa va co th e co n hiem trun g, soi va cay phan giup chan doan - N go d o c th u o c tr u sau c a rb a m a t va ph o sp h o hCm co: benh ca n h tie p xuc hoa chat bao ve th u c vat, co du ca hoi c h u n g (m u sca rin ic, n icotinic va hoi c h u n g than kinh tru n g u o n g ) va th u d n g nang, enzym ch o lin e sta se giam , xet n g h ie m doc chat thay th u o c tr u sau - N go doc m a tu y loai k ic h th ic h (can sa, th u o c lac): co kich th ic h , ao g ia c n h u n g co hoan canh dung m a tuy, dong t u th u d n g gian, h u ye t ap tang, xet ngh iem doc chat d u o n g tinh III XIy TRI Loai gay ngo doc cham (loai nguy hiem) • T ay doc: - G ay non neu m d i an tro n g vong vai g id , benh nhan c h u a non - R u a da day neu b en h nhan m d i an nam tron g vong g id , c h u a non - T n h o a t da lieu: ban d a u g/kg, sau ,5 g /k g /4 g id /la n , ke t h g p s o rb ito l lieu gap doi, n h ic lai tro n g n ga y dau T h e o d o i nhu dong ruot, non, dai tie n va n g u n g neu ta o bon h o a c non, tie u chay qua m ire • T ruyen dich, d a m b a o bu n u d e , dien giai: - Bu djch b ln g natri clo ru a 0,9% , R in g e r la cta te va th e m kali clo rid neu can, ket h g p uong O resol • G iam dau b un g b in g cac th u o c giam co th a t c o tro n C h o n g non neu benh nhan da non nhieu • T a n g th a i doc, lam tro n g dau, cang s d m cang tot: - T ruyen djch, Ig i tieu: th u ’c hien tu va o vien, nen d a t c a th e te r tin h m ach tru n g tam , bu djch, dien g iai va Igi tie u de ta n g th a i doc - L q c m au th a m ta c h (tha n nhan tao), loc m au lien tuc, th e o d ieu kie n c o sd 206 Huc3ng d An ch An bo An v A ei£u tri b £ n h NOi khoa • T h u o c giai doc: - S ilym arine : nu’d c ta chu>a co ch e ph a m tin h m ach, co co th e d u n g du’d n g u on g (L e g a lo n ) vien 70m g, n g u d i Idn uong vie n/n gay - B e n zylp e m cillin (P e n icillin G ) 0 0 - 100 0.0 00 d o n vi/kg/nga y, tru y e n tTnh m a ch (3 nga y dau) - N - a ce tylcyste in : nen d un g d u d n g tin h m ach, dac biet da co suy gan L ieu u on g ban dau 140m g/kg, sau m g /k g /4 g id /la n , tri td i tin h tran g vie m gan, suy gan cai thien Ket h o p chong non, bQC niem m ac da day (P h o sp h a lu g e l, G a stro p u lg ite ) • D ie u tri bien c h u n g vie m gan, suy gan, suy than va ca c trie u c h u n g khac: - D ieu ch inh n u d e - d ien giai, to a n - kiem - S uy th a n cap nang: lo c ngo th a n tu y th e o dieu kien - N e u co su y g a n , b iliru b in ta n g h o n m m o l/l I q c g a n (M A R S ) h o a c th a y h u y e t tu o n g phoi hop C W H - T y gan (g hep gan): neu suy gan khon g hoi phuc - C a c bien p h a p kh a c tu y th e o tin h tran g benh nhan Loai gay ngo doc nhanh (loai it nguy hiem) - G ay non: neu m d i an tro n g vong vai g id , c h u a non va b en h nhan la tre Idn, n g u d i Idn, tinh, h o p tac U ong n u d e va g a y non - R u a da day neu m d i an tro n g vong vai g id - T n hoa t lieu: g/kg can nang, co the them S o rb ito l lieu tu o n g d u o n g - T ruyen dich: natri clo ru a 0,9% , R in g e r lactat, bu kali neu can - G iam dau loai ch o n g co t h it c o tro n - K ich th ich , va t va, co giat d ia ze p a m (S edu xen), p h e n o b a rb ita l (L u m in a l), m id a z o la m ket h o p dam bao ho hap Tiem bap ho a c tin h m ach th e o tin h trang - Loan than: co th e d un g a m in a zin , lo p e rid o l, th u d n g c h i can tie m b ip - Hoi c h u n g m u sca rin : a tro p in th e o bang diem a tro p in (tu o n g t u ngo d o c p h o s p h o hCru c o hay ca rb a m a t) n h u n g lieu a tro p in th u d n g thap - T rong hau het cac tru d n g h o p , v d i loai nam gay ngo d o c nha nh, ca c bien p h a p ca p cu u , dieu tri trieu c h u n g , d ieu tri ho tro neu lam kjp th d i, dung va day du thi benh nhan se hoi phuc IV PHONG BENH - P han biet nam d o c va khon g doc rat kho, ca v d i cac c h u y e n gia N am d o c cung co h u o n g vi ngon T rong cac loai nam doc, nam luc hay nam d o c xanh den (loai nam d o c n h a t hien nay) co hinh th u c rat ngon va hap dan nhat - D e phong tra n h ngo doc nam tot nha t la khon g an cac loai nam m o c h o a n g dai TAl LIEU TH A M KHAO Vo Van Chi (1999), “A/am mtsc, n a m p h ie n dom chuong, n a m m a t trai, n a m d o c x a n h den, n im m y n tr&ng", T u d ien cac cay th u o c V ie t N am , Tr 809 - 813, N x u a t ban Y hoc, H a Noi Christine Karlson - Stiber, Hans Persson (2003), ‘ C y to to x ic fu n g i - an o v e rv ie w Toxicon, E lsevier 42, PP 339 - 349 POISINDEX® (2010), “M a n a g e m e n ts , M u sh ro o m s - g e n e l", M IC RO TVIEDEX® 1.0 (H e a lth ca re S e ries), T h o m s o n R e ute rs NGO OOC CAP PARAQUAT QUA DUONG TIEU HOA I O Al CU’O NG - Ngp doc p a q u a t tu vong rat cao, tinh chung co the td i 70 - 90% , vai tro va c o hoi de ap dgng cac bien phap dieu tri hien han che chat doc d u o c phan bo va gan nhanh vao phoi (trong vong g id dau da co th e dat nong gay ti> vong), gay ton th u o n g phoi, x o phoi tien trien T h d oxy lam tin h trang x o phoi tien trie n nhanh hon - Thai dieu tri chun g to co hieu qua nhat hien la khan cap tran h thu tron g nhu’ng g id dau sau uong v d i vie c d on g th d i ap dung cac bien phap tay doc, truye n dich, lo i tieu tich cue, loc m au, sau ket h o p lieu p p u c che m ien dich va dieu tri trieu ch u n g ii chAn o o An,oAn h g iA - Bgnh nhan uong hoa chat tru co, chat non co m au xanh, Iq dung dich m au xanh lam d u o c c h u a lo bang n h u a K h a n g djnh neu ten hoat chat la paraquat - Trong n h u n g g id dau dau rat m ieng hong, doc sau x u o n g u c va th u o n g vj V iem , loet, tro t m ieng, hong, th u c quan xu a t hien sau nhieu gid - Suy ho hap: cap tin h tien trien vai dau (ton th u o n g phoi, tran m ang phoi, tran trung that) hoa c k h d i phat sau hang tuan va nang dan sau (x o phoi) D a nh gia b in g S p 2, m £u dong m ach, X q u a n g phoi, chup cat Idp phoi, tham c h u c nang ho hap - Co the co tu t h u ye t ap, suy tim cap (toi cap) hoac suy than (xay s d m tron g dau), viem gan sau vai (X e t n g h ie m ) X e t nghiem cong th u c m au, ure, creatinin, bilirub in, dien giai, AST, ALT, m au dong m ach, to n g phan tich n u d e tieu - Xet ngh iem p a q u a t djnh tin h (test nhanh), giup chan doan xac djnh: djch da day m au hoa chat hoac n u d e tieu (co th e am tin h sau uong 24 g id neu than khong suy): + 10m l m au d o c ch a t nghi n g o d u o c kiem hoa b ln g N a H C de dat pH - 9, sau cho bot natri dithionit vao, n u d e tieu neu co p a q u a t se chuyen sang m au xanh lam (xanh d u o n g xanh da trd i) Co the thay p a q u a t nieu d u o n g tin h neu lay n u d e tieu vong 24 g id sau uong v d i c h u c nang than binh th u d n g N eu suy than, xe t ngh iem co the d u o n g tin h td i vai sau - D jnh lu g n g p a q u a t tron g m au (neu co dieu kien): lay m au tro n g vong 24 g id sau uong, giup tien lu g n g kha nang song sot ill chAn d o An p h A n b ie t - U ong cac ch a t an m on khac: vi du uong acid, kiem khac th u o c tru co glyp h o sa t d iq u a t (m au hoa chat khong co d a c d ie m nhan dang n h u tren, co ton th u o n g m em m ac n h u n g khong x o phoi) 208 H u Ong dan ch An bo An v A b i Eu t r i b e n h N oi k h o a IV O l£ u TR! - C ac bien p p ta y d o c va tang th a i doc phai th u c hien d on g th d i ca n g s d m ca n g tot kh o n g de bien phap anh h u d n g den bien phap khac H an c h e h i p th u d o c c h a t - G ay non: tro n g vo n g g id dau - R u a da day: tro n g vo n g g id dau, ru a td i n u d e het m au xa n h lam - H ap phu ch a t d o c (trong g id dau), uong m ot tro n g th u o c sau (u u tie n th e o th u tu ): + T n hoat: g /kg/lan , dung lan, g id /la n va so rb ito l lieu gap doi + Fuller's earth: n g u d i Idn 100-150g, tre em 2g/kg, pha ti le phan thuoc + phan n u d e theo luong + D a t set, dat thit ho a c dat th u d n g (neu d xa benh vien): pha n u d e uong T a n g th a i t r u c h i t d o c - Bai nieu tic h cu e , d a m bao 0 m l/g id : lam tron g 24 g id dau, tie p tu c neu p a q u a t nieu d uo ng tinh - Loc m au (neu co dieu kien): th u c hien tro n g vong 24 g id dau, can n h lc neu sau 24 g id paraquat nieu d u o n g tinh: + Loc m au hap phu (co t th a n hoat), nh a c lai m oi 12-24 g id ch o d e n p a q u a t nieu am tinh - N eu ch i co HD, co th e th u c hien tro n g g id dau sau n hiem doc L ie u p h a p u c c h e m ie n d jc h - M e th ylp re d n iso lo n : m g /kg /n g a y (pha v d i 0 m l g lu co se 5% , tru y e n T M g id ), tro n g - C yclo p h o sp h a m id : m g /kg /n g a y (pha v d i 20 m l g lu co se 5% , tru y e n T M g id ), tro n g - Sau do: d e x a m e th a s o n m g /la n x lan/ngay, tro n g 14 ngay, tie m T M , sau g ia m dan lieu va ngung - N eu P a < m m H g : d u n g lai ng a y m e th y lp re d n is o lo n n h u tre n , n h ic lai c y c lo p h o s p h a m id lieu n h u tre n tro n g n ga y (ch i nh a c lai th u o c neu lan d u n g tr u d c c a c h xa tre n 14 n g a y va bach cau > 3G /I) C a c th u o c c h o n g o x y h o a (tu y d ie u k ie n , n e u c o ) - N -a ce tylcy ste in tin h m ach: m g/kg, pha v d i 0 m l g lu c o s e 5% , tru y e n T M tro n g g id sau lan loc m au dau tien, sau 0 m g /kg , pha 50 m l g lu co se 5% , tru y e n m l/g id tro n g tu an - V ita m in E: 300 m g x lan/ngay, uong - D e fe rio xa m in (D e sfe n , d un g sau lan Iqc m au dau tien): 0 m g /kg , p h a v d i 0 m l g lu co se 5%, tru ye n TM 21 m l/g id , d un g D ie u t r j h o tr o - C h i cung ca p th e m o xy neu P a < m m H g ho a c S p < 80% - B oc niem m ac tie u hoa - G iam tie t djch vj: d un g d u d n g tin h m ach - G iam dau tot, co th e d un g che ph a m opiat - D inh d u d n g d u d n g tTnh m ach, nen bao gom dung djch lipid - G iai th ic h ch o gia d in h b en h nhan: can giai th ic h de h o p tac co c o hoi d ie u trj va hieu d u o c tien lu o n g cua ngo doc H ltO n g d a n c h a n o o An v a d i £u t r i b£n h N oi k h o a 209 V THEO DOI VA TIEN LU’CTNG (A p DUNG TUY THEO O l£U KIEN) - Lu’u y: tron g vai nga y dau benh nhan co the van binh thu’d n g , suy ho hap th u d n g xuat hien sau - C hup X q uang phoi hang ngay, chup c i t Idp phoi tuan/Ian - X et nghiem m au, c h d c nang gan, than hang - T ham chi>c nang ho hap on dinh va - tuan/Ian - Hen kham lai d inh ki VI PHONG BENH - Tot nhat la khon g st> dung paraqu at lam hoa chat tri> co - Khi s ir dung hoa chat nay: chi du’o c dung loai dung dich < 5% , khong lu’u hanh loai nong cao hon cong dong TAl LIEU TH AM KHAO A lvin C B ro n s te in (2004), "H erbicides", M edical toxicology, 3rd edition, Lippin cott W illiam and W ilkins, PP 1515-1 529 B rent R E kin s, R ich a rd J G e lle r (2001), “P a q u a t a n d diquat", C linical toxicology, W B S a unders com pany, PP 841- 847 Jam es F W in c h e s te r (1998), 'P a q u a t a n d the b ip y rid y l herbicide s", C linical m a n age m e nt o f poisoning and drug overdose , 3rd edition, W B S a unders com pany, PP 845 - 855 P O IS IN D E X ® M a n a g e m e n ts (2010), ‘P a q u a t", M IC R O M E D E X ® 1.0 (H e a lth ca re S eries), 1974 - 2010 T h o m so n R euters R J D inis - O liv e ira (2008), "P ara quat P o iso n in g s: M e ch a n ism s o f L u n g Toxicity, C linical Features, a n d T re a tm e n t, C ritica l R eview s in Toxicology, Info rm a H e a lth ca re USA, Inc., ISSN: 040 - 8444 p rin t/1 547 - 6898 online, 38, PP -7 R eb ecca L T o m in a c k , S u san M Pond (2002), "H erbicides", G o ld fra n k's to xico lo g ic em ergencies, 7th edition, Me G w - Hill, PP 1393 - 1410