Phau thuat vien Khoa phau thuat Chan thuong - Chinh hinh BV Viet Due. ---—-j[r]
(1)(2)BO Y TE
CAP CUU NGOAIKHOA■
TAP 1
(DUNG CHO BAC SI VA HOC VIEN SAU DAI HOC)
M A SO : D01.Z9.W
(3)Chi dao bien soan:
VU KHOA HOC v A dAO TAO - B0 Y TE
Chu bien:
GS DANG HANH DE
Tham gia to chufc ban thao:
ThS PHI VAN THAM TS NGUYEN MANH PHA
© Ban quyen thuoc Bo Y te (Vu Khoa hoc va Dao tao)
1054 - 2010/CXB/17 - 1758/GD Ma so: 7K874Y0 - DAI
(4)Chu bien:
(IS DANG HANH DE
Nguyen I •’ho Chu nhiem Bo mon Ngoai TrUdng Dai hoc Y Ha Noi Xguven Chu nhiem Khoa Phau thuat Tim mach - lx>ng ngu'c BV Viet, Due Chu nhiem khoa Xgoai BV HGfu Nghi
T h a m gia b ie n soan:
NGUY§N NGOC BiCH
PGS.TS Pho Trudng Bo mon Ngoai Tri/dng Dai hoc Y Ha Noi Tri/dng khoa Ngoai Benh vien Bach Mai
TRAN NGOC BICH PGS.TS Tri/dng khoa Phau thuat Nhi BV Viet Due
DANG HANH DE GS Nguyen Pho Chu nhiem Bo mon Ngoai Tri/dng Oai hoc Y Ha Noi Nguyen
Chu nhiem Khoa Phau thuat Tim mach - Long nguc BV Viet OCrc Chu nhiem khoa Ngoai BV Hufu Nghi
DONG VAN HE TS P hlu thuat vien Khoa Phau thuat Than kinh BV Viet Due
DLfONG DAI HA TS Phau thuat vien Khoa Phau thuat Than kinh BV Viet Difc
DUONG DUC HUNG TS Pho Tri/dng khoa Phau thuat Tim mach - Long ngiic BV Viet Due
d oAnq u o c HUNG TS Phau thuat vien Khoa Phau thuat Tim mach - Long ngue BV Viet Dl/c
TRAN HIEU HOC TS Pho Tru’Ong khoa Ngoai BV Bach Mai
PHUNG NGOC HOA ThS Phau thuat vien Khoa Chan thueing - Chinh hinh BV Viet Due
KIEU DINH HUNG TS Phau thuat vien BV Dai hoc Y Ha Noi
PHAM DUC HUAN PGS.TS Pho Trifdng Bo mon Ngoai tri/dng Dai hoc Y Ha Noi, Trifdng khoa
Phau thuat Tieu hoa BV Viet Due
NGUYEN XUAN HUNG PGS.TS Tri/ong phong Kham cap ci/u BV Viet Due
HOANG LONG TS Phau thuat vien Khoa Tiet nieu BV Viet Di/c
n g u yInvAn MAO ThS Giam doc BV Tim Ha Noi
TRAN BAO LONG PGS.TS Phau thuat vien Khoa Gan - Mat BV Viet Due
LE HONG NHAN TS Pho Tri/dng khoa Phau thuat Than kinh BV Viet Due
NGUYfN DUC PHUC PGS Phau thuat vien Khoa Chan thi/ong - Chinh hinh BV Viet Due
NGUYEN QUANG TS Phau thuat vien Khoa Nam hoc BV Viet Di/c
(5)
-HA VAN QUYET GS.TS Truong Bo mon Ngoai Truong Dai hoc Y Ha Noi Pho Giam doc BV
Viet Di/c
DANG HANH SON TS Phau thuat vien BV Tim Ha Noi
DO TRUONG SON TS Phau thuat vien Khoa phau thuat tieu hoa BV Viet Due
HOANG NGOC SON TS Phau thuat vien Khoa phau thuat Chan thuong - Chinh hinh BV Viet Due
-—-j
NGUYEN CONG TO PGS.TS Pho Truong Bo mon Ngoai Trudng Oai hoc Y Ha Noi Pho Giam doc
BV Viet Due
DO TRUONG THANH TS Pho Truong khoa Phau thuat Tiet meu BV Viet Dire
IE NGOC THANH PGS.TS Giam doc Trung tarn Tim mach BV E
HA KIM TRUNG TS Pho Truong khoa Phau thuat Than kinh BV Viet OUc
TRINH VAN TUAN TS Phau thuat vien Khoa Cap cull Tieu hoa BV Viet Oifc
DOAN THANH TUNG
_
PGS.TS Trudng khoa Phau thuat Gan - Mat BV Viet Ol/c
NGUYEN HUU UOC PGS.TS Pho Truong Bo mon Ngoai Trudng Oai hoc Y Ha Noi Pho Truong
khoa Tim mach - Long nguc BV Viet Due
(6)LCfl Gicil THIEU
Dao tao nguon nhan liic can bo chat ltfdng cao la mot nhutng moi quan tam hang dau cua nganh Y te Song song vdi viec dau tif cd sd vat chat cho cac cd sd dao tao, Bo Y te chu tang cUdng cac phudng tien day va hoc, viec bien soan tai lieu dav-hoc dac biet u!u tien
Sach Cap ctfu ngoai khoa diidc bien soan nham phuc vu cho viec dao tao sau dai hoc cua trtfdng Dai hoc Y Ha Noi, nhung cung la tai lieu tot de tham khao cho viec dao tao dai hoc va cho cac bac si ngoai khoa Sach duldc bien soan v6i phudng cham: Kien thiic cd ban, he thong; noi dung chinh xac, khoa hoc, cap nhat cac tien bo khoa hoc, ky thuat hien dai va thac tien Viet Nam
Cuon sach diidc bien soan boi cac nha giao, cac nha khoa hoc giau kinh nghiem linh viJc Ngoai khoa Sach da dUdc H6i dong chuyen mon lap theo quyet dinh so: 1683/QD-BYT ngav 20 thang narn 2010 cua Bo Y te tham dinh Sach du!dc ban hanh lam tai lieu sii dung chinh thiic phuc vu dao f ao dai hoc va sau dai hoc cua nganh Y te giai doan hien nay, dong thdi cur,g se la tai lieu hutu ich cho cac bac si tham khao hang
Bo Y te xin chan cam dn GS Nguyen Biiu Trieu, Chu tich Hoi dong tham
dinh, GS Do Dilc Van va GS Ha Van Quyet Uy vien phan bien va cac vien Hoi
dong da doc, dong gop nhieu y kien quy bau de cuon sach du!dc hoan thier;
Chung toi mong nhan di.fdc y kien dong gop cua dong nghiep va cac ^oc g; s de sach dadc hoan chinh hdn cho nhiing lan xuat ban tiep sau
(7)L d l NOI DAU
Cap cUu ngoai khoa luon la mot van de thdi sii khong nhutng cua cac phau thuat vien ma cua tat ca nhutng lam cong tac lam sang
Trong the ky trUdc Nha xuat ban Y hoc da xuat ban cuon Cap cufu Ngoai khoa, nhifng trai qua nhieu nam v6i nhutng tien bo nhanh chong cua y hoc noi chung cung nhu stf phat trien cua nganh Ngoai khoa noi rieng, cuon sach khong cap nhat nuta
Chung toi bien soan lai lan nham trUdc het phuc vu cho cong tac dao tao (dai hoc va sau dai hoc cac trifdng Dai hoc Y) va sau la cac dong nghiep d cac tuyen v te ca nifcic Nhutng ngifdi tham gia bien soan deu la cac can bo giang day Bo mon Ngoai trifdng Dai hoc Y Ha Noi v6i nhieu nam giang day va phau thuat tai cac benh vien 16n (Viet Due, Bach Mai, Saint Paul), thuoc dung chuyen khoa cua minh Vi the chung toi hy vong cuon sach se dap ling dutdc yeu cau cua cac dong nghiep
Noi dung cuon sach chi thu gon nhutng cap cUu ngoai khoa thong thifdng, rat hy vong tifdng lai co the bien soan cuon Ngoai khoa toan tap
(Textbook o f Surgery), mot cong trinh 16n doi hoi siJ tham gia cua nhieu ngiidi, nhieu chuyen nganh khac Sach ditdc bien soan tap:
- Tap gom cac chuyen khoa: Than kinh, Long ngiJc va Tim mach, Nhi - Tap gom cac chuyen khoa: Tieu hoa, Tiet nieu, Chan thifdng
Du da rat co gang nhu'ng van khong the tranh dude nhutng thieu sot nhutng tien bo khong ngung va nhanh chong nganh Y noi chung, viec cap nhat kien thuc khong the bat kip
Chung toi xin chan cam dn ong Phi Van Tham, chuyen vien cao cap Vu Khoa hoc va Dao tao Bo Y te da khuyen khich va tao moi dieu kien thuan ldi de cuon sach dude xuat ban Cam dn ba Nguyen Thi Thanh Binh, Thu ky Bo mon Ngoai da gop phan bien soan cuon sach
Chu bien
(8)MUC LUC
Ldi gidi thicu Ldi noi da u
P h a n THAN KINH
1 Ton thUdng da dau chan thUdng 11
(Nguyen Cong To)
2 Vd xUdng so 18
(Kieu Dinh Hung)
3 Vet th tfdng so nao 24
(Nguyen Cong To)
4 Mau tu ngoai mang cctng cap tinh 30
(Le Hong Nhan)
5 Mau tu dUdi mang cling cap tinh 38
(Le Hong Nhan)
6 Giap nao chay mau - mau tu n a o 45
(Le Hong Nhan)
7 Mau tu dUdi mang ciing man ti'nh 51
(Kieu Dinh Hung)
8 Mau tu nao tien phat 59
(Kieu Dinh Hung)
9 Chan thUdng so nao n a n g 65
(Dong Van He)
10 Phu nao 73
(Kieu Dinh Hung)
11 Hoi chiing tang ap liJc noi so 78
(Kieu Dinh Hung)
12 Ap xe nao 89
(Dong Van He)
13 Nao ung thuy tre e m 97
^ 0
(Nguyen Cong To)
14 Mau tu nao di dang mach nao 101
(Le Hong Nhan)
15 Chan thUdng cot song co cao 107
(9)16 Chan thifdng cot song co thap
(Hci Kim Trung)
1 Chan thifdng cot song lifng - that lifng co thUdng ton than kinh 1 -3
(Ha Kim Trung)
18 Vet thifdng
(Ha Kim Trung)
19 Hoi chiing chen ep ^ '
(Kieu Dinh Hung)
20 Thoat vi dia dem cot song that l u n g
(Ha Kim Trung)
21 Ton thifdng than kinh ngoai vi 152
(Nguyen Cong To)
22 Hoi cluing duoi ngUa 1-59
(Ditang Dai Ha)
P h a n LONG NGI/C - TIM MACH
1 Thai xii tri chan thifdng long ngifc 167
(Dang Hanh De)
2 Vd khi' - phe quan 181
(Dang Hanh De)
3 Thoat vi hoanh 186
(Le Ngoc Thanh)
4. Tran mang phoi tif phat .193
(Dang Hanh De)
5 Cac difdng md ngifc cap c i i u 196
(Nguyen Hi(u ifdc)
6 Xhung dieu can biet phau thuat mach mau .209
(Dang Hanh De)
7 Chen ep tim 214
(Le Ngoc Thanh - Dang Hanh Scfn)
8 Vet thUdng tim 220
(Le Ngoe Thanh)
9 Chan thUdng t i m 228
(Le Ngoc Thanh)
10 Vet thifdng mach mau ngoai vi .234
(Doan Quoc Hi/ng)
11 Vet thifdng mach mau vung co va nen c o 246
(Le Ngoc Thanh)
12 Vet thifdng mach mau chu nguc - b u n g 256
(DiAfng Dtic Hung)
(10)13 ThUdng Lon mach mau gay xUdng 264
(Di/cfng Du’c Hung)
1 Vd co dong mach chu 275
(Nguyen Van Mao)
15 Tac dong mach cfip tinh 284
(Dang Hanh De)
16 Ton thUdng mach mau thay thuoc gav nen 293
(Dang Hanh De)
17 Phong dong mach chu bung vd 298
(Le N goc Thanh)
18 Tac chac ba chu chau cap tinh 306
(Nguyen Hifu Ifdc)
19 Iloi chiing tinh mach chu tren va vai tro cua phau thuat 312
(DiMng Du’c Hung)
20 Benh huyet khoi tinh mach 319
(Nguyen Hitu ifdc)
P h a n NHI KHOA
1 Tco thUc quan - Ro thiic quan .331
(Tran Ngoc Bich)
2 Thoat vi^hoanh 348
(Trqn Ngoc Bich)
3 Tac mon vi va hang v i 362
(Tran Ngoc Bich)
4 Tac ruot sd sinh .367
(Trait Ngoc Bich)
5 Di tat hau mon - trUc trang .381
(Tran Ngoc Bich)
6 Thoat vi day ron va khe hd bung 398
(Trari Ngoc Bich)
7 Too du'dng mat 406
(Tran Ngoc Bich)
8 Hep phi dai mon vi 416
(Tran N goc B ich)
9 Long ruot d tre bu me va tre e m 425
(Trcin N goc Bich)
10 Tac ruot d tre em 439
(Tran N goc Bich)
11 Viem phuc mac phan xu .451
(11)12 Viem ruot hoai tu d sd sinh .4^6
(Tran N goc Bich)
13 Viem phuc mac d tre em ‘16-1
(Tran N goc Bich)
14 Viem hoai tii ruot non d tre cm 476
(Tran Ngoc Bich)
1 Viem ruot thtia tre em 486
(Tran Ngoc Bich)
16 (Jiun chui ong mat 497
(Tran Ngoc Bich)
1 Bang quang lo ngoai 506
(Tran Ngoc Bich)
18 Xoan tinh hoan d tre em 512
(Tran Ngoc Bich)
19 Teo ruot non bam sinh .516
(Tran Ngoc Bich)
20.,Tac ta trang .531
(Tran Ngoc Bich)
21 Tac ruot ruot quay va co* dinh bat thUdng 543
(Tran Ngoc Bich)
22 Ong tieu hoa doi d tre em 557
(Tran Ngoc Bich)
(12)PHAN 1
THAN KINH
1 TON THl/ONG DA DAU DO CHAN THl/ONG
Chan thifdng vung dau mat gom nhieu thUdng ton khac nhau, tti thUdng ton nhe toi thUOng ton gay chet ngUdi Mot cac thUdng ton can cap cCfu kip thdi, do la cac thUdng ton da dau ThUdng ton da dau ddn thuan hoac phoi hdp vdi cac thUdng ton so nao Trong bai nay, chi khu tru cac thUOng ton da dau khong kem v6i chan thUdng so nao kin hoac vet thUdng so nao Da dau co cau tao gom ldp: da, to chilc dudi da, can Galia, to chiic lien ket long, mang xUdng so.
Da dau dUdc cung cap mau bdi he thong mach canh (tit dong mach canh ngoai), chu yeu la dong mach chinh: dong mach cham, dong mach thai dUdng va dong mach tai sau To chiic da dau dUOc nuoi difdng tot nhd cac vong noi giau mach mau Ton thu'Ong da dau chu yeu la mat mau va neu thieu da la mat to chiic bao ve hop so
Da dau la to chiic nhat bao ve hop so, chiia nao bo Mat to chiic da dau co nghia la mat to chiic bao ve xUdng -so, mat ve dep tham my neu mat da d phan co toe Vi vay, cap cifu cac ton thUdng da dau, ngoai van de dieu tri chu y tdi tham my
Viec dieu tri ton thUdng da dau co tif hdn 3000 nam trUdc cong nguyen O Ai Cap, ngUdi ta nhan thay viec khong che phu va bao ve hop so se de doa sU song Nam 1776, bac si Patrick Vance da dieu tri cac thieu hut da dau bang cach khoan so, cac lo khoan so cach inch va hy vong rang dieu tri cong hai nam nhd vao sif bieu mo hoa Nam 1869, Reverdin da tim cach chuyen vat da, gan day vdi ky thuat vi phau thuat va phau thuat tao hinh da ghep vi mach nen viec dieu tri cac trUdng hdp mat da dau tot hdn trU6c
Ngav nay da dau la nguon cung cap da de va da cho cac thUdng ton da d vung khac cua cd the.
Trong bai chung toi xep ton thUdng da dau nhom dUa tren cac ton thifdng thuc the chan thUdng gay nen.
1 TU m A u D l / d l D A D A U
De la cac ton thifdng mot vung da dau nhUng khong co vet thUdng rach da gom co:
(13)Dung giap da dau: thudng vat tu va cham gav nen da dau bi dung giap ma khong co vet thUOng.
- Tu mau dudi da: mau chay dudi da dau thifdng nam d to chiic dudi da, dong banh, neu ton thudng sau hdn thi tu mau dudi 16p can Galia Cac tu mau neu nho thudng tif tieu
- Loc da dau: la hien tUdng tu mau ldn va rong dUdi ldp da dau, lam cho ldp da
khong bam vao ldp can so difdc d giuta no la banh mau dong Neu chay mau
nhieu, toan bo dien tich da phu xUdng so bi tach khoi ldp m ang xUdng, cac trUdng hdp co dau hieu mat mau.
1.1 L am sang
- Tai cho: vung da dau co bieu hien dung giap nhu dau hieu bam tim, noi u cuc vdi tinh chat u chac hoac mem, khong di dong, khong dap theo nhip mach, nghe khong co tieng thoi, an benh nhan thifdng khong dau nhieu ma chi co cam giac tuc
- Toan than: khong co bieu hien dac biet
- Dien bien: khoi mau tu thudng khong to len, mem hdn trifdc, an lom va doi nham vdi co lun xUOng so xung quanh o mau tu tan mau cham hdn
1.2 Can lam sang
Xet nghiem cd ban chu yeu la nhom mau va cong thiic mau Vdi tre em bu rat co gia tri de danh gia mat mau Xquang thudng quy de phat hien lun, vd xUdng
so kem theo.
1.3 Thai xii tri
Theo doi dien bien tri giac tii 48 den 72 gid Neu benh nhan tinh chi cho thuoc giam dau can Vdi cac trudng hop mau tu to dan len, co kem theo vd xUdng thi theo doi d chuyen khoa than kinh nham phat hien mau tu so ve sau
- Mau tu to nhUng khong kem vd xUdng so: choc hut qua da va bang ep: dung kim to (cd 16; 18) de choc hut mau tu, khong lUu kim va bang ep da dau bang bang gac thong thudng (tranh dung bang chun gian vi neu bang chat qua se gay thieu mau da dau) Nen han che choc hut va bang ep neu dUdc
- Loc da dau: vung tu lan rong, khoi mau tu ldn dan theo thdi gian Thai xU tri la trich rach da dau de lay mau cuc va mau tu, cam mau, bang ep sau mo
2 V E T T H l / d N G D A D A U
La vet thifdng di ttf ldp da tdi mang xudng so ma khong kem thUdng ton xUdng.
(14)Tuy theo nguyen nhan gay chan thifdng ma vet thifdng da dau rat da dang, tu' vet thudng sdc gon tdi vet thudng dap nat, tif vet thudng ddn gian den phiic tap tham chi vet thUdng da dau kem vdi mat mot phan da dau.
2.1 Lam sang
- Benh nhan tinh, tiep xuc tot.
- Kham vet thifdng: can co nguon anh sang tot de banh vet thudng xem rmic do nong sau cua vet thifdng, can xac dinh vet thUdng da dau hay vet thifdng so nao; (neu la vet thUdng so n<io thi phai co ton thUOng xUdng so, kem co dich nao tuy hay to chifc nao difdi vet thUdng).
- Khi tham kham neu thay co mau phun tia, cam mau tam thdi ngay,
loai bo di vat de lay Can phan biet vet thudng da dau den sdm: vet thUdng dang con chav mau vdi vet thudng den muon: bd mep vet thUdng mau xam, khong con chay mau, co the co dich due hoac mu chay ra.
- Vet thUOng m at mot phan da dau: tham kham phat hien nhu tren, xac dinh difdc dien tich mat da, mat da toan bo hav mat ca mang xUdng so.
2.2 Can lam san g
Xet nghiem cd ban
- Xquang quv ifdc tim thifdng ton xUdng so.
2.3 Thai xu1 tri
- Sd cifu: cam mau tam thdi: an tay hai ben mep vet thudng, bang ep, khau ep hai mep vet thudng.
- Cap cifu: cac vet thifdng da dau dii sach hav ban deu dUdc cat loc va khau da - Ky thuat khau da dau: mot ldp bang chi khong tieu, khau du cam mau nhUng khong gay hoai tif mep da thieu difdng
3 L O T D A D A U
3.1 Khai n ie m
Lot da la toan bo da dau bi tach khoi vi tri bao phu tu nhien, hau qua la lo xudng so, mat mau chay mau toan bo da dau bi lot khoi xUdng so, khong cuong nuoi thudng gap tai nan lao dong nhu day cu-roa cuon vao toe dai hoac mot phan cuong dinh vao cd the nan nhan
3.2 L am san g
- Toan than: benh nhan tinh trang choang: mach nhanh huyet ap tut, ap luc tinh mach trung ifdng thap Da xanh, mem mac nhdt, dau chi lanh
(15)- Tai cho: benh nhan den co the mat toan bo da dau de lo xUdng so hoac da
dau bi lot toan bo chi mot phan (cuong) dinh vao dau (thUdng phan cuong da d vung gay) Neu den sdm thi mep da dang chay mau, den muon hon thay mep
da dau lai tai tham, djch tiet due v v
- Kham thifc the: da dau mat toan bo, thudng de lai mang xUdng so Manh da rdi co toe va di vat nhu dau md, dat cat v.v C&n kiem tra xUdng so phia dudi xem co vd, lun Kham va theo doi tri giac theo thang diem Glasgow de phat hien ton thudng hop so kem theo, neu dien bien tri giac xau di hoac co khoang tinh, xuat hien cac dau hieu than kinh khu tru, can chup cat ldp vi tinh so nao de co chan doan xac dinh Kham day du cac bo phan nhu ngUc, bung, tii chi, cot song v.v de tim thUdng ton phoi hop
3.3 Can lam san g
- Xet nghiem nhom mau va cong thiic mau cap ciiu, neu benh nhan den muon thi phai lam cac xet nghiem cd ban day du
- Chup phim so quy Udc (so nao, long ngUc v v ) chup cat 16p vi ti'nh so nao de tim thudng ton phoi hdp.
4 THAI D O xty TR I
4.1 Cac triicfng hdp den sdm va da dau
4.1.1 So ciiu
- Tach benh nhan khoi nguyen nhan gay chan thUdng
- Chuyen benh nhan den cd sd y te gan nhat (neu da dau diit rdi, can mang
theo, nen de manh da rdi dung dich nUdc muoi sinh ly)
4.1.2 Cap ciiu
- Chong soc cho benh nhan: nam cho thoang, ho hap ho trd, lap dUdng truyen tinh mach, cam mau tam thdi da dau
- Manh da dau rdi dUdc bao quan dung dich nUdc muoi dang trUdng 0.9%
- Tiem huyet va vacxin cheng uon van - Khang sinh
- Xet nghiem cd ban - Chuan bi mo cap ciiu
4.1.3 M o cap ciiu - Gay me
- Xu tri vet thudng da dau: riia sach dau bang dung dich muoi dang trUdng trudc sat khuan vung mo Cat loc tiet kiem da dau va cam mau ky
(16)Sat khuan manh da Cdt loc da dau: cat bo toan bo ldp md diidi da tdi ldp bi (chu y tren lam sang tdi chan nang long)
- Khau cac mep da dau vdi (chu y cac diem moc de phan da dau vung tran, long may khong bi lech)
- Rach da kieu "quan cd"
- Bang ep nhe dau theo kieu "mu phi cong"
4.1.4 San soc sau md: thay bang, khang sinh v.v
4.2 Cac trifdng hdp den m u on
4.2.1 Trieu chung
- Tai cho: da dau thiidng mat, tai cho da co bieu hien nhiem khuan (mep da tham, khong chay mau), muon hdn, cho lot da co ldp gia mac hoac co mu
- Toan than: da xanh tai, sot cao (nhiem khuan, nhiem doc)
4.2.2 Thdi xii tri
- Sd ciiu: riia sach vung da dau va bang sach, khang sinh, chuyen den cd sd dieu tri
- Dieu tri: hoi siic chong nhiem khuan, nhiem doc bang khang sinh phoi hdp, lam cac xet nghiem cd ban Thay bang tai cho thifdng ton, cat loc to chiic hoai tii Khi tinh trang benh nhan on dinh, tien hanh khoan xiidng so de tao dieu kien cho to chi'fc hat moc, va da sau tinh trang toan than tot
tAi L IE U T H A M K H A O
1 Goniil E, Baysefer A, Kahraman S, Cklatekerlioglu O, Gezen F, Yayla O, Seber N, (1997) "Causes of infections and management results in penetrating craniocerebral injuries", Neurosurgical Review 20:3, 177 - 181
2 Greenes DS, Schutzman SA, (2001), "Clinical significance of scalp abnormalities in asymptomatic head — injured infants", Pediatr E m erg Care, 17(2): 88 — 92 Jacobs GB, Berg, RA, (1970) "Tangential W ounds o f the Head" Journal of
Neurosurgery 32:6, 642 - 646
4 Margulies SS, Thibault KL, (2000), "Infant skull and suture properties: measurements and implications for mechanisms o f pediatric -brain injury",
J Biomeeh E n g, 122(4): 364 - 71
5 Stone JL, Lichtor T, Fitzgerald LF (1995) "Gunshot W ounds to the Head in¥ Civilian practice", Neurosurgery 37: 6, 1104 - 1112
2- CC NGOAI KH0A-T1
(17)2 VO XLfONG SO■
1 M d D A U
Vd xUdng so la ton thudng hay gap trdng chan thifdng so nao Xudng so gom ba ldp: ban ngoai, 16p xUdng xo’p va ban Ban ngoai difdc m ang xifdng va da dau
9 *
bao boc Ban dUOc lot boi mang ciing 0 ngifdi tre mang ciing de boc tach nen hay bi mau tu ngoai mang Cling (NMC) hdn d ngifdi gia do mang ciing dinh chat vao xUdng sd Dong mach mang nao givia an ranh xUdng vung thai dUdng, bdi vay bj vd xUdng vung de lam ton thudng mach mang ciing gav nen mau tu NMC Xifdng xo'p chiia nhieu mau L6p phat trien theo tuoi vi vay vd xUdng so d ngUdi ldn chay mau d xUdng nhieu hdn d tre em.
H6p so difdc chia hai phan, vom so va nen so N en so phia trUdc tiep giap vcfi ham mat, vi vay vd nen so tang trU6c hay phoi hdp v6i chan thudng ham mat nhu gay Lefort gay xUdng ham dudi, vd xUdng go ma v v
Chan doan vd vom so chu yeu diia vao chup Xquang, nhUng vd nen so co the diia vao lam sang
V6 xUdng so don thu^n khong can phai can thiep, se tii lien sau thang vdi tre em ngUdi ldn thi lau hdn NhUng vd xUdng so rat hay kem theo cac bien chiing va cac ton thUdng phdi hdp phiic tap, vi vay viec xii tri phai vao cac ton thudng cu the tren lam sang.
2 cAc T O N T H t f d N G G IAI P H A U VA C H A N D O A N l A m SANG
2.1 V d v o m sp
V6 vom so kin: thudng bieu hien lam sang bang mau tu dudi da dau ma cu the la mau tu du6i mang xifdng Khoi mau tu khu tru d mot xUdng hoac hai xUdng do dUOng vd di qua khe khdp khac vdi mau tu du6i can Galea thudng lan rong Doi vdi tre em dUdng vd rong tren 4m m co nguy cd vd so tien trien can phai theo doi lau dai Bieu hien lam sang vd so tien trien bang mot khoi u diidi da dau to dan len, chan, dap theo nhip Vdi ngUOi 16n dac biet chu y dUdng vd vung thai dUdng de gay mau tu ngoai m ang ciing ton thudng dong mach m ang nao giOa.
Vd hd xUdng so la vd xUdng so kem theo vet thudng, phai chu y xem co nUdc nao chay khong Neu co nUdc nao chay tiic la vet thudng so nao hd.
Vd xudng so qua xoang tinh mach de ton thudng xoang gay mau tu NMC hai
ben hoac tren va dudi leu tieu nao neu ton thudng xoang ben
Vd xifdng sd qua xdang hdi tran bieu hien lam sang bang mau tu da dau vung tran va chay mau mui, neu vd sau de gay ro nif6c nao qua mui Nguy cd nhiem trung rat cao.
(18)Lun so d tre em da dau mong de dang nhin thay, hay gap lun so kieu qua bong ban Doi vdi ngUdi ldn khoi mau tu dUdi da dau kem theo nen khong s6 dUdc
manh lun, chi xac dinh dUdc bang Xquang Khi co lun xUdng can phai xac dinh manh xUdng lun co chen ep nao khong Doi vdi ngUdi tre lun qua mot nUa chieu day cua ban xUdng la co chen ep, nhUng ngudi gia nao teo nen lun nhieu
hdn mdi can phai can thiep
2.2 Vcf nen so
- Tang trUdc: rat hay gap, bieu hien lam sang bang tu mau hai ho mat kieu deo ki'nh ram, neu mau tu ho mat nhieu se day loi mat, chay mau qua lo mui Nhieu kem theo dich nao TrUdng hdp nang co to chiic nao loi qua mui
- Chan thudng tang hay kem theo ton thudng ham mat Dac biet la gav xUdng ham tren kieu Lefort, nang nhat la Lefort IV lam tach rdi tang so va mat
- Vd tang giuta: bieu hien lam sang bang chay mau tai, co ca dich nao qua lo tai, tu mau vung xUdng chum xuat hien muon hdn (dau hieu Battle)
Ngoai ra de gay ton thUOng day than kinh VIII lam diec tai, than kinh VII gay liet mat ngoai bien, co day VII bi phu ne sau chan thudng, bieu hien lam sang liet xuat hien muon hdn vai sau chan thudng Neu dUdng vd xUdng di qua me
dao thi ton thudng day VII khoang 40 - 50% cac trUdng hdp Neu vd phi'a ngoai me
dao thi ton thudng khoang 10 - 20%
- Vd nen so tang sau: gap chan thUOng vung co cham, bieu hien lam sang tu mau vung gay Vd xUdng vung co the lam ton thUOng dong mach dot song, hoac ton thudng cua tieu nao.
- Vd ranh trUdt: hiem gap va rat nang thudng kem theo ton thudng than nao.
3 CAC B IE N CHL/NG V A T O N T H l / d N G P H O I H d P
3.1 M au tu dvfdi da dau
Khi co vd xuong xUdng so mau chay ngoai tao mau tu duoi da dau, chay vao hop so mau tu NMC Vi vay, khong nen choc hut khoi mau tu du'6i da dau trudc 72 gid vi choc hut va bang ep mau co the chay vao tao mau tu ngoai mang ciing chen ep nao
3.2 M au tu n goai m a n g cufng
La bien chung rat hay gap cua vd xUdng sd, gap chu yeu d ngudi tre, ngUdi gia it hdn m ang nao dinh chat vao xUdng so Nguyen nhan chay mau tti ldp xudng x6p, ton thudng mach mang nao dac biet dong mach m ang nao gitia va rach xoang tinh mach.
(19)Lam sang co khoang tinh dien hinh, liet niia ngUdi ben doi dien va gian dong tii cung ben khoi mau tu neu de muon
3.3 Ton thvfofng nao
Hay gap giap nao d nen so, vung tiep xuc nhieu vdi xUdng so nhu thuy tran va thuy thai dUdng nen nhieu cac manh xUdng vd cam vao gay giap nao chay
mau Bieu hien lam sang phu thuoc vao ti'nh chat va miic ton thudng nao, benh nhan d trang thai ki'ch dong vat va va hdn me.
3.4 Ton thufdng cac d ay than kinh S9
- Day khiiu giac (day I) rat hay bi ton thudng nhat la vd la sang Bieu hien lam sang la ngUi kem va mat ngiii chu yeu la mot ben, thudng phat hien muon do benh nhan kem tinh tao hoac chay mau mui nen khong tham kham dUdc.
- Day than kinh thi giac (day II) la ton thUdng hay gap vd nen so tang trUdc, bieu hien lam sang la mu, gian ddng tii va mat phan xa anh sang Cd che ton thudng nhieu nguyen nhan khac nhu vd ong thi giac chen ep day II, hoac mau tu sau nhan cau chen ep phoi hdp vdi vd ben va tren cua ho mat, mau tu chen ep tmh mach lam tac tinh mach trung tam vong mac gay thieu mau
- Ton thUOng day III va VI do vd xUdng vung khe budm.
- Ton thudng day VII va day VIII vd xUdng da Bieu hien lam sang la giam thfnh liic nhieu diec hoan toan Ton thudng day VII bieu hien bang liet mat ngoai bien
3.5 T on thifdng m a c h m au
- Ton thUdng dong mach canh ngoai vd xUdng d lo tron be lam mau chay dO doi hinh mau tu ngoai mang ciing ho thai diidng, tien trien rat nhanh, khoang tinh ngan chi tinh bang phut, benh nhan tii vong rat nhanh chong neu khong cap ciiu kip thdi
- Ton thUdng dong mach canh xe rach mang ciing d doan dong mach di qua lam chay mau o at dong mach canh, kem theo thieu mau cua gan nUa ban cau, benh nhan nhanh chong di vao hon me va tu vong Ngoai ra, co the ton thUOng dong mach canh doan xoang hang lam ro dong mach canh xoang hang Bieu hien lam sang bang u tai lien tuc, loi mat mot ben va cac mach mau nhat la tinh mach mat cUdng tu, nghe thay tieng thoi lien tuc Khi ep vao dong mach canh vung co benh nhan het u tai va het tieng thoi Can chup dong mach canh de chan doan xac dinh
- Vd tang sau co the lam ton thudng dong mach dot song, bieu hien lam sang
chong mat, ngat quay co.
(20)3.6 T on thifdng m a n g cting
Khi ton thudng mang ciing se gay rd nUdc nao vao diidi da dau, qua mui, qua hong, hoac lo tai neu khong dieu tri kip thdi se gay viem mang nao
Khi vd vom so ton thiidng mang ciing gay ro niidc nao diidi da dau, kham thay mot khoi cang dudi da dau de nham vdi khoi mau tu Choc hut dich Vdi tre nho vd xUdng kem theo rach mang ciing de gay nen vd xUdng so
tien trien Do dich nao va to chiic nao chui vao dtfdng vd, day dan hai mep xUdng vd tach cang rong, lam nao thoat ngoai, nam dudi da dau Vd nen so tang trUdc, d vung xoang tran neu co ton thufOng sau xoang va mang ciing se gay ro nUdc nao qua mui va se di theo chieu ngUdc lai vao khoang dudi mang ciing
Ro qua xoang sang ft gap hdn, bieu hien rd nUdc nao vao hong
Vd nen so tang giiia gay rd nUdc nao qua lo tai, viec dieu tri kho khan hdn nhieu
4 cAc P H i / d N G p h A p t h A m d o c a n l A m s A n g 4.1 Chup X q u a n g so q u y ifdc
De dang thay ton thudng vd xUdng so, nhiing can phan biet vdi cac diidng mach mau an lorn vao xUdng, cac khe khdp
Khi co lun so can chup tiep tuyen
Vd nen so kho xac dinh diidc tren Xquang, thiidng khoi xUdng mat che lap Ngoai chup Xquang thay hinh anh so, dong mach canh hoac nao that rd thong vdi nao that
4.2 Chup cat ldp vi tin h (CLVT)
Xac dinh dude ton thiiOng cua xiidng so Khi nghi ngd ton thiidng day II can phai c^t day 2mm vung dinh hoc mat de tim ton thiidng ong thi giac Khi cd bieu hien vd xiidng da nen chup CLVT xifdng da
Tren phim CLVT cdn xac dinh diidc cac bien chiing nhii mau tu ngoai mang ciing, diidi mang ciing, giap nao, so, phu nao va thieu mau v.v
4.3 C h u p d o n g m a c h nao
Khi nghi ngd ton thiidng mach mau nhu dong mach dot song, rd dong mach canh xoang hang, can chup mach nao de xac dinh Trong rd dong mach canh xoang hang se thay difdc lo rd, gian tinh mach mat va thuoc len dong mach nao trade va giOa ngheo nan
4.4 X e t n g h ie m dich nao tuy
Choc rd song lam xet nghiem sinh hoa, te bao, cay vi khuan va lam khang sinh ro nude nao