Ebook Cấp cứu ngoại khoa (Tập 1): Phần 2

Neu nhtf khong sd ctfu kip thdi thi thtfdng la benh nhan se chet.. Trong tran khi mang phoi, dau hieu Xquang la dau hieu day (xem phan xep phoi)..[r]

PHAN 2

LONG NGI/C - TIM MACH• •

A LONG NGtfC

1 THAI DO XlT TRI TRONG CHAN THl/ONG LONG NGl/C Ve mat nguyen tac, xv( tri mot cha'n thtfdng long ngtfc kin cung giong nhtf mot vet thtfdng ngtfc hd, do bai chi nhiing dac diem ve thtfdng ton giai phau benh ly va lam sang mdi trinh bay rieng, thai xvf tri se trinh bay chung Chan thtfdng long ngtfc va vet thtfdng long ngtfc la hai thtfdng ton thtfdng gap cap ctfu hang Nguyen nhan gay bao gom: tai nan giao thong, tai nan lao dong, tai nan sinh hoat, dao dam Con chien tranh thi ph&n ldn la dan, bom, hoac m anh dan

La mot thtfdng ton nang anh htfdng trtfc tiep den hai cd quan sinh ton cua cd the: phoi va tim nen benh nhan ra't d i tOf vong ma nhiing tii vong ph£n ldn la sau bi thtfdng

Viec sd ctfu ban dau ddng vai trd het stfc quan nham ctfu benh nhan khoi nhtfng roi loan nang ne ve sinh ly tu£n hoan va ho ha'p, tao dieu kien du thdi gian chuyen benh nhan ve tuyen dieu tri thtfc thu

N guyen tac dieu tri nham phuc hoi thang bang sinh ly ve tuan hoan va ho hap, nhiing thtfdng ton giai phau dtfng hang thtf yeu, trif nhutng thtfdng ton la qua nang khong phuc hoi dtfdc thang bang sinh ly, luc dd mdi bat buoc phai can thiep p h lu thuat, nghla la cd chi dinh md ngtfc cap ciiu Nhtf vay p h ln ldn chan thtfdng long ngtfc va vet thtfdng long ngtfc khong can phai md ngtfc cap ctfu de stf a chiia cac vet thtfdng ton ben

1 NHAC LAI NHLfNG DIEM Cd BAN VE THANG BANG SINH LY VA HO HAP

Thang bang sinh ly ho ha'p dtfa tren ba yeu to' chinh: 1.1 T h a n h ngtfc

Bao gom kh ung xtfdng, cac cd ho ha'p, cd hoanh va m ang phoi la Thanh ngtfc vtfa viing chac, lai viia di dong thd

1.2 Dtfcfng ho hap

Tif mui, mom qua khi, phe quan vao den phe nang Dtfdng ho hap phai thong thoang de dam bao trao doi dtfdc tot

Trong chan thtfdng long ngtfc dtfdng ho hap rat d i bi can trd dich tiet tang len, mau chay vao hoac di vat, nhtfng mot dieu quan hdn la dau ma benh nhan khong ho khac de tong ngoai

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1.3 K h oa n g m an g phoi

Khoang m ang phoi la khoang gitfa hai m ang phoi: la th an h va la tang Binh thtfdng hai la sat vao nen thtfc te khoang mang phoi la mot khoang ao Ap ltfc khoang thap hdn ap life quyen, thay doi theo thi thd vao hay thd (-10 den -5 cm H^O), ho ap life thay doi hdn nhieu

Khoang mang phoi la mot khoang kin, bi thung (vet thtfdng ngtfc hd) ap life am se mat, phoi khong nd len dtfdc ntfa (tran m ang phoi) Khoang mang phoi thong thtfdng v6i khong ben ngoai gay nen nhtfng roi loan nghiem thd

Ba yeu to lien quan trtfc tiep v6i

Trong hoan canh binh thtfdng, khong co nhtfng roi loan ve ho hap va tuan hoan se co nhtfng hang so' sinh ly sau:

pH ,4 - ,4

p0.2 80 - lOOmgHg

p C 35 — 45mm Hg

BE (±2)

SB 24mEq

Trong chan thifdng long ngifc, nguyen t i c xtf tri la lap lai thang bang sinh ly ho hap, do can phai nam vtfng nhtfng yeu to' tren de dat dtfdc hieu qua dieu tri

2 NHLfNG T O N T H U D N G G IA I P H A U - C A C H XLf T R I 2.1 G ay xifofng sifofn

2.1.1 Xitdng sitdn bi ga y: la mot thudng ton thtfdng gap chan thtfdng long ngtfc Co hai cd che gav:

- Gay trtfc tiep: tac nhan gav chan thtfdng d dau thi xUdng stfdn gay d Day la loai gay ttf ngoai vao, do tang nao nam sat o gay de bi thtfdng ton nhat (thudng la phoi)

lung la mot vat can co djnh, long ngtfc bi ep det lai theo chieu trtfdc sau, cung ben cua xtfdng stfdn se bi gay Day la loai gay ttf ngoai Tang nam gitfa trung that la tang de bi thtfdng ton (tim, mach mau ldn) (hinh 2.1).

Hinh 2.1 Cd che gay xtfdng stfdn

1 Gay trtfc tiep; Gay gian tiep

* Ban than gay xtfdng stfdn la mot thtfdng ton lanh, nhe, thtfdng khong de lai di chtfng gi du khong dieu tri, chu yeu la nhtfng thtfdng ton kem theo mdi la thtfdng ton nang va de gay bien chtfng Tim cd che gay de cho de chan doan thtfdng ton kem theo

* Tuy nhien nhtfng trtfdng hdp gay xtfdng stfdn sau day can chu y:

- Gay xtfdng stfdn - : hai xtfdng stfdn dtfdc che phu phia trtfdc bdi xtfdng don, phia sau la xtfdng ba vai, dd rat hiem bi gay Treo qua bd tren xtfdng stfdn ttf ngtfc la dong mach dtfdi don, di kem la tinh m ach dtfdi ddn ttf ngoai vao va bd day than kinh dam rdi canh tay Phai mot chan thtfdng rat manh mdi lam gay xtfdng stfdn dtfdc, dd bd mach than kinh rat de bi thtfdng ton

- Gay xtfdng stfdn -9 : thtfdng ton kem theo la gan hoac lach, nghia la nhtfng thtfdng ton d bung

- Gay xtfdng stfdn d ngtfdi gia: ngtfdi gia xtfdng gion, de gay nhtfng gay gay dau, ngtfdi benh khdng dam ho, ddm dai tiet khdng dtfdc khac ngoai de tf dong gay tac phe quan lam xep phoi

- Gay xtfdng stfdn d tre em: tre em xtfdng stfdn cdn mem, rat kho gay, xtfdng stfdn bi gay cd nghia la tac nhan chan thtfdng rat manh, dd thtfdng ton kem theo la nghiem

Ttf nhtfng y tren, kham benh khdng nen chi dtfng lai d xtfdng stfdn gay ma can phai tim nhtfng thtfdng ton kem theo, chinh nhtfng thtfdng ton quyet dinh dien bien cua chan thtfdng

2.1.2 Cach, thiic xii tri

Co hai cach giam dau: dung cac thuoc loai paracetam ol, nhung tot hdn 1& giam dau tai cho bang phong be day than kinh lien stfdn vdi cac thuoc te (xylocain, marcatin) hoac gay te vung (gay te ngoai mang ctfng vdi morphin)

Neu phong be day than kinh lien stfdn thi co the tiem vao o gav nhtfng tot hdn la gay te goc day than kinh (4 khoat ngon tay ttf dtfdng gitfa ltfng)

2.2 M an g stfdn

2.2.1 M ang sildn cd nhieu loai

- M ang stfdn trtfdc hay goi mang tfc stfdn: gom xtfdng tfc va cac sun stfdn Day la loai mang stfdn gay roi loan nghiem ve ho hap va tu^n hoan vi cd hoanh co keo ho hap

Hinh 2.2 Cac loai mang stfdn

1 Mang si/dn kinh dien; NCra mang si/dn; Cac loai mang stfdn: T: trtfdc; B: ben; S: sau

- M ang stfdn ben la loai mang stfdn hay gap nhat, khong di dong nhieu nhtf mang tfc stfdn

- M ang stfdn sau la m ang stfdn it di dong nhat vi nSm m ang stfdn da bi han che di dong roi, khong can co dinh

- Niia mang stfdn: xtfdng stfdn chi gay mot ndi, m ang stfdn di dong kieu canh ciia v6i ban le la sun stfdn Xay d ngtfdi tre tuoi (hinh 2.2).

2.2.2 Dien bien

Sau hinh m ang stfdn, theo tinh chat di dong ma chia thanh: - M ang stfdn di dong: gay nen hai hoi chtfng: ho hap dao ngtfdc va trung that di dong

- M ang stfdn co dinh: cac dau xtfdng gay cai vao nhau, co dinh nhtfng mang stfdn co the di dong thtf phat thay doi ap ltfc dot ngot khoang

mang phoi (ho), thtfdng xay khoang - dau Ne'u nhtf khong di dong thi ap ltfc am tinh khoang mang phoi se hut mang stfdn thut vao moi mot sau hdn, de lai di chtfng han che ho hap

Mot dieu can nhd la nhieu xtfdng stfdn gay thi nhu mo phoi ben thtfdng la bi thtfdng ton, gay nen tran mau va tran khi, xep phoi Nhieu nhtfng thtfdng ton ma bat buoc phai mo de dieu tri

2.2.3 Cach xii tri

- Sd ctfu: sau chan doan co mang sUdn di dong, phai sd ctfu roi mdi dtfdc chuyen benh nhan ve trung tam dieu tri Muc dich sd ctfu la nham khong cho mang stfdn di dong: dung mot cuon bang dat vao mang stfdn roi lay bang khac cuon vong quanh ngtfc lam cho mang stfdn luon luon d ttf the thut vao ma khong phong len dtfdc Nhtf vay, se tranh dtfdc nhtfng roi loan tu£n hoan va ho ha'p nhtfng tat nhien la han che ho ha’p

- Dieu tri thtfc thu: co hai cach dieu tri

+ Co' dinh ben ngoai hay goi la co dinh giai phau, co the thtfc hien bang nhieu cach:

Dung nep Judet: can chon cd nep cho thich hdp vdi xtfdng stfdn: nep rong thi long, n^p be thi phai bop nhieu de thoai hoa xtfdng stfdn (hinh 2.3) xuyen dinh Kirschner qua o gay de gitf hai dau

Keo lien tuc: dung chi perlon to vong quanh xtfdng stfdn thuoc mang stfdn, co the dung kep vai mo, ta't ca nhtfng sdi chi (hay kep) buoc mot turn roi qua he rong roc, qua ta de keo lien tuc (hinh 2.4).

Trong ltfdng keo phu thuoc vao ttfng benh nhan, mien lam m ang stfdn bi keo ngoai ma khong thut vao dtfdc thd, de nhtf vay it nhat khojing mot tuan roi giam ltfdng ta xem mang stfdn co di dong khong roi dan dan bo han

+ Co dinh ben hay goi la co dinh sinh ly: benh nhan dtfdc dat noi quan (neu phai dat lau dai qua mot tuan thi nen md quan), dung thuoc gian cd, roi cho thd may Vi benh nhan khong ttf thd ntfa nen ap ltfc am tinh khoang mang phoi khong thay doi, do mang stfdn se khong di dong Sau khoang mot tuan roi tap bo may ttf ttf Co dinh ben thoat nhin thi ttfdng la ddn gian, de thtfc hien nhtfng thtfc te rat phtfc tap vi nhtfng cham soc thd may (tfic ddm dai, tran mang phoi, dinh dtfdng, ve sinh ca nhan v.v ) thtfdng sau mot thdi gian ngtfdi benh se bi nhiem trung dtfdng ho hap, rat kho cai may

Noi chung thai xtf tri doi vdi mang stfdn nhtf sau: doi vdi mang stfdn co dinh: phai theo ddi de phong di dong thtf phat; doi vdi mang stfdn di dong; keo lien tuc vdi mang stfdn trtfdc va ben, nep Judet cho mang stfdn ben, mang stfdn saukhong cin co dinh Mo de xuyen dinh co nhtfng thtfdng ton ngtfc can giai quyet dong thdi Dung may thd co doi ngu y ta tot, thao de ch&m soc

Can nhd mang stfdn ltfdng mau mat ttf cac o gay la dang ke 2.3 T ran m au m a n g phoi

Tran mau mang phoi la mot bien chtfng rat hay gap chan thtfdng long ngtfc va vet thtfdng long ngtfc Mau chay vao m ang phoi ttf ba nguon sau: phoi, ngtfc, mach mau trung that

2.3.1 Ve mat chan doan cdn dac biet chu y chup X q u a n g ngtfc

Vi benh nhan khong dtfng dtfdc nen phai chup n&m, hinh tran mau se khong co dien hinh ntfa, rat de bo sot hoac chan doan sai (hinh 2.5).

Hinh 2.5 Khi chup nam, mau se lang deu ttf day den dinh phoi khong nhtf chup dijfng

2.3.2 Dien bien

phai mo cap ctfu, neu khong mau tiep tuc chay co the gay day dinh m ang phoi Khi mau bi nhiem trung se mu mang phoi Doi mau dong cuc khong dan ltfu dtfdc ma phai mo

2.3.3 Cach xit tri

Tren nguyen tac, sau chan doan la tran mau m ang phoi, phai hut het Khi hut phai hut triet de va khong dtfdc gay boi nhiem Hut triet de la hut het va hut lien tuc, do tot nhat la dat ong dan ltfu mang phoi roi lap vao he thong hut lien tuc Chi khong co dieu kien (phtfdng tien va ngtfdi theo doi) thi mdi choc hut mang phoi bang kim

Do hut triet de ma khoang mang phoi dtfdc lap lai nhtf sinh ly binh thtfdng, nghia la khoang trd ao, ap ltfc am Phoi nd len ap sat mang phoi la tang vdi la thanh, ndi nhu mo phoi bi ton thtfOng se dinh vdi la thanh, bit kin ma khong chav mau ntfa Sau da dat ong d in ltfu va hut can phai theo doi so ltfdng mau chay va phoi co nd len khong Neu mau cang giam, phoi nd len nhtf vay dieu tri bao ton se cong Trong trtfdng hdp ngtfdc lai thi phai md ngtfc cap ctfu (xem phan chi dinh mo ngtfc cap ctfu)

2.4 T r a n k hi m a n g p h o i

Khi tran vao khoang m ang phoi ttf hai nguon: mot la vet thtfdng ngtfc hd, hai la khong ttf nhu mo phoi xi vao

Ngoai nhtfng dau hieu thong thtfdng cua tran m ang phoi, can chu y tdi tran mang phoi dtfdi ap ltfc, khong tran vao m ang phoi mot nhieu sau moi lan thd, ap ltfc khoang mang phoi mot tang, day lech trung that sang ben doi dien, ep phoi ben lanh, lam cho benh nhan kho thd dtf doi den ngtfng thd Neu nhtf khong sd ctfu kip thdi thi thtfdng la benh nhan se chet

Trong tran mang phoi, dau hieu Xquang la dau hieu day (xem phan xep phoi) Cach xii tri

Giong nhtf tran mau m ang phoi, tran mang phoi cung phai dtfdc hut triet de Hut lam cho het khong khoang, nghia la ltfu ltfdng hut phai ldn hdn ltfu ltfdng khong xi vao khoang mang phoi Neu nhtf hut khong dat dtfdc nhtf tren thi dtfdng nhien phoi khong nd - va hai la m ang phoi khong dan vao de bit cho khong xi ttf nhu mo phoi

Phoi nd len phu thuoc vao dtfdng thd co thong khong: neu bi t ic ddm dai thi phoi v ln xep du da tang ap ltfc hut

Trong trtfdng hdp phoi khong nd len dtfdc, bat buoc phai mo de xtf tri cho khong xi (thtfdng la nhu mo phoi bi dap nat nhieu hoac - phe quan bi vd)

Hinh 2.6 Van Heimlick

2.5 X ep phoi

Xep phoi la mot bien chtfng rat hay gap sau chan thtfdng N guyen nhan la tang tiet ddm dai, mau va di tat nam dtfdng ho hap, nhtfng chu yeu la phan xa ho cua benh nhan giam vi dau qua Chinh vi the giam dau co vai tro rft't quan de de phong xep phoi

2.5.1 Cdn phan biet chinh xac vdi tran m ang phoi. Xep phoi la dtfdng phe quan ttfdng iing bi tac Dau hieu Xquang la da'u hieu “co” nghia la: trung th&t bi keo sang (tren phim xac dinh bang bong quan so vdi cot song), cd hoanh bj keo len, cac khoang lien stfdn bi nho lai, xtfdng stfdn xuoi hdn Con tran mang phoi dau hieu ngtfdc lai nghia la “d^y”: trung tha't sang ben doi di?n, cd hoanh bi day xuong, long ngtfc rong hdn (cac khoang lien stfdn gian ra) Nhu mo phoi d day vi mat ap ltfc am tinh khoang mang phoi ma khong nd len dtfdc (chii khong phai la xep phoi) thu nho, vi the ma nhin ro dtfdng ranh gidi khoang ipang phoi (hinh 2.7).

(Xep ph6i) (Tran khi")

Xep phoi: la dau hieu co: trung thS't keo sang Tr^n khi: la dau hiSu dly: trung thSt sang bin <36i co hoanh keo len, ngtfc xep xuong dien cd hoanh d ly xudng, th^nh ngifc n4ng cao

Hinh 2.7

2.5.2 Cach xii tri

Giam dau sau chan thtfdng la chu yeu de de phong bi&n chiing Cin kich thich benh nhan ho va thd sau

Khi da xay xep phoi, phai tim cach kich thich ho de tong ddm dai ngoai: thuoc long ddm, the due lieu phap, kich thich ho Neu khong dd mdi bat buoc phai soi hut phe quan

2.6.1 M ot vet thuong (bat ky d dau, khong nhat thiet phai d ngtfc) lam thung mang phoi la thanh, khoang mang phoi thong vdi khong ben ngoai thj goi la vet thtfdng ngtfc hd

Vi tri vet thtfdng, ngoai ngtfc can phai chu y den nhtfng vet thtfdng khac nhtf ttf bung len, ttf co xuong

2.6.2 Sau co vet thudng, lo thung co the dtfdc bit lai (do sd ctfu hoac vet thtfdng ttf bit lai) khoang mang phoi khong thong vdi khong ben ngoai, chi tran khi' hoac va tran mau mang phoi Neu vet thtfdng van hd, se gay hai hoi chtfng ho hap dao ngtfdc va trung that di dong: thd khong mot phan ngoai, mot phan sang ben phoi bi thtfdng, trung that sang ben bi thtfdng lam cho khong ttf khoang mang phoi qua vet thtfdng ngoai Luc thd vao hien ttfdng ngtfdc lai (hinh 2.8).

2.6 V et thtfdng ngtfc hot

Thd

Hinh 2.8 Ho hap dao ngtfdc va trung that di dpng vet thuong ngi/c

Hai hoi chtfng gay tinh trang thieu oxy nghiem vi: khong hit vao lai co mot phan la khong can cua lan thd trtfdc ttf phoi ben bi thtfdng sang, phoi dang le phai nd len thi trung that bi hut sang lam cho nd kem, qua tim lie ltf lam cho mau ttf hai tinh mach chu kho trd ve tim Do thieu oxy ma benh nhan thd nhanh hdn, cang nhanh thi roi loan cang nhieu Vi the neu khong sd ctfu kip thdi, benh nhan rat de chet

2.6.3 Cach xit tri

Neu vet thtfdng dang hd, phai nhanh chong bit kin lai Khi da dtfdc bit kin, khoang mang phoi lai tran va tran mau Cach thtfc xtf tri nhtf hai phan tren da noi

2.7 V d phe q u a n 2.7.1 N guyen nhan

Khoang 30% cac trtfdng hdp la chet trtfdc vao vien Viec chan doan thtfdng ton ctfng rat kho, do anh htfdng rat ldn den ket qua dieu tri vi da de lai vtfng hep phe quan vdi xep phoi ttfdng tfng

2.7.2 Nhiing dau hieu sau day cdn nghi den vd p h e quan - Chan thtfdng kin, manh vao vung tren cua ngtfc

- Gay cac xtfdng stfdn ttf 1 -

- Kho thd nhieu, ho mau va tran dtfdi da

- Tran mang phoi dtfdi ap ltfc hoac tran ca hai ben, tran trung that - Phoi khong nd len dtfdc du da tang rat nhieu ap ltfc hut

- Kho thd nhieu hut ong dan ltfu mang phoi

Soi phe quan la mot tham kham rat quan de xac dinh chan doan, xac dinh vi tri ctfng nhtf mtfc thtfdng ton ttf dd de cach xtf tri Trong luc cap ctfu khong nen chup phe quan, da on dinh thi cd the chup

2.7.3 Cach thiic xii tri

Doi vdi nhtfng trtfdng hdp rach phe quan nhd, dieu tri bao tdn, soi phe quan de theo d5i stf lien Md quan thtfdng khong cd tac dung

Md khau phe quan rach la mot phau thuat kho Ngay ttf luc gay me dat noi quan da phai rat chu y neu khdng se gay suy hd hap cap Phai phau tich ky cang, cat bd nhtfng md dap nat roi mdi khau noi Nen dung chi Vicryl 3/0 hoac 4/0 2.8 V d d o n g m a ch chu ch an thutafng kin

Khong phai la mot thtfdng ton hiem gap, thtfdng la tai nan xe co (chiem tdi 20% cac trtfdng hdp mo xac): toe dtfng dot ngot, doan dong m ach chu xudng dtfdc cac dong mach lien stfdn gitf lai, cdn doan quai dong m ach chu theo quan tinh vang phia trtfdc, dd vtfng vd dong mach chu thtfdng la ndi tiep giap cua hai doan (phia chan dong mach dtfdi ddn trai) Khoang 80% la chet chay mau dtf doi vao khoang mang phoi, chi nhtfng trtfdng hdp ldp vd ngoai cua dong mach chu va mang phoi trung that ngan khdng cho chay mau ao at mdi song sot

2.8.1 K hong ke tdi nhiing trtfdng hdp chet chay m du dtf doi, nhtfng benh nhan cdn song den vien tinh trang on dinh, phai nghi den thtfdng ton cd nhung dau hieu sau:

- Tai nan xe co vdi toe nhanh

- Liet hay giam cam giac hai chan dtf thoang qua tren mot benh nhan khdng cd chan thtfdng cot song

- Chenh lech ap ltfc dong mach gitfa tay va chan.

- lie n g thdi tam thu trtfdc ngtfc hoac sau ltfng gitfa hai xtfdng ba vai - Mat hay giam mach d cd hay d tay (khi vd vung quai ddng mach chu)

( ’ hup ngtfc khong chuan bj: trung that rong hon 8cm, mat hinh quai dong mach chu, quan day lech ke ca phe quan trai, thtfc quan bi day

- Chup can quang dong mach chu - Chup cat ldp ngtfc

2.8.2 Cach xii tri

Mo cap ciiu la mot thu thuat doi hoi phai het siic khan trtfdng ca ve phau thuat lan hoi stfc

Mo in hoan hoac mo vao giai doan da mot tui phong dong mach chu: co thi gid chuan bi va co the dung may tim phoi ho trd cap dong mach chu Khau noi true tie]) hoac qua mot doan ghep (hinh 2.9).

(1)

Hinh 2.9 Vd dong mach chu nguc chan thu’Ong

1 Khoi mau quanh doan vd duoc boc boi mang phoi trung; Md khoi mau tu sau da cap hai dau, Khau noi true tiep hay qua mot doan ghep

2.9 V et thutofng n giic - b u n g

Vet thudng nguc - bung thudng dung de chi nhtfng vet thtfdng xuyen ttf ngtfc xuong bung qua cd hoanh hoac theo chieu ngtfdc lai day khong bao gom hai loai vet thuong ngifc va bung rieng biet (nghia la cd hdanh khong bi thung)

Vi cd hoanh bi thung non hai o ngtfc va bung thong vdi nhau, ap ltfc am khoang manh phoi hut len (mau, dich long dtfdng tieu hoa, hay ca cac tang bung)

2.9.1 Ve mat chan doan, cdn phai chu y de khoi bo sot thiiong ton d ben kia (doi vdi vet thtfdng bung xuyen len ngtfc, de sot ton thtfdng ngtfc va ngtfdc lai) Ngoai viec dinh htfdng dam xuyen, vi tri vet thtfdng, mot so dau hieu sau day can phai nghi den;

- Vet thtfdng vao ngtfc nhtfng co dau hieu chay mau hoac viem phuc mac (doi hai dau hieu rat kho kham vi mau hoac dich tieu hoa bi hut len phoi, hoac chi co vet thtfdng ngtfc ma lam ntfa bung co ctfng)

- Vet thtfdng bung nhtfng lai kho thd va tren phim X quang co tran hay tran dich

- Vet thtfdng bung hoac vet thtfdng ngtfc nhtfng co dau hieu thoat vi d ben ngtfc 2.9.2 Cach xii tri

May dieu chu yeu can phai nhd:

- Bao gid cung dan ltfu mang phoi roi mdi quyet dinh xii tri d dau trtfdc: sau d in ltfu mang phoi neu ton thtfdng ngtfc la khong co chi dinh mo cap ctfu, thi mo bung trtfdc

- Bao gid cung phai tim 16 thung d cd hoanh de khau kin lai

- Neu khong co chi dinh mo ngtfc (chi dan ltfu mang phoi) thi trtfdc khau kin cd hoanh can hut sach khoang mang phoi qua dtfdng bung, nhat la sau an no ma da day bi thung

- Cac ong dan ltfu (ngtfc va bung) deu phai hut va kin, khong dtfdc de ong din ltfu bung hd, khong qua se len khoang mang phoi

3 CAC CHI D IN H M O NGLTC CAP CUtJ

Phan ldn cac chan thtfdng ngtfc va vet thtfdng ngtfc deu dieu tri bao ton ma khong can mo ngtfc cap ctfu Nhtfng hoan canh phai mo se trinh bay dtfdi day: 3.1 Tran m au m an g phoi k h on g cam

Sau dan lUu mang phoi ltfdng mau chay vdi ltfu ltfdng 300ml/h gid lien Tuv nhien khong the may moc dua vao so ma quyet dinh Thi du: mau cuc lam tac dan lUu, d tre nho v.v Can phai can ctf them vao tinh trang toan than, hinh chup Xquang ngtfc

*> V

3.2 Tran m a n g phoi k h o n g cam

Du da tang ap ltfc hut ma phoi van khong nd len, ltfdng xi qua ong dan liiu lai tang len, doi tang ap ltfc hut lai lam cho benh nhan kho thd hdn

Thtfdng nhtfng trtfdng hdp la vd phe quan hdac nhu mo phoi dap nat nhieu

3.3 V et th ifO n g thifc q u a n Rat hiem gap

Soi thtfc quan se xac dinh chan doan

Md ngtfc khau thtfc quan can phai kem vdi mo thong dn day de nuoi dtfdng 3.4 C han thifdng tim (vd tim hoac vet thtfcing tim )

Khi co ton thtfdng tim (do vet thuong hay chan thtfdng kin) se the hien bang hai hoi chtfng Hoi chtfng mat mau va Hoi chtfng chen ep tim cap tinh

Doi vdi vet thtfdng tim: dau hieu gdi y la vi tri vet thung d vao tam giac tim

Doi vdi c h a n t hi fdng t im: d a u hieu gdi y la g ay xtfdng tfc (hinh 2.10).

Hinh 2.10.

a Tam giac gidi han bdi xifdng (sc va niim vu trai: b Buong tim bi thung, mau chay vao mang phoi va qua ngi/c ngoai gay choang mat mau: c Buong tim bj thung, mau chay vao buong tim, is lai ben

trong gay chen ep tim cap tinh

Choang mat mau Chen ep tim cap

Toan than Nam yen Giay giua

Nhdt Tim

HA dong mach Tut Kep

HA tinh mach Tut Cao

4 D AN LU\J M A N G PH O I

Dan ltfu mang phoi la mot thu thuat rat thtfdng lam chan thtfdng cung nhtf vet thtfdng ngifc D ay la mot thu thuat cd ban dieu tri Can phai thtfc hien dung nhtfng nguyen tac neu khong tai bien dem lai tac hai hdn la khong lam Trong thtfc te thtfdng thay nhtfng dan ltfu mang phoi lam sai quy cach

4.1 O n g d an ltfu

La mot ong nhtfa khong ctfng qua nhtfng cung khong mem qua se bi bep, phia difdc trang Silicon de tranh hinh mau cuc

Cd ong la ttf -3 F r doi vdi ngudi ldn, tre em dung cd nho hdn (3Fr = 1mm) Ong dai khoang 40cm, co mot vai lo ben khong doi xtfng d phan dat mang phoi, dau ngoai hon loe de de lap ong noi

Neu tot hdn ong co mot dtfdng chi can quang de chup ngtfc co the biet dau ong d dau

4.2 V i tri dat o n g d an ltfu

Sau dat can hut ong d in lifu Hut phai co tieu chuan: hut lien tuc 1/24 gid va ap life dieu khien d khoang —20cm HvO

Can co binh dieu chinh ap liic giiia may hut va ong dan liiu ngifc de dam bao chac chan la dat difdc ap life theo y muon

Toan bo he thong hut phai kin (hinh 2.11).

4.3 Hut lien tuc

Hut II | Bn

A\

Ong lo noi vdi ong d in ltfu ti/ benh nhan bao gid cung ngap dtfdi ntfdc; Lo dan ltfu cd bang dinh danh dau mtfc ntfdc ban dau; H la chieu cao cot ntfdc de chi ap ltfc hut

Sau da dat can theo doi ong dan lifu: - Lifu lifdng mau chay hang gid - Ltfdng phi

- Chup Xquang xem tf dong khoang m ang phoi khong, phoi co nd len khong?

Can luon luon vuot ong de tranh mau cue lam tac, neu ong dan luu tac can phat hien de thong lai hoac thay ong

Dau hieu tac la miie nude ong khong cdn len xuong thd (can thao khoi may hut de quan sat)

Khi da giai phong het khoang mang phoi khoi mau va khi, phoi da no len hoan toan thi phai rut dan luu khong nen de lau se boi nhiem khoang mang phoi

TAI LIEU T H A M K H A O

1 Textbook of Surgery Sabiston Pathologic chirurgicale Thorax Xgoai khoa Benh hoc phan nguc

2 VCI K H I-P H E QUAN

Vd - phe quan la loai thudng ton hiem gap, no chiem khoang ttf 0,7 - 2,2% nhung trtfdng hdp chan thtfdng ngtfc Tuy nhien doi vdi nhtfng tai nan kieu nhtf may bay bi rdi thi ty le co the tang hdn

1 CO C H E G A Y VC* K H I - P H E Q U A N (V K P Q ) CO T H E D O B A Y E U TO - Chen ep ttf trtfdc sau: long ngtfc bi ep lai, hai phoi gian sang hai ben, keo vao vung gitfa ttfc la chac ba - phe quan (carina) gay rach hoac vd

- Ap ltfc dtfdng ho hap tang dot ngot: quan dong kin luc long ngtfc bi ep manh, lam cho ap ltfc dtfdng ho hap tang len dot ngot

- Hien ttfdng rung giam toe dot ngot d gitfa hai diem co* dinh la quan va chac ba k h i-p h e quan

Ca ba yeu to phoi hdp vdi gay nen VKPQ Tuy nhien ngtfdi ta thay co tdi mot niia trtfdng hdp ben ngoai long ngtfc chi co nhtfng thtfdng ton rat nhe hoac khong thay thtfdng ton gi, dieu gdi y den mot cd che dac biet la yeu to quvet dinh khong phai la nang ltfdng dong ban dau ma la quan he gitfa nang ltfdng tac dong den dien tich tren ngtfc nhat la vtfng can xtfdng tfc Bang chtfng la neu nga ma ngtfc dung vao mot vat co dien tich nho (ghi dong xe, canh ban) thi de gay VK PQ

Co tdi 80% cac ca la vd quanh vung chac ba - phe quan cach carina khoang 2,5cm

Rat kho xac djnh ty le VKPQ vi mot so ldn nan nhan da chet trtfdc den benh vien (do thtfOng ton VKPQ hoac nhtfng thtfdng tdn phoi hdp) Ngtfdi ta thay khoang 30% la ttf vong, nhtfng mot nan nhan den vien song thi tdi 90% la vien dtfdc D ieu cot yeu la lam chan doan sdm va dieu tri dung se khong nhtfng lam giam ty le tii vong ma phuc hoi dtfdc chtfc nang ho hap cua vung ton thtfdng

2 VE M A T G IA I P H A U B E N H LY, CO N H tfN G T H l/d N G T O N S A U D A Y - Dtft rdi: rat hay gap, chiem tdi 50% Hai dau cach xa tdi - 5cm, chi ldp to chtfc bao quanh - phe quan gitf cho hai dau thong vdi het stfc mong m anh nen luc dau soi phe quan rat de bo sot Sau mot thdi gian hai dau khong thong vdi ntfa, phan phoi ngoai vi coi nhtf loai ngoai dtfdng ho hap

r ach ngang hoac doc keo dai vai centimet d phan tiep giap giiia phan mang va

phan sun.

- Loai phoi hop (15%): hiem gap, thudng thay d tre em - Vd vong sun: hiem gap hon.

3 CH AN D O A N

Nhiing dau hieu lam sang va Xquang: da dUOc tong hdp lai ttf lau de de dang chan doan nhtfng tren thtfc te ty le thtfOng tdn hiem gap lai trong mot benh canh co nhieu thtfOng ton phoi hop nen de dan den chan doan cham.

3.1 Co hai benh canh lam san g can phan biet

- Loai VKPQ khong dtfdc bao boc nghia la vung vd thong vdi khoang mang phoi Loai chiem ttf 60 - 80% Nan nhan tinh trang suy ho hap nang, tran dtfdi da ldn, tran mang phoi mot ben hay ca hai ben dtfdi ap ltfc, dan ltfu mang phoi khong het dtfdc

- Loai VKPQ dtfdc bao boc: vtfng vd khong thong vdi khoang m ang phoi hoac chi thong ft, bieu hien bang tran mang phoi khu tru, dan ltfu khoang mang phoi chong het khi, phoi dinh lai, rut dan ltfu, tran khi' khong tai phat

To chtfc xd bao quanh cho vd quan hay phe quan cung vdi mau tu va to chtfc hat hinh ttf tuan thtf nhat den thtf ba, tao mot vung hep hoan toan hay khong hoan toan dan den xep phoi thtf phat

- Neu hep hoan toan, phan phoi phia ngoai dtfdc bao ve khoi nhiem trung, van kha nang khau noi vai thang hay nhieu nam sau T rong thdi gian chiia khau noi lai, co hien ttfdng dong chav tat ttf dong mach phoi sang tinh mach phoi lam cho bao hoa oxy mau giam.

- Neu hep khong hoan toan, phan phoi phi'a ngoai se bi nhiem trung man tinh dan den gian phe quan va rat de loai bo kha nang khau noi lai (vi phan phoi khong chtfc nang)

Doi vdi loai VKPQ dtfdc bao boc, de thay co ho mau doi dtf doi buoc phai dat noi quan ttfng ben de tranh lam ngap mau dtfdng ho hap Co le dong mach phoi ranh lien thuy bi thtfdng ton kem theo

Mot thav nhtfng bat thudng sau day, can phai soi khi, phe quan nhieu lan cho den xac dinh khong co thtfdng tdn VKPQ:

- Tran trung that hoac tran vung cd nhtfng d sau, tran phia trtfdc cot song.

- Tran mang phoi thtf phat (co the tdi thtf 8)

- Xep phoi xuat hien muon ma khong co tf xuat tiet dtfdng ho hap

- Mau tu dinh phoi, trung that gian rong nhtfng khong co thtfdng tdn cac mach mau vung quai dong mach chu (dtfdc xac dinh bang chup dong mach)

- Tron phim X quang thay co gay xtfdng stfdn ttf thtf den thtf

Soi quan la mot thu thuat cd ban de chan doan ndi vd, loai thtfdng tdn, mtfc thtfdng tdn Tot nhat la dung ong soi mem tai phong md Phan ldn nhtfng trtfdng hdp khong chan doan dtfdc la co chay mau che lap vtfng vd Khoang 3/4 cac trtfdng hdp la chan doan dtfdc bang soi - phe quan

3.2 T om lai, dtfng trtfdc m ot h oan canh sau day, can nghi ngof co V K P Q - Chan thtfdng vung ngtfc tren

- Gay xtfdng stfdn ttf thtf nhat den thtf ba - Suy ho hap, tran dtfdi da, ho mau

- Tran khf m ang phoi (dudi ap ltfc hoac ca hai ben) - Tran trung that

- Phoi van khong nd du da dan ltfu mang phoi va hut tot - Tran khf m ang phoi ma phi ldn

- Suy ho hap tang ap ltfc hut mang phoi

Can xac dinh VK PQ bang soi phe quan Neu khong nhin thay trtfc tiep thtfdng tdn vd thi nhtfng dau hieu gian tiep sau day giup cho chan doan: chav mau tai cho, sui bot khi, vtfng phu ne Khi khong ro, neu lam sang va X quang van nghi ngd can soi lai phe quan

4 D IE U T R I 4.1 So? ctfu

Phai dam bao ho hap bang giai phap phong dtfdng thd va thong cho tot Dat noi quan mo la dieu het stfc rui ro, can phai tranh, vi ong noi quan co the xe rong cho vd dau ong chui vao trung that

Md quan cap ctfu la thuan ldi nhat vi de lam, dam bao ho hap van chuyen, lam giam khoang khong chet, giam ap ltfc dtfdng ho hap nhat la quan dong

Md m ang phoi ca hai ben de dan ltfu vi tran dtfdi ap ltfc rat de hinh 4.2 D ieu trj thtfc thu

4.2.1 Gay me

Co bon nguyen tac can tuan theo:

- Phau thuat vien va nhan vien phong mo phai s in sang de co the md ngtfc neu can

- Ong dan lUu mang phoi phai noi v6i he thong hut cho den long ngtfc dtfdc md - Muc dich nhat can dat dtfdc gay me la kiem soat dtfdc phan phoi co chtfc nang binh thtfdng

Co hai cach dat noi khi' quan:

- Dung mot ong noi quan thang, that dai, co bong, dat qua ong soi phe quan de co the nhin trtfc tiep vao long Dtfa ong vao phoi ben lanh hoac dtfa qua vung vd d carina Nhtf vay chi thong mot ben phoi Nhtfdc diem cd ban cua phtfdng phap la ong co the tuot nhat la dat ttf the benh nhan

- Dung ong Carlcns de co the co dinh chac chan vao vung carina va cung co the kiem tra bang ong soi phe quan mem

4.2.2 Phau thuat

+ Dtfdng mo phu thuoc vao thtfdng ton dtfdc xac dinh:

- Md ngtfc phai sau ben qua kheang lien stfdn dtfdc tfa dung nhat cho nhiing thudng ton vung quan, phe quan phai va ca trai neu chi cach carina dtf6i 2cm Can phai cat tinh mach azygos de de phau ti'ch

- Md ngtfc trai sau ben danh cho thtfdng ton ben trai lan tdi phe quan thuy - Md dtfdng gitfa xtfdng tfc thtfc hien co thtfdng ton m ach mau (than canh tay dau)

+ Nguyen tac phau thuat cung nhtf cac loai phau thuat tao hinh phe quan: - Tham va danh gia day du thtfdng ton, nhat la nhtfng thtfdng ton d ngoai vi, dong mach phoi, thtfc quan

- Hoc lo ro vung thtfdng ton: cat doi tinh mach azygos, luon day quanh phe quan - Xac dinh ro gidi han thtfdng ton

- Cat loc het nhtfng to chtfc dap nat nhat va mep cua - phe quan (vung sun hoai tii)

- Khau noi tan - tan: sun vdi sun, mang vdi m ang b ln g nhtfng mui khau rdi, chi Vicryl 3/0 cho sun, 4/0 cho mang

- Dung nhtfng vat co cuong, (cd lien stfdn, m ang phoi, m ang tim) de bao ve cho noi nuoi dtfdng dtfdc tot

- Sau noi xong, kiem tra ki'n va rut ong noi quan du xa cho noi Hut mau, chat xuat tiet bang ong soi mem trtfdc chuyen

- Neu thong kho khan, co p h lu thuat vien phai ltfa cho ong noi quan d vj tri tot, tham chi sang phoi ben doi dien qua ndi khau noi

- Doi vdi nhtfng VKPQ muon, doi hoi kho khan hdn:

Neu phe quan la tdc hoac dtft rdi hoan loan, hai dau bit thi phan phoi ttfdng iing dude bao ve Sau phfui ti'ch dtfdc hai dau, can khau noi lai bat ke thdi gian de chain la bao lau Can chu y nhung diem sau:

- Ben trai rat kho phau ti'ch vi vudng quai dong mach chu

- Khau noi kho khan to chtfc seo xung quanh va rat gan phe quan goc

- Nhu mo phoi bi xd va mat ti'nh dan hoi nen phoi khong nd sau khau noi, trtfdng hdp bat buoc phai cat phoi

- Neu khau noi trtfdc thang se co ket qua hoan toan, neu de lau hdn chtfc nang phoi se hoi phuc nhtfng khong the trd lai binh thtfdng dtfdc

- Phai hut, riia sach phe quan trtfdc khau noi

VO KHI QUAN VUNG CO

Thudng ton vd khi' quan vung co chiem khoang 20% cac thtfdng ton cua dtfdng ho hap (tuy theo thong ke chiem ttf 19 - 44%)

Nguyen nhan chan thtfdng trtfc tiep vad vung co Phan mang hay bj rach hdn Neu dtft doi thi dau dtfdi thifdng tut vao trung that Ho hap dtfdc tri la cac td chtfc xung quanh quan, cung chi'nh vi the ma tinh trang het stfc bap benh, phu thudc vao ttf the cua gav, trtfdng ltfc cac cd va nhat la dat noi khi' quan mo

Can chu y tc5i nhtfng thtfdng ton phoi hdp co gay cot song co

Benh canh lam sang chi'nh la tinh trang suy ho hap xuat hien nhanh chong ma luc trtfdc dang binh thtfdng on dinh Tran khf dtfdi da vung co va trung that, kho thd, giong noi thay doi la nhtfng dau hieu chi'nh

Tot nhat la dtfng ong soi phe quan mem dan dtfdng de dat ong noi quan Non lam phong mo, co phau thuat vien dtfng san sang

Cac thtfdng ton quan co the thtfc hien qua dtfdng mo d co rong rai, phau tich rong de co the danh gia day du thtfdng ton

Khi quan dtfdc khau bang chi tieu 4/0, mui rdi

Chi’ md quan phia dtfdi cho khau ndi hai vong sun

TAI LIEU THAM KHAO

1 J.P.Bex: E ncyclopedic m ed ico-ch irurgicale-T ech n iques chirurgicales P.Levasseur: Les traum tism es fermes du thorax

3 Current therapy in cardiothoracic surgery 1989.B C D ecker 42 -4 Le Ngoc Thanh (1992): Vd phe quan treng chan thtfdng ngtfc km

Ngoai k h o a -T a p 22, so

3 THOAT V| HOANH

1 MOT VAI DIEM VE GIAI PHAU

Cd hoanh la mot cd det, rong, dtfdc tao bdi mot vach can cd, ng&n cach long ngtfc va o bung

Cd hoanh hinh vong cung, giong nhtf mot cai vung up len o bung, vom hoanh gitfa hdi lom, vi co tim de len, do vom hoanh dtfdc chia lam hai vom hoanh trai va vom hoanh phai Doi chieu len long ngtfc d phia trtfdc, vom hoanh trai cao ngang mtfc khoang lien stfdn V; vom hoanh phai cao ngang mtfc khoang lien stfdn IV (ben phai cao hdn ben trai mot khoang lien stfdn) Tuv nhien vom hoanh cung thay doi theo hinh long ngtfc, theo luc thd hay hit vao, hoac theo ap ltfc o bung

Ve cau tao, cd hoanh dtfdc coi nhtf nhieu cd hai than tao cac gan trung gian bat cheo va xen dinh vao de tao nen mot ban can d gitfa goi la tam hoanh Cd hoanh bao gom nhieu lo, khe de cho cac tang, mach mau va than kinh ttf long ngtfc xuong bung hay ngtfdc lai ttf bung len ngtfc

1.1 Lo tinh mach chu dvfofi

Nam d tam hdanh, gitfa vom phai va vom trai, hinh bau due dtfdng ki'nh 3cm trd len Qua lo nay, tinh mach chu dtfcli chay ttf bung len ngtfc de trd ve nhl phai Tinh mach di'nh vao bd lo, doi day than kinh hoanh ben phai di xuong qua lo va n&m d trtfdc ngoai tinh mach

1.2 Lo dong mach chu

Nam trtfdc cot song, hai cot chinh tao Lo hinh bau due, dtfdng ki'nh trtfdc sau dai nhat - 5cm, rong 1,5cm Qua dong m ach chu ngtfc, day tang be ttf ngtfc x u o n g bung, ong ngtfc n&m sau dong m ach chu ngtfc, di ttf bung len ngtfc Ngoai ra, doi thay mot nhanh cua tinh m ach ddn ldn ben phai hoac nhanh cua tinh mach ban ddn dtfdi d ben trai

1.3 Lo thtfc quan

Nam d phan cd, trtfdc lo dong mach chu, hinh bau due, dtfdng kinh dai 3cm dtfdng kinh ngan 1cm Qua lo co cac tang chav ttf ngtfc xuong bung

- Thtfc quan, dinh vao lo

- Hai day X, day trai d trtfdc va day phai d sau thtfc quan - Cac nhanh noi cua dong mach hoanh tren va dtfdi - Cac nhanh noi gitfa tinh mach ctf a vdi tinh mach chu