{"id":29244,"date":"2023-04-29T10:13:51","date_gmt":"2023-04-29T03:13:51","guid":{"rendered":"http:\/\/noithathoaphat.in\/ctv\/?p=29244"},"modified":"2023-04-29T10:13:51","modified_gmt":"2023-04-29T03:13:51","slug":"tam-phe-man-huong-dan-chan-doan-dieu-tri","status":"publish","type":"post","link":"http:\/\/noithathoaphat.in\/ctv\/index.php\/2023\/04\/29\/tam-phe-man-huong-dan-chan-doan-dieu-tri\/","title":{"rendered":"T\u00e2m ph\u1ebf m\u1ea1n: h\u01b0\u1edbng d\u1eabn ch\u1ea9n \u0111o\u00e1n, \u0111i\u1ec1u tr\u1ecb"},"content":{"rendered":"

T\u00e2m ph\u1ebf m\u1ea1n l\u00e0 tr\u01b0\u1eddng h\u1ee3p ph\u00ec \u0111\u1ea1i v\u00e0 gi\u00e3n t\u00e2m th\u1ea5t ph\u1ea3i k\u00e8m suy tim ph\u1ea3i th\u1ee9 ph\u00e1t do t\u0103ng \u00e1p l\u1ef1c \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i, g\u00e2y n\u00ean b\u1edfi nh\u1eefng b\u1ec7nh l\u00e0m t\u1ed5n th\u01b0\u01a1ng ch\u1ee9c n\u0103ng ho\u1eb7c c\u1ea5u tr\u00fac c\u1ee7a ph\u1ebf qu\u1ea3n, ph\u1ed5i v\u00e0 l\u1ed3ng ng\u1ef1c nh\u01b0 b\u1ec7nh: ph\u1ebf qu\u1ea3n, ph\u1ed5i, m\u1ea1ch m\u00e1u, th\u1ea7n kinh v\u00e0 c\u01a1 x\u01b0\u01a1ng l\u1ed3ng ng\u1ef1c.<\/strong><\/p>\n

1. Ch\u1ea9n \u0111o\u00e1n t\u00e2m ph\u1ebf m\u1ea1n.<\/h2>\n

1.1. Tri\u1ec7u ch\u1ee9ng l\u00e2m s\u00e0ng c\u1ee7a t\u00e2m ph\u1ebf m\u1ea1n.<\/h3>\n

C\u00f3 ti\u1ec1n s\u1eed b\u1ec7nh ph\u1ed5i m\u1ea1n t\u00ednh \u2013 b\u1ec7nh c\u01a1 x\u01b0\u01a1ng l\u1ed3ng ng\u1ef1c:<\/p>\n

    \n
  • B\u1ec7nh ph\u1ed5i t\u1eafc ngh\u1ebdn m\u1ea1n t\u00ednh, gi\u00e3n ph\u1ebf qu\u1ea3n, hen ph\u1ebf qu\u1ea3n.<\/li>\n
  • Lao x\u01a1 ph\u1ed5i.<\/li>\n
  • X\u01a1 ph\u1ed5i, vi\u00eam ph\u1ed5i k\u1ebd, b\u1ec7nh ph\u1ed5i \u0111\u1ed9t l\u1ed7.<\/li>\n
  • M\u1ea3ng m\u00e0ng ph\u1ed5i, d\u00e1y d\u00ednh m\u00e0ng ph\u1ed5i.<\/li>\n
  • G\u00f9 v\u1eb9o c\u1ed9t s\u1ed1ng, d\u1ecb d\u1ea1ng l\u1ed3ng ng\u1ef1c b\u1ea9m sinh ho\u1eb7c m\u1eafc ph\u1ea3i (ph\u1eabu thu\u1eadt, ch\u1ea5n th\u01b0\u01a1ng).<\/li>\n
  • B\u1ec7nh l\u00fd m\u1ea1ch m\u00e1u ph\u1ed5i.<\/li>\n<\/ul>\n

    Bi\u1ec3u hi\u1ec7n c\u00f3 h\u1ed9i ch\u1ee9ng suy tim ph\u1ea3i:<\/p>\n

      \n
    • Kh\u00f3 th\u1edf: l\u00fac \u0111\u1ea7u khi g\u1eafng s\u1ee9c, sau kh\u00f3 th\u1edf c\u00e1c khi ngh\u1ec9 ng\u01a1i.<\/li>\n
    • Tri\u1ec7u ch\u1ee9ng tim m\u1ea1ch: nh\u1ecbp tim nhanh, m\u1ecfm tim \u0111\u1eadp d\u01b0\u1edbi m\u0169i \u1ee9c (d\u1ea5u hi\u1ec7u Harzer), T2 vang m\u1ea1nh \u1edf \u1ed5 van \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i, ti\u1ebfng ng\u1ef1a phi ph\u1ea3i \u1edf k\u00ec ti\u1ec1n t\u00e2m thu, ti\u1ebfng th\u00f4i t\u00e2m thu do h\u1edf van 3 l\u00e1 c\u01a1 n\u0103ng.<\/li>\n
    • Tri\u1ec7u ch\u1ee9ng \u1ee9 tr\u1ec7 tu\u1ea7n ho\u00e0n ph\u1ed5i ngo\u1ea1i bi\u00ean: ph\u00f9 2 ch\u00e2n, ph\u00f9 m\u1ec1m, \u1ea5n l\u00f5m, ti\u1ec3u \u00edt, t\u00edm m\u00f4i v\u00e0 \u0111\u1ea7u chi, m\u1eaft l\u1ed3i, c\u1ee7ng m\u1ea1c xung huy\u1ebft \u0111\u1ecf gi\u1ed1ng nh\u01b0 m\u1eaft \u1ebfch; gan to v\u00e0 \u0111au, t\u0129nh m\u1ea1ch c\u1ed5 n\u1ed5i, ph\u1ea3n h\u1ed3i gan t\u0129nh m\u1ea1ch c\u1ed5 d\u01b0\u01a1ng t\u00ednh.<\/li>\n<\/ul>\n

      1.2. \u0110\u1eb7c \u0111i\u1ec3m c\u1eadn l\u00e2m s\u00e0ng c\u1ee7a t\u00e2m ph\u1ebf m\u1ea1n.<\/h3>\n

      \u0110i\u1ec7n t\u00e2m \u0111\u1ed3<\/strong>: c\u00f3 d\u1ea5u hi\u1ec7u d\u00e0y th\u1ea5t ph\u1ea3i:<\/p>\n

        \n
      • P ph\u1ebf \u1edf c\u00e1c chuy\u1ec3n \u0111\u1ea1o DII, DIII, aVF.<\/li>\n
      • Tr\u1ee5c chuy\u1ec3n sang ph\u1ea3i l\u1edbn h\u01a1n ho\u1eb7c b\u1eb1ng 110 \u0111\u1ed9.<\/li>\n
      • R\/S \u1edf V6 nh\u1ecf h\u01a1n ho\u1eb7c b\u1eb1ng 1.<\/li>\n
      • rRs \u1edf c\u00e1c chuy\u1ec3n \u0111\u1ea1o tr\u01b0\u1edbc tim ph\u1ea3i.<\/li>\n
      • Block nh\u00e1nh ph\u1ea3i (ho\u00e0n to\u00e0n ho\u1eb7c kh\u00f4ng ho\u00e0n to\u00e0n).<\/li>\n
      • C\u00f3 th\u1ec3 b\u00ecnh th\u01b0\u1eddng trong m\u1ed9t s\u1ed1 tr\u01b0\u1eddng h\u1ee3p c\u00f3 t\u0103ng huy\u1ebft \u00e1p, d\u00e0y th\u1ea5t tr\u00e1i k\u00e8m theo.<\/li>\n<\/ul>\n

        X quang ng\u1ef1c th\u1eb3ng:<\/strong><\/p>\n

          \n
        • B\u00f3ng tim to ho\u1eb7c tim h\u00ecnh gi\u1ecdt n\u01b0\u1edbc, cung \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i n\u1ed5i, \u0111\u01b0\u1eddng k\u00ednh ngang \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i >16mm.<\/li>\n
        • C\u00f3 th\u1ec3 th\u1ea5y h\u00ecnh \u1ea3nh bi\u1ebfn d\u1ea1ng l\u1ed3ng ng\u1ef1c (g\u00f9, v\u1eb9o) ho\u1eb7c t\u1ed5n th\u01b0\u01a1ng nhu m\u00f4 ph\u1ed5i (x\u01a1 ph\u1ed5i, gi\u00e3n ph\u1ebf nang).<\/li>\n<\/ul>\n

          Si\u00eau \u00e2m tim<\/strong>: \u00e1p l\u1ef1c \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i t\u0103ng >30mmHg, th\u1ea5t ph\u1ea3i d\u00e3n.<\/p>\n

          X\u00e9t nghi\u1ec7m m\u00e1u<\/strong>: \u0111a h\u1ed3ng c\u1ea7u, t\u0103ng hematocrit v\u00e0 hemoglobin.<\/p>\n

          Kh\u00ed m\u00e1u \u0111\u1ed9ng m\u1ea1ch:<\/strong> giai \u0111o\u1ea1n \u0111\u1ea7u kh\u00f4ng c\u00f3 g\u00ec \u0111\u1eb7c bi\u1ec7t, giai \u0111o\u1ea1n sau c\u00f3 t\u00ecnh tr\u1ea1ng suy h\u00f4 h\u1ea5p m\u1ea1n t\u00ednh: toan m\u00e1u, PaCO2 t\u0103ng, PaO2 gi\u1ea3m.<\/p>\n

          1.3. Ch\u1ea9n \u0111o\u00e1n ph\u00e2n bi\u1ec7t.<\/h3>\n

          – Suy tim to\u00e0n b\u1ed9 do b\u1ec7nh van tim m\u1eafc ph\u1ea3i, b\u1ec7nh tim b\u1ea9m sinh, b\u1ec7nh c\u01a1 tim: X quang ng\u1ef1c th\u1eb3ng cho th\u1ea5y h\u00ecnh \u1ea3nh tim to to\u00e0n b\u1ed9, si\u00eau \u00e2m tim th\u1ea5y th\u1ea5t b\u1ea5t th\u01b0\u1eddng b\u1ea9m sinh ho\u1eb7c m\u1eafc ph\u1ea3i, gi\u1ea3m v\u1eadn \u0111\u1ed9ng 2 th\u1ea5t.<\/p>\n

          – Suy tim do b\u1ec7nh tim thi\u1ebfu m\u00e1u c\u1ee5c b\u1ed9, c\u1ea7n h\u1ecfi k\u0129 ti\u1ec1n s\u1eed c\u01a1n \u0111au th\u1eaft ng\u1ef1c, t\u0103ng huy\u1ebft \u00e1p kh\u00f4ng tu\u00e2n th\u1ee7 \u0111i\u1ec1u tr\u1ecb, c\u01a1n hen tim.<\/p>\n

          – H\u1ed9i ch\u1ee9ng Pick: t\u00edm m\u00f4i, ph\u00f9, gan to v\u00e0 ch\u1eafc, nh\u01b0ng kh\u00f4ng c\u00f3 bi\u1ec3u hi\u1ec7n kh\u00e1c c\u1ee7a suy tim ph\u1ea3i. Si\u00eau \u00e2m tim: d\u00e0y, v\u00f4i h\u00f3a m\u00e0ng ngo\u00e0i tim, d\u1ea5u hi\u1ec7u Deep-plateau tr\u00ean mode TM, kh\u00f4ng c\u00f3 t\u0103ng \u00e1p l\u1ef1c \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i, th\u1ea5t ph\u1ea3i kh\u00f4ng d\u00e3n, X quang ng\u1ef1c c\u00f3 th\u1ec3 th\u1ea5y v\u00f4i h\u00f3a m\u00e0ng ngo\u00e0i tim.<\/p>\n

          1.4. Ch\u1ea9n \u0111o\u00e1n nguy\u00ean nh\u00e2n.<\/h3>\n

          Do b\u1ec7nh ti\u00ean ph\u00e1t c\u1ee7a ph\u1ebf qu\u1ea3n, ph\u1ed5i:<\/p>\n

            \n
          • B\u1ec7nh ph\u1ed5i t\u1eafc ngh\u1ebdn m\u1ea1n t\u00ednh, hen ph\u1ebf qu\u1ea3n.<\/li>\n
          • X\u01a1 ph\u1ed5i v\u00e0 gi\u00e3n ph\u1ebf nang ho\u1eb7c kh\u00f4ng gi\u00e3n ph\u1ebf nang do h\u1eadu qu\u1ea3 c\u1ee7a lao x\u01a1 ph\u1ed5i, b\u1ec7nh b\u1ee5i ph\u1ed5i, gi\u00e3n ph\u1ebf qu\u1ea3n, x\u01a1 h\u00f3a k\u00e9n, vi\u00eam ph\u1ed5i k\u1ebd, x\u01a1 ph\u1ed5i, u h\u1ea1t th\u00e2m nhi\u1ec5m ph\u1ed5i, b\u1ec7nh sarcoidosis, b\u1ec7nh u h\u1ea1t c\u00f3 t\u0103ng b\u1ea1ch c\u1ea7u \u00e1i toan, t\u1ed5n th\u01b0\u01a1ng ph\u1ed5i do x\u01a1 c\u1ee9ng b\u00ec, b\u1ec7nh vi s\u1ecfi ph\u1ebf nang, c\u1eaft b\u1ecf ph\u1ed5i, b\u1ec7nh k\u00e9n ph\u1ed5i ti\u00ean ph\u00e1t, tho\u00e1i h\u00f3a ph\u1ed5i v\u00e0 thi\u1ebfu oxy \u1edf \u0111\u1ed9 cao.<\/li>\n<\/ul>\n

            Do b\u1ec7nh ti\u00ean ph\u00e1t l\u00e0m t\u1ed5n th\u01b0\u01a1ng c\u00e1c b\u1ed9 ph\u1eadn c\u01a1 h\u1ecdc c\u1ee7a h\u1ec7 h\u00f4 h\u1ea5p.<\/p>\n

              \n
            • G\u00f9, v\u1eb9o c\u1ed9t s\u1ed1ng v\u00e0 d\u1ecb d\u1ea1ng l\u1ed3ng ng\u1ef1c kh\u00e1c, c\u1eaft \u00e9p x\u01b0\u01a1ng s\u01b0\u1eddn, d\u1ea7y d\u00ednh m\u00e0ng ph\u1ed5i n\u1eb7ng, nh\u01b0\u1ee3c c\u01a1, b\u00e9o ph\u00ec v\u00e0 gi\u1ea3m th\u00f4ng kh\u00ed ph\u1ebf nang, x\u01a1 c\u1ee9ng b\u00ec, gi\u1ea3m th\u00f4ng kh\u00ed ph\u1ebf nang kh\u00f4ng r\u00f5 nguy\u00ean do.<\/li>\n<\/ul>\n

              B\u1ec7nh ti\u00ean ph\u00e1t l\u00e0m t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch m\u00e1u ph\u1ed5i.<\/p>\n

                \n
              • B\u1ec7nh th\u00e0nh m\u1ea1ch: t\u0103ng \u00e1p l\u1ef1c \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i ti\u00ean ph\u00e1t, vi\u00eam n\u00fat quanh \u0111\u1ed9ng m\u1ea1ch, vi\u00eam \u0111\u1ed9ng m\u1ea1ch kh\u00e1c.<\/li>\n
              • Vi\u00eam t\u1eafc m\u1ea1ch: vi\u00eam t\u1eafc m\u1ea1ch ph\u1ed5i nguy\u00ean ph\u00e1t, t\u1eafc m\u1ea1ch ph\u1ed5i trong b\u1ec7nh thi\u1ebfu m\u00e1u h\u1ed3ng c\u1ea7u h\u00ecnh li\u1ec1m.<\/li>\n
              • T\u1eafc m\u1ea1ch: do c\u1ee5c m\u00e1u \u0111\u00f4ng ngo\u00e0i ph\u1ed5i, t\u1eafc m\u1ea1ch do s\u00e1n m\u00e1ng.<\/li>\n<\/ul>\n

                2. \u0110i\u1ec1u tr\u1ecb t\u00e2m ph\u1ebf m\u1ea1n.<\/h2>\n

                2.1. Ch\u1ebf \u0111\u1ed9 \u0103n u\u1ed1ng v\u00e0 ngh\u1ec9 ng\u01a1i:<\/h3>\n

                – L\u00e0m vi\u1ec7c nh\u1eb9, th\u00edch h\u1ee3p, kh\u00f4ng ph\u1ea3i g\u1eafng s\u1ee9c. Khi \u0111\u00e3 c\u00f3 d\u1ea5u hi\u1ec7u suy tim ph\u1ea3i th\u00ec ngh\u1ec9 ng\u01a1i ho\u00e0n to\u00e0n.<\/p>\n

                – Ch\u1ebf \u0111\u1ed9 \u0103n nh\u1ea1t.<\/p>\n

                2.2. \u0110i\u1ec1u tr\u1ecb c\u00e1c c\u0103n nguy\u00ean g\u00e2y t\u00e2m ph\u1ebf m\u1ea1n.<\/h3>\n

                2.3. Oxy li\u1ec7u ph\u00e1p.<\/h3>\n

                – M\u1ee5c ti\u00eau: duy tr\u00ec SaO2 90 \u2013 92%, pH: 7.36 \u2013 7.42, PaCO2 40 \u2013 45 mmHg.<\/p>\n

                – Ch\u1ec9 \u0111\u1ecbnh khi PaO2 <55mmHg ho\u1eb7c SaO2 <88mmHg. Ho\u1eb7c PaO2 t\u1eeb 55 \u2013 59 ho\u1eb7c SaO2 88 \u2013 89% k\u00e8m t\u00e2m ph\u1ebf m\u1ea1n\/hematocrit >55%.<\/p>\n

                – C\u00e1ch th\u1ef1c hi\u1ec7n:<\/p>\n

                Th\u1edf oxy li\u1ec1u th\u1ea5p, d\u00e0i h\u1ea1n t\u1ea1i nh\u00e0, li\u1ec1u 1 \u2013 3 l\u00edt\/ph\u00fat, k\u00e9o d\u00e0i 18\/24h.<\/p>\n

                N\u00ean ti\u1ebfn h\u00e0nh ch\u1ecdn li\u1ec1u oxy th\u00edch h\u1ee3p cho b\u1ec7nh nh\u00e2n khi \u0111ang n\u1eb1m vi\u1ec7n. B\u1eaft \u0111\u1ea7u li\u1ec1u th\u1ea5p 0.5 \u2013 1 l\u00edt\/ph\u00fat. L\u00e0m l\u1ea1i kh\u00ed m\u00e1u sau 1h.<\/p>\n

                N\u1ebfu PaO2 <60mmHg ho\u1eb7c SaO2 <90% v\u00e0 PaCO2< 45mmHg: t\u0103ng li\u1ec1u oxy m\u1ed7i 0.5 l\u00edt, cho \u0111\u1ebfn khi \u0111\u1ea1t m\u1ee5c ti\u00eau.<\/p>\n

                N\u1ebfu PaO2 >60mmHg v\u00e0 PaO2 >45mmHg: gi\u1ea3m li\u1ec1u oxy m\u1ed7i 0.5 l\u00edt\/ph\u00fat, cho \u0111\u1ebfn khi \u0111\u1ea1t m\u1ee5c ti\u00eau.<\/p>\n

                N\u1ebfu PaO2 <60mmHg ho\u1eb7c SaO2 <90% v\u00e0 PaCO2 >45mmHg: xem x\u00e9t ch\u1ec9 \u0111\u1ecbnh th\u1edf m\u00e1y kh\u00f4ng x\u00e2m nh\u1eadp.<\/p>\n

                2.4. Thu\u1ed1c l\u1ee3i ti\u1ec3u.<\/h3>\n

                – Thu\u1ed1c l\u1ee3i ti\u1ec3u n\u00ean d\u00f9ng 3 \u2013 5 ng\u00e0y khi c\u00f3 ph\u00f9 ch\u00e2n, gan to, t\u0129nh m\u1ea1ch c\u1ed5 n\u1ed5i: furosemide 40mg 1 vi\u00ean\/ng\u00e0y u\u1ed1ng bu\u1ed5i s\u00e1ng. Tr\u01b0\u1eddng h\u1ee3p ph\u00f9 n\u1eb7ng c\u00f3 th\u1ec3 d\u00f9ng furosemide 20 mg 1 \u2013 2 \u1ed1ng ti\u00eam t\u0129nh m\u1ea1ch trong ng\u00e0y \u0111\u1ea7u sau \u0111\u00f3 chuy\u1ec3n sang d\u00f9ng furosemide 40 mg 1 vi\u00ean\/ng\u00e0y t\u1eeb ng\u00e0y th\u1ee9 2. D\u00f9ng k\u00e8m kaliclorua 0.6g x2 vi\u00ean u\u1ed1ng ho\u1eb7c kaliclorua 2g x1 g\u00f3i pha u\u1ed1ng.<\/p>\n

                – C\u00e1c l\u1ee3i ti\u1ec3u kh\u00e1c: spiromid 20\/50, spironolacton 25mg 1 \u2013 2v\/ng\u00e0y x3 \u2013 5 ng\u00e0y.<\/p>\n

                2.5. \u0110i\u1ec1u tr\u1ecb kh\u00f4ng d\u00f9ng c\u00e1c thu\u1ed1c sau:<\/h3>\n

                – Morphin, gardenal v\u00e0 c\u00e1c thu\u1ed1c an th\u1ea7n kh\u00e1c v\u00ec g\u00e2y \u1ee9c ch\u1ebf trung t\u00e2m h\u00f4 h\u1ea5p.<\/p>\n

                – Kh\u00f4ng d\u00f9ng thu\u1ed1c gi\u1ea3m ho.<\/p>\n

                2.6. Khi c\u00f3 b\u1ed9i nhi\u1ec5m:<\/h3>\n

                Ch\u1ec9 \u0111\u1ecbnh d\u00f9ng kh\u00e1ng sinh. Thu\u1ed1c kh\u00e1ng sinh c\u00f3 th\u1ec3 d\u00f9ng l\u00e0 penicillin, ampicillin, amoxillin, amoxicillin + acid clavulanic, cephalosporin, quinolone.<\/p>\n

                2.7. \u0110i\u1ec1u tr\u1ecb t\u00e2m ph\u1ebf m\u1ea1n do b\u1ec7nh ph\u1ed5i t\u1eafc ngh\u1ebdn.<\/h3>\n

                – Corticoid: d\u1ea1ng x\u1ecbt, d\u1ea1ng kh\u00ed dung, d\u1ea1ng vi\u00ean, d\u1ea1ng ti\u00eam.<\/p>\n

                – Thu\u1ed1c gi\u00e3n ph\u1ebf qu\u1ea3n: c\u01b0\u1eddng beta, kh\u00e1ng cholinergic, methylxanthin.<\/p>\n

                2.8. T\u00e2m ph\u1ebf m\u1ea1n do x\u01a1 ph\u1ed5i:<\/h3>\n

                Th\u01b0\u1eddng kh\u00f4ng \u1ee9 CO2 n\u00ean ch\u1ec9 c\u1ea7n th\u1edf oxy r\u1ed9ng r\u00e3i v\u00e0 cho corticoid.<\/p>\n

                2.9. T\u1eadp th\u1edf:<\/h3>\n

                L\u00e0m t\u0103ng \u0111\u1ed9 d\u00e3n n\u1edf l\u1ed3ng ng\u1ef1c v\u00e0 ph\u1ed5i, t\u0103ng th\u00f4ng kh\u00ed ph\u1ebf nang nh\u1ea5t l\u00e0 c\u01a1 ho\u00e0nh.<\/p>\n

                 <\/p>\n

                Ngu\u1ed3n: B\u1ed9 Y t\u1ebf 2012, Ph\u00e1c \u0111\u1ed3 \u0111i\u1ec1u tr\u1ecb b\u1ec7nh h\u00f4 h\u1ea5p.<\/p>\n

                 <\/p>\n","protected":false},"excerpt":{"rendered":"

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