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Bai giang Chong il6c

NgQ dQc cac thuoc va hoa chat gay co giat

1. Bai giang: Lam sang

2. thai gian giang: 2 tiet

3. dia di~m: Khoa Chong d9C BV Bach mai

4. muc tieu hoc tap:

4.2. Chdn doan xac dinn co giat do ng(J doc thuoc va hod chat

4.3. Chdn doan phdn biet co giat do cdc nguyen nhdn khac

4.4. Dieu tri co giat do ng(J doc thuoc hodc hod chat

5. NQi dung:

MQt vai con s6 (D!ch H~): Ty l¢ nhiem dQc cua Viet Nam ( theo nien giam thong ke BQ Y te 2000, trang 158):

Gan 80 benh nhan ND/lOO.OOO dan/nam. Hay 800 benh nhan ND/ltri~u dan/nam. 64000 twang hop ND/ 80 trieu dan/nam

Ty 1~ nr vong do nhiem d9C la:

15 benh nhan nr vong/l trieu dan/nam nrc 1200 ngiroi chet/ 80 trieu dan Tac nhan gay dQc nhieu, plnrc tap, va nguy hlem

Hoa chat bao ve thuc vat: gay co giat , gay rol loan nhip tim, rol loan tri nho va

tam than: Trifluoroacetate, Cyanacetamide, Striazin, Tetramin Kim loai nang: ChI, Hg, Arsenic, Thallium ...

Khi: CS (vii khi hoa hoc), CO, CN trong cac vu chay nha.,

Ca noc, thit coc, ong dot, ran d9C can, Ia d9C, thuoc dan gian (mat ca, du

mai ... ), nhiem d9C thuc pham, nam d9C, bot ngo ...

Rat nhieu cac hoa chat cong nghiep, nang nghiep va gia dung. Ma tiiy (opiate, cocain, amphetamin ... ), HIV

Qua lieu va tac dung phu cua diroc pham dong - tay y Va nhieu d9C chat c on chua xac dinh diroc

Nhiem dQc thanh cum, hang 10~t, gay 10 lang, btrc xuc cho xa hQi M()t so v~ diln hink qua bao chi:

• MH~n Bac:

- 280 nguoi nhiem d9C banh day tai 3 thon An PM, Xuan PM, Xuan An (Yen Dung, Bl1c Giang) (Bao Lao dong ra ngay 27/6/2002)

- 87 niX cong nhan cua Xi nghiep giay Lien Dinh va 119 niX cong nhan cua cong ty TNHH Sao Yang (Hai Phong) nhiem d9C tlnrc an (Bao Lao dong ra ngay 25/6/2002)

- V V nhiem d9C banh bot ngo a Ha Giang 2/2002, Cao Bang nr vong cao (19/21 BN)

- Cac vu nhiem d9C gay chet nhieu nguoi a Vii Tay -TMi Binh Thang (9-2002),

Dong lam - Hiep Hoa - PM ThQ (thang 12-2002) gay du lu(in xdu trong nhan dan vi bent: la va nhiing hien tuong me tin cung bai ...

• Mi~nNam:

154 hoc sinh twang Duong Minh Chan (TP HCM) nhiem d9C do tlnrc an nhiem vi khuan (Bao Lao dong, ra ngay 16/5/2002)

206 cong nhan cong ty Dong Yang (Long Khanh, Dong Nai) nhiem d9C thirc an (Bao Nhan dan, ra ngay 04/4/2002)

Thanh pho Hd chi Minh nam 2002 so vu nhiem d9C thirc pham la cao nhat trong 4 nam qua trong do co 14 vu nhiem d9C thuc pham a cac bep an t~p th~ gay benh cho 1465 nguoi. Dac biet la ti 1~ nguyen nhan do hoa chat chiem hon mra (57,1%) cung co xu huang tang manh

1

Bai giang Chong il6c

1. Chan doan xac dinh: a). Lam sang:

Co giat d¢t ngot xuat hien a mot nguoi khong co tien sir dong kinh la mot hoat dong nr dong, khong mong muon cua co, ket hop voi mat y thirc tren mot benh nhan thi phai nghi den bi ng¢ doc mot hoa chat, mot loai thuoc hay mot doc to nao do. Co giat la nguyen nhan chu yeu gay benh va nr vong do ng¢ doc.

Co giat kern voi trieu chung co th~ dinh huang tac nhan gay doc:

- Cac dan hieu song:

• Nhip tim nhanh, tang huyet ap, tang nhiet d¢ goi Y la ng<? doc cocain, amphetamin, hoi chung them nrou, benzodiazepin, cac chat kich thich khac, chat u-c che MAO, hoi chung Serotonin, hoi chung than kinh ac tinh.

• Tim nhanh, ha huyet ap goi y ng¢ doc thuoc chong tram cam 3 yang, theophilline, quinine hoac chloroquine

• Nhip cham, ha huyet ap goi y thuoc tic che beta (propranolone), photpho hiru co, carbamate, noc coc, digoxin

- Cac dan hieu v~ mat:

• Kho mat, co dan dong nr, goi y Atropin Belladon, thuoc khang histamin, thuoc tram cam 3 yang, ran hci can

• Dong nr co goi y meperidin, photpho hiru co va cacbamate, propoxyphen

• Rung giat nhan cau goi y carbamazepin (Seduxen, diazepam, ... ) hoac thuoc chong co giat khac

- Cac dan hieu v~ da:

• Da tai Ianh, u6"t goi y ng¢ doc Photpho hiru co, hoac hoi cluing thieu benzodiazepin, nrou hoac barbiturates

• Da do, kho thirong g~p trong ng¢ doc atropin, belladone

- Cac dan hieu v~ tim mach:

• Tim nhanh, QRS dan> 100 rusei, ha huyet ap goi y ng¢ doc cac thuoc chong rol loan nhip tim nhom 1, quirin, chloroquine

• Roi loan nhip, Bloc A.V, ngoai tam thu that goi y ng<? doc aconitin (cu au tau), nhip cham, QT keo dai goi y ng¢ doc noc coc

- Cac dan hieu v~ ho hap:

• Phil phdi cap, tang tier dich phoi, goi Y ng<? doc PPHC, Carbamate, heroin, nicotine, salisylate, nam doc

- Viem gan cap: goi y ng¢ doc nam doc, chl orin hydrocarbon, thuoc khang lao

- Ha Kali mau goi y ng¢ doc Theophylline

- Ha Canxi mau goi y ng¢ doc thuo c chuot tau loai Fluoroacetate

- Than kinh: kich thich rol loan tam than goi y ng¢ docc cocain amphetamines, thieu oxy do bat ky nguyen nhan nao. Tri tre, hon me, 10- dO- goi Y ng¢ doc thuoc an than, thuoc ngu, cacbon monoxide, opioids

2

Bai giang Chong il6c

- Ha duong huyet goi y ng¢ doc Iusulin, propranolon, cac thuoc uong ha duong

huyet,

b). Xet nghiem

• Can kiem tra cac enzym CPK, AST, ALT; chiic nang gan, than, duong mau cho Hlt ca benh nhan

• Do corboxyhemoglobin, dinh huong thuoc trong mau

• Do khi trong mau, dien tim, dien nao, CT scaner d~ kiem tra va thea doi

2. Chan doan phan biet vOi cac trang thai co gi~t

• Viem mang nao, viem nao, ap xe nao, u nao

• Tv mau dum mang cimg, tai bien mach nao, phil nao

• Thieu oxy, ha duong huyet, rol loan dien giai, nhip tim cham

• Dong kinh, hoi chung them nrou va an than

• Don van

3. Nguyen nhan gay co gi~t do dQc chat va thuoc

3.1. Cac chat dQc thunng g~p:

• Khang histamin, khang cholinergic (atropin)

• Cocaine, amphetamines, ergotamine

• Khi CO (Carbonmonoxide)

• INH (a benh nhan dang dieu tri lao)

• Thuoc trir sau: Photpho hiru co va cacbamate

• Theophylline, Salicylate, thuoc chong tram cam 3 vong

• Phenothiazine, Phencyclidine, Meperidin, thuoc gay ha duong mau

• Strychnin (rna tien), co trong ca thuoc diet chuot tau

• Fluoroacetate, cyanoacetate co trong thuoc diet chu ot tau

3. 2. Cac dQc chat it g~p:

• Butyrophenon

• Thuoc diet muoi

• Chloroquine, Lindane (dieu tri ghe)

• ChI, Lithium, Hydrocarbons 4. Tien lUQ11g va each phong:

Co giat keo dai, lien tuc la nguyen nhan chinh gay nr vong va benh t~t do suy ho hap cap thieu O2, tdn thirong nao, va suy than cap do tieu co van

5. Dieu tri

Muc tieu la bao ve duong ho hap va cat can co giat 5.1. Trunc benh vien:

- Tranh gay non

- Lay rang gia, tranh can phai Iufri, d~t canun mieng

5.2. Trong benh vien:

a). Thuoc cat con gi(it:

3

Bai giang Chong il6c

• Diazepam (Seduxen, Valium) 5-10 mg tiem tinh mach trong 2-5 phut, nhac Iai sau 10 phiit neu thay can. Tre em: 0,2 - 0,5 mg/kg moi 10 phiit neu can

* Dat ong noi khi quan neu diazepam khong dap ling, roi cho:

• Phenobarbital: lieu 18 mg/kg, tinh mach cho eli ngir Oi 1611 va tre em roi duy tri truyen 60 Ilg1 phut, truyen nhanh co th~ gay ha huyet ap

* Thuoc gian co, tho may voi oxy 40% neu Phenobarbital khong dap ling:

• Phenytoin

• Pentobarbital 5 -6 mg/kg/gio

b) Thong khi, dam bdo oxy (NKQ, Tha may)

c) Huy bO chai d()c:

- Rira da day: ong 1611 a ngiroi 1611 (36 -42 French) ong tre con (24-32 Frech)

neu ng¢ doc trong 3 gio dau, so hrong 1611

- Dong mot lieu than hoat l-2g/kg, neu ng¢ doc moi trong 1-2 gio dau, sau khi nra da day hoac khong nra da day

- Truyen dich ding twang tit 2-4lit/ngay.

Tranh suy than cap do tieu co van hau qua cua co giat

d). Chai gidi d()c (antidote)

Co giat do ng¢ doc INH: dung Pyridoxine (vitamin B6) 5g tim. Lieu co th~ nhac lai mot Ian mra sau 30 plnit (neu can) song khong virot qua 109.

4

Bai giang Chong il6c

NgQ dQc thuoc trir sao moo Nereistoxin

PGS.TS. Nguyln Tht DIJ Truong Khoa Chong d(Jc-BV B(_lch Mai

I. D~i cirong

Tit tnroc toi nay, loai thuoc trir san duoc nguoi ta biet den nh ieu nhat la Photpho hiru co VI tac dung diet trir san hai manh me cua no, song cung chinh no da gay nhieu nr vong do ng¢ doc cap va nhieu ng¢ doc man lam cho tat ca moi ngiroi quan tam, nghien CUu va xep loai doc III. 0 nhieu mroc da co quy dinh nghiem cam sa n xuat va sir dung Ioai hoa chat nay. Niroc ta cung khong nhap nhung loai hoa chat Photpho hiru co mra. Tuy nhien, tren thuc te lai xu at hien mot loai moi, duoc quang cao manh me va dang sir dung trong nang nghiep nham diet san cho hia, hoa mau va hoa qua. Do la: Shachong Shuang (SCS), Shachong Dan (SCD) do Trung Quoc san xuat, TmyQsx, hay Netoxin, Vinetox do Cty lien doanh cua mroc ta san xuat, hoac Dimotrin cua Nhat, Panda cua My. Tat ca d~u la loai Nereistoxin.

Nereistoxin trong cac pham thirong mai dung cho nang nghiep 0 tren duoc nhap vao mroc ta la 0 dang hat, bui phun hay bot de tan trong mroc, thong dung va re tien la loai dang bot goi 20g cua Trung Quoc va cua Sai Gon lien doanh san xuat - cac mat hang da quang cao nhieu v~ hieu qua trir san va it doc ch 0 nguoi. Song thirc te Iai trai ngiroc hoan toano Tong thai gian 2002-2003, khoa Chong doc chiing toi da tiep nhan 6 tnrong hop ng¢ doc cap va 3/6 benh nhan da nr vong. Sau day, chung toi xin trich dan v~ 6 benh nhan tren.

II. Sau benh nhan ngQ dQc Nereistoxi n tai Khoa Chong dQc - BV Bach Mai

1. Benh nhan mr, 23 tudi, Thuan Thanh-Bl1c Ninh, chuyen den khoa Chong doc 1 gio sau khi uong 1/3 goi (7g) Shachong Shuang voi muc dich doa nr nr. Kham hie vao: BN tinh, keu dau thirong vi, buon non, non, da lanh, va rna hoi. BN da duoc nra da day 0 tuyen tnroc, uong than hoat va giam dau bang Atropin Sulfate. Tho 2011in/phUt, M = 100 llin/phut, HA 95/60, sot 3rC, dong nr 3mm, HC 4,4, BC 16600, U 1,8 mmol/L, G = 6,4mmol, ChE 7042, Na 135, K 3,5, Cl 105, CK = 105dv, DTD: 100lan/ phiit, xoang binh thuong, Q)Q+c =340/397 ms. Ra vien sau 2 ngay dieu trio

2. Benh nhan nam, 27 tudi, Vinh Tuy, Ha Noi. Ngo doc Netoxin (Sai Gon - Viet Nam) VI nr nr, uong 1/2 goi (lOg) netoxin cung voi uong nrou. 20 plnit sau, non, dau bung, va rna hoi, xe van chuyen cap CUu, dira den khoa Chong doc trong tinh trang la do, Glasgow 8 diem, da lanh tai, va rna hoi, dong nr 4mm, giam phan xa tu chi, tho 30 lan/phut, M = 120lan/phUt, HA 80/50 va 70/0, ia long phan mau tum, sot 39,5 "C, CVP = 1, ChE 10800, Amylase 299/4942. Cac xet nghiem clnrc nang than, gan binh thuong, HC = 4,4, BC = 16700. BN duoc dieu tri: RDD, than hoat sau nra, truyen dich + Stilamin, Transzamin, Dopamin, truyen man. 3 ngay sau, BN hoi phuc ra vien

3. Benh nhan nam, 19 tudi, Yen Phong -Bl1c Ninh, uong 1 goi Shashongdan (20g) voi nrou, nr nr, duoc gia dinh dira ngay den BV huyen nra da day, uong than hoat. 1 gio sau, xu at hien co giat toan than, duoc d~t NKQ, cho thuoc an than, chuyen v~ khoa Chong doc - BV Bach Mai trong tinh trang Glasgow 3 diem, do da toan than kieu gian mach, xuat huyet, M = 150 l/ph, HA = 0, SpO 2 75%, ngirng tho, giat co nr nhien, xuat huyet tieu hoa, chay mau miii, mroc ti~u do sam. Sau 24gia cap CUu (truyen dich, thuoc van mach Sandostatin, thuoc bao boc da day, NKQ, tho may), BN tie n trien xau: van tim, chay mau, toan chuyen hoa, HA 60/40, BC 16100, ChE 10380, CK 29950, DTD: Bloc NT cap 1, T am nen gia dinh xin v~ M chet,

4. Benh nhan mr, 14 tudi, hoc sinh, Que VO -Bl1c Ninh, uong 1 goi Dibazan Nereistoxin nr nr, 10 phiit sau, xu at hien non, dau bung, tai lanh -> BV Que Vo nra da day, uong than

1

Bai giang Chong il6c

hoat, Ngay hie nra da day, xuat hien co giat tom than. Diroc d~t NKQ, chong co giat, chuyen den BV Bl1c Ninh, den khoa Chong doc -BV Bach Mai. Sau 9 gio, BN trong tinh trang dong nr dan, liet co ho hap, hon me sau, HA SO/30, do da toan than dan mach, phan mau, xuat huyet da day, chay mau miii, toan chuyen hoa, Prothoombri < 10%, He 3,73, BC 32900. Tai khoa Chong doc, dieu tri hoi sue rat tich Cl!C, tho may voi PEEP, Human A1bumine, truyen mau, Dopamin, Dobutamin, Omeprazo1 nhung bat kha khang. BN nr vong trong benh canh suy da tang

S. Benh nhan nam, 41 tudi, Van Lam-Hung Yen, uong 1 goi Apaschuang (Nereistoxin) nr nr, 10 phiit sau, non, dau bung, v~t va, keu 1a. 1 gio sau vao BV Van Lam nra da day, uong than hoat, truyen dich. 8 gio sau do, chuyen den khoa Chong doc -BV Bach Mai trong tinh trang tim toan than, ngirng tho, dong nr dan, mach roi rae, da lanh. Khoa Chong doc da cap CUu va hoi sire tich eire, tim dap lai, HA 110/70, CVP = S, SpO 290%, may co nguc, toan mau, chuyen hoa plI 7,1, PC0264, Pa02 83, HC0320,7, BE -20, HC S,6, BC 3400, ChE 10610, Prothombin 21 %, phan co mau, dich nao tuy co mau hong khong dong. BN tien trien xau, nr vong sau 10 gio nhap vien

6. Benh nhan nir, 26 tudi, Hung Yen, uong 1/2 goi N etoxin nr nr. 20 phii sau, non, dau bung, ia chay, duoc dira thing vao khoa Chong doc nra da day, uong than hoat, truyen dich, mach, huyet ap cin dinh

Tren day la 6 BN (3 ntt + 3 nam) ng¢ doc Nereistoxin, tudi tit 14 den 41, d~u song a vung nang thon san thuoc trir sau, mot nguoi uong it nhat la 1/3 goi, hai nguoi uong 1/2 goi va ba ngiroi uong ca goi. Ba nguoi uong mra goi va 1/3 goi thi song, can ba ngiroi uong ca goi d~u nr vong, chiem SO%. Nguyen nhan nr vong la suy ho hap, tut HA, chay mau va toan chuyen hoa chi trong vong 2-3 ngay. R6 rang Nereistoxin la mot hoa chat trir san gay chet nguoi.

III. Nereistoxin lit gi?

Trong nr nhien, Nereistoxin duoc tim thay trong tuyen mroc bot cua 1 loai oc d~c biet va Nereistoxin co tac dung gay doc cho san hia, hoa qua qua duong ho hap tieu hoa va tiep xiic. Nereistoxin tro thanh thuoc trir san do nhieu cong ty trong va ngoai mroc san xuat v6i nhieu ten thirong mai khac nhau nhir tren da noi.

Nereistoxin co ten goi khac la Dimehypo, Neretox.

Ten hoa h9C cua Nereistoxin la 4-N,N-dimethy1amino-l,2 dithio1ane. Phan nhom doc cua WHO: loai II

LD SO: 192mg/kg duong uong voi chuot due 2S0mg/kg duong uong voi chuot cai 316mg/kg duong uong voi tho

a khoa Chong doc, lieu nr vong dol voi 3 BN la 400mg/kg Dang sir dung: Bot, mroc, bot dong goi 20g

Sinh benh h9C: Nereistoxin hap thu vao co th~ qua duong da day ruot, da va duong ho hap Nereistoxin tac dung tnrc tiep tren da day ruot, gay tang co bop, non, dau bung, ia chay. Tren M than kinh, Nereistoxin tac dung ngung chen hoat dong than kinh ca. Tlnrc nghiem dira Img/kg Nereistoxin vao tinh mach hau qua co SO% chen than kinh co trong 2 -Sphiit, va tiep tuc se gay ra liet co ho hap va nr vong trong vai phiit. Quan sat mach va huyet ap sau truyen tinh mach Nereistoxin thay tim nhanh va giam huyet ap tam thu va tam twang. Tuy nhien, liet co ho hap g~p nhieu han suy tim - nguyen nhan nr vong neu khong co bien phap dieu tri kip thai

2

Bai giang Chong il6c

IV. Chan doan va xU trf 1. Lam sang:

Cac twang hop nhe va trung binh:

• Cac bieu hien da day ruot rat som, xuat hien sau khi uong la dau bung, non mira va ia chay, co th~ co chay mau tieu hoa

• Da tai Ianh, va rna hoi, kich thich, mach nhanh Twang hop nang:

• Trieu cluing da day ruot nang ne, va rna hoi, gay ra giam th~ tich tuan hom, co giat toan than, suy ho hap, tut huyet ap, dan mach tom than, rol loan dong mau, toan chuyen hoa va suy da tang. Tir vong do suy ho hap, suy tim cap va chay mau nang

Theo doi xet nghiem:

• Hong cau giam khi chay mau nhieu, bach cau tang cao

• Roi loan dong mau

• Giam th~ tich tuan hoan

• Roi loan nhip tim

2. Phat hien Nereistoxin bang sac ky khi (GC) hay sac ki long

3. Xu tri dieu tri :

1. Loai bo chat dQC

• Rira da day sau khi cho thuoc chong co giat va d~t ong noi khi quan

• Cho than hoat Ig/kg + 250ml sach quay d~u bam qua xong da day. Neu chua d~t duoc ong NKQ, BN con tinh thi cho uong than hoat

2. HE> tro va bao ve duong ho hap

• Dat ong NKQ bam bong chen

• Tho may khi rol loan y tlnrc

• Tho O2 va hut dam

3. Dat duong truyen tinh mach trung irong

• Do CVP

• Truyen dich phan nr hrong cao khi co soc

• Truyen mau khi co chay mat mau

• Dung thuoc van mach nang huyet ap 4. Di~u tri toan chuyen hoa

• Truyen Bicarbonate Natri

• L9C mau 5. Thuoc giai doc

• Cobal + Chloride co tac dung tot a chuot (Huj Zhang - China)

3

Bai giang Chong il6c

• Neostiguine va 4-aminopyridine co hieu qua 0 tho (Shopp RT Dechie ZW USA 1981)

• Dimercaptosucimic acid (DMS) (Ding G -S, Liang Y - Y journal of Applied

Toxicology, Vol 11-No 1)

Tom lai, Nereistoxin la thanh phan trong thuoc trir san Shachong dan, Shachongchuang, Netoxin, Vinetox, Dimotin, Panda. Nereistoxin la mot c hat co doc tinh cao gay nr vong cho nguoi. Thuoc nay can duoc quan ly chat che, giao due nang cao nhan tlnrc cho ngiroi diroc sir dung. Cac nha san xuat can than trong dir phong ng¢ doc khi dira ra thi twang quang cao sir dung cac loai thuoc trir san nay.

4

Bdi giang Chong doc

NgQ doc thuoc gay nghien

( Nhom OPI, Heroin va morphin )

PGS. TS Nguyen Th! Dv

Khoa Chong doc BV B<;tch Mai

Thuoc gay nghien: thuoc phien, codein, morphin va heroin rat d~ gay ngo doc cap khi xir dung, dac biet 0 nhfmg ngiroi lam dung thuoc va phu thuoc thuoc,

Co thtS tit vong do suy ho hap cap ( ngirng tho, phu phdi cap )

M(>t so dan chat opi la thuoc giam dau, giarn ho (d~c biet la ho ra rnau ) va earn ia chay, dung dai ngay co thtS gay nghien, NgU'O'i benh them thuoc, tim rnoi each dtS co thuoc dung. Co thuoc lai dung qua lieu se bi ngo doc cap, Tiem chich khong vo khuan gay nhiem HIV suy giam mien dich, viern noi tam mac,

Dieu tri chu yeu dam bao thong khi va thuoc giarn doc naloxon ( N arc an ). Dieu tri cai nghien diroc dam bao an toan nhat 0 cac Trung t am Chong doc,

I. Chan doan ngQ dQC cap:

1) Chan doan xac dinh:

Trieu clnrng ngo doc cap xay ra ttl' 30 - 60 giay sau khi dira thuoc gay nghien tren vao co thtS, ngU'O'i benh co cam giac " khoai cam ", " em dern " ( di may v~ gio ), sau do di vao hon me,

Cac dau hieu chu yeu:

Tho cham dan rdi ngirng tho, co thtS phu phdi cap, tim Milt y thirc, dong tit co nho, milt cac phan xa,

Huyet ap ha, Ianh do ha than nhiet

Tren benh nhan tre, co vet tiern trfch hay nghi lam dung thuoc 2) Chan doan phan biet:

Hon me do uong thuoc ngu va an tha n qua lieu,

Hon me do ha duong huyet, thirong g~p 0 nguiri tieu duong dung thuoc ha duong rnau qua lieu,

Tai bien mach nao,

II. XiI tri:

1) T~i cho:

Th6i ngat 14 - 16 Ian/I plnit ( neu ngirng tho)

1

Bdi giang Chong doc

ep tim ngoai long nguc ( neu ngirng tim)

Tiem naloxon 0,4mg (bap hay tinh mach ), Nhac lai sau moi 5 plnit. Neu benh nhan tinh Iai, tho' diroc, khong tim, dong tit 3 - 4mm thi thoi,

Neu benh nhan tinh, tv tho' roi nhanh di vao hon me lai, tho' cham, yeu, tim, cho lai N aloxon va goi xe cap ciru.

Thier lap mot dirong truyen tinh mach

2) Tren xe cap coo:

Bop bong ambu 14 - 161/phut, 30% oxy

Hoac d~t ong noi khi quan thO' may, neu benh nhan co phu phdi cap, cho Lasix 40mg/TM.

Truyen dich - thuoc van mach neu ha huyet ap, Naloxone truyen TM 0,4mg/giO'

III. Tai Khoa Cap coo va Chong doc

1) Nell benh nhan thO'dum 10hin/phut, tim, ha HA, dong til co: - Naloxon: 0,4 - 0,8mg TM.

Tre em 0,2 - - 0,4mg TM

Nam phiit sau khong tinh lai co tM cho tiep Ian 2 hay Ian tlnr 10 cho den khi co ket qua, giam dan naloxon.

Naloxon tiep tuc truyen lien tuc, duy trt 0,4mg/g iO' & ngiroi 16n va O,Olng/kg 3 phiit & tre em.

Dern nhip tho, thea doi y thirc, huyet ap va dong tit trong IOgio; Thong khi nhan tao:

+ Bop bong ambu v6i FiO 2 50%

+ ThO' may khong xam nhap neu con nhip tv tho,

+ Dat ong noi khi quan thO' may ( dac biet khi phu ph 6i cap ) trong khoang ttl' 1 giO' den 10giO'

+ Truyen dich nang HA ( co thtS dung them thuoc van mach )

2) Nell benh nhan thO' > 10hin/phut:

Naloxon 0,4mg tiern bap hay tinh mach, ThO' O2 4lit/phut

Truyen dich (glucose 5% )

Theo doi nhip tho, Y thtrc va huyet ap l Sph/Ian,

2

Bdi giang Chong doc

3) Theo doi dau hieu them thuoc sau dung naloxone.

D6 la: Dong tit gian ( va md hoi ), son gai OC, vat va, run CO', soi bung, non, tim nhanh, tho' nhanh ...

Cho them cac thuoc ngu va an than, dong thai lap ke hoach cai nghien cho benh nhan,

3

Bdi giang Chong doc

NgQ doc tlnrc pham

Ngo doc tlnrc pham (NDTP) Ia cac hoi clnrng lam sang xuat hien do:

1. Thuc pham bi nhiern cac vi sinh vOt hoac cac san pham cua cluing (tlnrong g~p nhat) ,

2. Thuc pham bi nhiern cac hoa chat doc, hoac

3. An phai cac thuc vOt hoac dong vOt co doc to.(11)

NDTP co tM anh lnrong rnoi doi urong, rnoi quoc gia (8,9,14), co thtS tac dong cung mot hie t6'i nhieu ngiroi, gay h Ou qua khong nhfrng v~ y te (tnroc milt va Iau dai) rna can v~ kinh te, trOt tv xa hoi,

o mroc ta, trong nhfmg nam gan day NDTP xay ra co xu lnro ng nhieu hon, No khong khong can chi Ia van d~ y te rna da ciln den su tham gia cua nhieu nganh clnrc nang co lien quan.

Dinh nghia thuc pham :

Tlnrc pham la nhirng d6 an, tlnrc uong cua con nguO'i 0 dang uroi song hoac da qua so che, che bien bao gorn ca d6 uon g, nhai, ngOm va cac chat diroc sit dung trong san xuat, che bien thuc philm.(2)

Ph an loai tlnrc pham

Theo phan loai Eurocode Main Food Group Clasification and Policy, version 99 -2. htm (16) phan Ioai nay gorn hai phan :

1.1. Phan Ioai cac nhorn thuc pham ch Inh :

1.1. Sua va cac san pham ttl' sua 1.2. Tnrng va cac san pham ttl' tnrng

1.3. Thit va cac san pham tir thit

1.4. Ca, Ioai nhuyen tM, bo sat, loai 16m cua va cac san pham

1.5.

Dau, rna va cac san pham ttl' dau, rna. 1.6. Ngii coc va cac san pham ttl' ngii coc

1.7. Hat dOu, cac Ioai hat, nhan cua hat va cac san pham. 1.8. Rau va cac san pham tir rau,

1.9. Qua va cac san pham ttl' qua.

1.10. Duong, cac san pharn dirong, cac san pham socola va banh keo, 1.11. D6 uong (khong phai sua).

1

Bdi giang Chong doc

1.12. Cac thuc pham khac, chao, sup, canh, mnrc sot, mnrc mam, nrong va cac san pharn.

1.13. Cac san pham dung cho muc dich dinh dirong dac biet, 1.2. Mo ta, phan Ioai va rna hoa cu thtS tirng nhorn thuc pham cung voi ca c vi du,

Phan loai tlnrc pham Aynrveda (Aynrvedafood classification )(17): Chia thanh 10 nhorn thuc pham la : Thit, sua, dau, banh keo, d Ou, rau, qua, rau thorn va gia vi, ngii coc, hat, V 6'i cac dac diem cua tirng nhorn v~ vi, che bien nong hay Ianh, tac dung sau khi diroc tieu hoa va tinh chat vOt lY.

Tieu chuan v~ sinh tlnrc pham :

- Theo danh muc tieu chuan v~ sinh doi voi hrong thuc, thuc pham cua B9 Y te (3), xin diroc neu tom tat, gorn co :

Muc 1 : Gioi han phu gia thuc phdm va cdc chat 0 nhiem Phu gia thuc phanu

- Khai niern chat phu gia thuc pham.

- Cac phu gia thuc pham diroc chi a lam 16 nhorn chat voi clnrc nang, cong dung, so

hrong chat 0 tirng nhorn diroc phep sit dung, T6ng so chat diroc sit dung 0 tilt cii cac nhorn la 246 chat,

Vi du : Mononatri L (-) glutamat (monosodium L( -) Glutamate, la my chfnh, thuoc nhorn cac chat dieu V! (Flavo enhancers) so hrong an vao hang ngay chap nhOn diroc (ADI : Acceptable daily intake) khong gioi han, voi thit cua hop gioi han toi da cho phep la 500 rng/kg,

GiOi han cac chat 0 nhi em :

1.GiOi han nhiem doc tovi ndm (Mycotoxin ).

2.Tieu chudn v¢ sinh an toan v Ot lieu thie: bi bao g6i chua dung thuc phdm. 3.Tieu chudn v¢ sinh an toan do chai tre em.

4.Tieu chudn v¢ sinh thuc phdm chat tdy rua dung rua dung cu chua an va chua dung thuc phdm.

5.Kilm tra gioi han kim loai ruing Sb, As, Cd, Pb trong dung cu chua dung, bdo qudn va ndu an.

6. Ham IUQ'ng kim loai cho phep trong cdc loai thuc phdm. 7.GiOi han thuoc thu y tal da cho phep trong san phdm thit

2

Bdi giang Chong doc

Muc 2 : Du luang thuoc bdo v¢ thuc vOt trong thuc phdm :

- Thuoc bao v~ tlnrc vOt Ia che pham co nguon goc ttl' hoa chat, thuc v Ot, dong vOt, vi sinh vOt dung dtS phong, trir sinh vOt gily hai tai nguyen thuc vOt.

- Co 144 thuoc BVTV diroc dung lam chi tieu, vi du: Methamidophos (O,S -

Dimethyl Phosphoramidothioate) tren dira chuot, hrong ton dir toi da Ia 1 mg/kg, Muc 3 : Trang thai cdm quan va cdc chi tieu If hoa doi voi mot so m(it hang luang thuc , thuc phdm chink .

Muc 4 : Gioi han () nhiem vi sinh vOt trong thuc phdm.

- Tuy nhien, voi su pha t trien cua khoa h9C, nhieu hoa chat diroc dira vao sit dung trong dOi song hang ngay, vi sinh vOt ciing thay d6i dien mao do con ngiroi sit dung nhieu hoa chat dtS tieu diet cluing va cung voi nhieu ly do khac khien cac nguyen nhan cua NDTP ngay cang tro nen phiic tap va kho kiem soat, Vi du, trong Iinh vue hoa chat bao v~ thuc vOt, cho tci nam 2000, 0 mnrc ta cof I)

Trieu clnrng chung cua NDTP

- VI co rilt nhieu cac tac nhan vi sinh v Ot, chat doc va cac hoa chat nen khi diroc vao co thtS cung voi tlnrc an se gily nhieu tri eu cluing khac nhau.

- Do dirong tieu hoa la con duong vao cua cac tac nhan do nen hau het cac benh canh cua NDTP deu co bitSu hien mot rmrc d¢ nao do cua viern da day ruot, co thtS n6i bOt 0 dirong tieu hoa tren hoac dirong tieu hoa diroi. Cac hoi cluing khac thuong thay bao gorn cac trieu cluing ngoai co quan tieu hoa, dac biet Ia v~ than kinh (11).

- Viec danh gia mot tnrong hop nghi ngo NDTP khong chi dua vao cac trieu clnrng khi benh nhan den vien rna con ciln quan tarn den benh sit, tinh chat tlnrc pham, thoi gian xuat hien cac trieu cluing tfnh ttl' thai diem an uong, hOM canh, rnua va cac trieu chirng xuat hien 0 nhfrng ngiroi khac cung an uong Ioai thuc pham nghi ngc' (21).

- Tan xuat bi benh 0 nhtrng ngiroi khong cung an Ioai tlnrc pham nghi ngc' ciing giiip chan doan,

- COn lam sang co tM giiip chan doan nguyen nhan va dinh hirong dieu tri.

3

Bdi giang Chong doc

- Trong pham vi d~ tai nay cluing toi se chi xin d~ c Op tci cac hoi clnrng NDTP co tinh cap tfnh, nrc Ia cac trieu chirng thuong bat dilu xuat hien trong vong 72 gio (18). Cac tnrong hop khac bao gorn cac hOu qua Iau dai cua NDTP cap, ngo doc cac thuc pham co chua cac chat doc voi ham hrong thap nhung gily tfch luy lieu khi dung Iau, ciing dtS lai nhfrng h Ou qua khong kern, chung toi khong co dieu kien di sau,

- Cac trieu cluing cu thtS cua NDTP se phu thuoc vao tirng nguyen nhan, Nguyen nhan NDTP

Chua day mot nita so vu NDTP diroc biet tim thay nguyen nhiln(41 %) (11). Trong do do tac nhan vi khuan Ia 79%; hoa chat 14%; virus 4% va ky sinh trung 1 % (10) va duong nhir cac tnrong hop khong thay nguyen nhan Ia do virus gily ra (15).

Ngt) dt)c thuc phdm do vi sinh vOt (13)

Nguyen nhan:

- V 6'i cac thU'c philm la rau qua, ngu coc, hat, sua va cac san philm : Cac Ioai tv cau, Bacilus cereus, Campylobacter fetus hoac yersinia enterocolitica.

- PhV nir co thai rilt d~ bi nhiern Lis teria, cac thuc pham tlnrong g~p nhat la thit ga khong diroc nau chin hoac cac san pham sua bi nhiem Listeria monocytogenes.

- Do nU'6'c hoac dung nU'6'c dtS rita thU'c philm: Cac nguyen nhan la E.coli (ca Ioai sinh doc to va xam nhOp), cac Ioai Shigella, Salmonella enteritis, Y. enterocolitica, C.fetus, hoac Vibrio cholera.

- Do thit va trUng: + Thirong Ia thit dll qua qua trinh xir ly, thit diroc nau khong

ky, bao quan Ianh khong day du hoac vOn chuyen khong dung, banh ngot co kern hoac co sfra-tning va cac san pham co tnrng khac bi nhiern cac vi khuan voi so hrong dat tci rmrc d¢ co tM gily benh,

o Cac vi khuan tlnrong la cac tv cau, C.perfringens, Rcereus, cac Salmonella va Campylobacter jejuni.

CO' che:

Theo mot trong hai co che sau:

- Viem da day ruot do xam nh Op:

o Vi khuan tnrc tiep xam nh Op niern mac ruot, gily thoai hoa cac vi nhung mao va phan trng viern manh me, bieu hien bang ia chay phan co mau, non, dau quan bung va chirong bung,

4

Bdi giang Chong doc

o Vi khuan tlnrong g~p nhat la Salmonella va E.coli xam nh Op. - Viem da day ruot do dt)c to ruot:

o Cac doc to cua vi khuan pha va co che v On chuyen mnrc va cac chat hoa tan qua rnang te bao dan tci ia chay phan khong co mau, dau quan bung, clnnrng bung va non.

o Cac tac nhan thirong g~p nhat Ia cac Ioai tv cau, E.coli sinh doc to ruot, Clostridium perfringens, B.cereus va Campylobacter jejuni.

Trieu clnrng:

- Cac trieu cluing tlnrc thtS khong dac hieu va chu yeu do milt mroc va cac tac dung tai ch6 tren duong tieu hoa cua doc to.

- Di~n bien: Hau het cac benh nhan sau vai ngay se hoi phuc hoan toano

- Viec hoi v~ qua trinh an uong va moi lien quan voi kh oi dilu cua trieu cluing se

giiip hirong t6'i nguyen nhan, a. Thai gian u benh. va bi benh: (*)

Vi khuan ? Thai gian bi benh
Ub~nh
(Trung bmh) Trung bmh Thay d6i
Tl;l cau 1 - 6 h 1 ngay 8 - 48 h
Bacillus cereus Gay hoi clnrng non 1 - 6 h 9h 2 - lOh
Gay benh ly ia chay 6 - 14 h 20h 16 - 48 h
Salmonella 8 - 48 h 3 ngay l-Ltngay
E.coli Sinh doc to ruot 12 -72 h 3 ngay l-Ltngay
Xam nhOp ruot 6 - 36 h 3 ngay l-Ltngay
V. cholera 12 -72 h 3 ngay 2-14ngay
Shigella 24 -72 h 3 ngay 1-14 ngay
(t6'i 7 ngay)
Y. enterocolitica 24 -72 h 7 ngay 2-30 ngay
(t6'i 6 ngay)
Campylobacter 2 - 11 ngay 3 ngay 2-30 ngay
C.perfringens 8 - 24 h 24h 8 -72 h 5

Bdi giang Chong doc

b. Cdc dau hieu song:

- Sot: Goi y benh ly xam nh Op, vi du nhir salmonella, C.fetus hoac E.coli.

- Nh!P tim nhanh do sot hoac milt dich,

- Huyet ap ha tlnrong do milt thtS tich dang ktS (tren 10 % t6ng thtS tfch)

- Nhiern Listeria co trieu cluing sot va viern thanh quan,

- Cac tac dung cua doc to , dac biet Ia milt mroc co tM n6i b Ot 0 tre em va ngU'O'i

cao tudi,

c. Da: Da kho va d¢ dan hdi kern cho thay tmh trang milt mroc,

d. tteu hod:

- Dau quan khap bung, chirong bung, ia chay, bung cang toan bo, co co bung chu dong: Gap 0 hau het cac tnrong hop va khong dac hieu,

- Kham tnrc trang thay niern mac bi viern, mun hoac xet nghiern thay co Hem: G¢ y tac nhan vi khuan xam nh Op.

e. ThOn: Luong mnrc titSu giam cho thay tmh trang thieu dich,

f. Nuoc va di¢n gidi:

- Non, ia chay va milt mroc dien giai thea con dirong khong thay co tM gily tang Natri rnau (milt mroc) hoac ha natri (milt natri toan b¢ co the), ha kali mau, ha cIo mau, ha magie mau, hoac ha phospho rnau.

- Co thtS co kiem chuyen hoa (non) hoac toan chuyen hoa (milt bicarbonat do ia chay),

g. co xuong:

- Thuong g~p co cirng co Ian toa va dau co,

- Nhiern listeria co trieu chtrng dau co,

h. Than kinh:

- Ngo doc thuc pham dan thuan do vi khuan khong co trieu clnrng than kinh dac hieu,

- Neu co liet vOn nhan hoac liet tit tren xuong thi ciln nghi ngc' nhiern Botulium.

- Nhiern Listeria co trieu cluing dau dau dir roi,

i. Nguoi cao tu6i va tre em:

Cac trieu tnrng nang han voi tre em va ngiroi cao tuoi mac du tit vong do soc va milt tM tich dich hiern g~p ngay ca 0 doi urong nay.

6

Bdi giang Chong doc

Xet nghiem:

1. Xet nghiern rnau co tM thay bach cau da nhan trong rnau tang, dac biet voi cac vi khuan xam nh Op.

2. Soi phan co thtS thay bach cau, vi khuan gily benh,

3. Cay tlnrc an, chat non hoac phan, dinh type huyet thanh vi khuan, xet nghiern doc to (tv cau, E.coli sinh doc to ruot, C.perfringens). Cay rnau cho thay vi khuan xam nhOp.

4. Ure, creatinin va dien giai rnau can diroc lam dtS danh gia h Ou qua cua milt mroc, Chan doan:

1. Khi co nhieu benh nhan tci vien cung hie ttl' cung mot noi hoac khu vue cho thay do cung mot nguon tiep xiic.

2. Khai thac benh sit v~ viec dung cac thuc pham va thoi diem trieu clnrng dilu tien xuat hien se giup phat hien nguyen nhan,

3. Cac co gang qua rmrc dtS xac din h nguyen nhan va nguon benh it co y nghia lam sang.

DieD tri:

a. Nguyen tdc chung:

- Viec dieu tri nen tOp chung giam cac trieu cluing buon non, non va ia chay cung voi viec clni Y tci kha nang thieu dich va soc.

- V 6'i cac benh nhan co milt mnrc nang va soc, dieu tr ! h6 tro trong do co boi phu dich co y nghia song con.

- Viec phan biet ia chay do vi khuan xam nh Op hay khong xam nhOp thirong du dtS dinh hirong dieu tri.

- Can xac dinh thai gian va qua trmh benh nhan an uong doi voi tilt ca cac tlnrc an diroc dung trong vong 48 gio,

- Khi co nhieu ca cung xay ra can phai thong bao cho trung tam y h9C du phong, b. C~ thi:

- Gay non, rita da day: Noi chung khong can thiet do benh nhan non nhieu,

- Khang sinh:

o Trong tnrong hop nghi ngc' nhiern trung do vi khuan xam nh Op, cay phan co tM co ty l~ am tfnh gia tci 40%, co thtS chi dinh dieu tri thuc te nlnr sau:

7

Bdi giang Chong doc

- Ciprofloxacin, 250 mg, 2 Ian/ngay, trong 5 -7 ngay, hoac

- Trimethoprim/Sulfamethoxazole, vien 160/800 mg, 2Ian/ngay, trong5 -7 ngay,

o Khi dll xac dinh diroc nguyen nhan, dung khang sinh tuy thea vi khuan,

Do virus: (25)

- Viem da day ruot do virus xuat hien nhieu hon so diroc phat hien, cac nguyen nhan dll diroc xac dinh gom co : Virus Norwalk, Rotavirus, Adenovirus dirong ruot, Calcivirus.

- Trong han het cac ca viern da day ruot do virus, chan do an xac dinh g~p kho khan do doi hoi cac ky thu Ot chan doan wong doi phiic tap,

Virus Norwalk:

- Duoc coi la nguyen nhan cua it nhat 1/3 cac vu dich viern da day ruot do virus 0 My.

- Virus chiu diroc nhiet, gily benh 0 ruot non la chu yeu; gily giam tieu hoa va h ilp thu cung voi viern ruot,

- Trieu cluing : non va ia chay cap tfnh cung voi cac bitSu hien giong cum, hiern khi keo dai qua vai ngay,

- Dieu tri trieu clnrng

Rotavirus:

- T6n tlnrong : pha huy lap vi nhung mao, lam giarn tieu hoa va hap thu, thay d6i nay co thtS keo dai tci 8 tuan,

- Doi urong d~ mac : Chu yeu la tre nho, tre bu sua me it bi mac hon,

- BitSu hien : Non, sau do ia chay phan mroc, keo dai trung bmh vai ngay, milt mroc

dien giai,

- Dieu tri : B6i phu mroc dien giai, Do ky sinh trung :

Do dong vOt don bao : (7)

Nhieu Ioai dong vOt don bao co thtS nhiern trong thuc pham va gily benh, * Amibe:

Benh Amibe do Etamoeba histolytica gily ra

8

Bdi giang Chong doc

Thuc pham bi nhiern : rau qua song, mroc la, tlnrc an bi nhiern phan co ken amip, qua ban tay biln.

- Nung benh : 1-14 tuan, tlnrong 2-4 tuan

- Benh canh : - Iy amip (benh amip dai trang):

+ Hoi chirng ly, thuong khong sot

+ Chiln doan : Xet nghiern phan tim amibe gily benh,

- Benh amibe ngoai dai trang (ap xe gan, viern phoi, tran dich rnang phdi): Chiln doan : Xquang, sieu am, chan doan xac dinh bang cac phan trng huyet thanh mien dich,

- Dieu tri : Metronidazol hoac cac che pham. *Giardia:

- Dong vat don bao co long roi Giardia Iambia.

- Thuc pham bi nhiern : Thuc pham mroc bi nhiern phan ngiroi va dong v at co ilu

trung Giardia.

- Trieu cluing : U benh 3 - 25 ngay; trung bmh 7 -10 ngay, BitSu hien : ia chay, co thtS phan mO', dau quan bung, thirong khong co t6n tlnrong ngoai ruot, benh tlnrong tv gioi han, dac biet 0 ngiroi sire d~ khang tot.

- Chiln doan : tim thay nang hoac cac thtS tv dirong trong phan (tlnrc hien it nhat 3 Ian tnroc khi diroc coi la am tfnh, hoac tim thay thtS tv duong trong dich ta trang hoac trong niern mac sinh thiet ruot non.

- Dieu tri : MetronidazoI, quinacrin, Furazolidol.

Nhiem vi nam : (11)

Clavicep purpurea : co trong cac Ioai ngii coc, dac biet Ilia mach

+D¢c to la Ergotamin : co bop co tit cung, co mach, co thtS dan tci hoai thu, + Hien nay hiern g~p.

-Aspergillus (Ioai A. Flavus va A.parasiticus):

- Co doc to la aflatoxin

- Thuc pham nhiem narn : Cac hat, hat dOu (nhu ngo, g ao , Ilia ml, d Ou

wong, lac, hat bong), thuc pham nay tlnrong diroc dtS 0 rnoi tnrong am, ilm. - Aflatoxin: chat gily ung thu manh, dac biet voi gan.

NgQ dQc tlnrc pluim do chat dQC co san tu nhien trong tlnrc pham.

9

Bdi giang Chong doc

Cay co (21,25,6,19 ):

Duoc biet rong rai va d~ dang nhat la cac chat co hoat tfnh diroc ly diroc thay trong nhieu phan khac nhau cua cay co.

Cdc Glycozide tra tim co tit cdc cay : co trong cay dirong dia hoang (Digitalis purpurea) va mot so cay khac,

Pyrrolizidine : co trong cay voi voi (Heliotropium) va mot so cay khac,

Cac alkloid Pyrrolizidine co trong cac cay nay co thtS gily sot, non, dau bung, va cuoi cung yang da, cd chirong, dan hieu cua benh ly gan tile nghen tinh mach,

* Cac cay nay diroc dung dtS che che, gia vi, d6 uong co ga va cac thuoc dan gian .

Cay dOu thien lj:(Lathyrus sativus)

- DOu nay diroc bao quan 0 cac vung co nan doi 0 chau Phi, chau A.

- BitSu hien : Liet dan 2 chi diroi, liet ctrng, liet nay co thtS kfch thich dan tci xo cot

ben teo co,

- Doc chat : NgU'O'i ta cho la : ~ - amino proprionitrile.

Cay dOu rang ngua (Vicia faba)

Hoat chat ; Hat chua cac dan chat pyrimidine oxy hoa, khi nguiri an vao dong thai neu co thieu men G6PD se gily thieu rnau tan mau, khong phai tilt ca nhfmg ngU'O'i an deu bi,

cac mroc Dia Trung Hai, viec phd bien Ioai d Ou nay nhir mot Ioai thuc pham va su thirong g~p cua thieu men G6 PD co xu huong dong thoi xily ra.

BitSu hien: Sau an vai ngay, thieu rnau va sot ndi b Ot sau do tv giarn va het trong vai tuan sau, nr vong 5%.

Dieu tri : Chu yeu dieu tri trieu cluing, ngiroi ta da d~ xuat viec lily hong cau tdn tlnrong ra bang phirong phap huyet thanh.

Cdc Glycozide co Cyanua.

Cac cay chua Hydro cyanua: San, Cac cay d Ou, bau bi, dira chuot, mang, qua Ake, chuoi chin, nhan hat qua mo.

Trieu tnrng ngo doc:

o Roi loan tieu hoa: Dau bung, budn non, ia chay,

10

Bdi giang Chong doc

o Than kinh: Chong mat, nlnrc dau, Nang hon co thtS co ctrng, co gi Ot, dong tit gian sau do hon me.

o Ho hap: Ngat tho, xanh tim, suy ho hap cap, gay tit vong nhanh. - Xet nghiern: Mau tinh mach do tum.

Chat non va mroc titSu co acid cyanhydric.

- Xit tri:

o Gay non, rita da day bang dung dich thuoc tim 2/1000.

o Neu nang d~t ong noi khi quan, tho may, tang thong khi, Fi02=1.

o Dung Hydroxocobalamin tinh mach, Glucose 20%.

o Chong soc.

Nam

Co hang nghin Ioai narn, chi dum 5% cac Ioai Ia doc, Song phan biet giira narn doc va khong doc rat kho khan.

* Nam muc (Copriruss atramentarius) - Doc to : coprine

- Tac dung giong Difulfiram, khi an co uong nrou, sau 30 plnit co nhip tim nhanh,

boc hoa, buon non.

* N am phien dam chuong (P aneolus campanuletus) - Doc to : Psylocibin

- Tac dung : Sau an 30 - 60 plnit, non nhieu, dau quan bung, ao giac, tang hoat

dong, Co thtS dung nap diroc Psylocibin nen thuong Ianh tinh . * Ndm mun trdng (Amanita pantherina)

- Doc to : Axit Ibotenic va cac dan xuat isoxazole

- Tac dung : 20 - 90 phiit sau an; gay Ian Ion, v Ot va, rei loan nhln,

* Nam mat troi :(A. Muscaria)

- Doc to : cac hop chat muscarine

- Tac dung : sau an 30 phiit, tang tiet dich ngoai tiet, nhip tim ch Om va cac dap irng

cholinergic khac,

* Nam dt)c xanh den: (A. phalloides).

- Doc to Amatoxins va Phallotoxins

11

Bdi giang Chong doc

- Tac dung : Ngo doc kitSu 2 pha : dau tien voi dau bung, non, ia chay xuat hien 6-712h sau khi an va tlnrong het trong 24h. Sau khi benh nhan 6n dinh 1 -2 ngay, benh tien trien voi suy gan, suy th On nang n~, nr vong cao(30 - 50% ) co thtS 19C rnau hap phu,

DQng vOt : (25, 6) Coc:

- Doc to: Bufotalin, Bufotenin, Bufotonin, co trong cac tuyen dum da, gan, tnrng,

- Trieu tnrng: Xuat hien 1-2 gia sau khi an:

o Roi loan tieu hoa: Dau bung, budn non, non.

o Tim mach: Ltic dau co huyet ap cao, nhip tim nhanh, co tM do Bufotonin.

Sau do roi loan tfnh kfch thich: ngoai tam thu, con nhip nhanh that, flutter that, rung that, Doi khi co block nhi that, nhip nut, dan den truy mach, C ac roi loan nhip co tM do Bufotalin.

o Roi loan than kinh va tam than: Bufotenin co tM gay ao giac, hoang nr ong, roi loan nhan each, lieu cao hon co thtS tic che trung tam ho hap, ngirng tho.

o T6n tlnrong thOn: Viern ong thOn cap,

- Xu tri: Thai trir chat doc, di~ u tri h6 tro va 19C rnau khi can.

Canoe

- Doc to Ia Tetradotoxin : ben virng voi nhiet, co nhieu 0 cac tang va dac biet la gan, da, tnrng, so hrong thay d6i thea mua,

- Trieu clnrng than kinh va tieu hoa xuat hien 10 -40 phiit sau an, nhung co tM chOm hon gorn di cam, te (dac biet quanh rnieng va 0 luai), chong mat, milt dieu hoa, tang tiet mroc bot, gi Ot co, non, kho nuot, dau bung, ia chay , milt tieng, liet, chu yeu co ho hap, Dong tit hie dau co sau gian milt phan xa anh sang, tut huyet ap, loan nhip tim, suy ho hap, Benh nhan van tinh tnroc khi chet, tit vong 60%.

- Chiln doan : Hoi benh, dien bien lam sang, co thtS xet nghiern doc chat voi mau ca nghi ngo,

- Dieu tri :

o Gay non, rita da day, than hoat,

o Dieu tri h6 tro: Dat ong noi khi quan, th 0 may co liet co ho hap co suy ho hap, dam bao huyet ap, nhip tim.

12

Bdi giang Chong doc

ca Scombroid

- Cac ca co rna trong thit nhir ca ngir, ca thu, doc to tfch luy dan trong thit ca do diroc giai phong dan ttl' qua trmh decacboxy hoa histidine cua vi khuan (chu yeu do Proteus morganii), doc to co lien quan tci Histamin, ben viing voi nhiet,

- Trieu clnrng : 15 - 45 plnit sau an, xuat hien cac trieu cluing dac tnrng cua phan trng Histamin boc hoa, dau dau, chong mat, dau bung, non, buon non, ia chay, Cac trieu clnrng het sau vai giO' va khong co tit vong.

- Dieu tri : Thuoc khang Histamin

N so dt)c ciguatera

- Chu yeu do an phai cac ca nhir ca nhong, ca chi vang va cac Ioai ca 0 tang day bien khac, Khi cac Ioai ca to hon an ca nho hon chua mot Ioai tao Lyngbia majusula thi Ioai tao nay diroc tfch lily dan trong thit ca va giai phong doc to khi ngU'O'i an phai,

- Ban chat la doc to than kinh, khong d~ bi bat hoat b oi nong hay Ianh, gily di cam (dac biet rnoi, IU'ai va hong), ngua, cac trieu chtrng tieu hoa trong do co non, ia chay, Co thtS co benh Iy nao, suy ho hap va soc.

- Cac trieu cluing thirong bat dilu 12h - 30h sau an, thirong la trieu cluing tieu hoa tnroc tien,

- Chiln doan : dua vao lam sang va hoan canh, co thtS xet nghiern nhanh doc to trong mau ca bang 1 test don gian,

- Dieu tri : Dieu tri h6 tro

N so dt)c trai, so :

- Do an cac dong vOt than mem co 2 manh vo, cac dong v Ot nay co chua tao Gonyanlax.

- Trieu cluing : Te 0 mat, rnieng, te cong sau do te 0 tay va chan, cac bieu hien ra sau an 30 plnit, kho nuot, kho noi, chong mat, dau dau vimg tran, tit vong (do suy ho hap), co thtS kern thea nhiern khuan do cac vi khuan co trong so, trai va di trng, - Chiln doan :

o Khi thay benh nhan da an thit hoac uong mroc cua trai, so tnroc kh i bi benh,

o Co tM xet nghiern doc chat bang quang phd hoac thir nghiern sinh h9C tren chu(>t.

13

Bdi giang Chong doc

- Dieu tri :

o Rita da day, than hoat

o Dieu tri h6 tro Cac amin hoat mach :

- Cac chat : Diamine Histamine va mot so monamine (tyramine, phenylethyl amine va Serotonin)

- Cac tlnrc pham chua cac chat nay: * Ham IUQ'ng tuong ddi cao

+ Pho mat (pho mat Y, pho mat xanh va pho mat Rockopho) + Rau (rau bina, ca tim)

+ Ruou vang do (vang kianti, Bourgogne) + Ca : Ca ngir, ca thu

+ Men nrou, bia.

* Ham IUQ'ng tuong ddi thdp - Ca chua

- Gan ga, bia, xiic xich

- Bap cai muoi

- Cac tlnrc an nay lam tang Histamin nieu sau bira an.

- Co thtrc an tuy co ham hrong Histamin thap nhung co ham hrong dang ktS Histidine, khi

vao co thtS diroc chuyen thanh Histamin.

- Cac tlnrc an co thtS co chua nhfmg chat co kha nang kich dong te bao mast giai phong Histamin : tnrng, dau tay, socol a, ca chua, cac qua ho cam, biroi. - Viec dung dong thoi mot so thuoc uc che chuyen hoa bmh thirong cua Histamin (nhu Izoniazid) gop phan vao van d~ nay.

- Cac thuc pham chua Monoamine : * Tyramine:

- Pho mat, men bia, vang do, ca trfch ngam darn, gan g a.

- So hrong it han co trong qua bo, chuoi, qua m On do, ca chua va ca tim.

* Phenylethylamine :

- Co trong pho mat, vang do. * Senotonin :

14

Bdi giang Chong doc

- Co trong chuoi, dtra, qua chuoi hi, qua bo, qua m On, ca chua va mot so dong v Ot

than mem (dac biet la bach tuoc) - Cac trieu clnrng :

Roi loan V! giac, phong rop niern mac rnieng, boc hoa, dau dau, co that phe quan, ha huyet ap, non, buon non, dau quan bung, ia chay, Cac trieu chirng tlnrong giam di sau vai gio; 0 cac benh nhan nhay cam, co thtS dung cac chat khang HI, H2 d tS phong hoac lam diu di,

- Cac Monoamin hoat mach bi MAO chuyen hoa, he men nay t Op trung 0 ruot, Cac thuoc uc che chuyen hoa nay lam tang tac dung cua monoamin. Cac thuoc, :

Iso carboxazid (marplan) Phenelzine (Nardil)

Tranyl cypromine (Parnate)

La cac thuoc chong tram cam tnroc day diroc dung.

+ Cac benh nhan dung thuoc nay can tranh cac thtrc an co monoamine

+ Cac benh nhan co nguy co la benh nhan Migraine va ngtra man tfnh, chu yeu trieu cluing se Ia dap irng v~ co that .

NDTP do hoa chat trong thuc phdm

Cac chat phu gia: (20, 25 ) Chat bdo qudn :

2 nhorn diroc dung rong rai khap the gioi Ia Benzoate va paraben. * Ben zoate:

- V u ditSn: Pham vi chong vi sinh v Ot, narn rong rai, rift it hoac khong doc khi dung dung ham hrong, re tien,

- Tac dung co hai hiern g~p va hau het 0 ngiroi hen va ngtra man tinh. Co thtS do cau tnic nrong tv cua Benzoate voi aspirin.

*Paraben:

- Methyl paraben, propyl paraben, heptyl parabens.

- Duoc dung chu yeu trong d6 my pham, cac che pham thuoc diroc dung tai cho, co

thtS diroc dira vao cac thuc pham mrong, cac rau qua diroc XU Iy, mO', dau va bot ng9t.

- Cac tac dung co hai : hau nhir chi co viern da tiep xiic.

15

Bdi giang Chong doc

*Sulfite:

- Dioxide sulfua, Sulfite natri, Bisulfite natri va kali, Metabisulfite natri va kali, day la cac chat bao quan va chong oxy hoa, da bi earn tren rau qua.

- Doc tinh: Da co tit vong do sulfite, co tM kich thich con hen, milt y thtrc, soc phan ve, ia chay, budn non va non.

*Natrinitrit :

- Dung trong thit che bien

- Tac dung : gian mach, da diroc phat hien la nguyen nhan cua "Hotdog headache)

Cac chat dieD V!

Trir muoi an, chat thirong g~p nhat la Glutamat natri.

- Tac dung : La mot chat kfch thich, bang viec khir eire, tac dung len cac receptor V! giac, mot tac dung co lien quan t61 tac dung co hai len cac yeu to than kinh ngoar vi 0 noi khac ngoai rnieng hroi,

- Tac dung phu thuoc lieu va phu thuoc ca tM.

- Hoi chirng "Nha hang Tau" :

o Duoc rna ta Ian dau tien nam 1968 0 My.

o 30% nguO'i My tnrong thanh bi anh huong, tre em d~ bi phan trng hon,

o BitSu hien : Trong vong 1 gio tro lai sau an; dau dau, lang lang, cam giac nong bong quanh dau va cd, that nguc, non, va md hoi, tv het trong 1 giO' hoac Iau hon, An nhieu co thtS lam kh oi phat con hen 0 mot so ngiroi,

Cac chat ngot t6ng hQP:

* Aspartame va saccharin:

Cac chat nay co thtS gay nhieu roi loan: Dau dau ( trong do co hoi cluing Migraine), chong mat, co giOt, tram cam, buon non, non, va dau quan bung, Co thtS lien quan tci tmh trang hoat dong qua rmrc cua tre em. PhV nit co thai can tranh dung cac bot ngot nay mac du chua cluing minh diroc tac dung gay ung thu,

Cac chat mau t6ng hQP:

Cac chat rnau co thtS thay 0 nhieu thuc pharn, tre em va ngiroi 16'n co tM tiep xiic voi cac chat gay ung tlnr nhir chat rnau do so 8,9,19, va 37, hoac chat rnau da cam so 17.

16

Bdi giang Chong doc

Cac chat 0 nhiem: ( 20, 23 )

Thudc tric sdu:

- Rau va qua co thtS chua tren b~ mat dir hrong hoa chat trir situ va _di~t co nguy hiem, Ham hrong cac thuoc trir situ trong rau qua uroi cao tci rmrc bao dong trong khi cac tlnrc pham dong hop co ham hrong thap hon nhieu,

- Hon 40 % cac thuoc trir situ la pho spho hiiu co, trong do co Malathion, Parathion, Daizanon, Dursban ngoai tac dung uc che Cholinesterase con gity bat thirong cho bao thai va gity ung thu,

Chat doc mau da cam: H6n hop cua hai thuoc trir co 2,4,5 - T va 2,4- D co thtS gity ung thir, NgU'O-i ta ciing da thay tac dung gity u nao tren chuot cua cac chat nay.

Cdc Dioxin: Co 75 chat doc trong nhorn Dioxin, la cac CIo hiiu co co doc tfnh cao va ton tai trong rnoi tnrong nhieu nam, NgU'O-i ta da thay trong cac dong v Ot, city co va ca, dac biet rong cac vOt nuoi, city trong, thOrn chi trong sua me, CO' che gity doc: Dioxin gan voi AND cua te bao lam thay d6i viec d9C rna, chi mot thay d6i nho co thtS anh lnr ong Ion len do-i song te bao va cac the he te bao sau.

Cdc dong vi ph6ng xa: Bang viec 6 nhiern dat, mroc, tlnrc v Ot, dong vOt roi gity benh cho con ngiroi. Co nhieu chat dong V! phong xa trong do phai ktS den mot chat nguy hiem nhat trong 10 phan irng hat nhan la Plutonium voi thoi gian ban huy la 24.000 nam,

Kim loai ruing:

- ChI xuat hien trong thuc pham co thtS qua rau qua va tron g sup diroc nau voi xirong hoac cac nguon b6 sung canxi diroc che tit xirong, hoac qua mroc ngam va mroc voi, Doc tinh cua chi co nhieu trong do co gity ch Om phat trien thtS chat va tinh than,

- Thuy ngan: Ca 0 tang day bien giln noi 6 nhiern co thtS bi nhiern thuy nga n. Nhirng ngU'o-i an phai tlnrc an nay co thtS bi mii, liet, va ch Om phat tritSn, dac biet 0 tre em

17

Bdi giang Chong doc

N gQ d o c r uuu

(Bai giang cho nhan vien y te co sa)

BSVfiThe'H6'ng

BS D(ing Quae Tuan

B¢ man H6'i suc cap cuu Truijng Dc;ti h9C Y khoa Ha noi

1. D~i cirong

1.1. Ruou wing (Ethanol) Ia chat co tac dung uc che than kinh trung irong, sau k hi uong nong d¢ nrou tang dan trong rnau. Tac dong cua nrou thay d6i my tirng ngiroi va hrong nrou da uong, Khi uong nhieu nrou, bitSu hien say TI!O' tnroc het la tmh trang kfch thich, roi loan hanh vi, tac phong, sau do benh nhan di vao tmh trang uc che, Ii bl, Khi nong d¢ nrou trong rnau cao qua benh nhan se bi ngo doc nrou,

1.2. Ruou methanol diroc sit dung trong cong nghiep, co thtS gily cac t6n tlnrong nang tharn chi tit vong.

1.3. M¢t so Ioai nrou hru hanh tren thi tnrong can co tM chua nhieu chat gily nguy hi tSm khac nhir aldehyt, tharn chi can co thuoc sau,

2. Dau hieu lam sang

Bai nay chi mo ta ngo doc nrou thuc sir, la ngo doc alcool ethylic (ethanol). + Hon me: goi hoi khong dap trng, hoac dap trng khi goi rdi lai nam yen Giai doan som : tha san, mat do trot, mach dap manh

Giai doan muon : tho' nhanh nong, mat kho, mach nhanh yeu, huyet ap tut,

dong tit gian,

+ Non. Co thtS sac chat non vao phdi gily ra suy ho hap : kho tho, tho' nhanh, tim rnoi, tha kho khe, 19C S9C.

+ Ha dirong rnau : tlnrong kho phat hien tren lam sang, VI cac dau hieu cua ha dirong rnau bi hon me do nrou che lap, Neu nang co thtS co co giat,

+ Ha than nhiet : co thtS anh hmrng den than kinh trung irong, dac biet Ia v~ rnua

+ Can clni y la mot ngU'O'i say nrou co tM bi nga, va co cac t6n tlnrong do riga (chan thirong, sac mroc, sac bun, ... )

3. XiI tri

3.1. Say ruou

1

Sang's Chong doc

Chua phai la ngo doc nrou : benh nhan khong co hon me, goi van biet, tra Ioi

diroc, khong co roi loan nhip tho,

+ Theo doi that tot, neu di vao hon me phai dira di benh vien ngay. + Cho nam nghieng an toan dtS tranh trao nguoc chat non vao phdi. + u am, tranh ch6 co gio Ilia.

+ Cho uong mroc duong neu con tinh.

+ Neu con tinh, di lai diroc : khong cho dieu khien cac plnrong tien giao thong, khong cho di mot minh, ThO' nhanh, manh, noi nhieu co tM lam cho tinh nrou nhanh hon,

3.2. Ngi) dt)c ruou

Khi nghi ngo, hoac xac dinh mot nguO'i la ngo doc nrou can phai chuyen that som den benh vien,

V an chuyen : phai cho benh nhan nam nr the nghieng an toan dtS tranh benh nhan

hit phai chat non vao phdi gily suy ho hap nang, Neu co thtS diroc :

- Truyen cho benh nhan dung dich dirong Glucoza.

- Tiern bap long vitamin Bl.

Viec dieu tri benh nhan ngo doc nrou & benh vien bao gorn : cho tho' may, truyen dung dich dirong U'U tnrong, bu mroc va dien g iai, rita da day va cho than hoat, Neu benh vien khong thuc hien diroc cac ky thuat tren thi phai so ciru rdi chuyen ngay den tuyen chuyen khoa.

2

Bdi giang Chong doc

NgQ dQc cap quinine

Quinine la mot alkaloid cua vo cay canh -ki-na. No la dong phan ta tuyen cua quinidine. Ngay nay, Quinine chi diroc dung dtS dieu tri sot ret khi ky sinh trung khang vof cac thuoc khac,

1. Chiln doan:

1.1. Chan do lin dirong tinh; a. Lam sang:

Hoi bent: : dang dieu tri sot ret bang quinine, hoac co y muon pha thai, hoac co If do dtS tv tit, co vo thuoc hoac thuoc roi vai,

Trieu chung: u tai, hoa milt, chong mat, non mira, roi loan y thirc, giam hoac milt thi hrc, diec mot phan hoac hoan toan, nang thi d a tim, Ianh, ha than nhiet, dai ra huyet sac to, loan nhip tim, tut huyet ap, hon me, chet do ngirng tho' sau vai gia den vai ngay,

b. Can lam sang:

Xet nghiern tim quinine trong mroc tieu dong vai tro quyet dinh

Dien tim: QT keo dai, T det hoac dao ngiroc, QR S dan rong, bloc nhi thai cap 1, khoang PR keo dai,

1.2.Ch:ln doan phan biet:

V 6'i ngo doc quinidine hoac chloroquine: trieu cluing tim mach nang hon, chan doan bang xet nghiern doc chat,

2. Nguyen nhan:

Ngo doc thirong xay ra do qua lieu dieu tri sot ret, do tv t it hoac do uong lieu cao voi muc dfch pha thai.

3.Tien lUQ11g:

Lieu dieu tri va lieu doc cua Quinine rilt gan nhau( lieu dieu tri: 1800 mg chia lam 3 Ian trong khi lieu gay tit vong la 1800 mg den 8g). Mat khac, ngay voi lieu dieu tri ciing co tM gay ra nhfmg rei loan dan truyen co tim. VI vay trong qua trinh dieu tri sot ret bang quinine ciln thea doi dien tim dtS phat hien kip thai cac roi loan dien tim.

Du phong: quan ly thuoc; giai quyet cac nguyen nhan dan den tv tit.

1

Bdi giang Chong doc

4. Dieu tri

1. Tuyen co sO': Gay non neu benh nhan chua non, chua roi loan y thirc, Than hoat: 19/1kg can nang uong kern sorbitol2g/kg can nang (neu co).

Truyen dich: Glucose 5%, Natri clorua 0,9%. Chuyen benh nhan den khoa cap ciru gan nhat,

2. Tuyen Huyen:

- 6n dinh cac clnrc nang song: thea doi cac dau hieu songjmach, huyet ap, ho hap, dien tim), tho' oxy, truyen dich glucose 5% va natri clorua 0,9%, natri bicarbonate 1,4%.

- neu co suy ho hap: thong khi nhan tao bang tho' may voi phirong tlnrc CMV, Vt 10 ml/ kg, tan so: 16-20lan/phut,

- Neu tut huyet ap: Dopamin 200mg long, pha vao 500 ml glucose 5% truyen tinh mach 15 giot/ phiitr' khoang 8 flg/kg/phut), dieu chinh tee d(> truyen dtS duy trt huyet ap mong muon ( huyet ap tarn thu > 90 mmHg )

- Theo doi dien tim, phat hien va xir trf loan nhip, Truyen kiem dtS dat diroc pH mau ttl' 7,45 den 7,50 co thtS ngan ngira roi loan dan truyen nang len va phong diroc cac loan nhip gily tit vong. Khong sit dung cac thuoc chong loan nhip nhorn 1A va 1C ...

- H<;I-n che hap thu doc chat: gily non neu khong roi loan y thtrc, rita da day 2 - 3lit nuO'c(den khi mroc trong).

Than hoat 60g kern sorbitol 120 g hoa trong 100mi mroc, uong chia lam 3 Ian each nhau 1-2 gio 1 Ian.

- Tang dao thai doc chat: Truyen nhieu d!ch(4 -Sl/ngay) glucose 5% va natri clorua 0,9%, lasix 20mg tiern tinh mach , duy tri Iuong mnrc titSu 4 -5 Ift/ngay, Neu dai it hoac vo nieu can nhac chi dinh than nhan tao hoac 19C rnang bung,

-Dieu tri h6 tro: chii y dieu chinh can bang mnrc dien giai, dinh dirong, cham soc tOM dien,

Chuyen tuyen tinh neu suy h o hap rna khong co may thO', suy than rna khong co than nhan tao, hoac loan nhip plnrc tap rna khong co may tao nhip,

3. Tuyen tinh:

Dieu tri nhir tuyen huyen, neu suy ho hap cho tho' may, chay than nhan tao neu co chi dinh va d~t may tao nhip neu co loan nhip plnr c tap

2

Bai giang Chong il6c

Ngt) doc cap phospho hiru co

I. D~! cunng

Thuoc trir san phospho hiru co (PPHC) la mot trong hai loai thuoc trir san thuoc nhom

uc che cholinesterse dang diroc sir dung rong rai trong nang nghiep. Ole hoa chat trir san nhom clo hiru co doc han nhir DDT da bi cam hoac han che sir dung. Do bi thuy phan nhanh thanh cac hQ'P chat vo hai va khong tich tv chat doc lau dai trong moi twang nen PPHC ngay rang diroc sir dung rong rai trong nang nghiepttrir sau) cung nhir trong nhar' trir gian.muoi ... ).Cung VI sir dung rong rai nhir vay nen ng<? doc cap phospho hiru co (NDC PPHC) la mot benh canh cap ciru rat thirong g~p, chiem khoang 80% twang hQ'P ng¢ doc cap thuoc trir san phai vao vien.

Phospho hfru CO' (Organophosphate - O.P) la cac hQ'P chat bao gam carbon va goc cua axit phosphoric. Chat dau tien diroc sir dung d~ diet can trung la Tetraetyl pyrophosphate (TEPP). Ngay nay co hang ngan hQ'P chat phospho hiru co ra doi nhung van tren co sa mot cong tlnrc hoa h9C chung:

C2H50 hoac CH30 P C2H50 hoac CH30

o (Iioac S)

o

R

II. Chuyen hoa:

Cac hQ'P chat phospho hiru co duoc hap thu rat tot qua duong da va niem mac, duong

tieu hoa va duong ho hap. Nguyen nhan nhiem doc co th~ la s ir dung khong dung trong nang nghiep, tai nan, nr nr, va hiem khi la bi dau doc. Tu nr thirong dan den nhung nhiem doc nang nhat, sau do la tai nan trong nang nghiep va cong nghiep, roi den tre em nhiem doc tai nha, Co th~ g~p ng¢ doc hang Ioat do thuc pham nhiem doc.Cac dan hieu va trieu cluing nhiem doc rat thay d6i tuy thea duong nhiem va rmrc d¢ nhiem doc; tuy nhien khoang thai gian tit hie bi nhiem den hie xlly ra trieu chung thirong dum 12 gio. Nhiem doc khi dan den trieu chung xlly ra trong vong vai giay. Nhung cung can biet rang mot so hoa chat moi nhir diclofenthion va fenthion hoa tan trong rna nhieu han nen co th~ gay ra wang cholinecgic muon (sau vai ngay) va trieu chung co th~ ton tai vai tuan den hang thang. Hien nrong nay co th~ la do thuoc trir san hie dau diroc giit lai trong cac rna rna va sau do diroc tai phan bo vao man. Ngoai ra, ng<? doc duong uong neu khong duoc t1iy rna duong tieu hoa tot va khong diroc dung

1

Bai giang Chong il6c

than hoat thi thuoc trir san u dong trong ruot se tiep tuc duoc hap thu vao mau trong nhung ngay sau va keo dai qua trinh benh Iy.

Phospho hiru co diroc chuyen hoa va klnr doc 0 gan boi cac enzyme mono - oxygenase.Tuy nhien, mot so phospho hiru co nhir parathion va malathion khi chuyen thanh oxon Iai co doc tinh manh han chat me nhieu Ian.

III. Co che tac dung va dQC tinh

Acetylcholin la chat trung gian hoa h9C tai cac synapes than kinh tnroc hach cua M than kinh nr dong (bao gam ca giao cam va pho giao cam) , cung nhir tai cac synapes hau hach cua than kinh pho giao cam va day than kinh giao cam chi ph oi cac tuyen rna hoi, 0 cac cue t~n cung cua cac day than kinh van dong chi phoi cac co van, 0 cac diem nol te bao than kinh trong nao. Sau khi tac dong len cac receptor dac hieu 0 mang te bao han synap, Acety1cholin se bi thuy phan boi acety1cholinesterse( AChE).

Phospho hfru co khi vao co th~ se gan vai AChE dan den phosphoryl hoa va lam mat hoat tinh cua ChE. Hau qua la sir tich tv Acety1cholin tai cac synap than kinh.Sir tich tv nay gay len sir kich thfch lien tuc qua rmrc cac receptor 0 hau synaprhic dau),sau do la giai doan kiet synap 0 ca M than kinh trung irong va than kinh ngoai bien. Str kich thich dan toi hoi chung cuong cholin cap va sir kiet synap dan den nhung thay d6i bieu hien ra ngoai thanh cac trieu chung benh canh NDC PPHC. Co hai loai receptor chiu tac dong cua acety1cholin: muscarin( 0 hau hach pho giao camjva nicotin ( 0 hach than kinh thuc v~t va 0 cac diem nol than kinh co van -cac ban van dong). VI vay cac trieu chung lam sang rat phirc tap va t~p trung thanh cac hoi chung benh ly khac nhau.

DQc tinh : lieu gay chet cho nguoi Ian khac nhau tuy hQ'P chat : 25g dol voi diadinon,60g voi malathion trong khi do chi tit 10 den 300mg voi parathion. LD50 cua cac OP eire doc thay d6i tit 1,3 mg/kg(Tebupirimfos), 7mg/kg(Phosphamidon va chlomephos) den 15mg voi Fenamiphos, 13mg/kg voi Parathion. Mot so loai PPHC co doc tinh cao thirong g~p 0 Viet nam la: Methamidophos(Monitor) - LD50 = 30 mg/kg, Methidathion - LD50 = 25 mg/kg, Monocrotophos - LD50 = 14mg/kg ...

IV. Trleu clnrng ngQ dQc dip:

Cac trieu chung cua ng¢ doc phospho hiru co tit nhe den nang bao gam mat ngu va rol

loan dinh huang, dau dan, chong mat nhin rna, yeu co, mat dong van, may co, run co,

2

Bai giang Chong il6c

liet co, ia chay, dau bung, chen nguc, tho rit va ho co dam. Co giat, rol loan y thirc, ia dai khong nr chu, han me san va tTVY mach la cac bieu hien cua tinh trang nhiem doc nang. Cac dan hieu va trieu chung cua ng¢ doc phospho hiru co se day du va de hieu de nho han khi xep chiing vao cac hoi chimg:

HQi clnrng cirong cholin dip:

Bao gam trong 3 hoi cluing thanh phan: hoi chung muscarin, hoi chung nicotin va hoi chung than kinh trung irong.

l.H()i chung Muscarin: do tac dong cua acety1cholin kich thich hau hach pho giao cam, tac dung chu yeu len cac co tron gay co that ruot, phe quan, va co tron bang quang, co dong nr va giam phan xa dong nr /anh sang, kich thich cac tuyen ngoai tiet: tang tier mroc bot, dich ruot, rna hoi, mroc mat, dich phe quan ... Benh nhan bi nrc nguc, cam giac chen nguc, kho tho, dau bung, buon non, non, ia chay, ia dai khong nr chu. Kham thay tinh trang suy ho hap, long nguc cang kern di dong, phdi nghe ri rao phe nang giam, co nhieu ran lim, doi khi co ran rit. Tren tim mach co th~ thay nhip cham xoang, giam dan truyen nhi that, rol loan nhip that,

2.H()i chung Nicotin: do sir tich tv cua acety1cholin a cac ban van dong dan den rol loan sir klnr eire cua cac co van gay giat co, may co, co cung co, Iiet co bao gam ca cac co ho hap; kfch thich M than kinh giao cam gay ra: da Ianh, xanh tai (do co mach) , mach nhanh, huyet ap tang, va rna hoi, dan dong nr,

3.H()i chung than kinh trung uong :

- Lo lang, bon chon, rol loan y thirc, noi kho, that dieu, nhuoc co toan than, hon me mat cac phan xa.

- Ngo doc nang: uc che trung tam ho hapva tuan hoan dan den suy ho hap ,tTVY mach, co giat, hon me san.

Hoi chung Muscarin voi bieu hien chinh la co that va tang tiet phe quan la hoi chung xay ra sam nhat va a tat ca benh nhan NDC PPHC. Cac hoi chung Nicotintvci liet co ) va hoi chung TKTW thuong chi g~p trong cac twang hop nhiem doc nang.

HQi clnrng trung gian :

La hoi cluing liet co type II do tac gia nguoi Srilanca d~t ten nam 1987 voi cac d~c diem sau.Bat dau tit 24-96 h sau nhiem doc, khi cac trieu chung wang cholin da duoc giai quyet, H/c bao gam: liet cac co goc chi, co gap cd, cac co ho hap va cac co do cac

3

Bai giang Chong il6c

day than kinh SQ chi phoi, liet mem, giam phan xa gan xirong, Liet khong ddp ung voi die'u tri atropin va PAM, doi hoi thong khi nhan tao khi co suy ho hap. HQi chung nay co th~ chinh la hau qua cua sir kich thich qua rmrc keo dai cac receptor nicotin dan den pha II kietcua h/c nicotin trong khi dieu tri tot h/c muscarin bang atropin.

HQi clnrng benh Iy than kinh ngoai vi muon :

Xay ra 8-14 ngay hay muon hon sau NDC PPHC. Benh canh bao gam: yeu co, liet co, chong met moi, chuot nit, kern voi cac rol loan cam giac ki ~u te bi kien bo , thuong bat dau 0 dau chi, co th~ tien trien den liet toan than va cac co ho hap gay suy ho hap va nr vong. Benh thoai trien sau vai thang den vai nam, teo co nhieu, phuc hoi cham va khong hoan toano Co che sinh benh la do chet cac soi tr VC than kinh. HQi chung nay rat hiem xay ra.

Tien tri~n:

Trong NDC PPHC, hoi chung cuong cholin xay ra rat s6m nhin chung thuong la tnroc 12 gio sau nhiem doc, co th~ vai giay sau nhiem duong ho hap, vai plnit den vai gio sau nhiem doc duong tieu hoa; nhi em doc duong da rmrc dQ nhe co th~ den muon hon. Trong hoi chung cuong cholin thi hoi cluing muscarin thuong den s6m nhat va la hoi chung trung thanh nhat, nghia la Iuon Iuon xay ra. HQi chung nicotin va hoi chung than kinh trung irong thirong chi xay ra khi nhiem dQC trung binh hoac nang. Tir vong thirong xay ra s6m trong ngay dau tien nhung cung co th~ xay ra trong nhtrng ngay sau. Khoang 50% nr vong co nguyen nhan tnrc tiep la suy ho hap. Co nhieu nguyen nhan dan den suy ho hap: tang tiet va co that phe quan, liet co ho hap, tic che trung tam ho hap, boi nhiem phoi trong do nguyen nhan co that va tang tiet phe quan chiem hang dau nhung lai co th~ khac phuc duoc nhanh chong voi lieu atropin thich hop.

HQi chung cuong cholin co th~ ton tai hang tuan hoac lau hon . V oi dieu tri lieu PAM thich hop hoi chung nay se nit ngan thai gian ton tai trong yang vai ngay(l -4 ngay).

HQi chung trung gian xay ra vao ngay tlnr 2 -6 sau nhiem doc, khong dap irng voi PAM va atropin, dieu tri can thiet duy nhat la tho may neu liet co dan den suy ho hap. Thirong khong co nr vong neu duoc bao dam ho hap va hoi phuc hoan toan sau 1 -2 tuan.

Xet nghlem:

4

Bai giang Chong il6c

- TIm dQc chat trong mroc tieu, trong dich da day, trong mau bang phuong phap sac ky lap mong va sac ky khi.

- XN enzymcholinesteraza hang ngay M thea d6i tien trien cua benh, phan Ioai dQ nang lam can cir dieu chinh lieu PAM dung cho benh nhan. C6 hai loai enzym cholinesterase: acetyl cholinesterase (cholinesterase hong cdu) , Butyryl cholinesterase (cholinesterase huylt tuang), Acetyl cholinesterase c6 trong hong can, t6 clnrc than kinh, phdi, Iach va chat xam cua nao; duoc nhieu tac gia cho rang phan anh trung thuc rmrc dQ ng¢ doc han; nhung toe dQ phuc hdi cham (2-3 thang); ky thuat xet nghiem cung c6 nhung kh6 khan nhat dinh lam cho kh6 ap dung lam sang.

o Cholinesterase huylt tuong (butyro choliesterase) c6 trong huyet nrong, do gan san xuat, nhung cung tim thay a t6 clnrc than kinh, tVY, tim va chat trang cua nao. Thay d6i hang ngay 100, va bi anh huang boi benh gan, viem man, suy dinh dirong, mocphin, codein, succiny1cholin va phan img qua man. Giam nhanh trong nhiem dQC cap va phuc hoi khoang 10% -20% mol ngay khi benh nhan duoc dieu tri Pralidoxime (PAM) day duo Dac diem nay cung voi ky thuat xet nghiem dan gian han cholinesterase hong cau n en duoc dung d~ thea d6i tien trien trong qua trinh dieu tri va la co sa d~ dieu chinh lieu PAM.

Di~n tim: ghi dien tim va thea doi tren monitor d~ phat hien rol loan nhip.

Cac xet nghiem khac : cong tlnrc mau - ure - dien giai mau Transaminase mau, Amylase mau, protein nieu te bao nieu.

chan doan

* Chan doan xac dinh ngQ dQc dip PPHC :

- Benh sir tiep xiic thuoc trir san trong vong 12 gio tnroc khi vao vien

- HQi chung cuong cholin cap( + )

- Xet nghiem ChE .giam <50% gia tri binh thirong (gia tri tnroc nhiem),

- thirc te diroc thay bang gia tri tol thieu cua hang so sinh h9C

- Xet nghiem dQC chat mroc ti~u hoac trong mau, dich da day (+)

Chan doan rmrc dQ nang nhe theo cac hQi clnrng benh ly lam sang :

- NDC PPHC nhe : Khi chi c6 h/c Muscarin ( M )

- NDC PPHC trung binh : Khi c6 h/c M+h/c Nicotin ( N )

ho~cM+TKTW

5

Bai giang Chong il6c

- NDC PPHC nang

: Khi co h/c Mj-h/c N+rai loan y tlnrc

- NDC PPHC nguy kich : Khi co 3 h k: tren cong voi suy ho hap cap

(Pa02 < 60 mmHg PaC02 > 40mmHg) va I hoac truy mach.

Chan doan rmrc dQ nang nhe theo gia tri nong dQ ChE huyet nrong :

NDC PPHC nang khi nang dQ ChE < 10% gia tri binh thuong, trung binh khi ChE = 10 - 20%, nhe khi ChE = 20 -50% gia tri binh thuong. Tuy nhien VI thuong khong co diroc gia tri binh thirong nen co th~ sir dung gia tri binh thirong tol thieu cua hang so sinh h9C.

dieu tri :

1. Cap cuu:

Neu benh nhan den s6m, chua co trieu chimg: Uu tien cac bien phap chong doc : Rira da day, tam nra, gQi dau ... , P

Neu den muon, da co trieu chung ng¢ doc hoac bien chimg: Uu tien hang dau la sir dung atropin (xem phan sir dung atropinjva cac bien phap hdi sue ho hap, tuan hoanrxem phan hoi sire).

2. Hoi sue:

-Htii sta: h6 http la quan trong hang dau va phai song song voi viec dung atro pin, VI nguyen nhan chinh gay nr vong la suy ho hap. Tuy tinh trang suy ho hap rna ap dung cac bien phap hoi sue ho hap. Tai thieu nhat cung phai cho benh nhan tho oxy qua sonde miii. Neu can thi d~t noi khi quan d~ hut dam va bop bong hoac tho may d~ bao dam thong khi.

-Htii sta: tudn hoan: - truyen dich bao dam khoi hrong tuan hoan: benh nhan ng¢ doc PPHC de bi mat mroc do non, ia chay, khong duoc an uong trong qua trinh dieu tri ... Ngo doc atropin cung gay nang them tinh trang mat mroc. Neu co tut huyet ap t hi nen dat catheter tinh mach trung tam d~ truyen dich thea ap hrc tinh mach trung tam. Neu da truyen du dich rna van tut huyet ap thi moi cho dopamin 5 -10 Mg/kg/phut.

-Cac bien phap hoi sue tong hQP: trong do can clni y toi dinh duong cho benh nhan. Can bao dam nang hrong 2000 Kcalo tro len. Trong 24 gio dau co th~ dinh duong dan thuan bang duong truyen tinh mach VI phai cho benh nhan uong than hoat va thuoc tay.Kleng rna va sua trong vong ltuan den 10 ngay d~ tranh tang hap thu phospho hiru co tan trong rna.

6

Bai giang Chong il6c

3.Cac bien phap chong dQc dac hieu:

3.1 Han chlhtlp thu: Rira da day la bien phap giam hap thu hieu qua khi ng¢ doc PPHC duong uong.Nuoc nra da day phai duoc pha 5 -9 g muoi an cho mol lit V oi than hoat pha vao 2-3 lit mroc nra dau tien, hrong mroc nra da day chi can khoang 10lit tro xuong. C6 th~ can nra lai Ian 2 sau khi trang thai benh nhan da 6n dinh.

Neu nhiem doc duong ho hap: nhanh chong dira benh nhan ra khoi vung c6 khi doc den noi thoang mat.Coi bo quan ao nhiem doc. Neu can c6 th~ thong kill nhan t ao d~ tang thong khi.

Nhiem doc qua da: tam nra va go! dau cho benh nhan bang xa phong. 3.2.Thuoc gidi d()c d(ic hieu :

Atropin la thuoc dol khang tac dung Muscarin va tac dung len M than kinh trung irong cua O.P. No Iam giam cac tinh trang: tang tier phe quan, mroc bot, rna hoi, lam mat dau bung, buon non, nhip cham va cam giac chen nguc, lam gian dong nr, Atropin khong c6 tac dung tren liet co va suy ho hap a benh nhan ng¢ doc nang.

Muc dich sir dung Atropin la tao ra mot tinh trang tham Atropin nham xoa h er cac trieu chung cua h/c Muscarin song chu yeu la lam tiet va het co that phe quan. Gian dong nr, mach nhanh, da hong am diroc sir dung nhir nhung yeu to tham khao cua tinh trang ngam thuoc han la muc dich dieu trio Va cung can nho rang mach nhanh, gian dong nr c6 th~ la trieu chung cua hoi chung nicotin. Duong dung Atropin thirong la tiem tinh mach cham, lieu thap c6 th~ tiem diroi da va lieu cao c6 th~ duoc truyen tinh mach lien tuc.

Lieu lUQ11g Atropin rat thay d6i tit vai chuc mg toi 20g trong ca dot di~ u tri, phu thuoc lieu O.P va dap irng cua benh nhan voi Atropin .: bat dau bang tiem 2-5 mg tinh mach nhac lai sau 5, 10 plnit mol Ian den khi dat diroc tinh trang tham Atropin. Tam dung cho den khi het dan tham thi tinh thai gian va lieu atropin da dung tit d6 suy ra lieu can thiet d~ duy tri dan tham.

Ve thai gian: tinh trang tham Atropin phai diroc duy tri cho den khi tat ca O.P da hap thu duoc chuyen hoa het thuong tit vai ngay den hang tuan. Giam lieu dan thea nguyen tlic dung lieu thap nhat d~ duy tri dir cc dan tham . Ngimg atropin khi lieu duy tri giam toi 2mg/24 gio.

Tac dung phu cua Atropin: Qua lieu Atropin gay sot, da n6ng, tho rit, kfch thich (sang nhe), dong nr gian va mat phan xa, kho chat tiet gay tlic dam.

Ngo doc Atropin dira Iai nhieu nguy hi em :

7

Bai giang Chong il6c

+ Lam benh nhan rol loan y thirc, gia liet co lam nham voi trieu chung NDC PPHC nang len.

+ Lam kho quanh dam dan den tl1c dam, xep phdi gay suy ho hap

+ Tang nhip tim, tang nhu cau oxy co tim dan den nguy co loan nhip, truy mach. + Liet ruot gay chuang bung can tro ho hap lam nang them SHH.

Tat ca lam cho tmh trang benh nhan nang len va lai duoc chan doan la NDC PPHC nang do d6 tang lieu Atropin va PAM va c6 th~ dan den loan nhip, ngirng tim do ng¢ doc Atropin .

De tranh ng¢ doc atropin c6 th~ ap dung bang diem atropin d~ thea dci phan biet giira ng¢ doc va tham atropin nhir sau:

Trieu chung Tham atropin Di~m N g¢ doc atropin Di~m
Co that va tang tiet khong nhung con 2 Dam kho dac khong hut 4
phe quan damloang duoc
Dong nr 3-4mm 1 >=5mm 2
Da hong am 1 n6ng do 2
Ml;lCh 80 - 100 1 .> 100 2
tinh than tinh binh thuong 1 kich thich hoac li bi 2
bVng mem binh thirong 0 chuang hoi, go trong 2
Cau bang quang khong 0 C6 2
, , , , , Cong tong so diem; Tham atropin: 4-6 diem; Ngo doc atropin: > 6 diem Pralidoxime la mot thuoc giai doc dac hieu thea co che trung hoa doc chat.

Tit nam 1951 Wilson (tac gia nguoi My) da cho rang cholinesteraes bi uc che c6 kha nang duoc tai hoat nho cac hop chat c6 kha nang nuc1eophile cao. Ngay nay da t6ng hop diroc mot so hop chat nhir Oximes hoac acide hydroxamine. Trong so chiing 2 - PAM (2 pyridine aldoxime methyl iodure hoac c1orua) ( dan chat cua Pralidoxime )duqc nhieu tac gia tra dung

- PAM se gl1n virng ben voi PPHC, gl1n long leo voi ChE tao thanh phirc hop b¢ 3, sau d6 enzym tach ra d~ lai phan phosphoryl-oxime se tiep tuc thuy phan d~ cho cac san pham thoai hoa cua PPHC va axit phosphoric .Nhu v¢y PAM dii khtc phosphoryl va tai hoat hod ChE.

- PAM con tac dung phong doc bang each gl1n vao va klnr doc cac phan nr PPHC con lai trong man.

8

Bai giang Chong il6c

Hau het cac tac gia d~u cho rang Pralidoxime la thuoc dac hieu can duoc sir dung trong dieu tri NDC PPHC .Tuy nhien each sir dung va lieu hrong co khac nhau:

Namba va CS 1971, Borowitz 1988, de Kort va CS 1988 : PAM co th~ hieu qua han khi duoc dung trong 24-48h dan, song no van co hieu qua 2 -6 ngay sau nhiem doc , nhat la a nhung benh nhan nhiem doc nang .

Mot so tac gia tiem TM 19 trong 10 phut, nhac lai moi 6 -8h trong 24-48h. Mot so dung lieu l-2g tiem TM hoac truyen TM voi 250ml NaCl 0.9% tr ong 30 phut, nhac lai sau lh va sau 6-12 h neu van co Iiet co va hon me .

Thompson cho rang truyen TM lien tuc 500mg/h tot hon Ia tiem TM .

Farrar 1990 da truyen duy tri 9 -19mg/kg/h ngay sau lieu dau 25 -50mg/kg pha trong dung dich NaCl 0.9%.

Thai gian dung: nhieu tac gia cho la phai dung s6m va PAM chi co hieu qua trong 24 - 48h dau sau nhiem doc.

Tuy nhien mot so khac lai cho rang can phai dung keo dai VI:

Mot so thuoc trir san (parathion) gay sir gia hoa cham (slow aging) cua ChE Khi uong mot lieu Ian thi PPHC dong trong ruot can diroc hap thu dan trong nhung ngay sau

Mot so Of' tan trong rna nhieu --> giai phong dan trong nhtrng ngay sau.

Wadia va Amin cho rang co th~ can truyen PAM trong 4 -6 ngay va toi 22 ngay dac biet la a cac twang hQ'P nhiem O.P tan nhieu trong rna nhir Fenthion.

Thomson (1987): Truyen TM 0,5g/h duy tri duoc nang d¢ > 4mg/L trong huyet nrong, la nang d¢ duoc coi la tol thieu co tac dung bao ve chong Iai doc tinh cua O.P. Nang d¢ Pralidoxime giam xuong nhanh chong <4mg/L tr ong vong 1,5-2h sau tiem TM 19 bolus.

Tai A9, tit 1996 da ap dung 1 phac do sir dung PAM lieu cao thich hQ'P trong do PAM diroc chinh lieu thea nang d¢ ChE va cac h/c lam sang. phac do da dem Iai hieu qua cao: giam ti l~ nr vong cua ng¢ doc PPHC tit 10% (1995) xuong can 2%(1999- 2000).PMc do duoc trinh bay diroi day.

Nguyen tac sir dung PAM:

- DUng rang s6m rang tot, lieu cao dong loat ngay tit dau.

- Truyen TM lien tuc.

- Lieu dung, thai gian sir dung se diroc dieu chinh thea dap img cua tirng

benh nhan: trieu chung lam sang, lieu atrropin, sir thay d6i hoat tinh ChE. - Giam lieu khi da kiem soat duoc h/c wang cholin

phac do sir dung PAM

9

Bai giang Chong il6c

* Ngay khi co chan doan xac dinh va phan loai lam sang:

+ Nang (va nguy kich ) : Tiem TM 19 trong 10 phiit rai truyen TM 0.5-lg/h cho den khi tham Atropin hoac co ket qua ChE

+ Trung binh : Tiem TM 19 trong lO plnit rdi truyen tinh mach 0,5g/h

cho den khi tham Atropin hoac co ket qua ChE

+ Nhe : Tiem TM 0,5g trong 5 plnit rai truyen TM hoac tiem TM 0,5g/2h

* Di~u chinh PAM thea ket qua ChE hoac thea lieu hrong Atropin nhir dum day: (lay ket qua ChE lam can cir chinh).

+ Neu Atropin > 5mg/h va/hoac ChE < 10% gia tri binh thuong tol thieu ( gtbt tt): tiep tuc truyen 0,5g/h

+ Neu Atropin 2-5 mg/h va/hoac ChE 10-20% gtbt tt tiep tuc truyen 0,5g/m6i 2h + Neu Atropin 0,5-2mg va/hoac ChE = 20-50 tiep tuc truyen 0,5g/m6i 4h

+ Ngimg PAM khi Atropin < 4 mg/ 24h va ChE > 50%

Chlln doan qua lieu PAM khi:

• Dang truyen voi toe d¢ >= 0,5g/h

• Tham Atropin tot voi lieu Atropin t hap.

• Xuar hien liet co ( moi ) hoac liet nang them.

• Tang huyet ap hoac truy mach.

• ChE dang co khuynh huong tang lai giam.

DQc tinh cua PAM:

- PAM co it doc tinh, lieu 40,5g trong 7 ngay hay 26g trong 54h da duoc dung rna khong co tac dung phu xay ra (Namba va CS 1971).

- Tiem nhanh qua 500mg/lphut co th~ gay ra nhip nhanh, co that phe quan, truy mach, nhin rna, chong mat, dau dau, non, cung co va liet co thoang qua.

a nang d¢ cao PAM co th~ ll"C che hoat tinh ChE (thi nghiem tren dong vat), Tuy nhien, tac dung phu nay trong nhung lieu dieu tri rat it hoac khong g~p a ngiroi. Nhimg nghien CUu a nguoi cho thay PAM co mot chi so dieu tri cao. Nhirng lieu 100 ( truyen TM lien tuc 0,5g/gia) dung cho nhung nguoi tinh nguyen trong thai ky dai khong thay gay doc.

10

Bdi giang Chong doc

NgQ doc rna tuy nhom Opioid

I. D~i cirong

Ma tiiy la mot van d~ nlnrc nhoi cua xh trong nhieu nam qua.

Ma tiiy th/dung la opi, trong do ph/bien nhat la morphin v heroin. D Cac kh/niem co ban

Opiat: Cac chat ng/gac ttl' nhua cay th/phien ( opium poppy).

Opioid: Cac h9P chat rna tilt ca cac t/dung tr/tiep deu bi Naloxone dai khang, Bang 1: So sanh cac thuoc glam dau gay ngo thuong dung

Lieu va dirong dung u: (gio) TD (gio) =10mg MS04
Thuac
Tl! nhien: 2-1 Omg, TB/TM I,S-2 4-S
MS04 60mg, uong
Codein (Methylmorphine) 60mg, uong 2,9 4-6 120mg
Ban t6ng hQP:
Heroin (Diacetylmorphine) 3mg, TB/TM I,S-2 3-4 3mg
T6ng hQP:
Propoxyphene 6S-100mg, U 3,S 2-4 240mg
Diphenoxylate Smg, uong 12-14 6-8 240mg
Fentanyl O,OSmg, TB/TM 2-4 SO-60ph TM O,12Smg
1-2 giO'TB
Meperidine SO-lOOmg, TB/TM 3,S 2-4 80-100mg
Methadone S-ISmg, TB/TM IS 36-48 80-100mg
Kfch thieh-U'e che 30mg, TB/TM 2-3 -
Pentazocine SOmg, uong Nghien opioid la hien urong phai lien tuc tang lieu dtS dat diroc cung mot dap trng sinh ly,

Neu dot ngot ngirng dung opiat, hrong enkephalin noi sinh khong du gay kfch thich than kinh,

tmh trang kfch dong voi cac trieu chirng thieu thuoc,

II. Bi~u hien lam sang

Co tM sau chich, hut, hit hoac do dirong qua da.

Do d6i dung thuoc sang ngiroi ban khac,

Do tang lieu dtS dat khoai cam.

1

Bdi giang Chong doc

Do tv sat hoac bi rmru hai, Tre em co thtS bi tai nan

Nhirng nguO'i khong nghien rna tiiy co thtS ngo doc dirong uong do co tmh (tv tit) hoac do tai nan dieu tri.

1. ftc che than kinh trung uong

La mot trong 3 tieu chuan cua ngo doc opiat.

Hiern g~p co giat do qua lieu opioid tinh che ngoai trir 0 tre em hoac ngo doc propoxyphene va meperidine.

Truong hrc co tlnrong khong thay d6i nhirng co thtS tang neu do qua lieu meperidine hay fentanyl.

2. Dong tit co nho

La dau hieu lam sang kinh dien tlnr hai

3. ftc che' h6 hap co thi gay tit vong

La dac diem tlnr ba cua ngo doc opioid.

Tho nhanh nong co thtS thay 0 benh nhan phu phdi cap t6n thirong

Do tac dung tic che TKTW cua opioid, phai xet chan doan viem phdi do sac 4. Tac dung tren h¢ tim macb

- Soc, truy tim mach: benh nhan ngo doc heroin do tiern chich co tM vao vien trong tmh trang soc. Soc co thtS Ia do suy tim toan b¢ cap, hoac do tiern doc chat vao tuan hOM (hoi clnrng soc do doc to - toxic shock syndrome).

Cac bien chirng tim mach khac la loan nhip cham va loan n hip nhanh do quinine, rung nhi kich phat, QT keo dai, viern noi tarn mac, ngirng tim do tang kali mau, tarn tnrong keo dai, phmh mach dang narn,

5. Cdc tac dung tren h¢ tieu hoa

Budn non va non; dung cac lieu tiep thea lai co tac dung tic che vimg nay va sau do ra t kho gily non.

2

Bdi giang Chong doc

Nhu dong ruot giarn trong khi tnrong hrc cac co that tang dan den hap thu thuoc rat cham va lam cho thai trir thuoc qua dirong tieu hoa co thtS cham tci 27 gia sau khi uong,

6. Cdc bien chung khac cua NBC opioid

Tieu co van, ha dirong mau, tang t han nhiet..

III. Xet nghiem

Nong d¢ heroin trong rnau khong co gia tri nhieu v~ lam sang nhirng co thtS phat hien diroc trong vong 36 gio, 6-MAM co thai gian ban thai trong rnau ngan (38 phiit) nhung co tM phat hien trong mnrc titSu bang phirong sac ky va la bang chUng sit dung heroin.

Dieu tri

1. Hoi sue tim mach:

Dung van mach cho cac benh nhan tut HA. Theo doi sat tang ganh tM tfch, clni y danh gia hrong dich vao va ra. Sau khi benh nhan 6n dinh co thtS chup phim X quang nguc,

2. Hoi sue uo hap:

Dat NKQ neu co chi dinh, Naloxone TM 0,8 -1 ,2mg, tiern lai each moi 5 plnit cho tci khi benh nhan tinh, tho' lai tot. Tut HA dieu tri bang van mach, Khong truyen nhieu dich & benh nhan phu phoi, Neu tmh trang benh nhan 6n dinh chup X quang phdi va lam khi rnau thea doi, Theo doi lien tuc dien tim. Dung oxy va co tM phai tho' PEEP. Digitalis va Ioi titSu khong co nhieu tac dung vi la phu phdi cap t6n thirong,

3. Naloxone

Naloxone la chat giai doc dac hieu co tac dung tic che & cii -l loai receptor opi (mu, kappa, sigma, delta). Nhanh chong dung naloxone thuong ciru diroc benh nhan ngo doc opi,

Lieu dung

1) Lieu thirong co hieu qua trong dieu tri cap ciru la 1 den Song (0,4 -2mg) tinh mach, Danh gia diem Glasgow hoac thang diem hon me khac, Neu khong co tac dung, dung them 1 lieu 2mg tinh mach (dung each 2-3 phiit cho tci tong lieu lOmg). Neu co dap trng 1 phan, tiern TM each 15 phiit cho tci khi benh nhan tinh, tho' diroc hoac khong co cai thien them. Neu co dap trng, bat dilu truyen tinh mach naloxone.

3

Bdi giang Chong doc

2) Phac d6 lieu truyen tinh mach lien tuc dtS h 6i phuc tac dung giam dau gily ngu dll diroc Goldfrank va cong su d~ xuat, Truyen tinh mach 4 mg naloxone/lit voi tee d¢ 400 Ilg/gia (0,4mg/gia). 0 ngiroi 16'n, dung 4 mg/lOOOm I Glucose 5% truyen 100 rnl/gic'

Bn tinh, tu thO' diroc: -Theo doi

-naloxone

0,4 mg moi 20-60 phiit theo lam sang

- oxy 4l/ph

-Truyen dich g5%,

nacl 0,9%, dam bao HA

Phac do dieD tri cap coo ngQ dQC cap opi

Hon me

Tho cham, ngirng tho, SHH cap Dong tit co nho

TutHA

Vet tiern chich

Bop bong oxy 100%

Naloxone 0,4 mg tinh mach

Bn khong tinh va/hoac thO' <10 Ian/phut Sao 3 phut:

- naloxone 0,4 mg tm 2-3 phut/lan

- tong lieu ~ 2 mg (5 Ian)

dap Ung 1 phan: -bop bong

hoac tho may qua mat na -truyen dich: g5%, naclO,9%

-naloxone 0,4 mg tm/30 phut.

Khnng dap Ung -dat nkq

-tho may

ippv ± Peep

4

Bdi giang Chong doc

NgQ doc khi CO

BS. BlHongThu Khoa chong doc : BV Bach M ai

I.D~i cuong ve co 1. Ti l~ mac:

Ngo doc cap CO rat thirong g~p & Phap (10000 cas/nam, 500 ngiroi chet) va rat thuong g~p ngo doc nhieu ngiroi tr ong mot gia dlnh,

Ngo doc cap co Ia nguyen nhan gay tit vong hang dau tai My ( 5613 tnrong hop trong nam 1979 - 1988 ).

Ti l~ di cluing: 10.000 ngiroi phai milt it nhat mot ngay nghi. Di cluing 4 - 40 % benh nhan xuat vien,

2. Dac diem ly hoa:

CO la mot chat khi khong mau.khong rnui.khong vi, khuech tan rnanh.khong gay kfch thich. CO co ti

3. Nguon CO:

CO la san pham chay khong hoan toan cua cac chat co chua carbon: nlnr khoi cua ca c vu dong dilt, 0 nhiern khoi cong nghiep, chat khi dong Iau & ham 10, tang ham, khoi thuoc Ia, khoi cac 10 sum, ..

4. Cu chl ngo doc CO

Khi vao co thtS: CO co dinh vao Hemoglobine (Hb) 85%, no co ai hrc gill voi Hb cao gilp 200 - 250 an so voi oxy, M¢t ph an can lai khi CO hoa tan vao plasma va co dinh vao myoglobine va vao cac cytocrome.

Ti l~ HbeO ( Carboxyhemoglobine ) diroc hmh thanh phu thuoc vao hrong HbeO ban dau ( dac biet & nguai hut thuoc ), vao thai gian nhiem, hrong khi CO va thong khi cua benh nhan,

Ti l~ Hbf'O: + Ngiroi khong hut thuoc Ia: 1 - 2% + Hut thuoc Ia: 5 - 10 %

+ Nong d¢ doc: > lO%z

Ngo doc oxyt carbon gay thieu oxy te bao do lam giam ti l~ Hb02, lam giam giai phong oxy tit Hb02, lam giam sit dung oxy cua te bao,

CO co thtS tham qua hang rao rau thai va co dinh vao Hb cua thai nhi.

CO diroc dao thai qua dirong ho hap diroi dang khong thay d6i. Thai gian ban thai la 4 gio; Khi thong khi voi oxy ding ap thi thai gian ban thai can 80 phiit va diroi oxy cao ap thi thai gian ban thai can 23 plnit.

CO gay ra thieu oxy chu yeu & he than kinh trung irong, doi voi co tim va thai nhi trong thai gian co mango Tinh trang thieu oxy se nguy hiem dac biet doi voi ngiroi Ion tudi, nguai thieu mau, suy ho hap va suy tim.

1

Bdi giang Chong doc

5.Phdt hien va dinh luong:

Trong giai doan ngo doc cap, RbCO diroc din h hrong bang may quang pho ke (spectrophometri ).

Chiln doan xac dinh ngo doc CO dua vao ti l~ RbCO > 10%. Nhtrng nguiri hut thuoc co ti l~ RbCO cao tlt 3 - 8%, tharn chi den 15 % ngay sau khi hut thuoc, D¢ nhay cua HbCO rat cao nhung d¢ dac hieu thap,

Dinh hrong CO cho ket qua dang tin cay, no diroc dinh hrong bang su hap phu tia cue tim, ket qua diroc do bang mmol/100ml hoac ml/100ml. DtS chuyen don V! mmol % thanh ml%, ta co cong tlnrc sau:

CO ml% = mmol% x 2.24 D¢ bao hoa RbCO diroc tinh thea cong thtrc sau:

RbCO% = Ti l~ cua CO ( ml % )/ 1,39 x nong d¢ Rb(g%)

Khi d9C ket qua phai clni y den thai diem lily rnau so voi thai gian bi ngo doc va thai diem hut thuoc cuoi cung 0 nguiri hut thuoc Ia tnroc khi bi ngo doc,

Khi HbCO > 10% khang dinh chan doan ngo doc CO.

II. Trieu chung ella ngo doc cdp

1. NgQ dQC cap co th~ gi_lp trong cac dam chay IOn va gay til vong nhanh chong.

Khoi dau bitSu hien bang dau dau, met m oi, chong mat, budn non, nhin rna, roi loan hanh vi kern thea cam giac sang khoai, nang hon co thtS dan den hon me. Chiln doan dua vao: - Hoi benh: hoi benh nhan va nhfrng ngiroi xung quanh: ngo doc thirong xay ra voi

nhieu nguO'i song trong cung mot nha, va co thtS co nhfrng dau hieu nhe ttl' nhirng ngay tnroc nhirng khong diroc phat hien, Nhirng vat nuoi trong nha la nan nhan cua ngo doc CO, co thtS bi chet nhir cho, rneo. Can hoi trong nha co dung 10 sum khong, bep than, hoac sira chua tang ham? ... Mot hoan canh khac co thtS gay ngo doc nhir Ia hit khoi cua dong co 0 to, xe may (doi khi Ia mot hmh tlnrc tv tit).

- Dinh hrong CO hoac RbCO khi benh nhan den benh vien hoac sau khi da tho oxy thi ti l~ RbCO va CO co thtS bmh tlnrong,

- Dang nang hoac hon me:

o tlnrong g~p khi bi nhiern doc d a Iau hoac 0 nguiri gia da bi suy tim hoac suy ho

hap, No tlnrong gay t6n thirong nao, co tim va he co,

- T6n tlnrong than kinh trung irong :

diroc bieu hien bang hon me tang tnrong hrc co, thai gian va rmrc d¢ hon me rilt thay d6i.

Co cac dau hieu ngoai thap.Mot so benh nhan hon me co thtS hdi phuc nhanh chong, mot so khac co cai thien thoang qua va khong hOM toan, tien trien nang len 0 tuan tlnr 2 ( Hoi cluing khoang - syndrome postinterval) dan den di clnrng than kinh hoac tam than. CO' che do t6n thirong chat trang cu a nao 0 vimg hai rna thea kitSu milt myeline va diroc phat hien bang chup cat lap nao, Di clnrng lam sang tlnrong g~p la nhfmg van dong bat thirong, tang tnrong hrc, t6n tlnrong he than kinh cao cap, cam va mu vo,

- T6n tlnrong co tim: phu thuoc vao nhu cau oxy VI co tim chiern 75% hrong oxy rnau hru hanh trong khi do cac co quan khac chi chiem 25% hrong oxy.Ton tlnrong co tim diroc bieu hien tren ECG bang thieu rnau co tim, loan nhip ( chiern 5 - 6 %) . Nhtrng roi loan chu yeu Ia roi loan tai eire, thay d6i cua song Tva doa n ST . No co thtS gay ra thieu rnau diroi noi tam mac hoac thieu rnau diroi thirong tam mac, hoac doan ST

2

Bdi giang Chong doc

chenh len hoac chenh xuong durri dirong ding dien don thuan, Nang hon bitSu hien bang troy' mach va phu phdi cap, Phii phdi cap Ia phoi hop cit phu phdi cap t6n thirong va phu phdi huyet dong, 0 nhfmg benh nhan bi benh mach vanh tnroc do co thtS gily ra nhoi rnau co tim.

- T6n tlnrong co diroc bieu hien diroi dang tieu co van (rhabdomyolyse). CO' che do ep vao mach rnau va than kinh. Nen tim mot each he thong nhfmg dau hieu cua tieu co van nhu: co cang, tang thtS tfch, milt mot hay nhieu mach ngoai vi. Xet nghiern thay CPK, transaminasse, amylase tang. Doi khi kho co tM phan biet diroc la do thieu oxy, do nr the nam sau hon me hoac do ngo doc CO gily ra.

- Bang 1. Trieu clnrng theo nong d¢ CO

% CO trong ThOi gian %COHb Trieu clnmg
khong khi tiep xiic
35 ppm Khong xd 3,5 Khong
50 - 100 Khong xd 5 Dau dau nhe, giam kha nang lam viec
100 Khong xd 10 Dau dau nhe, kho tho' khi gang sire nang
100 - 200 Khong xd 10 - 20 Kho tho' khi gang sire vira, hdi hop, dau dau vimg
thai dirong
200 -300 5-6 20 - 30 Dau dau nhieu, ngat, chong mat, nhin rna, budn
non va non
400- 600 4-5 30 - 40 Chong mat, thilt dieu, hi Ian, milt y tlnrc
700-1000 3-4 40-50 Lti Ian, tim nhanh, tho' nhanh, hon me, co giat
1100 - 1500 1,5 - 3 50 - 60 Cheyne stokes, hon me, co giat, shock, ngirng tho'
1600 - 3000 1 - 1,5 60-70 Hon me co giat, suy ho hap, troy' tim mach
>4000 Vai phiit Tir vong Bang 2. Theo rmrc dQ lam sang

Mrrc dQ Trieu clnmg Dau hieu
Nh~ Dau dau Non
Buon non
Chong mat
Vlta Dau nguc Machnhanh
Kho tap chung Tho nhanh
Nhln rna Hoai tit co
Kho thO' khi gang strc nhe Thilt dieu
N~ng Dau nguc Co giat
H6i hop Hon me
Milt dinh hirong Roi loan nhip tim
TutHA
Thien rnau co tim
Phong da 3

Bdi giang Chong doc

2. Sinh hod:

Tang dirong hu yet

Tang bach cau, chu yeu la bach cau da nhan trung tinh.

Toan ho hap do phu phdi. Toan chuyen hoa do suy tuan hoan phoi hop v6i tieu co van co thtS gily ra suy than cap,

Ngoai ra co thtS g~p viern tuy cap trong ngo doc nang,

3. Cdc dang lam sang

M¢t vai benh nhan co bieu hien ngo doc durri cac dang khong tlnrong g~p phu thuoc vao cac trieu chungs hoac co dia hoac Ia tien trien,

Dang than kinh - tarn than: Khoi dau di Ioang choang, kho tap trung nr urong, hanh dong khong phu hop va roi loan thi giac,

Tre em co thtS diroc phat hien bang co giat, Doi khi a nguiri 16'n, khoi dau ciing bitSu hien bang co giat,

NgU'ai gia: co thtS khoi dau bang tmh trang Ian Ion, doi khi co dau hieu than kinh khu tni lam nham chan doan,

a phu nit co thai: Khong co su ton tai song song giira rmrc d¢ nang cua me voi rmrc d¢ nang cua thai nhi. Trong thai ki dau, thieu oxy cua thai co thtS gily ra thai chet hru hoac gily ra di dang barn sinh. a giai doan cuoi cua thai ki co thai, ngo doc CO gily ra thai chet hru hoac benh nao cho thai. Tuy nhien ,ngU'ai ta co tM g~p thai nhi phat trien bmh thuong a nhfmg tnrong hop ngo doc nhe hoac trung binh,

M¢t nguyen nhan ngo doc dac biet ciln clni y la ngo doc khi chlore methylene va khi dichloromethane. Nhtrng dung rnoi nay se diroc chuyen hoa mot phan trong co tM th anh CO. Hai Ioai khi tren diroc sit dung trong cong nghiep va trong hoi hoa ( dtS tily tranh ), no thuong diroc sit dung trong nhirng noi kern thong khi va co thtS gily ra ngo doc khi CO nang,

III.Chftn doan

1. Chan doan xac dinh Khai thac benh sit Kham tlnrc thtS

Hbf'O rnau, Clni y nong d¢ eOHb khong urong quan voi lam sang va di cluing than kinh

2. Chan doan phan biet

Ngo doc nhe: d~ lam voi cam cum nhat la v~ rnua dong. Sau 4 gia tiep xiic CO 200ppm eOHb 15 - 20% -7 dau dau, CO 500 ppm -7 budn non

Ngo doc vira: d~ nham voi ngo doc tlnrc an (buon non, non); dau that nguc khong 6n dinh

Ngo doc nang can phan biet v6i cac nguyen nhan gily hon me va co giat khac, Mau do anh dao xuat hien khi tiep xiic qua nhieu (2 -3%). Day la dau hieu it nhay

IV.Di clnrng cua CO Sa stit trf tue

Tilm than Parkinson

4

Bdi giang Chong doc

Liet Mua von Mii vo

Benh ly than kinh ngoai vi Bilt hrc

T6n thirong than kinh xuat hien 2 - 40 ngay sau nhiem CO

+ 1 thong ke tren BN ngo doc diroc tho' oxy 100% trong ICU 14% song sot co t6n thirong than kinh khong hdi phuc

+ 1 nghien ciru 2360 BN ng (> doc CO thay 3% sa stit trf tue va Parkinson sau 1 nam

+ 1 nghien ciru tren 63 BN bi ngo doc nang 43% giarn tri nho, 33% thay d6i v~ tinh each sau 3 nam thea doi,

V. DieD tri:

Chien hroc dieu tri khong dua vao nong d(> RbCO, rna dua vao tmh trang co bi milt y thtrc hie dau hay khong", tmh trang hon me, cac yeu to tien hrong nang, va vao cac di clnrng than kinh.

1. Nhanh chong dira nan nhan ra khoi noi ngo doc:

cho phep RbCO phan ly nhanh chong. Trong khi keo nan nhan ra khoi vung bi ngo doc: nguai ciru nan phai hru y mang mat na phong doc hoac deo khdu trang am, phai d~ phong kha nang n6 cua khong khi giau CO.

2.ThO'oxy:

SV phan ly cua RbCO diroc tlnic day dum oxy lieu phap, VI vay can cho thO' oxy cang som cang tot, cho thO' oxy ngay sau khi lily rnau dinh hrong RbCO.

ThO' oxy 100% den khi CORb < 2%, doi voi BN co thai tht duy trl2 gio sau khi CORb v~ 0 nham keo dai thai gian thai trir CO tlt thai nhi

Dieu tri oxy ding ape ONB ) Ia bien phap dau tien, oxy diroc sit dung diroi dang masque hoac leu oxy & tre em. Lieu phap oxy cao ap ( ORB) chi dinh cho phu nO' co thai, hon me ( co tac dung lam tang ap hrc rieng phan cua oxy, lam tang su phan ly RbCO, lam tang su khuech tan cua oxy trong rnau va lam cho t6 clnrc sit dung oxy d~ dang hon.

3. Dieu tri trieu cluing:

Neu co suy ho hap can d~t noi khi quan, thO' may.

Dieu tri RA tut, dat catheter, dung thuoc van mach tuy thea rmrc d(> cua roi loan huyet

dong,

Theo doi chirc nang song co ban, lam khi rnau

Dieu tri toan chuyen hoa chi khi pR < 7,1. Tinh trang toan giup dirong phan ly oxy dich chuyen v~ phia ben phai thuan Ioi cho giai phong oxy cho t6 clnrc

4. Phong tai phat:

giao due benh nhan, V ~ sinh noi & va rnoi tnrong lao dong

VII. Oxy cao ap trong ngQ dQc CO

1. CO' sO' cua dieD tri

Giam thai gian nita dai song: Neu tho' 02 100% thai gian trong vong 40 plnit neu ROO 2,5 atm thi thai gian chi con 20 plnit (4 -86 plnit). Tang 02 hoa tan len 10 Ian Cung cap 02 cho t6 clnrc durri dang hoa tan trong plasma

5

Bdi giang Chong doc

Gay co mach nao nic thi trong khi van duy trt diroc 02 cho td chirc nao

Ngan chan su tong hop cac goc tv do tit hien urong peroxidation cua rna trong te bao nao do ngo doc co.

2. Chi dinh:

Ngat Hon me Co giat

GCS < 15 diem

Co dau hieu than kinh klnr tni hoac COHb > 25% (mot so >40% va > 25% neu kern

thea: co giat, loan nhip tirn,di chirng) hoac COHb > 15% & ph V nit co thai Thien rnau co tim

Loan nhip that

Sau khi dieu tri ban dau dn dinh sau 2 -4 gio rna trieu cluing than kinh khong phuc hdi (dau dau, that dieu, hi Ian)

6

Bdi giang Chong doc

NgQ doc cap Barbituric

BS. Diing Thf Xu/in

I. D~i cuong

Ngo doc cap barbituric la ngo doc rat tlnrong g~p trong cac khoa H6i sire cap ciru.

Nhieu benh nhan uong voi muc dich tv tit VI vay uong v6'i so hrong nhieu, nhieu Ioai thuoc, benh canh lam sang tlnrong plnrc tap va nang, Tren tlnrc te, hay g~p ngo doc & nhfrng benh nhan bi roi loan tarn than, dong kinh, nghien rna tuy,

Ngo doc cap barbituric la mot van d~ can phai quan tarn VI tit vong can cao do nhieu bien clnrng, & Viet Nam barbituric diroc dung nhieu nhat la ph enobarbital (luminal, gardenal). Ben canh ngo doc cap can co ngo doc man do lam dung thuoc,

II. tinh chat - chuyen hoa - doc tinh

1. Cau true va tinh chat If hod

Barbiturat diroc dung dtS chi cac dan xuat cua acid barbituric va ure vong cua acid malonic .

............................................

NH - i-r HO - C - C

O=C_""""! !

~; ;

NH - r. ~.? ~ 9 - C

-2H20 NH - CO

---____'~O=C _........

NH~

Vre

Acid Malonic

Malonylure (acid Barbituric)

Ban than acid barbituric khong diroc dung trong y h9C, nhung cac dan chat the & V! trf C 5 (doi khi & 1, 3) cho mot Ioat cac dan chat co tac dung gily ngu, chong co giat diroc goi la thuoc ngu barbituric. Neu thay ure bang Thio ure se diroc Thio-barbituric, khi thay H5 bang cac nhorn the khac nhau se cho mot dan chat gily ngu manh va nhanh dung lam thuoc gily me.

Noi chung barbiturat Ia nhirng tinh thtS trang, V! thay d6i, it tan trong mnrc va ete dau hoa, tan nhieu trong dung rnoi h iru co (alcol, ete, clorofoc). D~ thang hoa trong chan khong & 170 - 180aC. DitSm nong chay thay d6i tlt 100 - 190aC. Barbiturat thirong bi than, silicagen hap phu,

Axit barbituric co tinh axit manh (nhat la pKa=4.04). Do tinh axit nen tao muoi khong tan voi mot so kim Ioai nang, d~ tan trong dung dich kiem va carbonat kiern,

Barbiturat d~ tao plnrc hon hop voi mot so ion kim Ioai do do d~ tan trong dung rnoi, bi phan huy khi co rnroc, co rnau dac tnrnghoac tinh thtS dac hieu nen diroc dung khi kiem nghiem,

Hau het cac barbiturat co phd hap thu VV dac tnrng, quang pho phu thuoc vao pH cua dung dich,

1

2. Chuyin hod barbituric trong ClY thi

Barbituric d~ dang hap thu qua niern mac khi pH cua rnoi tnrong nho han pKa cua barbituric, do vay tham nhanh qua niern mac da da y.

Barbituric diroc chuyen hoa & gan do tac dung cua cac men co trong gan. VI vay & nguiri quen dung barbituric , lieu ngo doc cao han nguiri chua dung barbituric. Nguoc Iai, nguai suy gan d~ bi ngo doc, Thuoc diroc hap thu nhanh, phan bo nhieu trong t6 clnrc .

Cac barbituric cham (gardenal, barbitaL.) co thtS thai trir nhieu nhat qua mroc titSu diroi dang nguyen ven (65 - 80%), VI vay gay Ioi titSu la mot phirong phap dao thai tot. Cac barbituric cham diroc 19C qua cau than va tai hap thu & ong hron gan, Niroc ti tSu kiem lam giam tai hap thu barbituric, VI vay kiem hoa huyet thanh la mot bien phap tot dtS thai trir barbituric qua than,

3. Dt)c tinh sinh benh. hoc

DVa thea thai gian gay ngu, ngiroi ta chia barbituric ra lam 4 Ioai: + Tac dung cham (6 gio) : barbital, gardenal

+ Tac dung trung bmh (3 - 6 gio) : allobarbital, amobarbital, aprobarbital, butobarbitaL

+ Tac dung ngan (3 gio) : xyclobarbital, secobarbital, pentobarbital + Tac dung eire ngan dtS gay me: thiopental

Barbituric tac dung len cac ty Ia p thtS cua cac te bao lam giam tieu thu oxy, giam phat sinh ra nhiet hrong va acid lactic. V O'i lieu cao, barbituric tic che than kinh trung irong, tac dung tic che he thong hroi ARAS va vung nao trung gian lam cho benh nhan hon me.

Barbituric tic che cac trung tam van mach, ho hap, cac thu tM pH, PCO 2/P02' lam milt phan xa ho,

Tac dung cua barbituric con phu thuoc vao dac diem cua ngiroi dung thuoc : su nhay cam, tudi, clnrc nang gan than, nghien nrou, co dung thuoc thuong xuyen hay khong,

Tac dung cua barbituric tang len khi co mat cua cac thuoc tic che than kinh khac : morphin va che pham, clopromarin, bromua ... Tac dung ket hop giira barbituric va nrou co tM gay nr vong du nong d¢ barbituric rnau khong cao.

Cac tac dung nay co tfnh chat tam thai va milt d i khong dtS lai di cluing sau khi thuoc da diroc thai trir het,

Ngo doc tren 2g co thtS gay hon me sau va tit vong, tren 6g se gay tit vong nhanh chong neu khong kip thai ciru chua.

III. Trieu cluing lam sang ngo doc nang

Trong bai nay cluing toi chi d~ cap den ngo doc cap barbituric tac dung cham phenobarbital (gardenal)

1. Hon me sdu

2

Hon me khong co liet chi, benh nhan nam yen, cac chi mem nhiin, milt het phan xa gan xirong, ktS ca phan xa giac mac, nhirng phan xa dong nr voi anh sang van con va chi milt neu benh nhan ngat tho' do tut luai hoac suy ho hap,

Neu co tmh trang co ctrng kitSu milt nao phai coi chirng co thieu oxy t6 clnrc (tut luai, v dong dom dai)

Roi loan y thtrc ty l~ voi rmrc d¢ ngo doc, co dia dong kinh chiu dung lieu cao hon,

Hon me: Danh gia rmrc d¢ hon me thea bang diem Glasgow (tuy nhien bang diem Glasgow khong co gia tri dtS tien hrong benh nhan ngo doc barbituric)

Dien nao d6 giiip cho danh gia rmrc d¢ hon me va thea doi tien trien cua benh

Nhieu tac gia da khao sat su lien quan giira nong d¢ barbiturat trong rnau va rmrc d¢ lam sang. Nong d¢ nay thay d6i tirng Ioai,

Nong d¢ barbiturat (mg%) va giai doan Iam sang

(theo Bai giang kiem nghiern doc chat - Tnrong Dai h9C Diroc Ha Noi)

Mire d¢ ngo doc 0 1 2 3 4
Phenobarbital 1.0 3.4 5.5 8.0 15.0
Amobarbital 0.7 1.5 3.0 5.2 6.6
Pentaobarbital 0.4 0.6 1.5 2.0 3.0
Secobarbital 0.3 0.5 1.0 1.5 2.0 Tuy nhien nong d¢ barbituric con phu thuoc vao phirong phap xet nghiern va d¢ nang cua ngo doc cap barbituric phu thuoc vao cac dau hieu lam sang, clnrc nang song , bien chirng hon la nong d¢ barbituric rnau. Co benh nhan nong d¢ barbituric rnau khong cao nhung lai tit vong do tut luai, sac, nhiern trung benh vien ...

Co tM ha than nhiet hay sot cao.

Nhan cau tlnrong co dinh,

2. Rdi loan ho help

Rat tlnrong co, la nguyen nhan chu yeu gily tit vong CO' che: giarn thong khi phe nang:

Tile dirong ho hap do tut luai, dorn dai, milt phan xa ho, hit phai dich V! (hoi cluing Mendelson), la nguyen nhan chfnh gily tit vong. Tnroc khi benh nhan diroc d~t ong noi khi quan, nen dtS benh nhan & tu the nam nghieng an toano

Boi nhiern phdi & nhirng benh nhan nam Iau, d~t ong noi khi quan tho' may

3. Rdi loan tudn hoan

Te liet than kinh trung irong dan den giarn tlnic tinh thanh mach gily ra ha huyet ap, Tinh trang ha huyet ap & nhtrng nguO'i gia co tM gily nh irng bien cluing nang n~, co benh nhan sau khi dieu tri 6n dinh ngo doc cap lai phat hien ra nhiin nao do bi tut huyet ap keo dai, Thirong kern thea milt mroc, milt muoi, tile mach phdi.

3

4. Boi nhiem

La bien cluing rat tlnrong g~p, nhiem trung benh vien thuong do vi khuan gram am hoac true khuan mu xanh khang thuoc, dieu tri kho,

Viem phdi, viern phe quan phdi: do hit phai, do U dong dam dai, do cong tac cham soc, hut dam. Da so cac benh nhan tho' may bi nhiem trimg phdi, tlnrong la nguyen nhan keo dai thai gian thO' may, thai gian dieu tri, tham chi gily tit vong cho benh nhan .

Nhiem khuan tiet nieu, dac biet & nhfrng benh nhan d~t ong thong bang quang, nam Iau, dai thao dirong,

Loet muc

5. Suy than cap

Thirong la clnrc nang

Nlnrng co tM Ia thuc t6n do benh nhan co t6n tlnron g tiem tang & than, hoac do nam bat dong de ep vao chi gily tieu co van (rhabdomyolyse): dai it, sam mau, men CPK tang cao.

6. Benh. phoi hap

Benh nhan nam Iau co thtS co bien chirng: tai bien mach rnau nao , huyet khoi tinh mach chi dum, tac mach phoi, nhdi rnau co tim.

Tien hrong xa: co thtS thay viern nhieu day than kinh.

IV. Xet nghiern doc chat

Mau benh pham:

Dich co thtS: mau, mroc titSu, dich da day Phu tang

1. Dinh tinh barbiturat:

1.1. Phan trng chung cua cac barbiturat: phan trng Parris

Phan irng tao phiic hop hon hop co rnau hong voi Coban Nitrat hoac Coban Acetat trong rnoi tnrong Metanol.

Phan trng nay ky rnroc, co tM phat hien den O.03mg barbiturat trong mau thir, nhirng khong dac hieu, Tilt ca cac nhorn co CO - NH - CO deu cho phan trng nay.

Phan trng tren co thtS thuc hien tren sac ky lap mongo

1.2. Phan trng dac hieu tim Gardenal

Phuong phap sac ky lap mong so sanh voi mau gardenal chuan ( cham 5 -1Omcg mau chuan)

Dung rnoi trien khai: Clorofoc/Aceton 9/1

Thuoc thir: Millon hoac orthotoludin 1 % hoac 3 dung dich KaliIodu a 1 % trong mroc voi Benzidin bao hoa trong acid Acetic 1 %.

Duong tinh khi thay vet rnau trang xam tren nen trang (Rf trung voi Rf gardenal cua mau so sanh).

Phan trng nay co thtS dung dtS ban dinh hrong gardenal

1.3. Phan trng soi tinh thtS tren kinh hien vi d¢ phong dai 8 -10 liln

4

2. D!nh hrong barbiturat

Phan trng tao plnrc rnau roi do quang (hien nay it dung) Phuong phap do phd uv (phd hap thu tit ngoai)

Do trong dung dich N aOH 0.1N do hap phu & biroc song 240nm & pH = 10 cho Amax = 244 nm

& pH = 13 cho Amax = 249 nm

(co tM dung dinh hrong gardenal trong dich sinh ly) - Sac ky khi

V. Xit tri

Xir tri cap ciru phu thuoc vao rmrc d¢ nang khi benh nhan vao vien: Ioai bo chat doc tnroc hay hdi sire tnroc,

1. Baa dam thong khi truac

Dat ong noi khi quan, hut dam.

Ho hap nhan tao voi phuong tlnrc IPPV

M& khi quan neu co phu thiet hau, thanh mono Neu co xep phdi: soi hut phe quan

2. HC}n che ngq doc Khong gily non Rita da day:

+ Benh nhan tinh: d~t ong thong da day nho qua dirong miii, rita da day. Can phai tien hrong tnroc tmh trang benh nhan VI co thtS hon me va dien bien nang len rilt nhanh.

+ Benh nhan me: d~t noi khi quan co bong chen (cuff) va thong khi nhan tao tnroc khi rita da day,

+ Ky thuat rita da day: benh nhan nam nghieng trai, moi liln dira vao 100 - 200ml dung dich muoi 0.9%. So hrong dich rita: 3 - 5 lit, rnua Ianh dich rita phai diroc lam am, Lily dich rita da day & Ian dau dtS xet nghiern doc chat,

Cho benh nhan uong than hoat 100g (20g/2 gio), thuoc tily sorbitol 1 - 2g/kg chia d~u thea cac lieu than hoat,

3. Tang dao thai

Gay bai nieu cuong birc: truyen 4 - 6 lft/ngay (theo doi CVP) , cho Ioi titSu dtS tang thai barbituric. V 6'i cac benh nhan khong co suy tim, suy than, khi truyen dich nhieu, chua can cho Ioi titSu so hrong mroc titSu co tM dll tang. Nhfrng benh nhan co suy tim, suy than pha i thea doi chat tee d¢ truyen dich va CVP , cho Ioi titSu.

Ki~m hoa huyet wong: truyen bicarbonat

Cac bien phap tren co thtS tien hanh diroc & rnoi tuyen, trong da so cac tnrong hop ngo doc chi can hoi sire tot, rita da day, cho than hoat va thuoc tily la dll co thtS ciru song benh nhan,

L9C ngoai than: La bien phap thai trir chat doc rat co hieu qua nhirng khong phai & tuyen nao cling co thtS lam diroc, gia thanh cao.

+ Than nhan tao: chi dinh voi nhfmg benh nhan ngo doc nang: hon me sau, vo nieu, truy mach, nong d¢ barbituric trong rnau cao. Tuy nhien, trong dieu kien cua mroc ta hien nay,

5

chi dinh 19C ngoai than chu yeu dua vao cac dau hieu lam sang. Khi chay than nhan tao phai dam bao huyet ap bang truyen dich, dopamin hay noradrenalin.

VI thuoc tich luy nhieu trong t6 chirc, can clni y hien urong tai phan bo lai barbituric trong co thtS, trong hoac ngay sau khi chay than nhan tao benh nhan co thtS tinh ra sau do lai hon me tro' Iai.

+ L9C rnang bung 0- ngU'O'i co tut huyet ap co chi dinh tot han than nhan tao, hoac 0- nh trng benh nhan co them suy vanh, cao huyet ap, suy tim. Dam bao huyet ap rdi 19C rnang bung, NgU'O'i ta thay rang cu 6 giO' 19C rnang bung thi co hieu qua bang 1 gio chay than nhan tao, hay co nghia la chay than nhan tao 6 giO' tht bang 19C rnang bung 24 gio;

4. Dam bdo tudn hoan

H6i phuc mroc dien giai, thang bang toan kiern,

Dat catheter tinh mach truyen dich ngay 4 - 6 lit, trong do natriclorua 0.9%, glucose, bicarbonat, chi dn dung bicarbonat 1.4% 500ml/ngay. Theo doi CVP, mnrc titSu dtS dieu chinh hrong dich truyen.

Neu truy mach: chong soc, truyen noradrenalin, aramin, plasma, rnau. Dat ong thong bang quang thea doi mnrc titSu

5. Chong boi nhiem

Sit dung khang sinh thea khang sinh d6

Phoi hop hai khang sinh: cephalosporin va aminoglycosid.

6. Chong dong

Heparin 1ml 5000 VI moi 8 giO', tiern diroi da

Hoac fraxiparin 7500 VI - 15 000 VI /ngay, tiern diroi da

7. ou: tri phu phdi cap t6n thuong neu co

8. Khi nghi ngCl co hoi chung trao nguac phdi:

Soi hut phe' quan

Mo khi quan d~t canun co bong chen, tho' may co PEEP. Steroid lieu cao: methylpresnisolon 30mg/4 gio,

Giam bot hrong dich truyen (theo doi ky CVP) va dung furosemid.

9. tt» ly va cham soc

Dam bao dinh dirong: 1500 - 2000 Kcalo/ngay, benh nhan hon me cho an qua ong thong da day,

Nam dem chong Ioet, vat ly tri lieu, thay d6i nr the benh nhan tranh ty de gily tieu co hoac Ioet,

Giit am cho benh nhan, neu sot cao: chuom mat, cho thuoc ha nhiet d¢ Cham soc mat: bang milt, nho cloroxit 0.4%

V~ sinh than thtS: rnieng, bo phan sinh due

Vi tamin B1, vitamin C

6

Bdi giang Chong doc

£lieu tri ngQ doc cap va qua lieu rna tuy

PGSPTS.N guyen Tht Dlf

Ngo doc cap opioids Hi mot cap CUu nguy kich, co th~ dieu tri khoi nhanh qua thuoc khang doc (antidote) cua no Hi naloxone. Naloxone Ia mot thuoc co tit 20 nam, thuoc doi khang cho tat ca cac opioids, co dung nhieu duong : diroi da, tinh mach, tiem bap, Thuoc hau nlnr khong co tac dung phu, k~ ca dua mot lieu 100.

A. Nhfrng diem can chu y :

Khi dung naloxone can clni y 2 diem sau :

1. Thuoc co tac dung nhanh sau 2 -3 plnit, thai gian tac dung rat ngan 60 -90 plnit, no ngan hon tac dung cua tat ca opioids, Ioai trir fentanyl. Vi vay can dua nhac Iai hay truyen lien tuc naloxone 0 mot benh nhan ngo doc opioids nang.

2. Naloxone co th~ gay ra hoi cluing thieu t huoc sam 0 nguoi phu thuoc opioids, tuy nhien dung lieu cao se ngan chan duoc trieu clnrng suy ho hap trong hoi clnrng nay.

B. Trieu clnrng va dau hieu ngo doc, qua lieu rna tuy

1. Suy giam ho hap, tho cham, ngirng tho, chet nhanh trong vai phiit sau tiem, hoac 1-4 gia sau uong,

2. Co dong ri'r

3. Mat y tlnrc, hon me

4. H~ huyet ap

5. Phu phoi cap

6. H~ nhiet d¢

7. Neu hon me keo dai co th~ chet vi viem phoi

8. Tim vet tiem 02 cang tay, tinh mach c6, dui.

9. Xet nghiem mroc tieu : co morphine va 6MM (6 monoacetyl morphine) nen tim them barbiturate, benzodiazepine, quinin trong mroc ti~u ngiroi nghien.

C. dicu tri cap CUu ngo doc va qua lieu rna tuy

1

Bdi giang Chong doc

1. Benh nhan tho' yeu, ngap ca, ngirng thO' «10Hin/phut)

- Dam bao thong khi, bop bong ambu + oxy 1 00%, ho hap h6 tro

- Dam bao tuan hoan : ep tim ngoai long ngirc neu ngirng tim, truyen dich

- Ttr the an toan khi hon me, u am, thea d6i tho'

Bat dau bang :

- Naloxone Iml=0,4mg tiem TM (nguoi Ian va tre em). Co th~ cho lieu ban dau2mg ca ngiroi 100 va tre em neu rat nang.

+ Sau 2-3 phtit khong tinh : cho Iai O,4mg (co th~ toi 4 lieu) neu tho' Iai, co th~ cho naloxone qua duong tiem bap, dum hroi. T6ng lieu naloxone co th~ 10- 20mg/24 gio.

+ Neu lieu ban dau cua naloxone hieu qua (benh nhan tinh, tho' Iai) thi tiem nhac Iai sau moi 20 -60 phiit hoac duy tri bang dirong truyen tinh mach lien tuc.

+ Neu sau 4 lieu ban dau khong ket qua thi tim xem benh nhan co uong them thuoc khac : barbiturate, thuoc an than, nrou ... , hoac chan tlnrong dau, co th~ c ho them than hoat voi nhuan trang neu benh nhan ngo doc qua duong tieu hoa,

- Truyen dich nang huyet ap, thang bang dien giai,

+ Glucose vi d~ co ha duong huyet

2. Benh nhan tho' > 151an/phut

- Lieu dau : naloxone O,4mg tiem bap,

Neu dap img mot phan c 0 th~ cho tiep Ian 2 sau 20 -60 phiit - ThO' oxy miii 4L/phut

- Truyen dich, Glucose 5%, NaCI 0.9% dam bao huyet ap.

* Pha truyen lien tuc naloxone :

Cho bat ky Ioai opioids nao, dac biet Ioai tac dung keo dai nlnr methadone (30-36 gio), Truyen lien tuc dua vao nhip tho' va mach, huyet ap benh nhan dap img sau lieu dau. Truyen lien tuc se du phong suy ho hap Iai vi naloxone co thai gian ban huy ngan hon opioids.

Truyen dich + 0,4-0,8mg/gia a ngiroi 100 va O,Olmg/kg a tre em, danh gia sau moi gia a ngiroi 100 va moi 5 phiit a tre em. Truyen lien tuc co th~ tang len neu y thirc can giam, Nhieu tac gia cho thay truyen naloxone lien tuc trong 10 gia a mot don vi hoi strc tich eire Ia an toan bao dam va danh gia Iai tinh trang suy ho hap cua benh nhan sau 1 gia tiep d~ xem tac dung naloxone can hay ngo doc opioids can hoac ngo doc Ioai khac. Naloxone se khong co dap img neu xuat hien hoi clnrng thieu thuoc.

Tho may neu benh nhan hon me, phuong tlnrc dicu k hien th~ tich (CMV) hoac h6 ttro ap hrc, voi FiO 2 = 50%, dung PEEP neu benh nhan co phii phoi cap hay hoi cluing ARDS.

Cham soc nuoi dtrong dii calo.

2

Bdi giang Chong doc

phac do dicu tri ngo doc rna my

Ngo doc rna tuy (mat y tlnrc, thO' yeu, dong tir co,HA~)

Dam bao :

- Thong khi

- Tuan hoan

- Ttr the an toan

Naloxone

(ca ngiroi 100 + tre em)

1.0,4mg-O,8mgfTM ---+

bap

3 phut sau khong tinh Iai : cho Iai (co th~ den 10 Ian den khi co ket qua)

+--- O,4mg tiem

- Co dap img mot phan cho nhac Iai Ian 2,3

2. Truyen naloxone lien tuc sau khi co ket - Oxy : 4L/ph

qua.

O,4mg/gia cho ngiroi 100 - Truyen dich, glucose, dam bao tuan hoan

0,0Img/kg/3 phiit cho tre em

Dem nhip tho' va do HA tronglO gio. - Theo d6i the, HA, mach 20phut/lan

3. Thong khi nhan tao (bop bong ambuthO' may)

Tit Fi02 100% ---+ 50%

(1 gia ---+ 24 gio)

4. Truyen dich nang HA

cno«.

1. Cho than hoat va sorbitol neu benh nhan dung thuoc uong

2. Can tim cac ngo doc khac kern thea barbiturate, an than va fUQU, quinin va cac bien clnmg.

3. N eu co t6n thuong na 0 thi rat nang

4. Lieu naloxone truyen lien tuc 2mg (5 ong) + 500ml Glucose 5% cho 0,4mg/IOOml/gia.

3

Bdi giang Chong doc

Dieu chinh lieu truyen naloxone phii hop moi benh nhan

1. Neu lieu dau thanh cong (0,4 -0,8mg tinh mach) dua 2/3 lieu nay bang dirong truyen lien tuc.

2. Neu sau lieu dau that bai : - NKQ, bop bong, oxy

- Tiem nhac Iai sau 2,3 phiit dua len tai 10mg tnroc khi truyen

3. Neu sau lieu dau, benh nhan co dau hieu thieu thuoc

. .

- Giam bot lieu dau

- Neu xuat hien giam y thirc lai, nhac Iai 1/2 lieu b an dau cho tai hie co hieu qua.

- Tfnh lieu ban dau thich hop sau do cho truyen lien tuc

4. Neu benh nhan xuat hien dau hieu thieu thuoc khi dang truyen - DUng truyen cho tai khi dau hieu nay dO'

- Bat dau truyen Iai = 1/2 toe d¢ ban dau, thea d6i

- Tim nguyen nhan khac gay thieu thuoc

5. Neu benh nhan giam y tlnrc trong hie truyen : - Dua 1/2 lieu dau va nhac Iai cho toi khi tot

- Tang truyen lien tuc = 1/2 toe do ban dau

- Tim duong vao mau Iai cua opioids hay nguyen nhan khac gay giam y tlnrc.

4

Bai giang Chong il6c

NgQ dQc ca noc

I. Tieu chuan chan doan 1. Chfin dmin xac dinh a). Lam sang:

Sau khi an ca noc (can goi la Puffer fish, Balloon fish, Fugu -ten goi a Nhat Ban) hay ca kho, ruoc ca lam bang ca noc, trieu cluing xuat hien sau 10 -30 phiit: Te mieng, hrci, hai moi, dau dau, non, noi kho, te a ngon, ban tay chan, yeu va met, nr vong do liet co ho hap hoac suy tuan hoan cap.

Cac dan hieu khac: Tim cham, rol loan nhip, ha huyet ap, ha nhiet dQ, tang tier mroc bot, tim, ngirng tho, mat phan xa gan xirong va twang hrc c a.

Cac dan hieu lam sang co th~ mat di sau 24 gio neu benh nhan duoc ciru song.

b). Xet nghiem:

Mau: dien giai, ure, dirong, creatinin, thang bang toan kiem Dien tam do: nhip cham, rol loan nhip

Theo dci Sp02 va EtC02 (neu co dieu kien) hoac clnrc nang phdi (Vt, ap hrc am tho vao)

PMt hien doc chat Tetrodotoxin (TTX) trong dich co th~ hoac trong miiu benh pham: chi thuc hien duoc a nhung co sa xet nghiem hien dai

2. Chfin doan phim bie!:

• Cac chat doc khac a thuc pham (vi khuan, hoa chat trir sau, chat bao quan, ca dQC loai Scombroid, Ciguatera, Shellfish cung gay non, buon non)

• Cac nguyen nhan khong do doc: Viem da day cap, co that dai trang

II. Nguyen nhan gay benh:

Chat dQC trong ca noc diroc goi la Tetrodotoxin (TTX) la chat doc khong protein, tan trong mroc va khong bi pha huy a nhiet dQ soi hay lam kho, chat dQC bi bat hoat trong moi twang acid va kiem manh.

TTX t~p trung a tning ca, ruot gan, va tinh hoan cua ca. Chat doc nay can tim thay trong mot so loai v~t khac nhu: bach tuoc co vong xanh a tua (de Ian voi con mire), con sa-giong (Newts) va ky nhong (Salamanders)

Chat dQC TTX tac dung hra chon chen dong natri trong co che bam Kali - N atri va kenh Natrium tam van dong, do do TTX gay ra liet co, liet ho hap, dong tho TTX can phat dong vung nhan cam hoa h9C gay non, non lien tuc.

II. Tien lUQ11g & Cach phong:

DQ nang cua ngQ doc ca noc tuy thuoc vao hrong doc to va thai gian duoc cap CUu:

• Neu benh nhan co trieu chung nhe co th~ thea dci va khoi

• Neu co trieu chung rc, chua bi tim, dieu tri cap ciru ban dau va h6 i strc, se ciru duoc trong vong 24 gio,

• Neu thieu oxy lau, khong diroc cap ciru ban dau co th~ gay bien chung hoac nr vong

1

Bai giang Chong il6c

* Cach phOng ngita: Tot nhat la khong an ca noc, chuan bi nii cap CUu khi can thiet

III. Dieu trl:

* Truac khi vito benh vien :

- Neu benh nhan con tinh voi trieu chung nhe: cho uong than hoat 1 -2g/kg va Sorbitol Ig/kg cho ca nguoi 1611 va tre em tren 2 tu6i

- Neu benh nhan co tim, rol loan y thirc: Th6i ngat, bop bong ambu, rdi dira den co sa benh vien gan nhat

* Trong benh vien:

Neu dii xutlt hien trieu chung tim, rtfi loan j thuc

1. Khong gay non

2. Dat ong N ¢i khi quan, co bam bong chen d~ dam bao duong dan khi, h6 tro ho hap bang bong ambu, tho may

3. Dat xong nra da day neu moi an ca trong 1 gio dan, sau nra cho than hoat 1-2g/kg

4. Truyen dich G 5% va NaCl 9% d~ duy tri huyet ap Die'u tri cac trieu chung nang (nlu co):

- Ha huyet ap

+ Truyen dich 10-20 ml dd NaCl 9% qua duong TM va d~t benh nhan nr the nghieng trai, dau thap. Can theo d6i ap hrc tinh mach trung tam (CVP). Tranh truyen dich qua rmrc.

+ Neu truyen dich khong lam tang huyet ap can cho:

Dopamin 2-5 ug/kg/phiit lieu cho ca benh nhan ngiroi 1611 Ian tre em, dieu chinh tang lieu d~ dat hieu qua, song khong qua 15 !-lg/kg/phlit, co th~ them:

Noradrenalin 0,1 - 0,2 !-lg/kg/phlit, dieu chinh lieu d~ co ket qua, lieu cao qua khong co loi gay thieu mau t6 clnrc

- Co giat: la trieu chung hiem g~p, dieu tri co giat bang Seduxen, (Valium) 10 mg tiem tinh mach, neu khong dap img co th~ cho Phenobacbitan hay Phenyltoin sau khi da d~t ong noi khi quan, thong kh i h6 tro (Xem bai "Di~u tri co giat").

2

Bdi giang Chong doc

Rita da day trong ngQ doc cap.

I. D~i cuong:

Rita da day la mot trong cac bien phap han che hap thu, Ioai bo doc chat qua dirong tieu hoa trong cap ciru ngo doc cap dirong uong, Neu diroc thuc hien som, dung ky thuat thi day Ia phuong phap rat hieu qua dtS han che hap thu doc chat: neu diroc thuc hien som trong vong mot gio sau khi uong co tM Ioai bo diroc tci 80% hrong doc chat uong vao, neu rita muon hon se kern hieu qua, loai bo duoc it doc cha], tuy nhien van co tM giam nhe rmic d¢ ngo doc xuong duoi lieu nr vong, hoac chi it cling giam nhe rmic d¢ ngo doc,

Ngoai ra, rita da day can giiip lily dich dtS xet nghiern doc chat giiip cho chan doan nguyen nhan,

Rita da day thuong diroc ket hop voi cac bien phap nhu: cho than hoar tnroc trong va sau khi rita da day dtS hap phu doc chat trong long ong tieu hoa, sau do dung thuoc tily dtS nhanh chong dira doc chat ra ngoai co thtS.

Tuy nhien rita da day khong dung chi dinh, sai ky thuat thi khong nhfrng khong co Ioi rna can co thtS dan tci cac bien cluing voi nhirng hau qua nang n~, tham chi nr vong, Chinh VI v~y can phai can nhac khi chi dinh rita da day, d~c biet la doi v6'i tre em, neu loi Ich khong r5 rang rna nguy CO' bien clnmg 1611 thi khong nen rita.

Da day la doan phmh to cua ong tieu hoa a giira thuc quan va ruot non. Ttl' cung rang tren den tam V! dai khoang 40- 45 ern. Da day co hmh chit J rong 12cm, dai 22 - 25 ern, dung tfch chua khoang 1200 ml, tren thong voi ta trang qua 16 tam vi, diroi thong voi ta trang qua 16 mon V!. Doan mot ta trang thong voi da day qua rnon vi, nam ngang, hoi chech nen tren, ra sau va sang phai, Do la ly do khi rita da day chung ta phai d~t benh nhan nam nghieng sang trai, chfnh la dtS tranh dily doc chat trong da day qua mon V! xuong ruot,

II. Chi dinh va chong chi dinh: 1. Chi dinh:

Tilt ca tnrong hop ngo doc dirong uon g den tnroc 6 gio, khong co chong chi dinh rita da day va khong thtS gay non dU'qc( roi loan y thirc, giarn hoac milt phan xa non ... ). Tuy nhien co mot so diem can clni y:

Trong thuc te, thuong kho xac dinh chinh xac thai diem uong VI vay gioi han 6 gia tro' thanh wong doi,

1

Bdi giang Chong doc

Ngo doc mot so Ioai thuoc trong do co cac thuoc an than va thuoc ngu gily giam nhu dong dirong tieu hoa, VI vay sau 6 giO' van co thtS can mot hrong IOn doc chat nam trong da day, nhat la trong cac tnrong hop ngo doc nang, Tlnrc te tai A9 dll co benh nhan ngo doc nhieu Ioai thuoc ngu va thuoc an than phoi hop diroc rita da day sau giO' tlnr sau rna mroc thao ra van darn dac, thuoc lam due trang mnrc rita. VI vay nen d~t ong thong da day tharn do cho nhfrng benh nhan diroc cho la den muon, rita vai chuc mililit mnrc neu due ta se rita tiep,

Trong cac tnrong hop diroc cho la nhe, hoac benh nhan la tre em khong hop tac, Ioi Ich cua rita da day khong ra rang rna nguy co bien clnrng cao tht nen thay the rita da day bang cho uong than hoat,

2. Chong chi dinh:

2.1. Chong chi dinh. tuy¢t doi;..

Uong cac chat gily an man: a xit, kiem manh,

Cac chat khi g~p mroc tao ra cac phan irng lam tang tac dung doc hai: kim Ioai natri, kali, phosphua kern ...

Xang, dau hoa, cac chat tao bot,

Co t6n thirong niern m ac dirong tieu hoa : Ioet nang, chay mau, phmh mach thuc quan ...

Benh nhan co roi loan y tlnrc, co nguy co sac rna chua d~t noi khi quan co bong chen dtS bao v~ dirong tho.

2.2. Chong chi dinh. tuong doi:

T6n tlnrong niern mac rnieng: d~t ong thong nho dirong niii,

Tre em uong vai vien thuoc Ioai it nguy hiem, khong co dau hieu ngo doc,

PhV nit co thai: can can nhac Ioi hai VI d~ gily con co tit cung khi d~t ong thong rita da day.

III. Chuan bi: 3.1. Dung ClJ-:

B¢ dung cu rita da day he thong kin: gorn cac bo phan dong bo nhir sau:

ong thong Fauchet bang chat deo , dau tii, co nhieu 16 0 canh, dung dtS d~t duong rnieng, co cac ca sau:

+ So 10 dirong kinh trong 4 ern.

2

Bdi giang Chong doc

+ So 12 dirong kinh trong 5 ern. + So 14 dirong kinh trong 6 ern.

ong thong cho an thirong dung cho benh nhan uong it doc chat, chua an, dau hieu ngo doc hau nhir khong co, uong da Iau qua 6 gio.hoac khong co chi dinh rita nhung co chi dinh d~t ong thong dtS lily dich xet nghiem,

Day noi chit "Y" va cac van dieu chinh dong rna dirong ra dirong vao,

Hai tiii dung dich co chi a vach do moi 50 mL Ttii tren treo cao > 1m so voi mat giuong co dung tfch 3000 ml (dung mroc muoi 0,5 -0,9 % ). Ttii durri treo diroi mat giuong it nhat 30cm.

XO dung mroc sach (khoang 5 -10 lit mroc) co pha muoi voi ty l~ 5 -9 gam/lit mroc va xo hoac chau dung mroc dich sau khi rita.

Dung cu rna rnieng,

Canun GuedeL

Seringe 50 ml

ong nghe, born cho an hoac bong ambu: Dung dtS kiem tra xem xong da vao da day chua,

L9 dung dich da day dtS xet nghiern doc chat: Dung tfch khoang 200mL

Dau paraffin: DtS boi tron dilu ong xong, han che diroc chan thirong do dilu ong xong gily ra.

Muoi an: khoang 50 gam

Than hoar: DtS hap phu chat doc, tlnrong dung sau khi rita da day.

Trong tnrong hop ngo doc thuoc trir sau thi pha Iuon vao mroc rita da day sau khi da lily dich da day lam xet nghiern doc chat,

Thoc tay: Sorbitol hoac magne su Iphat co tac dung tang dao thai chat doc va than hoat qua duong phan, Thirong born cung than hoat sau khi rita da day.

Thuoc an than: Valium 10mg (ong tiem) dung cho benh nhan kfch thich vat va nhieu, ngo doc chat gily co giat,

3.2. B¢nh nhdn:

Neu benh nhan tinh: phai giai thich dtS benh nhan hop tac

Neu benh nhan co roi loan y thirc, giam hoac milt phan xa nuot phai d~t noi khi quan co bong chen tnroc khi tien hanh rita da day.

3

Bdi giang Chong doc

Khi benh nhan uong thuoc gily co giat (Thuoc chuot Trung Quoc, rna tien, ... ) phai dung valium dtS tranh co giat tnroc khi rita da day.

Neu benh nhan co suy ho hap, truy tim mach phai tru tien tien hanh cap ciru ho hap va tuan hoan, Den khi tmh trang benh nhan 6n dinh rnoi tien hanh rita da day. Co thtS vira rita da day vira bop bong hoac thO' may.

Trai mot tarn nilon a dilu giuong dtS tranh dich day chay ra gao TU' the benh nhan: Nam nghieng trai, dilu thap,

3.3. Nhan vien lam thu thudt:

Phai la nhirng ngU'O'i da diroc dao tao ky thuat rita da day, can phai d¢i mii, deo khilu trang, di gang tay sach,

Can co 2 nguoi: mot ngiro i d~t xong da day va co dinh xong, xoa bung trong qua trmh rita. Mot ngiroi dieu chinh hrong mroc vao ra.

Khi benh nhan can phai bop bong tht phai co them ngiroi tlnr ba. v. Ky thuat:

Buoc 1: DU'a ong xong vao da day.

Chon Iva ong xong: d~t dirong rnieng dung on g xong to, d~t dirong miii dung ong xong nho (loai xong dung mot Ian)

Do d¢ dai ong xong can dira vao: Bat dau ttl' cung rang ham tren keo vong ra sau tai rdi keo thing xuong miii tic. Danh dau d¢ dai ong xong can dira vao, Thong thuong ttl' 40-50 ern.

Boi tron dilu ong xong da day bang gac tharn paraffin. Dat duong rnieng:

+ Bao benh nhan ha rnieng neu benh nhan tinh, hop taco Neu can thiet dung dung cu rna rnieng, sau do Iuon canun Guedel vao rdi nit dung cu rna rnieng, sau do Iuon canun Guedel vao roi nit dung cu rna rnieng ra .

+ DU'a ong thong vao rnieng benh nhan tirng ti mot, ttl' ttl', khi vao den hau vira dira vao vira bao benh nhan nuot, Neu kho khan thi dtS dilu benh nhan g~p cam vao thanh nguc rdi vira dily vira bao benh nhan nuot, Khi dilu xong vao den da day thay co dich va thtrc an chil y ra trong long ong xong, Dieu chinh trong qua trmh rita da day dtS dilu ong xong Iuon Iuon a V! trf thap nhat trong dich da day.

+ Tien hanh co dinh dilu ngoai ong xong a V! trf da danh dau,

4

Bdi giang Chong doc

Dat duong miii: Luon ong xong cho an vao 16 miii khong co d~t noi khi q uan dong thoi dtS dau benh nhan g~p vao thanh nguc, Khi qua 16 miii sau vao den hau thi bao benh nhan nuot dong thai dily vao.Cac thao tac tiep thea cling giong nhir d~t dirong rnieng,

Khi d~t neu khong vao diroc thuc quan phai dung den noi khi quan dtS xac dinh V! tri thuc quan sau do dung panh Magil dtS gap dau ong xong dira vao thtrc quan dong thai mot ngiroi khac dily phan ngoai ong xong vao,

Khi co noi khi quan can thao bong chen tnroc khi d~t xong, sau do born bong chen tnroc khi rita da day.

Buoc 2: Noi he thong rita da day voi dau ngoai ong xong,

Noi chit "Y" hoac khoa ba chac vao dau ngoai ong xong,

Noi hai tiii vao hai dau con lai cua chit "Y" hoac khoa ba chac, + Ttii dung dich vao treo len cot truyen each mat giirong 0,8 -1m.

+ Ttii dung dich ra d~t thap hon mat giirong (theo nguyen tac bmh thong nhau) Buoc 3: Tien hanh rita da day

- DU'a dich vao: Dong duong dich ra lai, rna khoa dirong dich vao dtS cho dich chay vao nhanh khoang 200 ml, sau do khoa dirong dich vao Iai. Dung tay lac va ep vung thirong V! dtS can thuoc va tlnrc an dir qc thao ra thea dich,

- Mo khoa duong dich ra dtS cho dich chay ra nii dung den khi het so hrong dich dira vao, dong thai voi lac va ep bung dtS dich chay ra nhanh va du hon, Sau do lily dich cho vao chai dtS lam xet nghiern doc chat (khoang 200ml).

- Lam nhir vay cho den khi het so hrong can rita (3 -5 lit) hoac dich da day da trong khong con viln thuoc va thtrc an (neu <3 lit). Trong tnrong hop ngo doc thuoc trir sau hrong dich co tM rita toi da la 10 lit.

Chily:

+ Theo doi can bang hrong dich vao ra. Neu thay hrong dich c hay ra < 150ml nghi ngc' tac xong, kiem tra lai dau xong,

+ Dich dira vao can phai pha rnuof voi nong d¢ 0,5 -0,9% dtS tranh tmh trang ngo doc mroc do pha Ioang mau.

+ Thoi tietlanh nen dung mroc am 37 DC tranh tmh trang benh nhan ret va gily ha nhiet d¢.

5

Bdi giang Chong doc

+ Benh nhan ngo doc thuoc trir sau phai rita mroc co pha them than hoat dtS hieu qua Ioai bo chat doc ddiroc tot hon, sau khi dll lily dich da day lam xet nghiern doc chat, Thuong pha 20-30 gam/lit, pha trong 3-5 lit dau,

- Sau khi rita xong, hoa than hoar va sorbitol voi ty 1 ~ 1: 1 vao 50ml born vao dad ay rdi nit xong neu khong co chi dinh hru xong rita Ian 2. Lieu hrong than hoat va Sorbitol cho vao da day sau khu rita 1-2 gam./kg benh nhan, co tM chia lam nhieu liln cac nhau moi 2 gio, DtS dam bao ap hrc tham thau trong long ru (>t cao sau khi rita tranh tmh trang tao bon hoac tac ruoot do than hoat lieu hrong Sorbitol co thtS cao gilp 1,5 -2 Ian so voi than hoat, co tM cho lam 2 -3 Ian sau khi rita da day.

- Tnrong hop khong co nii dung dich chia vach va chac ba co tM dung pheu dtS lnrng dich d6 vao, doi den khi hrong dich trong pheu xuong gan het ta ha dau xong xuong thap hon mat giirong (theo nguyen tac bmh thong nhau) dtS cho dich chay ra dong thai lac va ep bung benh nhan dtS han che can thuoc va tlnrc an bam vao b~ mat da day va dich c hay ra diroc nhanh hon, Tot nhat van phai dung bo rita da day kin.

VI. Bien clnrng:

Non: hay g~p do khi dira dau xong vao den hong benh nhan co phan xa buon non va non nhat la tre em, benh nhan 10 sq. VI vay can phai giai thich cho benh nhan dtS benh nhan diroc hop tac trong qua trmh lam thu thuat, va qua trmh dat phai nhe nhang dung ky thuat

Viem phol do sac: la mot bien clnrng nang n~, d~ tien trien thanh ARDS gily tit vong neu khong phat hien va xir trf kip thai.

+ Gap 0 benh nhan co roi loan y thtrc rna khong diroc d~t noi khi quan co bong chen tnroc khi lam thu thuat hoac qua trinh d~t khong dtS benh nhan dung nr the, dat nham vao khi quan rna khong kiem tra tnroc khi tien hanh rita da day, hoac moi Ian cho dich vao qua nhieu, hoac khong hut het tnroc khi ngirng thu thu at,

+ BitSu hien: benh nhan kho tho tim rnoi va dau chi, nhip tho nhanh, nghe phdi co ran ilm hai ben thuong 0 ben phai, Xquang phdi co dam rna tlnrong 0 ben phdi phai,

+ Phong: Dat noi khi quan cho benh nhan co roi loan y thtrc, nam nghieng trai dau thap trong qua trmh lam thu that, kiem tra lai V! trf xong tnroc khi rita da day, moi

6

Bdi giang Chong doc

Ian dira dich vao nho hon hoac bang 200ml, hut het dich da day khi ngirng thu thuat .

+ Dieu tri: tuy thea tmh trang benh nhan rna co tM thea doi va dieu tru khang sinh hoac ket hop voi d~ t noi khi quan, soi hut va born rita phe quan,

Chan thuong vung thanh mon gay phu ne thanh mon, hoac phan xa gay co that thanh mon do dau xong di vito dmmg khi quan, dat tho bao .

+ BitSu hien: benh nhan co cam giac dau vung hong, noi kho, khan tieng, Nang co kho tho' thanh quan co thtS gily ngat thO' cap, Neu khong XU trf kip thai benh nhan co tM tit vong.

+ Dieu tri:

Nhe: Cho benh nhan khi dung corticoid.

Nang: Dat noi khi quan, neu khong diroc phai rna khi quan mot tht Chay mau:

Hay g~p chay rnau miii khi dat xong diron g miii do niern mac miii nhieu mach rnau nong, xong to, khong boi tron dau paraffin, d~t tho bao, Chay rnau rnieng it g~p hon chu yeu chay rnau chan rang khi kho rna rnieng benh nhan, benh nhan day giua khi dat ong xong, Chay rnau thuc quan da day g~p khi dung xong co dau ctrng, dira vao qua sau,

+ Phong: Phai giai thich dtS benh nhan hop tac, lam dung dong tac, nhe nhang dau xong khong vat canh va cirng,

+ Dieu tri: Chay rnau nhe thuong tv earn neu benh nhan khong co roi loan dong rnau. Nang co thtS dung adrrenalin pha nong d¢ 1/10.000 rdi nho vao cho chay rnau khi benh nhan khong co chong chi dinh dung adrrenalin. Neu khong dO' co thtS phai d~t nut gac 16 miii? Tot nhat nen moi chuyen khoa Tai Miii Hong dtS earn rnau. Trong tnrong hop chay rnau da day nang phai soi da day dtS earn mau, co khi phai truyen rnau khi co tmh trang milt rnau nang,

H~ than nhiet:

+ BitSu hien: Benh nhan ret run, da tim va n6i da ga, nhiet d¢ trung tarn ha <36 do

+ Phong: thai tietlanh phai rita da day bang mnrc am, noi kin gio, dung may suai trong qua trmh rita

7

Bdi giang Chong doc

+ Dieu tri: lau kho, u am cho benh nhan, dung may sU'O'i, cho benh nhan uong mroc gjrng-duong nong (khong dung girng cho benh nhan co huyet ap)

Roi loan mroc-dien giai: tlnrong g~p ngo doc mroc do rita nhieu mroc, khong pha muoi,

+ BitSu hien: Nhe: ha Natri, Kali mau, Nang: ph u phoi, han me, co khi co giat d~ gily sac phoi neu benh nhan khong xo noi khi quan,

+ Phong: Dung lasix tinh mach, b6 sung muoi sau khi benh nhan dll titSu nhieu (Natriclorua ong tiern TM va cho uong).

+ Neu han me, co giat phai dung thuoc chong co giat, d~t noi khi quan, tho' may, dung manitol truyen tinh mach,

Roi loan nhip tim: Thuong la do phan xa, co khi ciing do rei loan mroc dien giai nang gily ra nhat la ha Kali rnau. dac biet ngo doc mot so thuoc tac dong len tim (digitalis, chloroquin, cacabamat...)

Co thtS g~p: Nh!P cham xoang do kich thich day X; NTT that do ha kali rnau Dieu tri: Nh!P cham <40 Ian/phut tiern atropin 0,5mg TM.

NTT that khi co ha kali phai bu kali bang pha truyen TM.

8

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