NHAN XET VE CAP ClTU BENH NHAN NGITNG TUAN HOAN TAI KHOA CAP CtTU BENH VIEN THANH NHAN
DdngDuc Hodn , To Vdn Hdi', Mai Mgnh Tam'.Phgm Thi Trd Giang'
TOM T A T
Ngimg tuan hoan (NTH) la mgt cap cuu hdt sue khan cap, cd the xay ra bat ky nai nao tren dudng phd, trong bdnh vien, cong trudng, bai bien, gia dinh... Trong cac nghien cuu gin day ty Id bdnh nhan song sdt ra vidn sau cap ciiu ngimg tuin hoan chidm khdang 5%, rieng doi vd!
NTH do rung thit ti le nay 31 %.
Muc tieu: Nhan xet mdt so dac didm cua bdnh nhan NTH va cac kieu didn tim thudng gSp Tim hidu mgt sd nguyen nhan dan ddn NTH va budc dau danh gia ket qua eiia cap ciiu NTH.
Phmmg phap nghien cuu: Md ta, hdi ciiu kest hgp tidn cuu.
Ket qua nghien cuu: NTH ngoai vien la cap cuu gap chu ydu d bdnh nhan lira tudi trung nien trd ndn, nam gap nhidu ban nir. Mpt ty Id dang kd bdnh nhan khdng ed trieu chiing bao hieu trudc NTH. Cac trieu chiing bao hidu hay gap la: Kho thd, rdi loan y thuc, dau ngyc. Phan Idn cac tnrdng hgp NTH xay ra tai nha khdng cd chimg kien cua nhan vidn y td. Trong cac trudng hgp NTH cd ngudi chiing kidn, ty Id benh nhan dugc cap cuu HST? bdi ngudi ehung kidn con thap. Hinh anh didn tim tai thdi didm bdnh nhan vao cap cuu chu yeu la vd tam thu.
Kdt luan: NTH nguydn nhan khdng do tim chidm da sd cac trudng hgp. Cac nguydn nhan thudng gap: Tai bidn mach nao, va ngd ddc ma tiiy. Sau khi duge cap euu, chi cd mdt ty I? thap bdnh nhan dugc tai lap tuan hoan. Nhung chi co mgt ty Id rat nhd bdnh nhan dugc didu tri dn djnh ra vien.
T u khda: Ngimg tudn hodn.
ABSTRACT
CIRCULATORY ARREST EMERGENCY IN THANH NHAN HOSPITAL
Dang Due Hoan', To Van Hai', Mai Manh Tam',Pham Thi Tra Giang Background: Circulatory arrest is a very urgent emergency, can occur anywhere on the streets, in the hospital, the schools, the beach, at home... in the recent studies, the survival rate of patients with circulatory arrest accounts for about 5% particularly for circulatory arrest due to ventricular fibrillation rate is 31%.
Objetive: Get a look at some of the patients' characteristics and the types of ECG common. Learn some causes of circulatory arrest and preliminary evaluation results of giving first aid circulatory arrest.
Methods: Description, research in progress.
" Benh vien Thanh Nhan Ha Npi
TAP Ciri TIM MACH HOC VIET NAM SO 66 - 2014
Results: The patients with circulatory arrest are mostly m middle - aged, men more than women. Most cases of circulatory arrest occur at home, no witness of the medical staff... A significant proportion of patients wthhout symptoms for shadwowing. These symptoms are common signs: Difficulty breathing, consciousness disorders, chest pain. The images ECG when the patients come the emergency department are mostly asystole.
Conclusion: Circulatory arrest noncardiac causes is the majority of cases. The common causes: Stroke and drug poisoning after treatment, a low percentage of patienfs re-establish circulation. But only a very small percentage of patient were stable and discharged.
Key Words: Circulatory arrest.
1. DAT V A N D E
Ngimg tuan hoan (NTH) hay eung gpi la ngiing tim la mot cip ciiu hdt sue khin cap, cd the xay ra bat ky nai nao tren dudng phd, trong bdnh vidn, cdng trudng, bai bidn, gia dinh... Xii tri cap cuu NTH thudng dugc ggi la Hdi sinh Tim - Phdi (HSTP - CPR: Cardio - Pulmonary Resuscitation). Tuy theo phucmg tien cap ciiu dugc su dyng va trinh do ciia ngudi cap cuu ma chia thanh HSTP ca ban (Basic Life Support - BLS) va HSTP cao cap (Advanced Cardiac Life Support - ACLS). HSTP ca ban khi nhimg phuang tidn cap cuu chi cd rat ban chd hoac chi dugc tidn hanh bdi cac nhan vien khdng chuyen va thudng ap dung ngay tai nai xay ra ngung tuan hoan hd hap, trong khi HSTP cao cap la mdt cdng viec phiic tap diii hdi cu day du phuang tien cap ciiu va thay thudc chuyen khoa, thudng chi co the tien hanh tai khoa Cap cuu hoac khoa Hdi Siic tich eye, khoa Gay md hdi sue.
Tai My trong cac nghidn cuu gan day ty Id bdnh nhan sdng sdt ra vidn sau cap cuu ngimg tuin hoan chiem khoang 5%, rieng doi vdi NTH do rung that ti Id nay 31%(9). Tuy nhidn cac bdnh nhan nay it nhieu de lai cac di ehung dat biet la cac di chiing ve than kinh.
Tai Viet Nam theo nghidn cuu cua Phung Nam Lam va cdng sy nam 2008 tai khoa cap cuu Benh vidn Bach Mai t\' Id nay la 0%. Kdt qua nay phan anh phan nao tinh hinh cap cuu ngimg tuan hoan tai Viet Nam.
Nam 2009 khoa Cap ciiu Benh Vidn Thanh Nhan thuc hien qui trinh cap cuu mdi theo tidu chuan My nam 2007, chua cd nghidn eiiu nao ve cac bdnh nhan ngimg tuan hoan dugc cap ciru tu nam 2010 den nay.
Vi vay chiing tdi tien hanh nghidn cuu dd tai nay nham cac muc tieu sau:
/. Nhdn xet mgt so ddc diem cua Benh nhdn NTH vd cdc kiiu dien tim thuang gap.
2 Tim hiiu mgt so nguyin nhdn NTH vd buac ddu ddnh gid kit qud ctia Cdp ciru NTH.
2. DOI TlTQfNG VA PHlTONG PHAP NGHIEN CUtJ 2.1. Doi tugng nghien cihi
- Tiiu chudn chgn: Tit ca cac benh nhan NTH ddn va dugc cap ciiu tai khoa cap ciru bdnh vidn Thanh Nhan tir (1 /2010-9/2012) lay chin doan liic den vidn va khi ra vidn hoac tu vong.
- Tiiu chudn logi tru: Benh nhan khdng cd thdng tin bdnh an day du.
2.2. Phuung phap nghien cuu
- Nghidn ciiu md ta hdi cuu kdt hgp tien ciiu.
- Ndi dung nghien cuu:
+ Nghien cuu mdt so dac diem Bdnh nhan NTH va cac kidu didn tim thudng gap.
+ Nghidn ciiu nguyen nhan cua NTH.
+ Danh gia hieu qua cua cap cdu NTH.
- Phucmg tidn nghidn ciiu Thu thap thdng tin: Xay dyng mau bdnh an nghien ciiu va bieu mau thdng ke. Thdng nhat npi dung.
- Phucmg phap nghidn ciru vdi nhom tidn ciru:
+ Hoi benh va kham lam sang bdnh nhan ngimg tuan hoan vao cap ciru.
+ Chgn phac do cip ciiu phii hgp vdi tinh trang benh nhan, tung Ioai bit thudng dya tren didn tim.
+ Danh gia bdnh nhan trong liic cap curu, sy thay ddi didn tim, M, HA, hd hap... trong qua trinh cip cuu. Nhan dinh kdt qua sau qua trinh cap cuu. Cac thdng tin nghien cuu dugc lay tir benh an ciia khoa cip cuu va benh an tai phdng KHTH ciia bdnh vidn.
- Phuang tidn trg giup trong cap ctiu NTH:
+ May Monitor, may Shock didn. May ghi didn tim, may truydn djch, bom tidm didn.
+ Cac loai thudc trong cap ciru NTH: Adrenalin, Atropin, Aminodaron, Magie Sulfat,...
Tdng hgp va xu ly so lieu theo phuang phap thong ke y hgc Epi Info 6.04 3. KET QUA NGHIEN ClTU
Trong thdi gian 3 nam (thang 01/2010 ddn thang 9/2012), ehung toi thu dugc 118 bdnh an Clia bdnh nhan NTH vao khoa Cip ciiu.
Bang 1. BN NTH theo gidi GiiH
Nam Nu Tons
Nam 2010 N 36 12 48
Ty le % 75 15 100
Nam 2011 N 31 13 44
Ti le % 70,1 29,9 100
Nam 2012 N 18 8 26
Ty le % 69,2 30,8 100
Tdng N 85 33 118
Tvl?%
72,1 27,9 100 Nam chidm 72,4 cao hem nii.
Nam Tuoi 15 <
16-30 31-40 41-50 51-60 61-70 71-80
>S0 Tong so
2010 N
1 8 9 4 11 6 3 6 48
Ty 1| % 2,1 1.76 18,8 8,3 22,9 12,5 6,2 12,5 40,7
Bang 2. BN NTH theo tuoi 2011
N 1 6 6 7 9 4 8 3 44
Ty le % 2,3 13,6 13,6 15,9 20,5 9,1 18,2 6,8 37,3
2012 N
1 3 2 4 6 2 5 3 26
Ty 11 % 3,8 11,5 7,7 15,3 23 7,7 19,2 11,5 22,0
Tong N 3 17 17 15 26 12 16 12 118
Ty le % 2,5 14,4 14,4 12,8 22,1 10,1 13,6 10,1 100 Tu vong a nhom 51 ~ 60 tu6i chiem ty le cao nhat 20,8%.
TAP CHi TIM MACH HOC VIET NAM SO 66 - 2014 200
Bang 3. Ty le BN NTH so vdi Tong sd BN den cap cuu fidi tirong
BNNTH TSBNd6n cap ciiu Ty le %
Nam 2010 48 60.005
0,08
Nam 2011 44 48.577
0,09
Nam 2012 26 40.125
0,06
Tong si 118 148.707
0,07 Nam 2011 Ty Jd BN NTH la cao nhit.
Bang 4. Trieu chiing trudc NTH Trieu Chung
Khong r6 Kho tho R61 loan y thuc Dau nguc Dau dau Dau bung Non ra mau Ho ra mau
Trieu chimg khac(m^t m6i,s6t,an u6ng kem) T6ng
N 39 24 16 11 4 4 5 2 13 118
T j l e ( % ) 33 20,3 13,6 9,3 3,4 3.4 4,2 1.7 11,1 100 Bang 5. D^c diem dien tim
Bac diem dien tim Vo tam thu
Rung thit /Nhip nhanh thSt Phan ly dien co
R6i loan nhjp khac(Nhip tu that,bl6c nhi thit cSp 3, xoin dinh) T6ng
N 87 16 2 13 118
Ty le%
73,7 13,6 1,7 11 100 Hinh anh didn tim ghi dugc chu yeu la vd tam thu (87 trudng hgp,73,7%)
Bang 6. Nguyen nhan NTH Nguyen nhan NTH
Co benh ly tim tir tnroc Khong c6 b?nh ly tim T6ngs6
N 47 71 118
Ty le % 39,8 60,2 100 Da so BN NTH vao khoa cap ciiru khong co benh ly tim.
Bang 7. NTH Khong do tim, qui theo cac chinmg binh ICD 10 NTH khong do tim
Tai bien mach nao Diing qua lieu ma tiiy Suy than m?n Chan thuong Xuat huydt tieu hoa Hen phe quan COPD Treo CO Hon me gan Soc nhiem khuan Dien giai Ngat nude Ho ra mau Tran khi mang phdi Tdng
N 15 10 9 8 6 3 5 3 4 2 2 2 1 1 71
%
21.1 14,1 12.7 11.2 8,5 4.2 7,0 4,2 5.6 2,8 2.8 2,8 1,4 1,4 100 Benhly TBMN(2I.1%) la nguyen nhan thudng gap d cac BN NTH khong do tim.
Bang 8. Noi xay ra NTH Nod lay ra NTH
Tai nha Xe chuyen vien Xe cap cuu 115 Tai khoa cap curu Tong
N 76 18 15 9 118
Ty le (%) 64,4 15,3 12.7 7,6 100 Da so BN NTH xay ra tai nha.
Bang 9. Ket qua c3p curu NTH Ket qua cap ciru NTH
Tim dap tnj lai, BN tmh Tim dap tra lai, BN hon me sau Tim khong tu dap tra lai T6ng
N 2 12 104 118
Tyle(%) 1.7 10,2 88,1 100 Cac BN NTH vao cip cuu nhung kit qua chu ylu la Tim khong dap tro lai.
TAP CHi TIM MACH HOC VIET NAM SO 66 - 2014 202
Bang 10. Kdt qua cip cuu NTH theo nam
Tim dap tra lai, BN tinh Tim d^p tra lai, BN tii vong Tim khong dap tra lai Tong
2010 N 0 4 44 48
Tyl?
(%)
0 3,39 37,29 40,68
2011 N
1 5 38 44
Ty le (%) 0,085
4,26 32,20 37,29
2012 N
1 3 22 26
Tyle
(%)
0,085 2.55 18,61 22,03
T6ng N 2 12 104 118
Tyle
(%)
1,7 10.2 88,1 100 Ty le BN dugc cap cuu NTH thanh cdng tang din theo thdi gian, ket qua cd y nghTa thdng kd vdi p<0,005.
4. BAN LUAN
(1) Nhf n xet mpt so dac diem ciia Benh nhan NTH va cac kidu didn tim thudng gap:
Trong nghien ciiu cua chiing tdi, bdnh nhan NTH gap d nam nhieu ban nu (72,4% so vdi 27,9%). Tudi trung binh ciia nhdm bdnh nhan nghidn ciiu la 4.052 ket qua nay tuong duang vdi ket qua Clia Phiing Nam Lam (10) ty Id nam la 70,4%. Dang chu y chiing tdi gap 2,5% bdnh nhan < 15 tuoi (Bang 2) cd the giai thich didu nay theo chiing tdi \ i khoa cip ciiu Benh vien Thanh Nhan bao gomca cap cuu Nhi.
Kha nhidu bdnh nhan NTH ma khdng cd trieu chiing ggi y tnrdc (33%). Day la mot trong nhimg kho khan cho cdng tae phat hien va cap euu NTH. Cac trieu chiing bao hidu hay gap lan lugt la: Khd thd (20,3%), rdi loan y thiic (13,6%), dau ngyc (9,3%).
Nghien ciiu cua chiing tdi khac vdi nghidn ciiu cua Clark va cdng sy (3) ty Id bdnh nhan dau ngyc la 75,6%, giai thich cho didu nay co le la do ca cau bdnh tat cua cac nude phat trien chii ydu nguyen nhan NTH la do benh ly NMCT va dugc theo doi va dieu tri tai nha sat sao.
NTH chu ydu xay ra tai nha, chiem ti le cao nhit 64,4%. NTH tren xe cip cuu chuyen vidn chiem mdt ti le dang kd 28% (15.3%-12,7%), chi diing thu 2 sau NTH tai nha. Day la mgt dac didm ridng uong nghidn ciiu cua chiing toi so vdi cac tac gia nude ngoai nhu Dirt Muller va cdng sy (4) ty Id nay chi chidm 5%. Dya vao giiy td chuyen vidn va cac ghi chep ciia Nhan vidn Y td trdn xe cap cuu 115. chiing toi bidt dugc la nhiing bdnh nhan thudng dugc gpi cap ciiu sau khi da cd dau hieu nang hoac dd cd thdi gian dieu tri d tuyen dudi, hoac do nguyen vong tu phia gia dinh bdnh nhan, ndn bdnh nhan dugc chuyen Idn tuydn trdn. NTH thuemg xat hien trudc khi kjp chuyen bdnh nhan ddn bdnh vidn tuyen tren. Da sd trudng hgp NTH cd ngudi chiing kidn ddu dien ra trdn cac xe cip ciiu ed Nhan vidn y te di ciing. chidm 35,6%. Trong sd cac trudng hgp NTH dugc chiing kien, mdi co 40% ngudi chiing kien tien hanh HSTP cho bdnh nhan, con Iai 60% trudng hgp ngudi chiing kidn khdng tidn hanh HSTP chi cd ging nhanh chdng ehuydn bdnh nhan den bdnh vidn.
Trong hoan canh ngoai bdnh vien, vide danh gia xem mdt nan nhan bit tinh co dang thd binh thudng hay khdng la mot khd khan doi vdi ngudi chirng kidn, cho dii hpla nhan vien y td.
Nhieu trudng hgp bdnh nhan thd ngap hoac bdnh nhan nam im khdng thd nhung ngudi chiing kidn tudng nham la bdnh nhan van dang thd binh thudng hoac dang ngii, va do do khdng tidn hanh HSTP.
Trong khi dd, theo Clark va cgng sy (3) hien tugng thd ngap cd thd xuit bidn tdi 40%
trudng hgp NTH [3]. Hinh anh didn tim la vd tam thu chiem ty le cao nhat 73,7%.
Nghien ciiu cua chiing tdi tuang duang vdi nghidn cuu cua Phiing Nam Lam va cgng su (10) ty le nay la 74%. Rung thit/nhip nhanh thit dung thii 2 (13,6%). Hai bdnh nhan ehung toi cip cuu thanh cdng (dugc dieu tri dn dinh ra vien) deu la bidu hien rung that trdn didn tim va dugc danh sdc didn kip thdi didu nay cung phii hgp vdi nghidn cuu cua Safranek va cgng sy (7) ty Id benh nhan NTH cd rung thit cip ciiu kip thdi thanh cdng den 35%. Ty le vd tam thu ctia chiing tdi cao hoa trcmg khi ^ Id rung tiit/nhip rJianh iMt thip hon so vdi cac tac gia Mickey S. Eisenberg (5) ty Id nay la 64%... Cd the ndi, vd tam thu chidm phan idn rdi loan nhip tim la mpt khd khan trong cip cuu benh nhan NTH ngoEii vidn khi dua vao khoa cip cuu, va khi do kha nang hoi sue thanh cdng la rat hidm Larsen MP va cpng sy (6) ty Id thanh cdng chua den 0,5%.
Trdn thd gidi hien nay, loai rdi loan nhip tim dugc xac dinh bang cac thidt bi cam tay, ghi ngay tai hien trudng khi nhan vien cip cuu tidp can dugc bdnh nhan. Trong nghien ciiu ciia chiing tdi, khdng cd benh nhan nao xac dinh dugc loai rdi loan nhip tim tru'dc khi ddn vdi chiing tdi tai khoa cip cuu. Do do, ddi vdi trudng hgp NTH can sdc didn (rung that hoac nhjp nhanh that vd mach), thay vi can phai dugc sdc dien cang sdm cang tot ngay tai hien trudng, benh nhan vin phai chd cho ddn khi dugc van ehuydn ddn ca sd y te ed kha nang xac dinh dugc loai rdi loan nhip tim, va co may sdc didn.
(2) Nguyen nhan dan den NTH va budc dau danh gia kdt qua cua Cap ciru NTH Trdn lam sang NTH hudng tdi nguyen nhan khdng do tim (60,2%) chiem ti le cao han NTH nguyen nhan do tim(39,8%). Tai bidn hay gap nhit trong nhom nguyen nhan NTH khdng do tim..
Kdt qua ciia ehung tdi khac J. Engdahl. M.Kuisma (2): NTH khdng do tim chiem ti id thap ban, dao ddng tir 25% den 35%, trong dd chan thuong hay gap nhat. Chiing tdi gap mpt ty le benh nhan NTH do ngd ddc ma tiiy, giai thich cho dieu nay theo chiing tdi co thd do vi tri dja ly Clia bdnh vien Thanh Nhan. Chan doan phan loai nguyen nhan chi dya vao bdnh canh lam sang nen khdng tranh dugc bd sot, do do ndn dya vao kdt qua giai phlu benh ndu cd. Trong didu kien thyc td d Viet Nam, da sd bdnh nhan sau khi tu vong dugc ngudi nha xin khdng mo tir thi, khdng lam giai phlu bdnh. Trong nghidn cuu ciia ehung tdi chi co 02 benh nhan song sot cho den khi ra vidn va ddu la nhimg trudng hgp NTH xay ra ngay tai khoa Cap cuu va co sy chiing kidn cung nhu tidn hanh kip thdi cua nhan vidn y td tai khoa Cap cdu. Da sd cac trudng hgp NTH khdng phuc hdi (88,1 %). 10,2% trudng hgp tim dap trd lai nhung bdnh nhSn hon md sau duoc dua va khoa HSTC nhung sau do tu vong hoac gia dinh xin vd vi tinh trang benh nang.
Theo Safranek DJ(7) ty Id sdng sdt ddn khi ra vidn la 1,5%; theo Grubb NR(8)la 0,7%.
Nhin ehung ty Id sdng sdt cua NTH d cac trung tam cap ciiu trdn thd gidi chua vugt qua 5%. So lugt ngudi tham gia cip cuu NTH cd du ky nang can thidt la rat it, bdn cgnh dd thuoc va cac trang thidt bi may moc phuc vu cho cap cdu NTH khdng cd hoac thidu.
TAP c m TIM MACH HQC VIET NAM SO 66 - 2014 204
5. KET LUAN
(1) Dae diem cua BN NTH va cac kidu didn tim thudng gap:
-.NTH ngoai vidn la cip cdu gap chu yeu d benh nhan lua tuoi trung nien trd ndn, nam gap nhidu ban nu.
- Khdng cd trieu chiing bao hidu trudc khi NTH chiem 33%.
- Cac trieu ehung bao hieu trudc khi NTH hay gap la: Khd thd, rdi loan y thuc, dau ngyc.
- Phan Idn cac trudng hgp NTH xay ra tai nha khdng cd chiing kidn cua nhan vidn y td.
- Trong cac trudng hgp NTH cd ngudi chiing kien, ty Id bdnh nhan dugc cap cuu HSTP bdi ngudi chiing kien con thap. Hinh anh didn tim tai thdi diem bdnh nhan vao cap ciiu chu ydu la vd tam thu.
(2) Nguyen nhan NTH va kdt qua Cip cuu NTH:
- Nguyen nhan NTH khdng do tim chidm da sd cac trudng hgp. Cac nguydn nhan thudng gap: Tai bien mach nao, va ngo ddc ma ttiy.Sau khi dugc cap cuu.
- Kdt qua cip cim NTH: Chi c6 mpt ty le thap benh nhan dugc tai lap tuan hoan. NhuTig chi cd mdt ty Id rat nhd bdnh nhan dugc didu tri dn dinh ra vidn.
6. KIEN NGHI
- Thudng xuyen cap nhat cac kidn thuc vd cSp cuu NTH cho cac can bp y td. Td ehue cac kip cap cuu NTH chuyen nghiep tai khoa cap cuu.
- Dua ra mpt sd ydu cau tdi thidu vd trang bi va thudc cho cap ciiu NTH trdn xe cap ciiu cung nhu tai phdng cap ciiu tai cac co sd y td.
TAI LIEU THAM KHAO
I.Cardiac Arrest and Cardiopulmonany Resucitation Outcome Reports: Update and Simplification ofthe Utstein Templates for Resuscitation Registries.A Statement for Healthcare Professionls From a task force ofthe International Liaison Committee on Resuscitation.(2004) CircuIation,l 10,p.3385-3397.
2. M.Kiusma, A. Alaspoo (I997).Out-of-hospital cardiac arrest of non-cardiac orgin. Eur HeartJ, 18,p. 1122-1128.
3. Clark JJ, Larsen MP, Culley LL, Graves JR, Eisenberg MS (1992). Incidence of agonal respirations in sudden cardiac arrest. Ann Emerg Med, 2, p. 1464-1467.
4. Dirk Muller, Rahul Agrawal, Hans-Richard Amtz (2006). How sudden is sudden cardiac death?.Circulation, 114,p. 1146-1150.
5. Mickey S. Eisenberg, Terry J. Mengert (2001). Cardiac resucitation. N Engl J Med, Vol.
433,No.l7,p. 1304-1313.
6. Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP (1993). Prediting survival from out-of-hospital cardiac arrest: a graphic model. Ann Emerg Med, 22,p. 1652-1658.
7. Safranek DJ, Eisenberg MS, Larsen MP (1992). The epidemiology of cardiac arrest.
Lancet, 346, p. 417-421.
8. Grubb NR, Elton RA,Fox KAA (1995). IN-hospital mortality affler out-of-hospital cardiac arrest.
9. PhilipJPodridM)MortonFAmsdorf>lDJMCC JieChengJvID,PhDMCC(2007). Outcome of sudden cardiac arrest. Uptodate.
10. Phiing Nam Lam, Vu Quang Ngoc, D6 Trong Nam (2008) "Nhan xet mpt s6 ylu to anh huong tcri hieu qua cap ciiu NTH", Tap chi Y hoc lam sang Benh vien Bach Mai so 1128, trang 207-213.
11. To Van Hai, Vu Van Giang, Dang Dure Hoan (2010) Nhan xet cac Benh nhSn tij vong truoc khi vao khoa Cap cuu Benh vien Thanh Nhan trong 3 nam; Tap chi Y hpc thirc hanh so 10/2010, trang 8-16.
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