Summary
INTRAORBITAL HEMATOMA A LESSON FROM PATIENTS DIAGNOSED FOR CELLULITIS AND RETINAL BLEEDING
Orbital intraconal and subperiosteal hematoma is an ophthalmic emergency that can lead to visual loss due to optic atrophy and corneal exposure. On time diagnosis and treatment helps to recover the vision, ocular motility and lower the high intraocular pressure. Objective: To highlight the clinical features and therapeutic cuteomes of patients mistaken for orbital cellulitis and retinal bleeding to avdid repetitive mis- takes. Method: We present three eases with different clinical aspects to highlight the significance of proper diagnosis and on time treatment. Results: Subperiosteal hematoma can be mistaken for orbital cel- lulitis. The bleeding cause can be unidentified. Early drainage cures the vision while corneal lesions and optic atrophy can be encountered in patients with prolonged exophthalmos and compression. Recurrent orbital hemorrhage is related to a systemic disease. Conclusion: Hematoma drainage should be a surgical eye emergency so that vision can be restored. Systemic investigation should be done in case with recurrent orbital bleeding.
Keywords: Hematoma, perlostlum, orbit
H/V HUYET A P T U T H E d BENH NHAN TON THLfONG TUY SONG DO CHAN THUONG VA HIEU QUA CAN THIEP
Nguyen Do Hiing, Vu Thi Bich Hanh Trifdng Dai hoe Y Ha Ndi
Ida huyit ip td the d benh nhin liet tuy sdng do cha'n thddng gay trd ngai rat Idn den qui trlnh tip Iuyen vi ket qui phuc hoi chifc ning. Muc tieu: md ta die diem ha huyit ip td thi vi dinh gii hieu qua can thiep d benh nhin liet tuy. Doi tugng va phuang phap nghien ctfu: md ta cit ngang va can thiep tien cdu d 70 BN liet tiiy do chin thifang tuy sdng dieu trj tai Trung tim Phuc hoi chdc nang, benh vien Bach Mai. Kit qua: Benh nhin thudc do tuoi lao ddng chiem 91,17%o. Nam/nd « 4. Cd 45,6% BN bj ha HA tU the cd biiu hien lim sing; 82,35%o bj glim tuin hoin nio. Trong sd BN biha huyet ip tU the 67,7% benh nhin bj ton thdang tuy tren 76; 70,69%o BN thudc nhdm ASIA - A,B; cd 82,4%o BN phai sinh boat tai giddng. Chenh lech HA tim thu cd gii tri trung vj li 27,5mmHg. Chenh lech HA tim trdang cd gia trj trung vj li 18,03mmHg. Sau dieu trj 100%o benh nhan het trieu chdng glim tuin hoin nio. Thdi gian het tneu chdng phu thudc vio mifc dd ning cua ton thifang tuy sd'ng. Kit luan: Cho BN ngoi day sdm vi ap dung bang ep ed hieu qua rd ret trong kiem soit ha huyet ip tif thi.
Tfl khoa: ha huye't ap tfl the, cha'n thflpng tiiy sdng, phuc hdi chdc nang
I. D A T V A N D E trong tdn thfldng tuy sdng, ha huyet ap tfl the Ela huyet ap tfl the gap trong nhieu benh ly thfldng gap va vdi ty le kha Idn. Theo lllman va khae nhau nhfl; Chan thfldng tuy sd'ng, suy da he epng sfl, 7 4 % benh nhan Met tuy cd ha huyet I p thdng, parkinson, dot quy, suy t h i n kinh tfl dpng, tfl the trong khi dieu tri van dpng, vat ly trj lieu va p h l u thuat e l t be t h i n kinh glad cam... Rieng 59% benh nhan ed bieu hien lam sang [3]. 6
benh nhan tdn thflpng tuy se'/ng sfl xua't hien ha huyc'!''t ap tfl the rat sdm, e l treng giai ddan cap vA keo dAi vAi nam sau ehan thifpng [7, 2], lam trd ngai eho tien trinh phuc hdi chflc nang, va tham gia phuc hdi ehfle nang sdm. Ha huyet I p tfl the dflng dflpe dinh nghia theo Uy ban Thd'ng Nha't cua Hpi T h i n kinh Tfl dpng My vA Vien Han lam Than kinh My (1996) la tinh trang giam huyet ap lam thu ft nhat 20mmHg hdae g i l m huyet I p tam trifdng it nha't l O m m H g khi thay ddi tfl the tfl n l m ngda sang tfl the dflng, khdng ke ed hay khdng . eae trieu ehdng khae
F-lien nay, d Viet Nam viee phan loai I p dung cac bien phap phdng va dieu tri ha huyet ap tfl the'? ddng tfldng flng vdi mdi the benh eho benh nhan tdn thifdng tuy sdng edn chfla difpc dfla ra.
Chfnh VI vay ehung tdi tie'n hanh nghien eflu de tAi nAy nham muc tieu:
/ . Mo ta dac diim ha huyit ap tU thi d benh nhan tdn thuang tuy sdng do chin thuang.
2. Danh gia hieu qua can thiep cho benh nhan co ha huyit ap tu the
II. DOI TUONG VA PHU'ONG PHAP NGHIEN CL/U
1. Do'i tUPng nghien cflu: F)di tfldng la ta't ca e:ac benh nhan bi tdn thifdng tuy sdng dd chan thifpng den dieu tri tai Trung tam Phuc hdi chflc nang benh vien Bach Mai tfl t h | n g 01/2008 den thang 10/2008.
1.1. Tieu chuin chgn benh nhan
Benh nhan tdn thifdng tuy sdng do c h i n thfldng edi sdng: gdm liet td ehi vA Met hai ehi dfldi.
- lOp tudi tfl > 1 6.
- Ngifdi benh tinh t l o , tri giae binh thfldng.
1.2. TIcu chuan loai trijf
Ticn sd ha huyet ap tfl the trflde c h i n
thflpng. Dung thiie')'e glAn maeh hoae ldi tie'^'u. Cd benh tim maeh. l d n thifdng g l y xfldng ehi difdi hoae xflpng chau, tdn thifdng bung anh hfldng den viee dieu trj.,Tien sfl khdng m l e c i e benh kem theo dfldi day; Suy da he thdng, parkinson, dot quy, guillain barre, phau thuat eat bd than kinh giao e l m , thieu nang thflpng than, suy t h i n kinh tfl dpng.
2. Phuong phap nghien cu'u
Phifdng phap md t l lam s i n g ta't e l e l e tnfdng hpp tdn thifpng tuy sdng do ehan thifdng difpe dieu trj tai Frung tam Phuc hdi chflc nang Benh vien Bach Mai; ed 28 BN dflpe x l e djnh ed ha huye't I p tfl the, difpe dieu trj vA thee doi den khi ra vien.
Phifdng phap thu thap so' lieu; Benh nhan dflde kham va d i n h g i l lue vAd vien, quan sat va danh gia cac chi sd', bien so' treng khi dieu tri va lue ra v i e n .
+ X l e djnh tudi, gidi, thdi gian bj benh.
+ Xac djnh ha huyet I p tfl the; Do HA vao budi sang khi BN di tap PHCN, ngAy 1 lan, dung cu do IA may dd huyet ap AI.PK2 eua Nhat.
-I- Xae djnh trieu chflng kem thee khi ed ha' huyet ap tfl the.
+ Xae djnh vj tri tdn thflpng, mfle dp nang nhe, tinh trang bat dpng tai gifldng, e l e ehi sd huyet ap tam thu va tam trifdng, trflde vA sau dieu trj.
3. Xfl ly ke't qua: Sd lieu dflpe xfl ly theo ehflpng trinh thdng ke Y hpe SPSS 16.0.
III. KETQUA
1. Dac diem ha huye't ap t f l the
Tfl thang 1 - 2008 den thang 10 - 2008 ed 70 benh nhan tdn thflpng tuy sdng do cha'n thflpng, trong dd 34 benh nhan ha huyet ap tfl the' ehiem 48,57%. Cd 28 benh nhan ha huyet ap tfl the dflde can thiep.
Bang 1. Ha huyit ap ttf the theo vi tri tdn thuang, mtfc do tdn thtfang, tinh trang sinh boat
Miic dp tdn thflpng
Ha HA tfl the Khong ha HA tfl the
"/<> n %
Vi tri tdn thifdng
Mfle dp tdn thfldng ASIA
Tren T6 Dfldi T6 A
21 13 19
67,7 33,3 55,9
10 27,89 26 72,11 10 27,89 14,79 7 19,44
23,5 8 22,22
Tinh trang sinh hdat
D
Tai gifldng Ra khdi gifldng
2 28
6
5,9 82,4 17,6
11 7 29
30,55
• 19,4 80,6 Nhan xet: Benh nhin bj ha huyet ip tif the xay ra ehu yeu d nhdm benh nhan tdn ihifdng mifc tuy Iren 76 (67,7%;, mifc do tdn ihdang nang (ASIA A,B: 70,69), sinh boat tai giddng (82,4%o).
Bang 2. Chenh lech HA d benb nhan ha HA tU thi do TTTS do chin thuang
Chenh lech HA tam thu (mmHg) Chenh lech HA tam trflpng (mmHg) 2 0 - 4 0 4 5 - 6 0 0 - 20 25 - 40
% n % n % n % ASIA A
ASIA B ASIAC ASIA D
18 2 8 2
60 6,65 26,7 6,65
1 3 0 0
25 75 0 0
15 2 7 2
57,7 7,7 26,9
7,7
4 3 1 0
50 37,5 12,5 0 Nhin xet: Chenh lech HA tim ihu d benh nhan tdn thUdng tuy sdng nhiiu td 45mmHg - 60mmHg chi gap d mifc tdn thifang tuy ASIA - A,B chiem 100%o. Chenh lech HA tim trdang nhieu td 25 - 40mmHg gap chu yeu d nhdm tdn thifang ASIA - A,B chie'm 87,5%o.
2. Hieu qua cua cac bien phap can thiep 2.1. Kit qua diiu tri sau thdi gian can thiep
Ty le khdi ve mat trieu chflng giam t u i n bean nad la 28 benh nhan ehiem 100%. Ty le khdi h l n ve trj sd I IA la 1 8 benh nhan ehiem 60,7%.
Bang 3. Thdi gian hit trieu chtfng giam tuan hoan nao theo mtfc do tdn thuang ASIA va vi tri tdn thuang tuy sdng Mfle dp ton thflpng 1 tuan 2 tu|n 3 tuan 4 tuan
Mfle dp tdn thflong theo ASIA
Vj tri tdn thfldng tuy
A B C D Tren T6
4 0 3 1
8 8 1 2 0
3 3 0 0
9 3 0 0 0
Dfldi T6 11
Nhan xet: Thdi gian het trieu chdng tang din theo mifc do ldn thuang cua ASIA. Thdi gian bet trieu chdng ciia nhdm benh nhin ASIA - A nam trong khoang td 1 den 4 tuan, cua nhdm ASIA - B nim trong khoing td 2 - 3 luan, cua nhdm ASIA - C nam trong khoing td I - 2 tuin, vi nhdm ASIA - D li 1 tuin.
6 mde tdn thifdng dfldi T6, 100% benh nhan het trieu chflng giam t u i n bean nad trdng vdng thdi gian can thiep tfl 1 - 2 tuan dau. 0 mfle tdn thfldng tren T6 ed 8 benh nhan ehiem 4 7 % la bet trieu chdng tuan hdAn nad trong 1 - 2 t u i n dau, edn lai 9 benh nhan ehiem 5 3 % bet trieu chflng g i l m tuan hoAn nao trong 3 - 4 t u i n dieu trj tiep theo.
3.4. Hieu qua cai thien vi tri sd HA (gia tri trung vi - diem gitfa cua cac gia tri HA) Bang 4. Chenh lech HA tam thu va trUang 6 tU thi nam va dtfng trade va sau diiu tri
Chenh lech huyet ap
Chenh lech HA tam thu Chenh lech EIA tam trifpng
Khi vao (mmHg)
30 20
-1 tuan (mmHg)
20 10
-2 tuan (mmHg)
15 10
-3 tuan (mmHg)
15 10
-4 tuan (mmHg)
10 10 N/-icin xe?!: Trung vj chenh lech HA tam thu trddc vi sau diiu trj giam dan theo thdi gian td TOmmHg xudng cdn lOmmTIg, tim tnfang glim tif 20mmHg xud'ng lOmmhlg.
I V . B A N L U A N
Dac diem lam sang ha huyet ap tfl the^:
Ty le ha huye't ap tif the d benh nhan tdn thifdng tuy sdng; ty le ha HA tfl the treng nghien cdu cua ehung tdi IA 48,6%, t h i p hdn so vdi t i e gia i;V Sidordv IA 6 0 % , lllman la 73,6% | 1 , 6).
Ty le ha huyet ap tfl the phu thupe vao vj trt tdn thifdng tuy sdng; b i n g 1 cho thay benh nhan ha huye't ap tfl the nam trong nhdm tdn thfldng tuy tren T6 nhieu hdn, ehiem 67,7%. Nguyen nhan do nhflng benh nhan tdn thifdng mfle tuy tren T6 sc; kem thc?m tdn thifdng he giad e l m hcae eat dflt dan truyc^n eua he giac cam, gay len g i l m trifdng life maeh d tfl the dflng dan den ha HA. Vi vay ty le ha i\A tfl the d nhflng benh nhan tdn thifdng tuy tren T6 cad hdn. Theo EV Sidorov va cpng sfl nghien cdu tren 89 benh nhan, ty le ha huyet I p tfl the tren T6 IA 92,45% 161, theo Selvaganapathy vA cpng sfl ty le nAy IA 9 0 % [5|, theo t i c g i l Ill- man A vA epng sfl la 71,42% 13).
Ly le ha huyet I p tfl the phu thupe vAo mfle dp nang cua tdn thfldng tuy sdng;
Fy le ha HA tfl the d nhflng benh nhan tdn thfldng tuy sdng nang (ASIA - A) la 55,9%, trong dd d nhdm ASIA - \i,C,D Xy le nAy l l n lifpt la 14,79%; 23,5%; 5,9%. Sfl khac biet nAy cd y nghia thdng ke vdi p < 0,05.
FDieu nay giai thieh dflpe vi khi mot benh nhan tdn thifdng mfle ASIA - A ddng nghTa vdi viee benh nhan dd Met van dpng hoAn tcAn phai bat dpng kee dai lam thay ddi chflc nang tim maeh, cung vdi mat boat dpng cua bom cd van do liet cd, rdi loan t h i n kinh giao e l m (tdn thflong Iren T6) mfle dp nang, nen lAm ehd benh nhan dc bj ha huyet I p tfl the hpn.
Md'i Men q u i gifla tinh trang sinh hoat va ha HA tfl the;
Ket q u i nghien eflu d b i n g 1 cho tha'y trdng nhdm ha HA tfl the ed tdi 8 2 , 4 % benh nhan ed ehe dp sinh boat tai gifldng. Trong khi dd ehi ed 17,6% benh nhan ha HA tfl the ed che dp sinh boat ra khdi gifldng, nhflng benh nhan nay de tdn thflpng mfle dp ASIA - D hoae vj tri tuy tha'p; DIO, D I I , L l . Nhfl vay, ha HA tfl the Men quan mat
thic^'t vdi tinh trang bat ddng eua benh nhan dac biet IA nhflng benh nhan tdn thfldng tuy mfle dp nang vA vj tri d tren cao.
Chenh lech huyet ap d benh nhan ed ha HA tif the; do tdn thifdng tuy sdng; Theo nhfl b i n g 2, chenh lech FIA tam thu khi thay ddi tfl the ed g i l trj trung vj IA 27,5mmElg, khnlng chenh lech ldn tfl 45mi-nFlg trd len ehi cd d nhdm ASIA A vA ASIA - B, trong khi dd chenh lech du'di 45mml-lg gap d ta't ea eae nhdm ASIA. Dae biet trcng nhdm ASIA \) ed 2 be;nh nhan chenh lech d mfle tha'p nhai 20mmllg. Fheo nghien eflu cua t i e g i l Selvaganapathy vA epng sfl, gia trj trung vj IA 50mml Ig, eht'nh lech ft nha't IA 24mml-lg, chenh lee:h nhic'u nha't IA 156mmHg 15]. Qua dd ta tha'y difpc mfle dp tdn thifdng theo ASIA eang nang thi ehenh lech HA cAng nhieu. Dieu dd eung de hieu vi mfle dp anh hifdng Idn he giao e l m , he bdm eP van, he tim maeh phu thupe vao mde dp tdn thifpng nang hay nhe eua Xwy sdng, nhflng he nAy difpc l)ie''l den ed vai tro duy tri FIA tfl the dflng.
Che^nh lech hiiyc'M ap tam trfldng d benh nhan ha I IA lif the'' dd tdn thifdng luy 5e')ng; tidng nghien ei'fii eua ehung tdi ed gia trj trung vj IA I S m m l l g , Frong sd 34 benh nhan ha FIA tfl the, ed 29 benh nhan ha HA'tfl the ea tam thu va tam trfldng, ehi cd 5 benh nhan la ha FIA tam thu khdng kem ha IIA tam trifdng. Khdng cd benh nhan nad ddn thuan ehi ha IIA tfl the tam trflpng
Hieu qua cua cac bien phap can thiep:
Ket qua dieu trj sau thdi gian can thiep; Ty le khdi vc n-iat trieu ehdng giam tuan hoAn nao IA 28 benh nhan ehie'^'m 100%, sau dieu trj benh nhan e:d the ngdi xe lan tham gia q u i trinh tap Iuyen phuc hdi ehde nang sdm mA khdng xua't hien bat cfl mpt trie^u ehi'fng gi eua g i l m tuan hoAn nAo. Iy le klidi h l n vc" tri sc')' I I A IA 17 bcjnh nhan chico'm 60,7"/,,. Sau can lhie}p ehung tdi van edn 11 benh nhan mac: du khdi hoAn toAn ve mai trieu chdng
nhflng van edn xua't hien tut HA tfl the. Dd IA do benh nhan ra vien sdm (3 benh nhan ra vic>n ngay sau 2 tuan can thiep).
Cai thien ve trieu ehdng g i l m t u i n hoan nao;
Thdi gian he't trieu chflng g i l m t u i n hoAn nad tang d i n theo mfle dp tdn thflpng eua ASIA; Thdi gian bet trieu chflng cua nhdm Ijenh nhan ASIA - A n l m trong khoing tfl 1 4 tuan, e:ua nhdm ASIA - B nam trong k h o i n g tfl 2 - 3 tuan, cua nhdm ASIA C nam trong khoang tfl 1 - 2 tuan, va nhdm ASIA - D IA 1 t u i n . Sail 2 tuan ed 67,85% benh nhan khdng edn trieu chdng, d t u i n thd 3 IA 89,2%. Vay mfle dp tdn thifpng tuy cAng nang thi thdi gian hdi phue ci\A benh nhan vc mat trieu chflng eang dAi. Tuy vay, so' lieu nAy can difcJc theo ddi the'^m de ed gia trj thdng ke ehinh xae hdn.
Thdi gian het trieu chflng giam tuan bean nad theo vj tri tdn thifdng: Frung vj ihdi gian can thiep la 21 ngay, sd ngay dieu trj nhieu nha't la 28 ngAy, ft nhat IA 7. CJ mde tdn thfldng dfldi T6, 100% benh nhan sau thdi gian tfl 1 • 2 tuan dieu tri khdng eon trieu ehdng. Frong khi dd d mfle tdn thifdng tren F6 chi ed 8 L)enh nhan e:hiem 4 7 % la cAn thdi gian dieu tri 1 - 2 t u i n de hot trieu chflng, 537o btMih nhan ed thdi gian dicoii trj 2 - 4 tuan. Nhif vay, nhflng benh nhan cd mfle: tdn thflpng tren 16 can phai ed thdi gian can thiep dieu trj dAi hdn de het trieu chflng. Ly dd la nhflng benh nhan tdn thflpng tren mfle T6 se kem theo tdn thifPng he giao e l m nen kha nang thich nghi kem hdn vA thdi g i l n dieu tri cung dAi hdn 14].
Hieu qua cai thien vd trj so' HA:
Chenh lech FIA tam thu d tfl the n l m vA ddng trifdc vA sau dieu trj: Trung vj chenh leoeh FIA lam thu trflde vA sau dicu trj g i l m d i n thee thdi gian, thdi diem vAd vien chenh lech EIA tam thu ed gia tri trung vj la 30mmFlg, sau 1 tuan, 2 tuan, 3 tuan, 4 tuan dieu trj, gia tri nAy lan Ifldt la 20, 15, 15,.
lOmmFIg, sfl khae biet ed y nghia thei'ng ke (Kruskal - Wallistest, p = 0,001).
Chc'-nh lcc:h I IA l a m trfldng d tif the' n l m va dflng trifdc vA sau dieu t r i ; Sau khi dieu tri che'Mih Icjeh HA tam thu gian-i dan thed thdi gian tuy nhic^n sfl giam nay khdng ddng deu. G i a m chu yen sau 1 tuan dieu t r i , sau tfl 2 - 4 tuan thi sfl g i l m cham lai, tham chf ehung tdi tha'y mot so' benh nhan huyet ap l a m trifdng tfl the dflng cdn cad hdn ea tif the n l m d tuan thfl 2, 3, 4.
Nguyen nhan eua sfl ehenh lech nay can difdc l i m hie'^u them.
V . K E T L U A N
Dac diem lam sang ha huyet ap tfl the:
l y le ha huye't I p tif the d benh nhan tdn thifdng tuy sdng la 48,6%. Trdng dd ty le bieu hien trieu chflng giam tuan hoAn nAo IA 82,35%.
- Ty lc ha HA tif the d mfle tren T6 gap nhieu hdn chiem 67,7%. Gap ehu yen d tdn thfldng van dpng hoAn toAn (ASIA - A,B) ehiem 70%.
- Ha huyet ap tfl the Men quan mat thiet vdi thdi gian bat ddng keo dAi, 8 2 , 4 % benh nhan ha f IA tfl the ed ehe dp sinh boat tai gifldng.
Che"'nh lech EIA tam thu cd g i l tri trung vj la 27,5mmHg, tam trflpng IA 18,03mmElg.
Hieu qua ciia cac bicn phap can thiep:
- Sail can thiep 100% benh nhan he't trieu ehdng giam t u i n hoan nao, 60,7% benh nhan khdi ban ha HA tfl the.
Fhci gian he)t trieu ehi'fng g i l m tuan h o l n nao d nhdm tdn thifpng mde ASIA - A,B la 4 t u i n , d nhdn-i tdn thifdng mfle ASIA - C,D la 2 tuan.
KHUYEN NGH!
Phdng ngfla ha FIA tfl the b i n g each g i l m thdi gian bat dpng, phdng ehdng loet, eho benh nhan
tap PHCN sdm.
Nhflng benh nhan tdn thifdng mfle tuy ead va mfle dp nang can ehu dpng eho benh nhan van ddng sdm va ed dung eg hd trd de ban ehe ha HA tfl the ddng thdi ke't hpp e l e phfldng phap dieu trj.
T A I L I E U T H A M K H A O
1. Faghrl P.D., Yount J.(2002). Eleetric.ally induced and voluntary activation of physiologic muscle pump: a eomparisdn between spinal cord - injured and able - bddied individuals, Clin Rehab 16, 878 - 885.
2. Frisble J.H.(2004). f^dstural hypotension, hypdnatremia, and salt and water intake: ease reperts, jSpinal Cord Med 27, 1 3 3 - 1 37.
3. lllman A., Stiller K., Williams M. (2000).
The prevalence df orthostatic hypotension during physiotherapy treatment in patients with an acute spinal cord injury" Spinal Cord 38, 741 747.
4. Mathias C.J., Frankel H.L. (2002), Autonomic disturbances in spinal cord lesions. In:
Mathias CJ, Bannister R (eds). Autonomic Failure;
A Textbook of Clinical Disorders df the Autdnomie Nervous System, 4th edn, Oxford UniversityPress Oxford, 494 513.
5. Selvaganapathy et al, (2004). F ffeet of circumferential pneumatic compression on Orthostatic Elypotension among people with disorders of spinal cord", IJ Phys Med Rehabil 15, 7 - 1 1 .
6.Sidorov E.V. el at (2008). Orthostatic hypotension in first month following acute spinal cord injury, Spinal Cord 46, 65 - 69.
7. Silver J.R. (2000). Early autonomic dysreflexia", Spinal Cord 38, 229 233.
