la nhdm tudi 41-60 va thap nhat la nhdm tren 60 tudi TAI LIEU THAM K H A O
1. Arthur Disalvo (2009), Mycology-Dlmorphicfungi.
pathmicromed,sc.edu/mycology/mycology-6.htm.
2 Cooper, Jr. (2007), "Epidemiology and Laboratory Diagnosis of Fungal Diseases", Medical Mycology (BIOL 4849), 1-6.
3. Fungal infections (2012, http://www.
healthcommunities.com/fungal-infections/fungal-
infections-oven/iew.shlml.
4. Histoplasma capsulalum (2007), microbewiki.
kenyon.edu/index.php/Histoplasma_capsulatum.
5. Quinn P. J , Markey B. K., Leonard F. C, FitzPatrick E. S., Fanning S.. Hartigan P. J. (2011). Veterinary Microbiology and Microbial Disease, 2nd Editon, Blackwell Science.
6. Le Thi Xuan (2008), Ky sinh trung thuc hinh, NXB Giaoduc, HaNoi, tr 113
KET QUA DIEU TRj GAY KHUNG CHAU KHONG VUNG BANG KHUNG CO DINH NGOAI
TOM TAT
Muc tiiu cOa nghien cOU la danh gia kit qua dieu tri gay khung chau khdng vung b^ng khung cd dinh ngoai.
Phuang phip nghien cUu: Tiin cUu. Danh gia kit qua theo 4 miJc: rat tit, tot, trung binh va kem.
Ket qua nghien cUu: Vdi thdi gian theo ddi trung binhli 17,7thing, chOng tdi thu duac kit qua nhu sau:
100% lien XUdng ky dau. T^ le rit'tdf dat 71,42%, tdt 17,85%, trungbinhia 10,73%.
Kit luan: SCr dung ci dinh ngoii dieu tri cho cac gay khung chau khdng vOng cho kit qua kha quan nhd tac dung ed dinh vOng chic 6 gay. BN cd the tap van ddng sdm, tranh duac cac biin chUng do nim lau.
Thuan Ipi cho viec cham sdc BN va dieu tri cac thuang tin kit hap.
Tifkhoa: Gay khung chau, Khung d dinh ngoai.
SUMMARY
OUTCOMES ON TREATMENT UNSTABLE FRACTURES OF THE PELVIC RING
Purpose: Determine the outcomes treatement of unstable fractures of the pelvic nng by fixation external for treatement shock, the union and rehabilitation.
Methods: In this prospective study, we evalue the results among 4 level: excillence, good, fair and bad.
Results: with 17.7 months follow -up, 100% of the union of the pelvic. Excillence 71.42%, good 17.85%
and fair 10.73%.
Conclusion: The results was rather well immidiate after fixation, the patients can sit early, excercise gently. Therefore, they can avoid the complications of lying for long time. Especially, it was very convenient for taking care and treating patients who also had combine lesion.
Keywords: Unstable fractures of the pelvic nng, external fixation.
OATVA'NDE
Gay khung chau la mot ton thUOng nang ne, c 6 1 / le tCf vong cao chi sau cha'n thuong so nao, trong do nguyen nhan ehCi yeu la do tai nan giao thdng.
Khi benh nhan gay khung chau cd the kem theo cac thuong ton ket hpp khac nhu cha'n thuong bung kin, chan thUdng bang quang, g l y nhieu xudng . nen rat de cd sdc va nguy cd tLf vong rat cao.
Phuong phap dieu tri kinh dien lau nay v I n duoc ap
DANG HOANG ANH, PHAM DANG NINH Benh vien 103
dung la phong chdng sdc tich eUc va de benh nhan nam bat dong gac chan tren gia Braun tu thd diii ech trong 5- 6 tuan. Mdt sd benh nhan cd the ket hop vdi bien phap t-eo vong de ep va ed dinh khung chau hoac keo hen tuc [1], [2], Tuy nhien bien phap nay khdng thuan Ipi trong ca'p ciru dieu tri eac benh nhan ngoai gay khung chau cdn cd nhieu thUdng ton ket hpp can xOtri sdm cung nhUsan sdc hau phlu.,.
Do g l y khung chau chay nhieu mau va dau ddn nen de ptidng chdng sdc cd hieu qua thi can phai ed dinh ehac d g l y va ep 2 mat gay de cam mau. Xua't phat tu nhuTig ly do tren day, tren the gidi va Viet Nam da cd nhieu phlu thuat vien nghien eifu sir dung khung cd djnh ngoai vao dieu tri cap cuU gay khung chau nham muc dich phong chdng sdc. tao thuan Ipi cho xif tri cac ton thuong ket hdp va du phdng cac bien chimg do nam lau. Nhieu nam qua. Bd mdn khoa Chan thuong chinh hinh Benh vien 103 da img dung phuong phap cd dinh ngoai mot ben bang bd coc ep ren ngUpc chieu cCia Nguyen Van Nhan de dieu tri cho cac gay khung chau, bUoc dau thu dupc ket qua kha quan.
Chiing toi tien hanh de tai nghien cUu nay nham muc tieu: Dinh gii kit qua dieu tn cOa phuang phap tren cac mat phdng chong soc, lim lien xuang va phuc hdi choc nang.
DOI Tt/ONG VA PHUONG P H A P NGHIEN CLTU 1. Ddi tUdng nghien cUu: Gdm 35 benh nhan gay khung chau dupc cap cifu dieu trj bang khung cd d|nh ngoai tai BV 103 trong thdi gian tU thang 7/ 2011 den thang 9/ 2014. Bao gdm 24 nam va 11 nif tuoi tU 17 den 52, tudi trung binh la 30,56,
Nguyen nhan gay xUdng. TNGT* 29 BN; TNLD: 6 BN.
Phan loai gay khung chau theo Tile (1988) Tat ca deu gay khung chau mat vung gom 9 BN gay loai B va 26 BN gay loai C (CI. C2 khdng cd gay loai C3).
- Ton thUdng ket hdp- cd 11 benh nhan.
+ Gly khung chau + Chan thuong bung kin: 5 BN + Gay khung chau + Vd bang quang: 2 BN + Gly khung chau + Rach tang sinh mdn: 2 BN + Gly khung chau + gay hd xUdng chay: 1 BN + Gay khung chau kem theo sai khdp hang ben phai: 1 BN
Y HOC THUC HANH (957) - SO 4/2015
^ Cd 1 benh nhan vUa chan thuong bung kin vUa gay cang chan.
2. Phuong phap nghien cUu: Nghien cUu tien edu, the nghiem iam sang khdng doi chifng, theo ddi dpc.
2.1. Dung cu
Bp coc ep ren nguoc chieu (CERNC) cua Nguyin van Nhan loai dai 35 cm.
Dinh Schanz cd dudng kinh 4,5mm dai 125mm.
Khoan dien, khoan tay va mui khoan d i n dudng cd QK 3,0mm. Hai doan dinh Steinmann DK 5mm, dai 60mm.
2.2. Phuang phap vd cam
Thuc hien tai giudng hdi sUc cap cifu hoac sau khi ddng xong vet mo cap cifu giai quyet cac thUdng ton d bung.
Neu iam tai giUdng ehi can gay te tai chd bang Lidocain 1 % d cac vj tri khoan xUdng de bat cac dinh Schanz, ket hpp vdi thudc an than, giam dau toan than,
2.3. Ky thuat xuyen dinh lip khung co dinh ngoai
Benh nhan nam ngCfa, hai dui gae tren gia Braun tu the con ech, thuc hien ngay tai giudng sau khi da kham va theo ddi khdng cd thuong tdn ket hpp trong d bung.
Xac dinh vi tri xuyen cac dinh: 2 dinh dau tien dat d mao chau, dUdi gai chau tifdc tren tU 1,0 -1,5 cm.
Rach da dp 5mm khoan bang mui khoan 3,5 mm theo hudng tir tren xudng dudi, tU trudc ra sau. tU ngoai Chech vao trong. Diing khoan tay de bat 2 dinh Schanz theo id vira khoan, sau dd lap coc ep ren ngUpc chieu thif nhat ket ndi 2 dinh nay, diing cd le 10 de van dan dan ep khung chau nham thu hep khoang each 2 gai chau trudc tren trudc khi khoan va bat 2 dinh sau
Khoan va bat tiep 2 dinh Schanz con lai d mao chau, each vi tri dinh dau t U 5 - 6 cm, hudng dinh cung tUdng tu nhu hai dinh dau. Lap tiep coc thU 2 sau do lien ket giCfa 2 coc bang hai doan dinh Steinmann.
Can cU vao mife do di lech mat viJng cua khung chau, tinh trang doang ciJa khdp mu tren phim XQ de van ep cho 2 mat gay ap vdi nhau va lam cho khung chau viimg hdn. Chup lai XQ sdm khi toan than benh nhan on djnh de tiep tuc van chinh ep cho khung chau trd ve binh thudng.
Cd 4 BN khi vao cd gay khung chau loai C2, mdt nu^ khung chau b| keo len tren, ehiing tdi xuyen dinh keo lien tuc de ve vi tri binh thudng rdi mdi thUe hien cd dinh ngoai.
2.4. Thdi di^m thuc hien ky thuat
+ Thuc hien ngay sau khi md cap cifu: 5 BN {3 BN md chan thUdng bung kin va 2 benh nhan vd bang quang).
+ Thuc hien tU ngay thU 2 den ngay thU 4: 27 BN + Thuc hien vao ngay thU 5 den ngay thU 7. 3 BN.
Thdi gian mang khung: TU 6 - 8 tuan
3. Danh gia ket qua: DUa theo nhifng tieu chuan ve tac dung giam dau, phdng chdng sdc, ket qua lien xuong va cac bien chifng, chung tdi xay dung mot bang phan loai ket qua gom 4 mUc tdt, kha, trung binh va kem.
KET QUA N G H l i N ClfU
1. Ket qua gan: Tat ca cac benh nhan deu dd dau ngay sau khi xuyen dinh va lap khung co djnh ngoai.
Tar 5 BN md bung ket hpp phai ddi khi ttnh lai mdi th%
khung chau dd dau.
Ket qua XQ kiem tra thay tat ca cac benh nhan deu dUdc nan ehinh phuc hdi ve hinh the giai phlu tU miic kha trd lan. Cac dinh Schanz dUOc bat dung vi tri, nam trong xuOng mao chau. Khong cd BN nao bj xuyen dinh trUdt ra ngoai.
Bien chifng nhilm khuan chan dinh: 14 BN (25%), Cac benh cd thuong tdn ket hpp:
+ 3 BN cha'n thuong bung deu dUdc xif tri ^n thUdng bung on dinh, khong benh nhan nao cd bd sot thUdng ton.
+ 2 benh nhan tdn thUdng bang quang dUdc mo ca'p cifu tu gid thO" 4 den gid thU 6. D i l n bien sau md tdt.
+ Hai benh nhan ed rach tang sinh mdn deu duOc xCf tri eat Ipe vet thuong, thay bang ket qua lien vet mo ky hai.
+ Hai BN gay hd xuong chay, mot benh nhan dilOc md ket XUdng dinh ndi tuy ngay thu" 10, vet me lien ky dau va 1 BN dupe ket xUOng chay bang khung co dinh ngoai.
+ Benh nhan sai khdp hang phai dUde keo lien tuc nan ehinh ket hpp co ^ n h ngoai d gay khung chau. Ket qua benh nhan dUdc nan chinh het sai khdp hang va dieu trj lien vet thUdng Idc da d dui.
2. Ket qua xa
Chiing tdi da kiem tra dUOc ket qua xa dupc 28 BN vdi thdi gian theo ddi tU 6 thang den 3 nam, trung binh la 17,7 thang. 7 benh nhan khdng theo ddi dupc kel qua xa do benh nhan di lam an xa.
Ket qua tdt cd 20 benh nhan (71,42%), kha 5 bSnh nhan (17,85%) va trung binh 3 benh nhan (10,73%).
Khong cd ket qua kem.
Cd mot BN bien chifng nhilm khuan chan dinh ro mil keo dai tdi 3 thang, chung tdi gay te tai chd, tai cho nao het phan xUOng viem, sau dd het viem rd. Benh nhan ket qua trung binh do gay khung chau phifc tap, cdn ngan chi 3cm.
BAN LUAN
1. Ve chi djnh cua phUdng phap co djnh ngoai trong dieu trj gay khung chau
Theo Tile' Letoumel, Judet va Muller [3], [4] thi chi djnh dieu trj cac gay khung chau trudc het phaii can cii vao tinh trang toan than cCia benh nhan va phan loai gay khung chau. Hai bang phan loai cOa Muller va ciia Tile hien dang dUpc nhieu phlu thuat vien ap dung.
Ddi vdi gay loai A la cac gay khung chau nhung la gay XUdng vuYig, neu khdng ed cac thuong tdn ket hpp c6 the cho nam bat ddng gac chan tU the diii e'ch trong 4 tuan. Vdi cac gay loai B va loai C, la nhung gay khong vijng. Khai niem khdng vCfng d day khdng chi la di/dng g l y ma ndi den sU ma't vung cua vong chau (cunfl trudc va cung sau deu gay). Ddi vdi gay loai nay cac tac gia deu chij trUdng phau thuat ket xUdng lam viing khung chau.
Y HOC THUC HANH (957) - SO 4/2015
Chung toi chpn phuong phap cd djnh ngoai vi:
- Trudc het dayla phuong phap cd (Snh o gay vutig dhac.
• Thao tac ky thuat ddn gian, chan thuong p h l u thuat khdng Idn nen do an toan rat cao. Cd the chi gay te tai cho ket hdp giam dau toan than nen cd the thuc hien ngay lai phong hdi sifc va lam sdm trong ngay dau.
Viec CO djnh d gay vung chae vUa cd tac dung giam dau VLfa cam mau va tien Ipi cho viec thUe hien cac cong tac cham sdc ho ly cho BN sdm, an toan hdn,
Ket qua dieu tri 35 BN vdi nhiJng thUdng tdn nang ne va phUc tap deu thoat sdc, lien xuOng va PHCN tot da chifng to su lUa chon ciia chiing tdi la diing.
2. Ve ky thuat ket xudng
- Ve thdi diem tien hanh: chiing tdi cho rang nen lam sdm, cang sdm cang tdt vi muc teu quan trpng la giam dau va cam mau de phdng chdng sdc. Do dd, neu benh nhan cd thuong ton ket hpp can phai mo thi se de BN len nha md va cd dinh khung chau sau khi ddng vet mo bung. Neu BN khong cd thuong ton ket hpp trong d bung thi nen iam ngay tai giudng benh va cung can lam sdm.
Theo Letournel, Ruedi, Murphy, Nguyin Ngpc Toan vdi muc dich cd djnh d gay va khung chau de giam dau, d m mau, thuan tien cho di chuyen BN khi can thiet va do chan thuong phlu thuat khdng nhieu nen cac tac gia nay da chii trUong lam sdm hdn [2], [3], [4]. Cac trudng hop khi vao cap eUu, da thuc hien cac bien phap chdng soc cd ban nhutem giam dau, truyen dd djch va mau ma v I n chua thoat sdc thi cung nen CDN sdm de cam mau. Chinh khung cd dinh ngoai ep mat g l y xUdng chau lai cd tac dung cam mau khi XUdng dang chay mau giup cho BN thoat sdc.
Vi tri xuydn dinh: chpn mao ehauja vj tri xuyen dinh. Vj tri nay sd thay ngay dudi da, de lam va khdng sd cd ton thUdng mach mau, tdn thuOng tang trong o bung. Mot so tac gia cdn xuyen ca 2 dinh vao nganh cliau - mu, lam nhu vay luc ep dan deu hon nhung can
phai de phdng bien chifng ton thUOng tang d phi'a dudi.
Phai khoan trUde bang mui khoan cd dudng kinh 3,5mm qua 2 vd xUOng chau, sau dd dung khoan tay de bat eac dinh ed ren. Lam nhu vay de bat cac dinh chinh xac va chae vao thanh xUOng chau.
Khi lap coc ep nen de eoe each da thanh bung 3-4 cm la dii de thay bang eac vet md bung neu cd.
Chpn khung la coc ep ren ngUpc chieu cua Nguyin van Nhan ed nhieu Ipi diem vi: day la bo khung ma quan y quen su" dung, thao tac ddn gian, co dinh chae va cung la loai khung s i n cd d cac BV quan y. Khung coc ep ren ngUpc chieu co the sCf dung cho nhieu vj tri gay xuOng nen rat tien cho viec bao quan, sij" dung d tuyen trUdc trong dieu kien chien dau.
KET LUAN
Cng dung phuong phap cd djnh ngoai mot ben bang bo eoe ep ren ngUdc chieu cQa Nguyin Van Nhan de dieu tri cho cac gay khung chau khdng vijtig cho ket qua kha quan nhd tae dung ed djnh viJng ehac d gay, cam mau kip thdi nen gdp phan chdng sdc tdt.
TTiuan Ipi cho viec cham sdc cac BN va dieu tri cac thudng tdn ket hpp. BN cd the tap van dpng sdm, tranh dupc cac bien chifng do nam lau. Ket qua lien xUdng va phuc hdi chUc nang tdt dat 71,42%, kha dat 17,85%
va trung binh la 10,73%. Bien chUng nhilm khuan chan dmh la 25%.
T A I L I E U THAM KHAO
1. Nguyin van Ninh (2011). "Dinh gii kit qua diSu tri gay khung chau khdng vOng bing khung co' dinh ngoai tai Benh vien 103" Luan vSn Thac sy. HVQY
2. Nguyen Ngoc Toan (2005) "Danh gia kit qua diiu tn gay khung chau khdng vOng bang khung co dinh ngoai tai BV Chg Riy". Luan vSn Thac sy. HVQY.
3. Ruedi T.P., Murphy W.M (2001). Pelvic ring injuries, assessment and concepts of surgical management. AG principles of fracture management, p 395 - 417
4. Larry D.I.. Marc F.S , (1994). Fracture of the pelvis, samm and coccyx. Manual of acute orthopeadic therapeutic 4 th. 1994. p 2007 - 220.
MOT SO YEU TO LIEN QUAN DEN NHU CAU KHAM CHOA BENH TAI KHU DIEU TRI Tir NGUYEN A
TOM TAT
Muc tieu: Md ta mdt so yiu to lien quan din nhu cau khim chOa benh (KCB) tai Khoa dieu tri tu nguyen (DTTN) A tai Benh vi'dn Nhi Trung uang nim 2014.
Phuang phap: Nghidn cOu md ti cit ngang. Kit qui:
Nghien cUu tr6n 527 doi tupng la ngudi nha cOa eic b$nh nhi din kham bdnh tai khoa DTTN A Benh vien wih/ Trung uang cho thiy: Phan Idn doi tuang deu cd trinh dO Tmng hoc phi thdng trd len vdi 98.63%. Tile ngudi cd thu nhip cao la 82,98%. Chi phi tang Idn 20%
so vdi cac djch vu la phu hdp vdi djch vu kham tif
THACH PHUONG NHUNG, DANG DUC NHU Khoa Y Dugc, D^i hoc Quae gia Ha Ngi D 6 | THANH TUNG - Benh vien Nhi Trung utfng D A O D I N H T H O I - Dai hgc Y Ha Ngi
nguyen. Su tin tudng vao chat lUdng kham cua Khoa DTTN A cung nhu viec giim til thdi gian chd dai chiem tile cao. Kit luan: NgUdi dan lira chon Khoa DTTN A la do duac tu lua chon dich vu chim sdc sUc khoe ma minh mong mijon cung nhu giup giam tai thdi gian chd dpi. Vi vay. can nang cao chat lupng kham chOa binh di tao su hai Idng dd'i vdi ngudi dan.
Tifkhoa: Khoa diSu tri tu nguyen A, Benh vien Nhi Tnjng uang. khim chOa berih.
Y HOC TH^rC HANH (957) - SO 4/2015