suy tim cap

7/25/2019 Suy tim cap

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SUY TIM CP

Ts. Trn Vit An

MC TIU

1. Nu c nguyn nhn v sinh bnh hc ca suy tim cp.

2. Trnh by triu c im chn on suy tim cp.

3.

Nm vng c im cc thuc v phng php iu trsuy tim cp.

NI DUNG

1. NH NGHA

Suy tim cp c nh ngha l tnh trng khi pht nhanh chng cc triu chng

v du hiu do chc nng tim bt thng. Suy tim cp c thxy ra bi biu hin suy tim

ln u tin hoc trn nn suy tim mn, thng c gi l suy tim cp mt b. Ri lon

chc nng tim c thdo ri lon chc nng tm thu hoc tm trng, ri lon nhp, hoc

sthay i b trkhng y ca giai on tin ti hoc hu ti. Suy tim cp thng

e da tnh mng bnh nhn v i hi iu trkhn cp.

2. SINH BNH HC

C chsinh bnh hc ca suy tim cp l khng ng nht, c nhiu c chchng

cho nhau. Do , sinh bnh hc ca suy tim cp c hiu r nht l nhng c chtim

n gp phn thnh mc khc nhau tng bnh nhn, kt qul biu hin triu chngv du chng suy tim cp. Sinh bnh hc ca suy tim cp l kt quca stng tc gia

bnh l nn, c chban u v c chkhuch i.

Bnh l nn da vo cu trc v chc nng tim, c th l chc nng tht bnh

thng nhng thay i t ngt chc nng tim cp tnh nh nhi mu c tim hoc vim

c tim cp. Mt s trng hp khc khng c tin s suy tim nhng bnh l nn bt

thng (ri lon chc nng tht tri khng triu chng vi giai on B). Cui cng, hu

ht bnh nhn suy tim cp c nn tng suy tim mn cn b v sau tin trin mt b.

Phn ln nguyn nhn bnh l nn l khng thhi phc.C chban u thay i v tng tc vi bnh l nn, c thdo tim hoc ngoi

tim. Tn thng c tim (vim c tim) bnh nhn c c tim bnh thng. Nhng yu t

ri lon trn bnh nhn bnh l nn bt thng (ri lon chc nng tht tri khng triu

chng) nh tng huyt p, rung nh, thiu mu c tim. bnh nhn suy tim mn cn b


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hoc n nh, nhng yu tnh khng tun thiu trhoc chn, sdng thuc

khng vim khng steroid v nhim trng sgy ra suy tim mt b.

C chkhuch i bao gm hot ha thn kinh-hormon, ha cht trung gian vim,

tn thng c tim tin trin v suy gim chc nng thn, gp phn thc y v lm xu

hn bnh cnh suy tim cp.

3. NGUYN NHN

Bng 1. Nguyn nhn v yu tthc y gy suy tim cp

Thiu mu c tim Suy tun hon

HC vnh cp Nhim trng huyt

Bin chng c hc sau NMCT Nhim c gip

Nhi mu tht phi Thiu mu

Van tim Shunt

Hp van Chn p tim

Hvan Thuyn tc phi

Vim ni tm mc Suy tim mn mt b

Bc tch MC Khng tun thiu tr

Bnh c tim Qu ti dch

Bnh c tim hu sn Nhim trng

Vim c tim Bnh mch mu no

THA/RL nhp Ngoi khoaTng huyt p Ri lon chc nng thn

RL nhp Hen, COPD

Ngc: thuc, ru

4. CHN ON

4.1. Lm sng

Lm sng suy tim cp thng biu hin di 1 trong 6 dng sau:

Suy tim mn nng hn hoc mt b (66%): bnh nhn suy tim mn ang iutrdin tin nng hn v c bng chng sung huyt hthng v phi.

Ph phi cp (17%): biu hin suy h hp nng, thnhanh v kh thvm,

km theo rales phi v bo ha oxy mu ng mch (SaO2)


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Bng chng thn kinh giao cm tng nh nhp nhanh v co mch. p ng vi

iu trthch hp nhanh v tvong bnh vin thp.

Chong tim (4%): c bng chng gim ti mu m (HATT 30 mmHg v thiu niu hoc v niu


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HATT 100 mmHg HATT 90-100 mmHg

Dn mch(NTG, nitroprusside,

nesiritide, levosimendan)

Dn mchv/hoc

Vn mch(Dobutamin,levosimendan)

Bi hon thtchVn mch(Dopamin)

P NG KMTng co bpDn mch

Htrc hcCatheter ng mch phi

P NG TTLi tiu, UCMC/chn thth,

Chn beta

X-quang tim phi :chp sm (nu c th) bnh nhn suy tim cp nhp vin

nh gi mc sung huyt phi.

Kh mu ng mch:gip nh gi tnh trng oxy, CO2v pH, v nn xt nghim

tt cbnh nhn suy h hp cp nguy kch.

Peptide thi natri niu:nh lng trong giai on sm chn on loi trsuy

tim. Hin nay, ngng gi trBNP hoc NT-proBNP chn on suy tim cp cha c

sng thun.

Siu m tim:l cng crt gi trnhm nh gi nhng thay i vcu trc v

chc nng ca bnh l nn hoc lin quan suy tim cp.

Xt nghim khc: gm cng thc mu, in gii , chc nng thn, glucose,

albumin mu, men gan v INR.

5. IU TR

iu trsuy tim cp da vo s 1.

S 1. Chin lc iu trsuy tim cp theo huyt p tm thu

iu trtheo m hnh huyt ng:

m v kh: iu trsuy tim mn lu di.

m v m (67%): nitroglycerin, nhng iu trchnh l tng liu li tiu.


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Lnh v m (28%): s dng dn mch (nitroglycerin or nitroprusside) nhm

ti mu, sau dng li tiu.

Lnh v kh: khng thy trong trng hp cp cu.

5.1. Thoxy v thng kh

Ch nh th oxy cng sm bnh nhn gim oxy mu nhm t SaO295%

(>90% bnh nhn COPD).

Thng kh khng xm ln vi p lc dng cui th thra (PEEP) nn c xem

xt sm bnh nhn ph phi cp do tim v suy tim cp do tng huyt p. Khi u

PEEP t 5-7,5 cmH2O, tng ln n 10 cmH2O v FiO20,40. Thng ch nh 30

pht/gicho n khi ci thin kh thv bo ha oxy mu. Thng kh khng xm ln

nn thn trng bnh nhn chong tim v suy tht phi.

Chnh t ni kh qun v thng kh c hc phi hn ch, c thbnh nhn

khng m bo oxy vi thmask v thng kh khng xm ln, v trng hp tng CO2

km theo suy h hp tng ln hoc kit sc.

5.2. Li tiu quai

Chnh bnh nhn sung huyt phi v qu ti dch. Qu liu li tiu c thgy

gim thtch v hnatri mu, v tng nguy c tt huyt p bnh nhn sdng thuc

UCMC hoc chn thth.

Bng 2. Liu li tiu v chnh trong suy tim cp

Qu ti dch Thuc Liu lng Ghi ch

Trung bnh Furosemide

Bumetanide

Torasemide

20 - 40 mg

0,5 - 1 mg

10 - 20 mg

nh gi p ng lm sng.TD: K, Na, creatinine v HA

Nng Furosemide

Bumetanide

Torasemide

40- 100 mg

5 - 40mg/h TTM

1 - 4 mg

20 - 100 mg

Khng tr vi litiu quai

Phi hp:hydrochlorothiazide

hoc metolazonehoc spironolactone

50 - 100 mg

2,5 - 10 mg

25 - 50 mg

Metolazone, hiu qu nuCrCl


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5.3. Morphine

Chnh nhng bnh nhn suy tim cp nng c kch ng, kh th, lo u hoc

au ngc.

Liu 2,5 - 5 mg TM. Cn theo di tnh trng suy h hp.

Morphin nn trnh bnh nhn c tt huyt p, xut huyt ni s, ri lon thc,

hen phqun, bnh phi tc nghn mn tnh, gim thng kh.

5.4. Thuc dn mch

5.4.1. Ni trate

Nitroglycerin v isosorbide dinitrate tc dng chyu dn tnh mch v dn mch

vnh v c tc dng rt nhanh. Nitroglycerin truyn tnh mch thng c dng kt hp

vi li tiu nhm ci thin nhanh triu chng sung huyt phi.

Liu khi u nitroglycerin l 10-20 g/pht v tng 5-10 g/pht mi 3-5 pht,

ti a 200 g/pht. Isosorbide dinitrate l 1mg/gi, tng ln 10 mg/gi.

Tc dng ph: tt huyt p v nhc u.

Cc chng chnh ca Nitrate:

Mch >110 ln/pht hoc


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5.5. Thuc tng co bp c tim

Chnh nhng bnh nhn c tnh trng gim cung lng tim, tc dng phgy

ri lon nhp.

Dopamine: liu 1 - 3g/kg/pht chyu kch thch ththdopaminergic nn lm

dn ng mch, c bit l ng mch thn. Liu 3 - 10g/kg/pht kch thch thth1

nn lm tng co bp c tim v liu cao >10g/kg/pht kch thch 1 v c tc dng gy

co mch.

Dobutamine: tc dng kch thch thth1v 2nhiu hn nn c tc dng tng

co bp c tim, dn mch lm tng cung lng tim v gim hu ti. Liu khi u 1-

2g/kg/pht tng dn.

Levosimendan: ci thin chc nng co bp c tim v tc dng dn mch thng qua

knh Kali nhy ATP. Truyn tnh mch levosimendan bnh nhn suy tim cp lm tng

thtch nht bp v cung lng tim, v gim khng lc mch mu phi v hthng.

6. TIN LNG

Yu ttin lng chnh bnh nhn suy tim cp l huyt p thp v tng BUN lc

nhp vin. Ngoi ra, mt syu ttin lng khc: gim natri mu, tng creatinine, tui

ln, kh thkhi ngh, tng troponin v sung huyt lc nhp vin.

TI LIU THAM KHO

1.

Dickstein k (2011), Acute and Chronic Heart Failure, ESC Guidelines Desk

Reference, Springer Healthcare, pp.316-342.

2. Krger W and Ludman A (2009), Acute heart failure syndromes, Acute heart

failure, pp.47-70.

3.

Meyer TE, Krishnamani R and Gaasch WH (2010), Acute Heart Failure and

Pulmonary Edema, Cardiac Intensive Care 2, pp.275-292.

suy tim cap

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