Ths BSCKII Nguyn Hng H

Ths BS Nguyn Quc Thi

Ti liu ph bin kin thc

BNH UN VN

Vin Cc bnh Truyn nhim v Nhit i Quc gia

H NI thng 3 - 2008

Bnh un vn 2008

1

MC LC

1. Lch s bnh un vn v nhng vn ni bt hin nay .................................................2

2. Tnh hnh bnh un vn hin nay ....................................................................................8

3. S ly truyn bnh un vn v cch phng chng ......................................................... 12

4. C ch gy bnh ca vi khun un vn ......................................................................... 18

5. Biu hin lm sng ca bnh un vn ........................................................................... 23

5.1. Vt thng ng vo ........................................................................................... 23

5.2. Thi gian bnh ................................................................................................... 23

5.3. Thi k khi pht ................................................................................................... 24

5.4. Thi k ton pht ................................................................................................... 25

5.5. Thi k lui bnh ..................................................................................................... 27

5.6. Cc th lm sng ................................................................................................... 27

6. Chn on bnh UV ..................................................................................................... 30

7. iu tr bnh un vn ................................................................................................... 31

8. Bin chng v tin lng bnh UV .............................................................................. 36

8.1. Din bin v kt cc .............................................................................................. 36

8.2. Bin chng ............................................................................................................ 36

8.3. Phn v tin lng ............................................................................................ 37

Bnh un vn 2008

2

1. Lch s bnh un vn v nhng vn ni bt hin nay

Un vn [UV] c m t rt sm trong lch s y hc Ai Cp, Trung Hoa v

Hy Lp vi c trng cng hm v co cng c c lin quan n vt thng

[22]. Cc tc phm ca Hippocrates ni nhiu n UV [42], trong c mt

s im tin lng nh bnh nhn co git do UV cht trong vng 4 ngy, nu

qua c th s hi phc (Cch ngn, V.6), hoc UV xut hin trn nn bng

nng th din bin xu (Cch ngn, VII.13). Din mo lm sng sinh ng ca

bnh c Aretaeus x Cappadocia ghi chp vo th k th hai: Mt tai ng

man r! Mt cnh tng kh coi! Mt cnh gy n au cho n c ngi

chng kin, mt bnh nan y! Nh vo s xon vn m nhng thn bng yu qu

nht chng nhn ra, v bi s nguyn cu ca nhng ngi mc kch, trc y

vn c cho l khng ngoan o, nay tr nn t t, th l bnh nhn c th t

gi ci i, hoc gii thot khi n au v nhng ti li xu xa eo ng.

Nhng ngay c ngi thy thuc, d cho c n v xem bnh cng khng th

gip ch g thm, v nh duy tr cuc sng, gim au hoc lm cho d hnh.

V nu mun lm thng chi, ng ta ch c th ct v b chi ca ngi ang sng.

Ri, vi nhng ngi b cn bnh ny ch ng, ng ta ch c th by t nim

cm thng. y l iu bt hnh ln nht ca ngi thy thuc. [17]. Sau

Galen rng ct dy thn kinh lm ngng co git UV nhng gy lit b

phn c chi phi [22].

Nn y hc Trung Hoa ngay t thi Tin Tn c nhng m t chi tit v bnh

UV. Trong cun sch c coi l c nht ca nn y hc c truyn Trung Quc,

sch Ng thp nh bnh phng c khai qut t m thi Hn M Vng

i, bnh c gi tn l thng kinh v cun sch ny c ti 6 phng

thuc iu tr cn bnh ny. n thi Tu ng, ln u tin trong cun

sch L thng tc on phng ca Ln o Nhn, bnh c m t k

hn di tn gi ph thng phong vn cn c dng cho ti ngy nay [82].

Bnh un vn 2008

3

Vo th k XIV, nh phu thut ngi Anh tn l John of Arderne (1307-1380)

m t mt trng hp UV vi cng hm (chut rt m) sau vt thng lm

vn 11 ngy [22]. n th k XVIII, UV c cho l hu qu ca tn thng

thn kinh. Ngi ta vn cn ln gia UV ton th vi ng kinh [22].

Hnh 1. Minh ha mt bnh nhn un vn ca Charles Bell nm 1809 [22]

UV s sinh c gi l bnh by ngy M, bnh ngy th tm n

v cn chn ngy Dublin. Nm 1846, Sims a ra gi thuyt sung huyt

v UV s sinh. ng cho rng t a tr nm nga s p chm v gy tc tnh

mch ty. Beumer xc nh rn l ng vo ca UV nm 1887 [19].

Cho n u th k XIX, ngi ta vn cha UV bng cc liu php tng tng

hn l c ch thc s. H c th cho a ht mu, trch mu tnh mch, ct ct,

dng acid hydrocyanic, ph t, gy nn vi ipecac. Nm 1811 c gi rng

dng cura km theo h hp nhn to l c li trong UV. Cch ny c dng

trn ng vt nm 1835, v trn ngi nm 1858 nhng khng thnh cng do

thuc dng dng ch phm th v thiu ton b kin thc v sinh l hc h

hp. Nhng bi hc v th my ko di thu c trong dch bi lit nhng nm

1950 cui cng lm cho iu tr bng thuc gin c tr nn kh thi [56].

Nm 1829, Ceroli m t dng morphin iu tr UV. Nm 1861, Hutchinson

v Jackson bo co dng ether trong UV [22]. Nm 1872, Rose m t UV

th u vi lit mt [15]. Antonio Carle v Giorgio Rattone chng t kh nng

Bnh un vn 2008

4

truyn nhim ca UV trn th thc nghim nm 1884 [87]. Cng trong nm

ny, Arthur Nicolaier bo co v mt c t tc dng ging strychnin chit t

vi khun k kh trong t, chng minh vai tr ca t trong bnh sinh UV. D

nhn thy vi khun ny, ng vn khng th phn lp c n [54]. Tuy nhin

ch trc 5 nm, trn bo ch y hc vn cn c ngi cho rng tn thng

do kim chc vo dy thn kinh gy nn UV [77]. Nm 1887, Rosenbach m t

mt trc khun c u tn cha bo t trn trong m ly t ngi, UV xut

hin khi tim dch tit m ny cho ng vt [87]. Nm 1888, trong cun sch

gio khoa ca mnh, Sir William Gowers m t hon ton chnh xc bnh

cnh in hnh ca UV: UV l mt bnh ca h thn kinh c c im co cng

tng trng lc ko di vi cc cn kch pht ngn. Co cng gn nh lun bt

u t c c v hm gy kht cht hm (trimus cng hm) v b cc c thn

mnh nhiu hn chi. Khi pht bnh lun cp tnh, v mt t l ln nhng

ngi b bnh phi t vong. ng cng nhn thy c ti 20% bnh nhn UV

khng lin quan g n chn thng v gii thch bnh do rt run t ngt hoc

cn s hi. Mc d Gower thy UV ging triu chng ng c strychnin nhng

ng khng tn thnh chng cng c ch sinh l bnh, ng thi ng cng b

qua bo co u tin ca Nicolaier v mt c t tc dng ging strychnin chit

t vi khun k kh trong t [22]. Shibasaburo Kitasato, mt hc tr ca Koch,

phn lp c Clostridium tetani, lm tha mn c nh Koch v bo co

vic trung ha c t bng khng th c hiu vo nm 1889 [87]. Nm 1890,

Von Behring v Kitasato chng t rng tim chng cht tinh chit bt hot

t vi khun ny phng c bnh UV trn ng vt, ln u tin m t min

dch ch ng vi gii c t UV [15,54]. Nm 1890, Tizzoni v Cattani v

Knud Faber phn tch c c t UV v chng minh c t l tc nhn gy

biu hin lm sng. Nm 1892, Bruschettini khng nh rng c t UV di

chuyn ngc dng trong si trc ca t bo thn kinh ti thn kinh trung ng

[59]. T 1893 Roux v Vaillard ch khng huyt thanh chng UV. Nm

Bnh un vn 2008

5

1897, Nocard chng minh hiu qu bo v ca khng c t khi truyn th

ng, v khng huyt thanh chng UV ch t nga c dng rng ri trn

ngi trong Chin tranh th gii I [21,28]. Nm 1898, Roux v Picard

xut liu php huyt thanh ni ty nhng tht bi do cht bo qun phenol trong

huyt thanh [15]. Nm 1906, Blake bo co 2 trng hp UV iu tr bng

magi sulfat dng ni ty [21]. Nm 1923, Gaston Ramon thng bo vic thm

formol vo c t bch hu trong nhng iu kin nht nh chuyn thnh

gii c t khng c c tnh nhng cn kh nng sinh min dch, v hai nm

sau ng cng lm nh vy vi c t UV [15]. Nm 1924, Descombey ch gii

c t UV v tnh hiu qu ca vic to min dch ch ng c chng

minh trong chin tranh Th gii th hai [21,28].

Hnh 2. Shibasaburo Kitasato, ngi u tin phn lp c trc khun un vn nm 1889

Nm 1940, Dietrich chn nn vit: Mt tng kt ton b y vn v bnh UV s

tht s, gy kh hiu, rt cuc mu thun nhau v chng gip ch g my i

vi ngi thy thuc ang c gng iu tr d ch mt a b b UV. [56]. Su

nm sau, Pillemer v cng s ln u tin tinh chit c c t UV gy co

Bnh un vn 2008

6

git l tetanospasmin [7,87]. Trong thp k 50 ca th k XX, nhiu phng th

nghim trn th gii pht hin ra rng c t UV gn vo tn cng thn kinh

c v synap neuron vn ng, gii thch c ch xut hin cc triu chng co

cng, co git [59]. Nm 1955, Mollaret v cng s m t hi chng huyt

ng sm khi dng cura gi m vn ri lon thn kinh thc vt trong UV

[15]. Trc Gower (1888) m t ri lon thn kinh thc vt trong UV

nhng ch khi ko di c s sng ca bnh nhn UV bng my th th ngi

ta mi nhiu n vn ny. Nm 1968, Kerr v cs m t hi chng cng

hot ng thn kinh giao cm, t vn khng ch ri lon thc vt bn cnh

khng ch co git [13]. Tuy nhin, mt nghin cu gn y ca cc tc gi

Brazil [42] li nhn nh rng ri lon chc nng tim mch, nht l cc ri lon

cng giao cm gp trong mi th un vn, k c nhng th nh. iu quan

trng l trc y chng cha c n v x tr thch ng.

Nm 1954, Lewis v cs ln u tin c gng chng t corticosteroid c th lm

gim t l t vong ca UV. Tuy nhin, kt qu cc nghin cu sau ny vn cn

cha thng nht v c ch tc dng ca corticosteroid bnh nhn UV vn cn

cha r nn cho d y l hng nghin cu y ha hn th vic s dng

corticosteroid trong UV vn c coi l c tnh cht th nghim [22]. T nhng

nm 1960 ngi ta bt u dng diazepam trong iu tr UV v mc d i lc

cn c kin phn bc [38] nhng diazepam vn c dng cho n hin nay

nh mt thuc u tay trong iu tr UV [55].

Nm 1965 ln u tin mt Hi ngh Quc t v UV c t chc ti Bombay.

Sau c khong 3-4 nm mt ln li c mt hi ngh quc t v UV c t

chc.

Cc tc gi l t a ra thang phn dnh cho tin lng: Ramond, Patel,

Mollaret, Ablett, Phillips, Vakil, Veronesi, Bleck, Udwadia, cho n Hi

Bnh un vn 2008

7

ngh Quc t v UV ln th t hp Dakar (1975) thng nht phn da

trn vic cho im cc yu t tin lng, v thang phn ca Vakil cn c

bit n vi tn gi thang phn Dakar [32]. Sau , vic phn bnh UV

vn cn thu ht s quan tm ca nhiu nh nghin cu [1,6], v cc thang phn

ngy cng c xut hon chnh hn vi nhng c liu khoa hc hn

[78].

Cho ti nay hn 100 nm bit v c t UV, trnh t acid deoxyribonucleic

ca vi khun c gii m [26] v c ch tc dng ca c t UV c

xc lp [59]; chng ta c khng c t v vc-xin d phng bnh nhng

UV vn cn l vn ln v y t cng cng trn ton th gii, nht l cc

nc ang pht trin. Vic iu tr bnh nhn UV nng v lm gim t l t

vong do UV vn rt nan gii. Hin nay c rt t nghin cu hoc th nghim

thc s cht ch mang tnh thuyt phc cao v iu tr v d phng UV. Trong

vng hn 30 nm va qua, tnh n nm 2003, ch c 9 th nghim ngu nhin

c i chng c thc hin trn th gii [77]. Con s ny thc s khng tng

xng vi c tnh mt triu trng hp mc UV mi nm v t l t vong ca

bnh dao ng t 6% n 60% [23].

Bnh un vn 2008

8

2. Tnh hnh bnh un vn hin nay

Mc d c nhng thnh cng ca Chng trnh Tim chng M rng, bnh UV

vn l vn sc khe ton cu [66]. Cui nhng nm 1970, T chc Y t Th

gii c tnh mi nm c 1 triu trng hp t vong do UV, trong c ti

99% l cc nc ang pht trin [15]. Cc nc pht trin hin nay cng vn

gp UV nhng ch yu tp trung i tng cao tui v thng ph n [31].

Nm 2000 ch c 18.833 trng hp UV trn ton cu c bo co vi T

chc Y t Th gii. By mi su quc gia, trong c nhiu nc nguy c

cao khng cung cp d liu, v thng tin cc nc ny thng khng y

. Cc cuc iu tra cho thy ch c 3% UV tr s sinh c bo co. Trn c

s d liu v nghin cu ca T chc Y t Th gii v d liu t Trung tm

Bnh Nhit i Thnh ph H Ch Minh, nm 2003, cc tc gi Thwaites v

Farrar c tnh t l mc thc s ton cu l 700.000 n 1.000.000 trng hp

mi nm [77]. Tuy nhin, ch trc 10 nm, cc c tnh ca T chc Y t

Th gii cho bit mi nm c 800.000 n 1 triu trng hp t vong do

UV, trong 80% chu Phi v ng Nam . UV vn cn lu hnh 90 quc

gia trn th gii [37].

Php, t l mc chung trc y l 1,06/100.000/nm [39], hu nh khng

gp tui di 40. Hai phn ba s ngi mc trn 65 tui. T l mc nhm

tui ny vo khong 3/100.00. Ch yu b n, nht l trong tui 40 n

65. Phn ln cc trng hp b vng nng thn [15]. Tng kt trong nm

2000-2001 ca Antona [16] cho bit hin nay t l mc chung gim xung

cn di 1/1.000.000 dn, c ti 87% l ngi trn 70 tui v 78% l ph n,

t l t vong 20%.

, qua tng kt t nm 1971 n 2000 [58], t l mc gim t 0,5/100.000

dn nhng nm 1970 xung cn 0,2/100.000 dn nhng nm 1990. Trong

khong thi gian ny, t l t vong ca bnh gim t 68% xung 39%. l

Bnh un vn 2008

9

nc c s trng hp UV c bo co nhiu nht chu u. i tng mc

bnh ch yu l ph n cao tui: t l bnh nhn n trn 64 tui chim 60%

nhng nm 1970 tng ln 76% nhng nm 1990.

UV hu nh khng cn gp Anh, mi nm ch c khong 12-15 trng hp

[33]. Ba Lan, nm 2001 gp 21 trng hp, tt c u trn 50 tui, chim t

l 0,04/100.000 dn, t l t vong 33,3% [72].

M t l mc 0,2/100.000/nm [39]. Hng nm c khong 50 n 70 trng

hp mc, hu ht l do cha c tim phng hoc tim phng khng y

[17]. Tng kt 110 trng hp nm 1989-1990 M cho thy 58% l bnh nhn

trn 60 tui, 78% c vt thng ng vo cp tnh v 5% l ngi nghin

chch [61]. Mi nm sau, tng kt 1998-2000, M c trung bnh 43 trng

hp UV mi nm, 15% l ngi nghin chch. Nhm nguy c cao vn l ngi

cao tui, nht l ngi cao tui b i ng. T l t vong 18%, trong 75%

l ngi trn 60 tui [57].

Brazil l mt nc pht trin Nam M, tnh hnh bnh UV nc ny cng

nh cc nc pht trin khc. l xu hng gim t l mc chung nhng tng

t l mc v t vong nhm ngi cao tui [53].

cc nc ang pht trin, t l mc bnh mi nm trn 50/100.000, c bit

cao n (200/100.000), chu Phi (B Bin Ng 100/100.000, Kenya

146/100.000). Lesotho UV him gp nhng Nigeria rt thng gp v c

khi chim ti 14% cc trng hp nhp vin v 7% cc trng hp t vong ti

mt vin-trng Ibadan [74]; Dakar l 32,5/100.000 [39].

Mt s nc chu tin tin nh Nht Bn, Hn Quc hin nay gp rt t UV.

Mt tng kt trong 21 thng ti mt bnh vin-trng 900 ging c 17 trng

hp UV, ch yu l ph n nng dn ln tui. Ch c 53% c chn on

Bnh un vn 2008

10

ng ngay t tuyn u [71]. Ti Nht Bn, t 1982, t l t vong do UV l

0,02/100.000 dn/nm, cc bnh nhn t vong ch yu do bnh nn, rt t do

bn thn bnh UV [35].

Trc y Iran l khu vc UV lu hnh nhng hin nay c mt xu hng rt

r l t l mc bnh ang gim i nhanh chng. Qua tng kt trng im tnh

hnh bnh UV trong 20 nm 1978-1997 t hai bnh vin tnh chuyn tip nhn

cc bnh nhn UV, tc gi nhn thy t l mc bnh tnh chung trn c qun th

gim i r rt: 1,8/100.000 dn nm 1978, 0,31/100.000 dn nm 1987 v

0,02/100.000 dn nm 1997. Ngi ta cho l do nng cao trnh dn tr;

tng cng c s y t, nht l c s dnh cho ph n c thai; gio dc thay i

hnh vi nguy c, c bit l cho cc b v bc s a khoa; v thnh cng ca

chng trnh tim chng m rng. Tnh hnh cng tng t nh vy cc nc

khc cng khu vc Trung-Cn ng [20].

Cc yu t c coi l c nh hng n tnh hnh mc bnh UV l (1) kinh t

km pht trin; (2) khng c phng bnh y bng vc-xin v (3) vn cn

cc hnh vi nguy c nh i chn t, ti nh, theo cc tp tc lc hu nh

bi phn b hay t st vo rn dn n UV rn tr s sinh [17].

Theo T chc Y t Th gii, c tnh c khong 300.000 bnh nhn UV t

vong vo nm 2000 [85]. T l t vong chung ca UV c th n 70% [87].

Ngay nh Php nm 1997, t l t vong cng ti 30% [31]. Th Nh K, t

l t vong ca UV l 58% [36], Brazil l 35% [41] v Hn Quc l 24%

[71]. Mt s c s iu tr c kinh nghim v c trang b phng tin tin

tin c th gim c t l t vong xung cn 18% [21, 25, 57], 15% [81] thm

ch 11% [37]. Tnh trn c qun th th t l t vong do UV mc 7-15/100.000

dn/nm chu Phi, 40-60/100.000 dn/nm n nhng ch 0,13/100.000

dn/nm M v 0,72/100.000 dn/nm Php [39].

Bnh un vn 2008

11

Vit Nam l mt nc nhit i ang pht trin, nm trong khu vc cc nc

c t l mc UV cao. Theo thng k nm 1990 ca Vin V sinh dch t H Ni

th tnh trn ton quc t l mc UV chung l 1,87/100.000 dn/nm, t l t

vong chung do UV l 0,24/100.000 dn/nm [5]. Ti Trung tm bnh Nhit i

Thnh ph H Ch Minh, qua thi gian theo di 21 thng (5/1997-2/1999) c

500 trng hp UV khng phi s sinh nhp vin, 68,6% l nam, bnh nhn

di 15 tui chim 18,8%, trn 65 tui chim 12,2%, t l t vong l 19% [37].

Tng hp d liu t 1993 n 2003 vi 2072 bnh nhn, t l t vong ti bnh

vin ny l 19,6% [78]. Qua s liu cng b theo mt nghin cu ngu nhin

i chng trong 3 nm 2002 n 2005 ti bnh vin ny [78] th t l t vong

vi cc trng hp nng (im Dakar trung bnh 2,0) vn cn l 13-16%. Ti

Vin Y hc Lm sng Cc bnh Nhit i H Ni trc y hng nm c

khong 110-130 trng hp nhp vin, t l t vong khong 25%. Theo tng

kt ca Vin t nm 1985 n nm 1994 c 982 bnh nhn, t vong 227 bnh

nhn chim 23,1% [5]. Tuy nhin, vi s pht trin ca cc phng tin k

thut hi sc th t l t vong do UV hin nay gim nhiu. Theo con s thng

k ti Khoa iu tr tch cc Vin Cc bnh truyn nhim v Nhit i Quc

gia t thng 7/2006 n thng 8/2007, trong tng s 114 bnh nhn UV nhp

vin ch c 1 bnh nhn t vong (0,9%).

Bnh un vn 2008

12

3. S ly truyn bnh un vn v cch phng chng

Do trc khun UV khng pht trin c trn m ngi lnh, cn phi c s

hin din ca nhng yu t cn thit sinh c t UV tetanospasmin trn vt

ch ngi. iu kin thun li chnh l s kt hp t hai yu t sau y tr

ln [67]: (1) Vt thng xuyn lm bo t C. tetani xm nhp; (2) ng nhim

cc vi khun khc; (3) M cht ti vt thng; (4) D vt trong vt thng; (5)

C hin tng thiu mu cc b.

Bng 1. Phn loi vt thng [63]

Biu hin lm sng C xu hng UV Khng c xu hng UV

Thi gian b vt thng > 6 gi 6 gi

Hnh thi Hnh sao, nham nh Thnh ng thng

su > 1 cm 1 cm

C ch tn thng m, gip, bng, nt B mt sc nhn (knh, dao)

M cht C Khng

Nhim bn (phn, nc bt...) C Khng

Un vn gp khp ni trn th gii, nhng thng xuyn nht l nhng

vng ng dn c kh hu nng, m c t giu cht hu c. Mm bnh thy

ch yu trong t v ng rut ca ng vt v ngi. Ly truyn ch yu

do vt thng nhim bn (nhn thy r hoc khng). Vt thng c th ln hoc

nh. Tuy nhin, trong nhng nm gn y, s cc trng hp c vt thng

nh tr nn nhiu hn, c l v nhng vt thng nng c nhiu kh nng

c x tr ng cch hn. Un vn c th xut hin sau m, bng, vt thng

xuyn su, vt thng gip, vim tai gia, nhim trng rng ming, ng vt

cn-t, sy thai v cha. Un vn khng ly nhim trc tip t ngi sang

ngi. y l bnh duy nht phng trnh c bng vc-xin m ch b nhim

trng ch khng ly nhim [28].

Vic s dng khng sinh chng UV d phng khi c vt thng va khng

c ch li khng thc t, v trong nhng trng hp c vt thng th to min

Bnh un vn 2008

13

dch chng UV ph hp c vai tr quan trng hn. Rt him khi xy ra UV trn

bnh nhn c tim phng y vc-xin UV [70]. Ch nh tim vc-xin

v khng huyt thanh UV tu thuc vo tin s tim vc-xin v tnh trng vt

thng.

Bng 2. TIM PHNG UV KHI B VT THNG

Tin s tim vc-xin Vt thng nh, sch Cc vt thng khc

Vc-xin Khng huyt

thanh Vc-xin

Khng huyt

thanh

Khng r hoc < 3 liu C Khng C C

T 3 liu tr ln Khng* Khng Khng** Khng

*C, nu liu cui cng tim trn 10 nm **C, nu liu cui cng tim trn 5 nm

Nu nh vt thng ln, gip nt v bn m bnh nhn ch mi tim di 3

mi vc-xin hoc c tin s tim vc-xin UV khng r rng th nn tim c vc-

xin v khng huyt thanh. l do cc mi vc-xin trc c th cha gy c

min dch m mi ch kch thch h min dch. Khng huyt thanh trong trng

hp ny c tc dng cung cp min dch tm thi vi khng c t trc tip,

m bo cho c th c bo v chng UV trong thi gian ch i c th sinh

min dch theo p ng vi vc-xin [28].

Mc d tim phng vc-xin c hiu qu phng bnh vi vic c c qun th

t bo TCD4(+) mang k c min dch hu hiu [28] nhng tnh min dch ny

vn gim i theo thi gian. Thm d ti mt khoa cp cu bnh vin ti B

th ch c 64% bnh nhn c min dch bo v chng un vn, qua cho

thy vic hi tin s tim phng cha tin cy v i hi phi c cc cng c

khch quan hn trong nh gi, chng hn nh que th nhanh min dch un

vn [74]. Cc khuyn co hin nay thng nht trong vic khuyn tim nhc li

vc-xin sau mi 5-10 nm [28].

Bnh un vn 2008

14

Bn cnh vic cung ng y vc-xin v khng huyt thanh UV, s hiu bit

y v cch phng bnh UV ca nhn vin y t v ngi dn ng vai tr

thc s quan trng trong vic y li v tin ti thanh ton cn bnh ng s

ny. Qua iu tra th -li, n , mt nc c con s mc v cht do

UV c th ni l nhiu nht trn th gii [50], ch c 7% bc s tim phng UV

theo lch, cn li a s ch tim vc-xin khi c vt thng. C cha n mt

na cc bc s c hi bit c ch nh ng n ca khng huyt thanh

UV. Tuy nhin, tnh hnh cng khng kh quan hn cc nc pht trin. Qua

mt nghin cu iu tra nhn vin y t khoa cp cu ngoi ca 67 bnh vin

Anh nm 2007 [67], c ti 29% ngi c hi cng nhn rng vn cn cha

tun th ng cc khuyn co hng dn phng UV ban hnh. Th nhng

ti Cuba, mt quc gia ang pht trin v ang phi gnh chu nhiu kh khn

do M bao vy cm vn th n nm 2004, quc gia ny khng cn mt ngi

no mc bnh UV, l cn bnh m khong 3 thp k trc y c t l t vong

cao nc ny. t c thnh tch ny, Cuba thc hin mt cch h

thng v trit chin dch tim chng m rng trn ton quc. Ring bnh

un vn tr s sinh c loi tr cch y 33 nm. Cc chng trnh tim

phng c pht ng thng xuyn Cuba vi s tham gia ca tt c cc cp,

ngnh, t chc qun chng v ton th nhn dn. Cng tc tuyn truyn l v

kh chin lc t c thnh tch to ln ny [12].

Vit Nam, t nm 1981 Chng trnh Tim chng m rng c trin

khai th im ti H Ni. T nm 1995 n nay, 100% x phng trong c nc

u c bao ph bi dch v ny. Vi i tng ca Chng trnh l tr em

v ph n c thai hoc ph n trong tui 15-35 mt s vng trng im,

nhiu bnh truyn nhim b y li, trong c UV, nht l UV s sinh.

Mc tiu ca Chng trnh cho n nm 2010 l tim liu vc xin UV cho

ph n c thai t > 80% v cho ph n tui sinh vng c nguy c cao

t > 90% v loi tr UV s sinh trn quy m huyn. Di y l lch tim

Bnh un vn 2008

15

chng nh k UV cho tr em di 1 tui v ph n theo Chng trnh Tim

chng m rng [2].

Bng 3. LCH TIM CHNG VC-XIN UV CHO PH N

Mi 1: Cng sm cng tt khi c thai ln u hoc n 15 -35 tui vng c nguy c mc un vn s sinh cao

Mi 2: t nht 4 tun sau mi 1

Mi 3: t nht 6 thng sau mi 2 hoc trong thi k c thai ln sau

Mi 4: t nht 1 nm sau mi 3 hoc trong thi k c thai ln sau

Mi 5: t nht 1 nm sau mi 4 hoc trong thi k c thai ln sau

Bng 4. LCH TIM CHNG CHO TR DI 1 TUI

Tn vc xin S ln

tim/ung

Phm vi p

dng

Thng tui

Bnh un vn 2008

16

- Vc xin DT (bch hu - un vn) phng cc bnh bch hu, un vn. Do loi

vc xin ny c cha gii c t bch hu mc cao nn n khng c s dng

tim cho tr trn 6 tui hoc ngi ln.

- Vc xin Td (vc xin un vn - bch hu cho ngi ln) cng ging nh DT

nhng thnh phn bch hu thp hn. Loi vc xin ny ph hp vi nhng tr

trn 6 tui v ngi ln k c ph n c thai. S xut hin ca Td cng tng

thm kh nng phng bnh bch hu v un vn.

Vc xin TT hoc Td khi tim cho ph n c thai khng ch bo v bnh un

vn cho m m cn phng un vn s sinh cho con. Sau khi tim vc xin TT

hoc Td, khng th hnh thnh s truyn cho thai nhi bo v cho tr trong

khi sinh v sau 1 vi thng. ng thi khng th cng phng un vn cho

b m. Ba liu vc xin TT hoc Td c kh nng phng un vn cho b m v

un vn s sinh t nht 5 nm. Nu tim 5 liu c th phng un vn trong sut

thi k sinh .

Nu lng l vc xin TT trong thi gian di, l vc-xin s chia thnh 2 phn

dung dch v phn lng cn di y l. Do phi lc k trc khi s dng.

Vc-xin TT/DT/Td/DPT khng c ng bng. Nu vc-xin b ng

bng phi hy b. Nhng vc-xin c cha thnh phn un vn thng l phn

ng nh, t gy phn ng nng. C khong 1/10 trng hp sau tim 1 3 ngy

c biu hin au nh, ni mn, nng v sng ty nh ti ch tim. Nhng phn

ng nh ny tr nn ph bin hn nhng ln tim sau v c th gp 50%

n 80% nhng ngi tim nhc li. Khong 1/10 trng hp c tim c

biu hin st nh sau tim.

phng bnh UV cho m v UV s sinh cn tng t l n c tim vc xin

c thnh phn UV khi cn nh hoc tui hc ng. Khi n tui sinh , t

Bnh un vn 2008

17

l mc UV m v UV s sinh s gim xung: tim ng, 3 liu DPT tr

nh c gi tr bo v tng ng 2 liu un vn/Td ngi ln.

Bnh un vn 2008

18

4. C ch gy bnh ca vi khun un vn

Hnh 3. Trc khun un vn

Bnh UV do Clostridium tetani gy nn. Th hot ng ca C. tetani l trc

khun Gram dng, c to nha bo, di ng v k kh tuyt i, pht trin tt

nht 330C n 370C. Vi khun nhy cm vi nhit v khng th tn ti c

khi c mt oxy, cn nha bo th nhit 1200C trong vng 30 pht mi cht

v khng vi cc cht st khun thng thng [7].

Hnh 4. C. tetani vi ni bo t th u tn ging hnh di trng (nhum da cam

acridine) [37]

Trc khun UV c th gp khp ni, sng hoi sinh trong rut ngi, b, v

mt s ng vt nhai li khc. Khong 10% ngi bnh thng c C. tetani

trong i trng [17]. N sng lu trong t, nht l t m t. T l gp trong

Bnh un vn 2008

19

cc mu t kho st t 2% n 23% [66], nhng cng c th ti 20% n 65%

[17]. Cng c th thy trc khun trn b mt da v v trong heroin nhim

bn [76].

Trc khun UV sinh hai loi ngoi c t l tetanolysin v tetanospasmin, trong

tetanospasmin (cn gi l c t UV) l c t thn kinh rt mnh, trong s

cc c t vi sinh ch ng hng th hai sau c t botulinum. Liu 1 mg c

t UV c th git cht 50-70 triu con chut [17]. C tc gi c tnh liu

c trn ngi l khong 500 pg/kg, tc l 25 ng/ngi ln 70 kg [37], cn c

tnh liu cht ti thiu l 2,5 ng/kg th trng [28]. Tetanospasmin l c t chu

nhit, c tnh khng nguyn mnh nn ngi ta dng sn xut vc-xin

phng bnh [7].

Sau khi xm nhp c th, trong iu kin ym kh ca vt thng hoc vng

hoi t, trc khun UV tit ra tetanolysin gy hy hoi t chc xung quanh

nhim v to iu kin cho vi khun nhn ln [33], ng thi cng tit ra

tetanospasmin l c t thn kinh gy cc biu hin lm sng.

Hnh 5. Cu trc tinh th ba chiu ca chui Hc [37]

Gen c t UV c m ha trn mt plasmid 75kb v tng hp nn mt chui

polypeptid n c trng lng 150.000 Da. Polypeptid ny sau c bin

Bnh un vn 2008

20

i sau dch m thnh hai on ni nhau bng cu disulfid gi l chui nh (L)

v chui nng (H) (hnh 5). Phn tn carboxyl ca chui H, gi l HC bc cu

gn vi gangliosid (GD1b v GT1b) trn dy thn kinh ngoi vi, sau c t

c nhp bo. T c t di chuyn t h thn kinh ngoi vi vo n trung

ng nh vn chuyn ngc dng si trc v lan truyn xuyn synap. Ton b

phn t c t nhp bo vo trong t bo tin synap v qua mt qu trnh i

hi c on HN (phn tn amin ca chui H), chui L c gii phng t ni

th (endosome). Chui L l mt metalloprotease km, ph v synaptobrevin.

y l mt thnh phn tch hp mng ca ti synap v cn cho vic ha ti

synap vo mng tin synap. S ph hy ca chui L lm cho cht cha trong

cc ti synap (ch yu l cht dn truyn thn kinh c ch acid -aminobutyric

(GABA) v glycin) khng c gii phng vo trong khe synap [37]. Nh vy,

c t gy phong ta tin synap cc synap t bo Renshaw c ch v si 1a

thn kinh vn ng alpha ca h dn truyn GABA v glycin, dn n s mt

s kim sot c ch cc t bo thn kinh thuc h dn truyn GABA v glycin

[33]. c t UV cng c th gy phong ta thn kinh c ngoi vi qua vic ngn

cn gii phng acetylcholin ging nh c t botulinum. Tc dng ny gii

thch c ch lit thn kinh ngoi bin trong UV th u [84].

Hnh 6. S cu trc c t UV [68]

Bnh un vn 2008

21

Hnh 7. Cu trc khng gian ba chiu ca c t UV [68]

Mt kim sot c ch cc n-ron vn ng sng trc ty sng dn n

tnh trng hng phn lin tip gy ra biu hin co cng v co git c c trng

ca UV. c t UV cn tc ng n ty sng, thn no, thn kinh ngoi bin,

lin kt thn kinh c v trc tip ti c. Ngoi ra, c t UV cn c kh nng

tc ng n cc cu trc trn thn no [46]. C ch gy co cng c l do tng

in th ngh (mt c ch) ca n-ron vn ng cng vi mt s c ch p

ng phn x vn ng trc kch thch cm gic hng tm. C vng hm, mt

v u thng biu hin trc tin do chng c ng i si trc thn kinh chi

phi ngn hn. Mt c ch thn kinh thc vt dn n ri lon kim sot thn

kinh thc vt vi tng hot tnh h giao cm (v m hi, nhp tim nhanh v tng

huyt p...) v nng catecholamine mu tng cao [33].

Tc di chuyn ca c t theo ng thn kinh vo khong 75 n 250 mm

mi ngy [66]. Nu c t c sinh ra vi mt lng ln th s thm vo mu

v bch huyt, tc dng ca c t s xy ra nhanh v lan rng hn [37].

Tc dng ca c t UV trn cc t bo sng trc ty sng, thn no v cc

n-ron thn kinh thc vt ko di kh lu. c t gn h thn kinh khng o

Bnh un vn 2008

22

ngc, hi phc, c th cn sinh cc tn cng trc thn kinh mi v c t

phi b phn hy, iu ny gii thch din bin ko di ca bnh UV, thng l

t 4 n 6 tun [33].

Bnh un vn 2008

23

5. Biu hin lm sng ca bnh un vn

5.1. Vt thng ng vo

Vt thng ng vo thng sau chn thng, tai nn, ng hng u, chim

40-60% vi t l t vong 29% [39]. Thng thy cc vt thng chi di (2/3

cc trng hp [15]). Cc vt thng c th nh nh gai m, inh m, xc

da, gip mng, ngoy tai, xa rng... n cc vt thng to, rng, nhiu ngc

ngch nh gy xng h, bng su..., thm ch c th gp sau c kim sot

t cung, c st rau, no thai, sau m ng tiu ha, ct tr, ct rn vi cc dng

c b nhim bn [5]. chu Phi, gp mt t l khng nh (20% Dakar) do ct

bao qui u nam v xu tai ph n [39]. Ngoi ra cn c cc trng hp

UV sau tim quinin (rt nng, t l t vong trn 90% [39]), tim chng, nht l

tim chch ma ty [76]. c bo co v UV xut hin sau khi tht tr [47].

C mt t l nht nh khng tm thy ng vo, dao ng t 8% [39] n

30% [37] ty theo cc tc gi. Nhng trng hp ny trc y c xp vo

UV ni khoa-khng c vt thng [10], nhng hin nay nhiu tc gi cho l do

bnh nhn vng nng thn b cc vt thng rt nh lp i lp li nhiu ln [15,

67].

Hin nay, vi tnh hnh bnh i ng ang gia tng, cc vt thng lot hoc

hoi th do i ng cng ng vai tr ng k trong vic dn ti bnh un

vn [63].

5.2. Thi gian bnh

Thi gian ny tnh t lc b thng, trc khun UV xm nhp c th cho n

lc bnh xut hin, thay i theo tng tc gi, ni chung t 1 n 60 ngy [33],

thng l khong 5-10 ngy [10]. Ni chung v tr vt thng cng xa thn kinh

trung ng th thi gian bnh cng ko di. Trong UV s sinh, triu chng

Bnh un vn 2008

24

thng xut hin t ngy 3 n ngy 14 sau sinh, trung bnh vo khong 7 ngy

[87].

5.3. Thi k khi pht

Thi k ny tnh t lc mi hm n khi co cng ton thn v c cn co git

u tin, ko di trung bnh 1 n 7 ngy [5]. Thi gian khi pht cng ngn

th bnh cng nng [4,10]. Triu chng khi u l cng hm gp khong

75% cc trng hp [17]. Cng hm l hin tng co cng c nhai v c thi

dng, biu hin bng s hn ch m ca ming [31]. Lc u ch l mi

hm, kh nhai, kh h ming, sau cng hm tng dn v xut hin lin tc.

Bnh nhn thy au vng c nhai khi h ming ri au lin tc vng c nhai,

khng th n v ni c. Trong nhng trng hp cng hm kn o, ngi

ta tm du hiu li [signe de l'abaisse langue captif]: dng ci li khm

th thy c hm co r, hm cn cht hn [31]. Cc tc gi Dakar rt tm c

vi du hiu ny [39]. Cng c th lm nghim php li [the spatula test]

m Apte v Karnad m t (1995): chm hng ming bng ci li, thng

thng nghim php ny gy phn x e, bnh nhn c y ci li ra

(nghim php m tnh) cn trong un vn, bnh nhn s co cng c nhai kiu

phn x v cn vo ci li (nghim php dng tnh). Trong mt nghin

cu 400 bnh nhn, nghim php ny c nhy 94% v c hiu 100%,

khng thy hu qu c hi g (nh co tht thanh qun) t nghim php ny [34].

Bn cnh cng hm, cc c khc co cng hnh thnh nn biu hin c bit ca

bnh UV. C bm da mt co cng, bnh nhn ci th mt nhn gi trc tui,

n ci rt au kh [risus sardonicus]. C c co cng, c nga dn, hai c c

n chm ni r. C dc sng co cng lm bnh nhn t th n cong

[opisthotonos]. Trong mt s trng hp, bnh nhn c th i khm v triu

chng au lng xut hin trc tin [72]. Hai c thng bng ni g ln, s bng

cng nh g. Nhng trng hp co cng c bng xut hin sm c th nhm

Bnh un vn 2008

25

vi biu hin bng ngoi khoa, v tng c bnh nhn b m bng v c bng

co cng nh vy. Nu c lng v c bng i khng cn bng th bnh nhn

nm thng [orthotonos]. Nu ch co cng mt bn thn th bnh nhn cong mt

bn [pleurothotonos]. C chi trn thng co cng t th gp, c chi di

t th dui. C thnh ngc, c lin sn co cng lm lng ngc di ng hn

ch. Khi c kch thch (s m, ting ng, nh sng...) hoc thm khm, cc

cn co cng tng ln lm cho bnh nhn rt au. Trong thi k ny, ton thn

bnh nhn hi mt mi, c th st nh hoc khng ty tnh trng vt thng

[10].

5.4. Thi k ton pht

Thi k ny ko di t 1 n 3 tun [5] vi ba biu hin r nht l co cng c

ton thn lin tc, cc cn co git ton thn trn nn co cng v ri lon thn

kinh thc vt m c tc gi gi l tam chng UV [33].

Co cng c ton thn lin tc tng ln khi c kch thch v rt au. in hnh

th ngi bnh nhn n cong. Co cng cc c h hp lm gim kh nng ho

khc, khc yu gy ng m ri. Nhiu trng hp bnh nhn co cng c

h hp ti mc di ng lng ngc khng m bo chc nng thng kh,

bnh nhn trong tnh trng chn ngc, cn h tr h hp cp cu. C thanh

qun c th co cng gy ngt, ngng th-ngng tim. Phn x nut b ri lon:

bnh nhn kh nut, d sc v ng m ri. Cc c vng cng co cng gy

b i tiu tin [10].

Bnh un vn 2008

26

Hnh 8. Cn co cng ca bnh nhn un vn

Trn nn co cng c nh vy, bnh nhn xut hin cc cn co git ton thn

mt cch t nhin, cn tng khi c cc kch thch. Trong cn, bnh nhn vn

tnh nhng d b co tht thanh qun, co cng c h hp dn n ngt. Cn git

ko di t vi giy n vi pht hoc lu hn. Sau cn bnh nhn mt l, v

nhiu m hi.

Ri lon thn kinh thc vt gp trong cc th nng, xut hin vi ngy sau co

git v ko di trong 1-2 tun [33]. Bnh nhn c tnh trng nhim c ton

thn, da xanh ti, ni vn tm, thn nhit tng cao, nhp tim nhanh, huyt p dao

ng, th nhanh, tng tit m ri, v nhiu m hi... Tnh trng ny thng c

cc bin chng suy tun hon, suy h hp... d dn n t vong. St hu nh

bao gi cng c. Trong cc trng hp nng, st ti 390C v khi c cn co cng

th ln ti 400C. Sau khi bnh nhn tt th, nhit vn cn ln [10].

Bnh un vn 2008

27

Bng 5. Cc ri lon thn kinh thc vt gp trong UV [21]

Tng huyt p ko di hoc thong qua

H huyt p tin trin v dai dng

Co mch ngoi vi

Nhp tim nhanh (thng tng cn)

Nhp tim chm v v tm thu

Lon nhp tim

St

V m hi, a nc bt

Tng dch tit ph qun

tr d dy v lit rut

B i

Trong giai on ton pht, v mt xt nghim c th thy mt nc ngoi bo.

Do dng thuc iu tr barbituric v diazepam c thnh phn t dc gy ri

lon tnh thm thnh mch m Na, protein v nc c th thot ra khong k,

gy ph k v gim th tch tun hon. Mun hn, c th thy thiu mu v

tng bch cu [15], chc nng iu ha glucose b ri lon [10] v c th tng

ng niu thong qua [62]. Nhng trng hp co git nhiu c th tng creatin

phosphokinase trong mu [9].

5.5. Thi k lui bnh

Sau khi tri qua thi k ton pht, cc cn git tha dn ri ht git. Tnh trng

co cng ton thn cn ko di nhng mc gim dn. Ming bnh nhn h

rng dn ra, phn x nut tr li. Bnh nhn th tt ln, phn x ho khc dn

v bnh thng. Thi k ny ko di vi tun n hng thng ty theo mc

bnh [5].

5.6. Cc th lm sng

Theo tin trin ca bnh, t thi Dieulafoy (1897) nhn nh hai th UV din

bin nhanh v chm. Nm 1931, Ramond [32] chia ra cc th ti cp, bn

cp v mn tnh. Ngoi ra, cc tc gi cn m t r th trng din v th ti

Bnh un vn 2008

28

pht [10,49]. Mc chia da vo thi gian t khi b bnh n khi lnh bnh hoc

t vong.

Trn c s khu tr cc triu chng lm sng, c ba th UV c m t theo

nh khu. l UV ton th, cn gi l UV th in hnh nh m t trn

y; UV khu tr v UV u.

- UV khu tr l mt th bnh khng hay gp. Trong th ny bnh nhn c s

co c lin tc cng vng gii phu vi vt thng. C c th co lin tc vi

tun trc khi gim dn. UV khu tr c th bo trc khi pht UV ton th,

nhng ni chung l nh hn. T l mc chim khong 13% cc UV [45], ch

khong 1% cc trng hp l t vong [28].

- UV u l mt th him ca bnh, chim khong 6% cc trng hp UV [45],

thnh thong gp cng vim tai gia, hoc sau vt thng vng u. C s tn

thng cc dy thn kinh s, nht l vng mt, thm ch trong 42% cc trng

hp c lit thn kinh s trc cng hm [45]. Thi gian bnh c khi ch 1-2

ngy [17]. Kinh in chia UV u thnh hai th nh l UV u th Rose c lit

mt ngoi bin thng cng bn vi vt thng v UV lit vn nhn th Worms

sau khi b vt thng vng hc mt c lit vn nhn v lit mt ngoi bin [31].

Th u c th tin trin thnh UV ton th 2/3 s trng hp vi t l t

vong 15-30% [45].

- UV ton th l th hay gp nht (chim khong 80% n 90% [17, 45]).

Theo hon cnh xut hin UV, cn phi xem xt mt s trng hp ng vo

c bit. UV s sinh l mt dng ca UV ton th xut hin tr mi , thng

gp trn tr khng c min dch th ng bo v v m khng c tim chng.

ng vo thng thng l t cung rn, nht l khi ct rn bng dng c

nhim bn. UV s sinh gp nhiu mt s nc ang pht trin (c tnh

Bnh un vn 2008

29

270.000 t vong hng nm trn th gii) [28]. UV ni tng cng l mt dng

ca UV ton th vi vt thng t mt ni tng nh rut, t cung... nhng nguy

kch v tin lng rt nng [10].

Bnh un vn 2008

30

6. Chn on bnh UV

Khng nh phn ln cc bnh nhim trng khc, chn on UV thng l d

thy v ch yu da vo lm sng [67]. Nu c iu kin nh lng khng c

t UV trong huyt thanh, kt qu trn 0,01 n v/dl th t ngh n UV [17].

Tuy nhin, ngay c trong trng hp bnh nhn c tim phng y th

kh nng b UV vn khng th loi tr [70]. Cc xt nghim khc thc ra khng

c gi tr chn on ngoi tr vic loi tr ng c strychnin [66].

Ngoi vic loi tr cc nguyn nhn nhim trng khc, chn thng, khi u v

cc bnh ti ch gy cng hm [31], cn phn bit UV vi cc bnh c bnh

cnh tng t nh: h calci mu, lon trng lc (nh do phenothiazin), ng

c strychnin, hi chng an thn kinh c tnh [67], vim no [63], thm ch c

histeria [10]. Nhiu tc gi xut cc tiu chun chn on bnh UV. Cc

tiu chun ny gip ch nhiu trong cng tc nghin cu v iu tra bnh.

Theo Nguyn Duy Thanh [11] th tiu chun chn on UV l: (1) cng hm;

(2) co cng c vi c im: au v lin tc, xut hin trnh t khi u l c

nhai, c mt, c bng ri cui cng l t chi; (3) co git ton thn tng cn trn

nn co cng; (4) c th pht hin c ng vo ca trc khun UV.

Theo J.B. Greco v cng s [41] th bnh nhn UV c t nht 2 trong s cc

triu chng sau: (1) au nhiu nhm c; (2) Di chuyn kh khn; (3) Cng

hm; (4) Co cng c; (5) Co cng khi kch thch; (6) Mt nhn; (7) Cng n

ngi; (8) Vn cn thc; (9) Cc du hiu cng giao cm (ri lon nhp tim,

huyt p bin ng khng n nh, v nhiu m hi).

CDC Hoa K nh ngha lm sng ca bnh UV [28] nh sau: (1) tng trng

lc c khi pht cp tnh hoc (2) co cng c gy au (thng l c hm v

c) v co git ton th m khng thy cn nguyn ni khoa r rng no khc.

Bnh un vn 2008

31

7. iu tr bnh un vn

Duy tr thng kh v oxy ha mu trong khi kim sot co cng-co git c l

mu cht ca x tr ban u [66]. Nguyn tc ca vic x tr UV bao gm:

- Tiu dit vi khun ngn khng cho gii phng thm c t. Kinh in

thng dng Penicillin. Tuy nhin do thuc ny c tc dng i khng vi h

GABA, gy hng phn h thn kinh trung ng nn xu hng hin nay thay

bng Metronidazol [67].

- Trung ha c t cn trong c th, ngoi h thn kinh trung ng. Xu hng

hin nay dng Globulin min dch UV t ngi hoc Huyt thanh khng UV

t nga, dng ng tim bp hoc ng trong ng sng [67]. T nm 1898,

Roux v Picard i tin phong trong vic dng khng huyt thanh UV ng

ng sng nhng sau phi ngng do tai bin bi cht bo qun phenol [15].

Gn y th nghim lm sng ngu nhin c i chng ca cc tc gi Brazil

[50] cho thy dng globulin min dch khng UV ng ng sng c tin trin

lm sng tt hn v rt ngn thi gian nm vin hn l ch dng tim bp. Mt

s tc gi n cng nhn thy dng globulin min dch khng UV ng

ng sng c hiu qu i vi cc th bnh va v nh [39].

- Gim thiu ti a tc dng ca c t gn vo h thn kinh. Cc bin php

bao gm khng ch cn git v gim co cng c, khng ch ri lon thn kinh

thc vt v rt quan trng l chm sc h tr [14, 24, 37, 60]. Baclofen dng

ng ng sng hoc ng ung [42] tng c ca ngi nhng cng c

nhiu trng hp bo co tht bi [77]. Magi sulfat [78] ang l hng nghin

cu hin nay nhng thc s khng lm gim c vic bnh nhn phi th my

m ch c hiu qu phi hp vi cc thuc khc trong kim sot co cng-co

git v ri lon thn kinh thc vt.

Bnh un vn 2008

32

V vic x tr vt thng ng vo, a s tc gi khuyn co cn rch rng,

ly ht d vt, m hoi t v ra sch, nhng c mt s tc gi, trong c

Bleck T.P. li cho rng vic x tr vt thng ng vo khng c li im g

r rt i vi bn thn bnh UV [22, 23, 54]. X tr bnh UV kh phc tp, i

hi s h tr t nhiu chuyn khoa. Tc gi Bleck T.P. h thng ha cc

bc iu tr di dng phc d thc hin ti cc tuyn c n v hi sc

[22]. Tuy nhin, la chn kim sot ng th ca nhiu tc gi khi c suy h

hp l t ni kh qun, sau mi m kh qun khi t ng qu lu [27].

cc nc ang pht trin hin nay, khi c ch nh thng m kh qun ngay

nhm trnh cc kch thch khng cn thit [5, 82]. Cc ch nh m kh qun

[5] l: (1) c nguy c e da ngt do co tht thanh qun, chn ngc; (2) ng

nhiu m ri ng th. Xu hng hin nay nhiu ni p dng k thut m

kh qun qua da ti ging thay v m kh qun phu thut truyn thng nh

trc y [37]. Trong x tr bnh UV thng cn bo v ng th v h tr

thng kh t sm. Hin cha c c s nh gi v tc dng khc nhau ca

cc phng thc thng kh h tr khc nhau. Trong giai on sm ca bnh,

khi co cng v co git ni tri th cn lm lit c v thng kh iu khin c

kim sot. gin n v oxy ha km do co cng c hoc do cc bin chng

phi c th gii quyt c bng cch kt hp thng kh kim sot p lc v p

lc dng tnh cui k th ra. giai on cui ca bnh, ni chung ngi ta a

dng cc phng thc cho php thng kh t nhin (thng kh iu khin ngt

qung ng th, p lc ng th dng tnh lin tc v p lc ng th dng

tnh hai pha) v cc phng thc ny c th ti u ha kiu th, gim nhu cu

an thn, gim thiu vn c tha v gim kh nng b bnh l dy thn kinh hoc

bnh l c mc phi sau bnh l hi sc. Tuy nhin vn ch c rt t lun chng

trong UV v phng thc th h tr [37].

Sau y l phc iu tr bnh UV do T. Bleck xut [22]

Bnh un vn 2008

33

1. Chn on v n nh tnh hnh: gi u tin sau khi vo khm A. nh gi ng th v thng kh. Nu cn, chun b t ni kh qun v thuc gin c (nh vecuronium 0,1 mg/kg). B. Ly mu bnh phm xt nghim nng khng c t, strychnine v th nghim i khng dopamine, xt nghim in gii , ur mu, creatinin, creatine kinase v myoglobin niu. Nu thy cn chn on phn bit vim mng no th tin hnh chc dch no ty. C. Xc nh ng vo, thi gian bnh, thi gian khi pht v tin s tim chng. D. Cho dng benztropine 1-2 mg tnh mch (TM) hoc dyphenhydramine 50 mg TM gip loi tr phn ng lon trng lc. E. Cho dng benzodiazepine TM (diazepam mi ln tng 5 mg hoc lorazepam mi ln tng 2 mg) kim sot co git v gim co cng. Ban u, dng liu gy an du v gim co git phn x xung mc ti thiu. Nu liu ny gy c ch ng th hoc thng kh th t ng ni kh qun, trc c dng thuc gin c tc dng ngn ri chuyn bnh nhn ti khu vc yn tnh, ti ca n v chm sc tng cng.

II. Giai on x tr sm: 24 gi u A. Cho dng globulin min dch un vn ca ngi (HTIG), 500 n v tim bp (TB). B. Tim bp ti v tr khc mt gii c t un vn hp ph nh vc-xin un vn-bch hu 0,5 ml hoc vc-xin bch hu-un vn-ho g 0,5 ml ty theo la tui. Sn c gii c t un vn hp ph khng cha gii c t bch hu dnh cho cc bnh nhn c tin s phn ng vi gii c t bch hu; nu khng, nn dng vc-xin kt hp ng theo la tui. C. Nu cn nhc vic dng khng c t trong ng sng th nn dng vo thi im ny. D. Bt u metronidazol 500 mg TM c 6 gi mt ln trong 7 n 10 ngy. E. Tin hnh m kh qun sau khi t ng ni kh qun v dng thuc gin c nu co git gy cn tr h hp bt c mc no, hoc nu xut hin kh nut hoc xut tit kh x tr. F. Ct lc vt thng nu y l ch nh v pha vt thng (vic ny khng c nh hng r nt trong din bin bnh un vn). G. t mt ng mm, khu knh nh cho n ng mi hoc mt catheter tnh mch trung ng nui dng. H. Dng benzodiazepine khi cn kim sot co git v gy an du. Nu khng t c s kim sot thch ng th dng thuc gin c tc dng ko di (nh truyn vecuronium hoc tim pancuronium cch qung). Tip tc benzodiazepine gy an du c theo di in no m bo ng u. I. Bt u l liu php lm thng thong phi v tp bin vn ng th ng sau khi bnh nhn dng thuc n nh cng sm cng tt. Nn dng thm thuc gy an du trc mi ln tr liu v li dng trong khi tr liu nu liu php gy co git.

III. Giai on x tr trung gian: 2 n 3 tun k tip A. iu tr cng giao cm bng labetalol TM 0,25 n 1,0 mg/pht hoc morphine 0,5 n 1 mg/kg/gi. Xem xt phong b ngoi mng cng bng thuc t cc b. Trnh dng li niu kim sot huyt p v gim khi lng tun hon s lm xu thm tnh trng mt n nh h thc vt. B. Nu c h huyt p, t catheter ng mch phi v mt ng ng mch, v cho b dch, dng dopamine hoc norepinephrine. C. Nhp tim chm ko di thng cn phi to nhp. Atropine hoc isoproterenol c l c ch trong khi ang t my to nhp. Nn trnh to nhp ngoi tr khi bnh nhn ang dng thuc gin c. D. Bt u heparin d phng phng trnh tc mch phi. E. Nu c th, dng ging m nc phng lot da v lit thn kinh chy. Nu khng th phi m bo ln tr thng xuyn v dng bt chng xoay. F. Duy tr benzodiazepine cho n khi khng cn cn dng thuc gin c, nu c dng, v khi mc co git gim r rt. Gim dn liu trong vng 14 n 21 ngy. G. Bt u vch k hoch phc hi chc nng.

Bnh un vn 2008

34

IV. Giai on phc hi A. Khi khng cn co git na, bt u l liu php. Nhiu bnh nhn cn liu php tm l h tr. B. Trc khi ra vin, dng liu gii c t un vn thch hp k tip.

C. Hn liu gii c t th ba 4 tun sau khi dng liu th hai.

Ti Khoa iu tr tch cc Vin Cc bnh Truyn nhim v Nhit i Quc gia

hin nay ang p dng phc iu tr bnh UV nh sau:

1. Nguyn tc - m bo yn tnh v trnh cc kch thch i vi ngi bnh. - Dng khng sinh tiu dit trc khun un vn. - Trung ho c t un vn cn lu hnh trong mu bng SAT. - Khng ch co cng c, co git v ri lon thn kinh thc vt. - Duy tr chc nng sng bng cc iu tr h tr. 2. Khng sinh tiu dit trc khun un vn: - Metronidazol 0,5 g x 3 ln, truyn tnh mch cch 8 gi/ln. - Dng trong 7-10 ngy.

3. Trung ho c t un vn cn lu hnh trong mu: - Nu c tim SAT ti bnh vin tuyn trc th cn nhc vic tip tc dng SAT. - SAT 1500 n v x 6-10 ng tim bp. Th test trc tim. - Nu th test SAT dng tnh th gii mn cm theo phng php Besredka.

4. Khng ch co cng c, co git v ri lon thn kinh thc vt: - Thuc dng ban u: Diazepam

+ Cch 2-4 gi dng thuc mt ln. + Dng xen k thuc tim (tim tnh mch) v thuc ung (bm qua ng thng d dy).

+ Tu p ng lm sng, iu chnh liu ti thiu bnh nhn nm yn, khng cn co git nhng vn co cng c mc nh khi kch thch. + Khng nn dng qu 240 mg Diazepam/ngy.

- Khi dng Diazepam liu ti a m khng hiu qu th dng thm Thiopental + Pha Thiopental 1-2 g vo chai NaCl 0,9% 250-500 ml. Truyn bolus qua catheter tnh mch trung tm khi bnh nhn co git. Ngng truyn ngay khi bnh nhn ht co git. + Khi dng Thiopental nn m kh qun cho bnh nhn h tr h hp khi cn. + Khng nn dng qu 4 g Thiopental/ngy

- Nhng trng hp bnh nhn co git do ngt c th dng ngay hn hp Cocktailytique: + Thnh phn hn hp: Aminazin 0,025g x 1 ng + Dolargan 0,1g x 1 ng + Dimedrol 0,01g x 1 ng + Hn hp cc thuc sau khi ly vo bm tim c tim bp ngay - 1 liu.

5. H tr v chm sc h hp: - M kh qun

+ Ch nh sm cho nhng trng hp tin lng nng. + Ch nh khi bnh nhn co cng chn ngc (khng th c) hoc ng m ri (khng ho khc c).

- Th oxy + Ch nh khi bnh nhn cn t th c, th kh tri SpO2 < 92%

Bnh un vn 2008

35

+ Th oxy qua gng mi (cha m kh qun) hoc qua ng ch T ( m kh qun).

- Th my: + Ch nh khi bnh nhn ri lon nhp th, khng t th c hoc th oxy nhng SpO2 < 92%.

+ Bnh nhn ang dng Thiopental nn cho th my. - Ch v sinh rng ming v ht sch m ri.

6. H tr tun hon - m bo khi lng tun hon bng truyn dch trn c s cn bng nc v in gii. - Nhng trng hp dng Diazepam tim liu cao v dng Thiopental phi t catheter tnh mch trung tm. - Duy tr huyt p tm thu lun > 90mmHg bng dch truyn v cc thuc vn mch. 7. Lot stress

- D phng v iu tr lot stress bng thuc gim tit acid dch v kt hp vi thuc bng nim mc d dy. - Nhng trng hp xut huyt tiu ho cao ko di cn nui dng bng ng tnh mch.

8. Cc h tr v chm sc khc: - Cho n qua ng thng d dy. - Bnh nhn to bn ko di dng thuc nhun trng Sorbitol. C th dng thuc ty Magi sulfat. Nu khng hiu qu th tht tho bng nc m. - Bnh nhn b i nn t thng tiu sm. - Nhng trng hp bi nhim s dng thm khng sinh chng nhim khun bnh vin. - Ch x tr vt thng ng vo khi bnh nhn c kim sot tt v h hp, tun hon v dng khng sinh tiu dit trc khun un vn v SAT:

+ Rch rng vt thng ly ht t chc hoi t v d vt + Bm ra nc oxy gi + Khng khu kn ngay vt thng.

- V sinh c th v cc hc t nhin. Chm sc thay i t th chng lot.

Bnh un vn 2008

36

8. Bin chng v tin lng bnh UV

8.1. Din bin v kt cc

T l t vong ca bnh v nguyn nhn t vong thay i rt nhiu ty theo c

s iu tr. Vi iu tr chm sc tng cng, c tc gi bo co t l t vong

gim t 44% xung cn 15% [81]. Trong s cc bnh nhn t vong vi chm

sc tng cng ny th c 40% l do ngng tim t ngt v 15% l do hu qu

cc bin chng h hp. Vi nhm chng lch s trc y khi khng c n v

chm sc tng cng th 80% t vong l do suy h hp cp sm. cc nc

ang pht trin, khi khng c c s chm sc tng cng v h tr thng kh

di ngy th t vong do UV nng c th ln ti trn 50% do tc ng th, suy

h hp, suy thn. Mc tiu chp nhn c cho cc nc pht trin l h t l

t vong ca bnh xung di 10%. Chm sc tng cng hin i ngn khng

cho bnh nhn cht v suy h hp cp nhng kt qu l li lm cho ri lon

thn kinh thc vt nhng UV nng tr nn d thy hn. Ngoi ra, nhng bin

chng quan trng ca chm sc ti n v chm sc tng cng bao gm nhim

trng bnh vin, nht l vim phi lin quan th my, nhim trng huyt,

thuyn tc mch v xut huyt tiu ha.

Ni chung nhng trng hp UV nng cn nm n v chm sc tng cng

khong 3-5 tun. Bnh nhn c th hi phc hon ton, tr v hot ng chc

nng bnh thng. Tuy nhin, qua mt nghin cu theo di bnh nhn UV sng

c th thng thy nhng vn v th cht v tm l ko di dai dng [33].

8.2. Bin chng

Cook T.M. v cng s [33] lit k cc bin chng ca UV trong bng sau:

Bnh un vn 2008

37

Bng 6. Cc bin chng ca UV

H c quan Bin chng

ng th Sc* Co tht thanh mn/tc nghn ng th* Tc nghn ng th lin quan thuc an thn*

H hp Ngng th* Thiu oxy* Suy h hp typ I* (xp phi, sc, vim phi) v typ II (co tht thanh mn, co git ton thn ko di, an thn qu nhiu) ARDS*

Cc bin chng do h tr thng kh ko di (nh vim phi) Cc bin chng do m kh qun (nh hp kh qun)

Tim mch Nhp tim nhanh*, tng huyt p*, thiu mu* Tt huyt p*, nhp tim chm* Lon nhp nhanh, lon nhp chm* V tm thu*

Suy tim*

Thn Suy thn a niu* Suy thn thiu niu* tr ng tit niu v nhim trng

Tiu ha tr d dy Lit rut a chy Xut huyt*

C quan khc St cn* Huyt khi thuyn tc mch* Nhim trng huyt v suy a tng* Gy xng ct sng do co git Bong gn do co git

Du * ch cc bin chng e da tnh mng.

Cc bin chng c th l hu qu ca bnh nh co tht thanh qun, gy xng,

tiu c vn; l hu qu ca iu tr nh mt tri gic, sc hoc ngng th do

thuc an thn; l hu qu ca can thip nh nhim trng bnh vin, vim phi

do th my.

8.3. Phn v tin lng

T u th k XX ti nay c nhiu tc gi nghin cu v phn v tin

lng UV [1, 32, 78]. Trn c s phn tch din bin v kt cc bnh, mt s

c im, triu chng v du hiu c coi l c ngha tin lng bnh UV

Bnh un vn 2008

38

nh vt thng ng vo, thi gian bnh, thi gian khi pht, mc co

cng c, mc co git, st, nhp tim... [1]. Cc tc gi c gng h thng

ha nhng yu t ny theo cc thang im hoc bng phn [6]. Tuy nhin,

t nhng thang im tin lng ban u nh ca Patel (1959) [41], Ablett

(1967) [21] cho n nhng thang im ra i gn y nh ca Udwadia (1994)

[82] hay ca n v Oxford ti thnh ph H Ch Minh [78] u c u-nhc

im ring. Ty theo iu kin c s, kh nng theo di v nh gi cng nh

c im nhm bnh nhn m thy thuc iu tr hoc nh nghin cu chn la

cc thang im hoc cc nhm yu t tin lng khc nhau.

Theo Patel v Joag (1959) [41,50], da trn nm tiu chun phn : Cng

hm; Co cng kiu phn x; Thi gian bnh khng qu 7 ngy; Thi gian

khi pht khng qu 48 gi; Nhit nch trn 37,20C (990F) khi nhp vin

hoc trong vng 24 gi khi nhp vin phn chia lm 5 UV tu theo c

c bao nhiu tiu chun phn .

Php, ni chung ngi ta theo phn ca Mollaret v cng s (1965) [15]

chia lm 3 nhm theo cc tiu chun din tin, triu chng v iu tr:

Nhm I: cc th th s, thc t ch c cng hm, khng cn phi dng n cc k thut

hi sc

Nhm II: un vn khi pht nhanh, co cng ton thn, kim sot ti thiu phi m kh

qun v iu tr an thn

Nhm III: cc th nng, tin trin rt nhanh, cc cn git mau, chn ngc v cn git kch

pht t nhin, kh kim sot bng an thn, m kh qun v thng kh nhn to, c th

phi cn thuc gin c.

Phn ny n gin, d p dng cc nc ang pht trin, nht l trn cc

i tng UV khng r ng vo.

Bnh un vn 2008

39

Phn loi ca Phillips (1967) [37] chi tit v kh phc tp. Mc d vy, khi so

snh vi cc thang phn khc, vic da trn thang im Philips cng khng

gip ch nhiu trong phn loi bnh nhn [78].

Yu t im

Thi gian bnh

< 48 gi 5

2-5 ngy 4

5-10 ngy 3

10-14 ngy 2

> 14 ngy 1

V tr nhim trng

Ni tng v rn 5

u, c v thnh khoang c th 4

Ngoi vi gn 3

Ngoi vi xa 2

Khng r 1

Tnh trng tim phng

Khng 10

M h 8

tim > 10 nm 4

tim < 10 nm 2

Tim phng hon ho 0

Cc yu t lm nng thm

Thng tn hoc bnh e da cuc sng 10

Thng tn hoc bnh nng nhng khng ngay lp tc e da cuc sng 8

Thng tn hoc bnh khng e da cuc sng 4

Thng tn hoc bnh nh 2

I thang ASA* 0

Tng s im * I thang ASA: Xp I trong H thng Phn loi Tnh trng Thc th ca Hip hi Cc nh gy m Hoa K [American Society of Anesthesiologist Physical Status Classification

System], bao gm: sc khe rt tt, khng c bnh ton thn khng hn ch hot ng khng c nguy c e da t vong loi tr bnh nhn cc cc tui: qu nh, qu gi

Bnh un vn 2008

40

Thang phn ca Ablett (1967) [21,33] kh n gin, v theo Udwadia th

phn ny ch quan v c on nhng ng vng trc th thch ca

thi gian [82].

Cc biu hin lm sng

I Nh Cng hm nh n va; ni chung c co cng ; khng kh th; kh nut nh hoc khng

II Va cng hm va; co cng rt r; co git nh n va nhng ngn; kh th va phi vi nhp th tng trn 30 nhp/pht; nut kh nh

III Nng cng hm nng; co cng ton thn; co git kiu phn x ko di; nhp th tng trn 40 nhp/pht; c cn ngng th; nut rt kh; nhp tim nhanh trn 120 ln/pht

IV Rt nng III v cc ri lon thc vt d di lin quan n h tim mch. Huyt p tng cao v nhp tim nhanh xen k h huyt p tng i v chm nhp tim, bt c biu hin loi no cng c th ko di.

Tc gi Veronesi Brazil cng ngh thang phn ca mnh (1974) [86]:

Thng s Nh Rt nng

Thi gian bnh > 10 ngy < 10 ngy

Tin trin > 48 gi < 48 gi

Co git Khng c cho n nh Nng

Tng trng lng lc c Khng c cho n nh Nng

Kh nut Khng Nng

Cn ngng th Khng Nng

Suy h hp Khng Nng

Hiu qu ca thuc Rt tt Ti

St Khng Cao

Bnh nhn b bnh va cho n nng c nhng thay i cc thng s trn trong khong nh

v rt nng.

Phn lm sng T l t vong

nh khng hoc rt thp

nng 20-40%

rt nng 50-90%

Bnh un vn 2008

41

Ti hi ngh Quc t v UV t chc ti Dakar nm 1975 [32], thang phn

sau y c chp nhn v s dng rng ri hin nay trn th gii:

Yu t tin lng im Dakar

im 1 im 0

Thi gian bnh < 7 ngy 7 ngy

Thi gian khi pht < 2 ngy 2 ngy

ng vo Rn, bng, t cung, gy h, vt thng ngoi khoa, tim bp

Cc ng vo khc v ng vo khng r

Co git C Khng

St > 38,40C < 38,40C

Nhp tim nhanh Ngi ln > 120 nhp/pht Tr s sinh > 150 nhp/pht

Ngi ln < 120 nhp/pht Tr s sinh < 150 nhp/pht

Tng s im

Tng s im Dakar T l t vong

0 v 1 Khng c

2 4%

3 16% (gp 4 ln 2 im)

4 64% (gp 4 ln 3 im)

Theo cc tc gi Armitage v Clifford [18], trong nhng nm 1960, qua phn

tch hi quy logistic 1385 bnh nhn un vn, cc yu t tin lng t vong c

lin quan n: thi gian khi pht (thi gian t triu chng u tin n khi c

co cng c ton thn khi kch thch), thi gian t khi c triu chng u tin

n khi nhp vin, nh gi lm sng mc nng khi nhp vin. Cui nhng

nm 1970, cc tc gi ny a ra mt nhm ba yu t tin lng mi: thi

gian t triu chng u tin cho n khi n vin, c co cng c khi kch thch

lc nhp vin hay khng v un vn tr s sinh.

Tc gi chuyn v lnh vc bnh UV l T. Bleck cng xut cch phn

tin lng UV ca mnh (1991) [28] nh sau:

Cho mi biu hin sau y 1 im:

Thi gian bnh di 7 ngy

Thi gian khi pht di 48 gi

Bnh un vn 2008

42

Un vn mc phi sau bng, vt thng ngoi khoa, gy xng phc hp hoc sy thai nhim trng

Nghin ma ty

Un vn ton th

Nhit trn 400C

Nhp tim nhanh > 120 nhp/pht Tng s im chia lm 4 mc :

Nh: 0 1 im Va: 2 3 im Nng: 4 im Rt nng: 5 6 im

Ti Khoa iu tr tch cc ca Vin Cc bnh Truyn nhim v Nhit i Quc

gia hin ang p dng bng phn sau y [5], trong ch trng yu t thc

t d s dng trn lm sng m vn nh gi c cc yu t quan trng c nh

hng n kt cc ca bnh nhn.

Yu t tin lng I (nh v va) II (nng) III (rt nng)

Thi gian bnh > 12 ngy 7-12 ngy < 7 ngy

Thi gian khi pht > 5 ngy 2-5 ngy < 48 gi

Cn co git ton thn

Tc dng ca thuc an thn

Khng hoc rt nh Seduxen tc dng tt

Ngn v tha

Seduxen liu cao

Nng v mau M kh qun v thng kh nhn to

Mch Huyt p

< 100 ln/pht Bnh thng

100-140 ln/pht Bnh thng

> 140 ln/pht H

Xut huyt d dy (Dch nu en)

Khng Khng hoc c t Khng km chng bng

Nhiu v km chng bng

S d c qu nhiu thang v bng phn loi tin lng bnh nhn UV nh vy

l do kt cc bnh nhn UV nng, iu tr lu di v tn km, vic tin lng

bnh UV thc s kh khn [10]. Trong tng lai, chng ta hy vng tt c nhng

cng trnh k trn s ch li cho chng ta hc tp v phng php, khi m

bnh UV c khng ch v thanh ton trn phm vi ton th gii.

Bnh un vn 2008

43

TI LIU THAM KHO

Ti liu tham kho ting Vit 1. Chng trnh Tim chng m rng. Trang tin in t. Xem ti:

http://www.cimsi.org.vn/TCMR/defaults/default.asp

2. Chng trnh Tim chng m rng. Trang tin in t. Xem ti: http://www.moh.gov.vn/homebyt/vn/portal/HomeArea.jsp?area=207

3. Duy Cng (1997). nh gi tin lng v gp phn nghin cu c t t do lu hnh v khng c t trong mu bnh nhn UV. Lun vn tt nghip Bc s ni tr bnh vin. Trng i hc Y H Ni.

4. Bi i, Nguyn Vn Mi, Nguyn Hong Tun (2002). Bnh un vn. Bnh hc Truyn nhim. XB ln th hai. NXB Y hc. H Ni. 401-10.

5. Nguyn Hng H (2001). Bnh UV. Ti liu o to chuyn ngnh Truyn nhim. Vin Y hc Lm sng Cc bnh Nhit i-Phng Ch o tuyn Bnh vin Bch Mai, H Ni. 234-48.

6. Nghim Mnh H (1994). Gp phn nghin cu lm sng v mt s yu t tin lng bnh nhn UV. Lun vn tt nghip Cao hc. Hc vin Qun Y.

7. Bi Khc Hu (2001). Trc khun UV. Vi sinh Y hc. B mn Vi sinh vt Trng i hc Y H Ni. Nxb Y hc. 264-9.

8. Hong nh Ngc (2001). Nghin cu nhng ch nh v tai bin ca m kh qun trong iu tr bnh UV ti Vin Y hc Lm sng Cc bnh Nhit i. Lun vn thc s Y hc. Trng i hc Y H Ni.

9. Th Nhn (1995). Ch nh m kh qun v bin chng tiu c vn trong UV. Lun vn Thc s khoa hc Y dc. Trng i hc Y H Ni.

10. Trnh Ngc Phan (1985). Bnh UV. Bnh truyn nhim, tp II. Nxb Y hc. 111-7. 11. Nguyn Duy Thanh (1992). Bnh UV. Bnh truyn nhim. Nxb Y hc. 459-77. 12. Thng tn x Vit Nam. Cuba thanh ton xong bnh un vn. Bn tin. 19/01/2005.

Ti liu ting nc ngoi 13. Abdelmoneim T., DeNicola L.K., Hasan M.Y. (1997). Tetanus: Complications and

Management in a Pediatric Intensive Care Unit. In: The Rare Case Registry of

PedsCCM: The Pediatric Critical Care Web Site, September 16, 1997. Available from:

http://PedsCCM.wustl.edu/RARE/Tetanus.html

14. Abrahamian F.M. (2001). Management of Tetanus: A Review. Current Treatment Options in Infectious Diseases, 3, 2001. 209216

15. Amstutz Ph., Levy F.M., Offenstadt G. (1982). Ttanos. Encycl. Md. Chir., Paris, Maladies Infectieuses. 8038 G10. 11, 1982.

16. Antona D. (2002). Le ttanos en France en 2000 et 2001. BEH, 40. 10-2002, 197-9 17. Aretaeus. The Extant Works of Aretaeus, The Cappadocian. Edited by: Francis Adams

LL.D. (trans.). Boston Milford House Inc. 1972 (Republication of the 1856 edition).

18. Armitage P, Clifford R. Prognosis in tetanus: Use of data from therapeutic trials. J Infect Dis. 1978 Jul;138(1):1-8.

19. Bartlett J.G. (2001). Tetanus. Cecil Textbook of Medicine. Goldman Lee, Bennett J.C. (eds). 21stEd. W.B. Saunders, Philadelphia, 2001. 1675-7.

20. Beheshti S., Khajehdehi A., Rezaian G.R., Khajehdehi P. (2002). Current Status of Tetanus in Iran. Arch Iranian Med 2002; 5 (4): 216 218

21. Bhatia R., Prabhakar S., Grover V.K. (2002). Tetanus. Neurol. India, 2002. 50:398-407.

Bnh un vn 2008

44

22. Bleck T.P., Brauner J.S. (1997). Tetanus. In: Infections of the Central Nervous System. Scheld W.M., Whitley R.J., Durack D.T. eds. 2nd Ed. Raven Press, New York, 1997.

629-53

23. Bleck T.P. (2000). Clostridium tetani (Tetanus). Principles and Practice of Infectious Diseases. Mandell G.L., Bennett J.E., Dolin R. (eds). Churchill Livingstone, 2000. 2537-

43.

24. Boyles C.S., Mills M.H., Trupiano P. (1998). Tetanus: critical implications for nursing. Crit Care Nurse. 1998 Jun;18(3):44-9.

25. Brauner J.S., Vieira S.R.R., Affonso S.S. (2001). Comparison of two cohort of patients with severe tetanus in ICU. 21st International Symposium on Intensive Care and

Emergency Medicine: Poster abstracts

Brussels, Belgium. 20-23 March 2001. Crit Care 2001 5(Suppl 1):P095

26. Bruggemann H, Baumer S, Fricke WF, et al (2003). The genome sequence of Clostridium tetani, the causative agent of tetanus disease. Proc Natl Acad Sci. 2003 Feb

4;100(3):1316-21. Epub 2003 Jan 27.

27. Bunch T.J., Thalji M.K., Pellikka P.A., Aksamit T.R. (2002). Respiratory failure in tetanus: case report and review of a 25-year experience. Chest. 2002 Oct;122(4):1488-

92.

28. Cavalcante N.J.F., Sandeville M.L., Medeiros E.A.S.. Incidence of and Risk Factor for Nosocomial Pneumonia in Patients with Tetanus. Clin. Infec. Dis., 2001. 33(11).1842-6.

29. Cellerai C, Harari A, Vallelian F, Boyman O, Pantaleo G. Functional and phenotypic characterization of tetanus toxoid-specific human CD4+ T cells following re-

immunization. Eur J Immunol. 2007 Apr;37(4):1129-38.

30. Centers for Disease Control and Prevention. (2007). Tetanus. In: Epidemiology & Prevention of Vc-xine-Preventable Diseases "The Pink Book". Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. 10th ed. Washington DC: Public Health

Foundation, 2007. 71-80.

31. Ciroldi M., Gachot B. (1999). Ttanos: Physiopathologie, diagnostic, prvention. Rev. prat. 1999. 49:2145-2148.

32. Comptes rendus de la quartrime confrence internationale sur le ttanos Dakar, Sngal, 6-12/4/1975. Fondation Mrieux, ed., Lyon 1975.

33. Cook T.M., Protheroe R.T., Handel J.M. (2001). Tetanus: a review of the literature. Br. J. Anaesth., 2001. 87:477-87.

34. Dire D.J. (2002). Tetanus. eMedicine, July 17, 2002. Available from: http://www.emedicine.com/emerg/topic574.htm

35. Ebisawa I., Homma R. (1986). Tetanus in Japan: trends of mortality, case fatality and causes of death. Jpn J Exp Med. 1986 Aug;56(4):155-61.

36. Ergonul O., Erbay A., Eren S., Dokuzoguz B. (2003). Analysis of the case fatality rate of tetanus among adults in a tertiary hospital in Turkey. Eur J Clin Microbiol Infect Dis

2003; 22:188

37. Farrar J.J., Yen L.M., Cook T., et al (2000). Tetanus. J. Neurol. Neurosurg. Psychiatry 2000. 69:292-301.

38. Gangadharan N., Chandrasekar S., Adithan C., Shashindran C.H. (1982). Evaluation of diazepam in the management of tetanus. Ind. J. Pharmac., 1982,14 (3) 223-228

39. Geeta MG, Krishnakumar P, Mathews L. Intrathecal tetanus immunoglobulins in the management of tetanus. Indian J Pediatr. 2007 Jan;74(1):43-5.

40. Gentilini M., Dufflo B. (2000). Le Ttanos. Mdicine Tropicale. AUPELF 2000.[online version]

Bnh un vn 2008

45

41. Greco J.B., Tavares-Neto J., Greco Junior J.B. (2003). Accidental tetanus: prognosis evaluation in a historical series at a hospital in Salvador, Bahia, Brazil. Rev. Inst. Med.

Trop. S. Paulo, 2003 Jan-Feb. 45(1):35-40.

42. Guglani L, Lodha R. Enteral baclofen in the management of tetanus-related spasms: case report and review of literature. J Trop Pediatr. 2007 Apr;53(2):139-41. Epub 2006 Dec

10.

43. Henriques Filho GT, Lacerda HR, Albuquerque A, Ximenes RA. Sympathetic overactivity and arrhythmias in tetanus: electrocardiographic analysis. Rev Inst Med

Trop Sao Paulo. 2007 Jan-Feb;49(1):17-22.

44. Hippocrates. Aphorisms. Hippocrates Works. Francis Adams transl. Sydenham Society, London, 1849. sec. V-VII.[online version]

45. Hsu S.S., Groleau G. (2001). Tetanus in the emergency department: a current review. J Emerg Med 2001 May; 20(4): 357-65

46. Ijichi T., Yamada T., Yoneda S., Kajita Y., Nakajima K., Nakagawa M. (2003). Brain lesions in the course of generalised tetanus. J Neurol Neurosurg Psychiatry. 2003

Oct;74(10):1432-4.

47. Kasher JA, Mathisen G. Acquiring tetanus after hemorrhoid banding and other gastrointestinal procedures. J Gastrointest Surg. 2007 Apr;11(4):515-9.

48. Khajehdehi P., Rezaian G.R. (1997). Early acute respiratory failure due to severe tetanus: evidence for intrapulmonary shunting of blood. Irn J Med Sci. 1997; 22: 63 6

49. Kimura F., Sasaki N., Uehara H. (2001). Long-term recurrent infection of tetanus in an elderly patient. J Emerg Med 2001 March; 19(2) [online version]

50. Kumar R, Taneja DK, Dabas P, Ingle GK. Practices and knowledge regarding prevention of tetanus among doctors in Delhi. Asia Pac J Public Health. 2006;18(3):30-

2.

51. Miranda-Filho DB, Ximenes RA, Barone AA, Vaz VL, Vieira AG, Albuquerque VM. Clinical classification of tetanus patients. Braz J Med Biol Res. 2006 Oct;39(10):1329-

37.

52. Miranda-Filho D.B., Ximenes R.A.A., Barone A.A., Vaz V.L., Vieira A.G., Albuquerque V.M.G. (2004). Randomised controlled trial of tetanus treatment with

antitetanus immunoglobulin by the intrathecal or intramuscular route. BMJ 5 March

2004.[online version]

53. Moraes E.N., Pedroso .R.P. (2000). Ttano no Brasil: doena do idoso? Rev Soc Bras Med Trop. 2000 May-Jun;33(3):271-5

54. Nathan B.R., Bleck T.P. (1999). Tetanus. Tropical Infectious Diseases: Principles, Pathogens & Practice. Guerrant R.L., Walker D.H., Weller P.F. (eds). Churchill

Livingstone, 1999. 517-26.

55. Okoromah C.N., Lesi F.E.A. (2004). Diazepam for treating tetanus. The Cochrane Library, Issue 1, 2004.[online version]

56. Palmer P.E.S., Reeder M.M. (2000). Tetanus. The Imaging of Tropical Diseases, with Epidemiological, Pathological and Clinical Correlation. Springer-Verlag, Heidenberg,

2000. Chap 33.[online version]

57. Pascual F.B., McGinley E.L., Zanardi L.R., et al (2003). Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ 52(3), 2003.1-8.

58. Pedalino B., Cotter B., Ciofi degli Atti M., et al. (2002). Epidemiology of tetanus in Italy in years 1971-2000. Euro Surveill. 2002 Jul;7(7):103-10.

59. Pellizzari R., Rossetto O., Schiavo G., Montecucco C. (1999). Tetanus and botulinum neurotoxins: mechanism of action and therapeutic uses. Philos Trans R Soc Lond B Biol

Sci. 1999 Feb 28;354(1381):259-68.

Bnh un vn 2008

46

60. Prabhakar S., Grover V.K. (2002). Tetanus. Current Treatment Options in Infectious Diseases 2002, 4:473484

61. Prevots R., Sutter R.W., Strebel P.M., et al. (1992). Tetanus surveillance--United States 1989-1990. MMWR CDC Surveill. Summ 41,1992.1-9.

62. Rezaian GR, Khajehdehi P, Beheshti S. (1998). Transient renal glucosuria in patients with tetanus. Nephron. 1998 Nov;80(3):292-5.

63. Rhee P, Nunley MK, Demetriades D, Velmahos G, Doucet JJ. Tetanus and trauma: a review and recommendations. J Trauma. 2005 May;58(5):1082-8.

64. Rogers LC, Frykberg RG. Tetanus prophylaxis for diabetic foot ulcers. Clin Podiatr Med Surg. 2006 Oct;23(4):769-75, vii-i.

65. Saito T., Miyai I., Matsumura T., et al. (2000). A case of Bickerstaff's brainstem encephalitis mimicking tetanus. J Neurol Neurosurg Psychiatry 2000;69:695-696

66. Sanford J.P. (1995). Tetanus-Forgotten but Not Gone. NEJM Vol. 332 (12), March 23, 1995. 812-813

67. Savage EJ, Nash S, McGuinness A, Crowcroft NS. Audit of tetanus prevention knowledge and practices in accident and emergency departments in England. Emerg

Med J. 2007 Jun;24(6):417-21.

68. Schiavo, G., Matteoli, M., Montecucco, C. Neurotoxins affecting neuroexocytosis. Physiol. Rev. 80: 2000. 717-766.

69. Sexton D.J., Westerman E.L. (2007). Tetanus. UpToDate online 15.2. 2007. Available frrom: http://www.uptodate.com

70. Shimoni Z., Dobrousin A., Cohen J., Pitlik S. (1999). Tetanus in an immunised patient. BMJ 1999; 319: 1049

71. Shin D.H., Yu H.S., Park J.H., Shin J.H., Kim S.J. (2003). Recently Occurring Adult Tetanus in Korea: Emphasis on Immunization and Awareness of Tetanus. J.Korean

Med.Sci. 2003; 18: 11-6

72. Simpson J, Inglis A, Gordon MW. Back pain as the presenting symptom of generalised tetanus. Emerg Med J. 2007 Jan;24(1):e5.

73. Sitarska-Golebiowska J., Zielinski A. (2003). [Tetanus in 2001] Przegl Epidemiol. 2003;57(1):135-7. [Article in Polish] [Medline]

74. Stubbe M, Swinnen R, Crusiaux A, Mascart F, Lheureux PE. Seroprotection against tetanus in patients attending an emergency department in Belgium and evaluation of a

bedside immunotest. Eur J Emerg Med. 2007 Feb;14(1):14-24.

75. Talabi O.A. (2003). A 3-year review of neurologic admissions in University College Hospital Ibadan, Nigeria. West Afr J Med 2003; 22:150

76. Talan D.A., Moran G.J. (1998). Tetanus among injecting-drug users--California, 1997. Ann Emerg Med September 1998;32:385-386

77. Thomas RM, Bellamy MC. Tetanus in a subcutaneous drug abuser: ineffectiveness of intrathecal baclofen. Anaesth Intensive Care. 2006 Dec;34(6):811-5.

78. Thwaites CL, Yen LM, Loan HT, Thuy TT, Thwaites GE, Stepniewska K, Soni N, White NJ, Farrar JJ. Magnesium sulphate for treatment of severe tetanus: a randomised

controlled trial. Lancet. 2006 Oct 21;368(9545):1436-43.

79. Thwaites CL, Yen LM, Glover C, et al. Predicting the clinical outcome of tetanus: the

tetanus severity score. Trop Med Int Health 2006; 11: 27987. 80. Thwaites C.L., Farrar J.J. (2003). Preventing and treating tetanus. BMJ 2003:326:117-8 81. Trujillo M.H., Castillo A., Espana J., Manzo A., Zerpa R. (1987). Impact of intensive

care management on the prognosis of tetanus. Analysis of 641 cases. Chest. 1987

Jul;92(1):63-5

82. Trung Quc Y hc thng s gin bin.

Bnh un vn 2008

47

83. Udwadia F.E. (1994). Tetanus. New York: Oxford University Press, 1994 84. Udwadia F.E. (1996). Tetanus. Oxfords Textbook of Medicine. Weatherall D.J.,

Ledingham J.G.G., Warrell D.A. (eds). 3rd Ed. Oxford University Press 1996, 624-630.

85. Vandelaer J., Birmingham M., Gasse F., et al. (2003). Tetanus in developing countries: an update on the Maternal and Neonatal Tetanus Elimination Initiative. Vc-xine 2003; 21:3442

86. Veronesi R. (1981). Tetanus-Important new concepts. Excerpta Medica, Amsterdam, 1981. 144-152.

87. Weinstein L.L., Harrison R.E., Cherry J.D. (1999). Tetanus. Textbook of Pediatric Infectious Diseases. 4th Ed., Vol. 2. W.B. Saunders, 1999. 1577-87.

Sach Benh uon van version 3 upload BiaSach Benh uon van version 3