SA Doppler Tim Cap Cuu

7/25/2019 SA Doppler Tim Cap Cuu

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VAI TR CA SIU M DOPPLERTIM TRONG CP CU

VIN TIM MCH VIT NAM

BS. NGUYN TUN HI

[email protected]@bachmai.edu.vn

TRNG I HC Y H NI


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I CNG

Emergency Medicine Clinics of North America, Volume 22, Issue 3, August 2004 , Pages 621-640

1980: Lnutin p dngSiu m Doppler tim cp dnglnutikhoa cpcu Hoa K.

Thmd khng xm nhp(hocxmnhptithiu), c ththchinnhiu

ln. Thng tin thu c: nhanh, chnh xc

Khng dn tri, tptrung vo mctiu

chnh Huhtcc trnghp: S 2D, +/-

phihpvi Doppler nhgi huytng

Chnonnhngtnhhung

lmsng trmtrng

nhhng

cho canthipiutrngay tckhc


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CH NH LM SNG CHNH: Pht hin dch mng tim, tm du hiu p tim

nh gi chc nng tim trong trng hp ngng tunhon

nh gi chc nng tht tri

nh gi chc nng tht phi

Pht hin phnh tch MC ngc on gn

Tnh trng thiu oxy ko di

Ti u ha iu tr: thc hin th thut di hng dnca siu m.

CH NH LM SNG


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MT S CH NH C BIT:

nh gi p lc y tht: tha dch/thiu dch

Chn on ph phi cp huyt ng hay tn thng

Ti u ha iu tr vn mch trong sc nhim khun

CH NH LM SNG


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Chn thng

Ngng tun hon

Tnh trng sc, hoc huyt ng khng n nh

au ngc

Suy h hp cp

Thiu oxy ko di, khng p ng vi iu tr

Hng dn t dn lu mng ngoi tim

TNH HUNG LM SNG


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Btnvhuytngkhng r nguyn nhnSc

Ph phicp

S Doppler cpcu+/- Cmtay

Mtcttithiu: dibsn, tmmtim

Dchmng tim (+++)p TP/NP, Gin TMCD

TP gin, kovnng

TT gim/khngvnng

Tim tngng,TMCD xp

PTIMCP

TCNGMCHPHI

SUY TIMCP:

Nhimu ctimVim ctimNhimc

GIM THTCH TRMTRNG: chy

mu trong?SC NK?

KHC?


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Siu m Doppler qua thnh ngc:

Pht hinccbtthngcutrc v chcnngtim.

Kh khn: Hnh nhqua thnh ngcm mtct

dibsn.

Siu m Doppler qua thcqun: (ch chngchnh)

Bnhnhn chnthng, achnthng

Bnhnhn sauphuthutTm kimcc lungthng trong tim

Trcscinchuynnhp: loitrhuytkhi

nhgi hotngcavan nhn to

CC HNH THC S DOPPLER


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S qua thnh ngc : u tin s 1, d thc hin, d lpli, thng tin nhanh chng

S qua thc qun > S qua thnh ngc: Chn thng ngc kn Bnh nhn thng kh nhn to Bnh nhn sau phu thut tim, v sau phu thut

chung Bnh l c nguy c gy thuyn tc t tim

LA CHN HNH THC S NO?


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Pht hin c dch mng tim v bit cch chn on

tnh trng p tim

Pht hin tnh trng gin, suy chc nng tht phi o kch thc tnh mch ch di v nhn nh

Pht hin ri lon vn ng vng ca tht tri, v

nh gi chc nng tht tri.

YU CU TI THIU


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CC YU CU V K THUTSIU M DOPPLER


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1. u d t cnh c tri: Mt ct trc dc

Mt ct trc ngang

2. u d t ti mm tim Mt ct 4 bung

Mt ct 5 bung

Mt ct 2 bung

3. Ca s d-i mi c Mt ct 4 bung

Mt ct trc ngn

4. Ca s trn hm c

MT S MT CT THNG QUY TRNSIU M QUA THNH NGC


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Mt ct

4 bung

Mm timD-i b s-n

Mt ct

trc dc

Cnh c tri

Mt ct

trc ngang

S MT S MT CT THNG QUY

Mt ct

trn hmc


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MT S MT CT THNG QUY TRNSIU M QUA THC QUN


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2D: gii phu cc bung tim, hot ng van tim TM: Chc nng tim theo p/p Techolz, b dy thnh tim

Doppler xung: Dng chy c V = 2 3 m/s. Dng o cung lng

tim, dng chy qua cc van tim.

Doppler lin tc: Dng chy c vn tc cao. Dng trong HoHL,

HoC, hot ng van nhn to, ALMP.

Doppler mu: nh gi c thay i v gii phu v huyt ng.

Doppler m c tim: nh gi chc nng tim, p lc y tht,

pht hin mt ng b

CC KIU SIU M DOPPLER


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CH NH CA CC MT CT SCHNH MTCT S NHNNH

Pht hindch Di bsnTrc dc cnh c

Nhanh nht, dtipcnnhtPhn bitdchmng tim v mng phi

ChcnngTP Trcdc cnh c4 bung t mm

nhgi vnngvngSo snh kch thcTP/TT

ChcnngTTton b

Trc dccnh c ochcnngtrn TM theo Teicholznhgi tnh trngvan hailas

Hotngvan tim Mt ctt mm nhgi ddng viDoppler mu, xung

nhgi thtch 4 bungdi bsn, TMC di

Thay itheo h hpcaTMC dinhgi thtch TT cuitm trng

Sc/Ttp Dib sn,Trc dc cnh c

nhgi MC, mng phi, dch bng

BnhMC cp Trcdc cnh ccao, 2 bung tmm, trn hm c

Gin MC ln (> 40 mm)Tch nimcMC ln, quai MC, MCxung

Ngngtim Dibsn Nhanh nht(di10 giy): Dch, v tmthu, gimngTP

Emerg Med Clin N Am 29 (2011) 759787


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Dd

Ds

Phngphp Teicholz

Phngphp Simpson

NH GI CHC NNG TM THU THT TRI


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Nh tri Din tch Th tch

Dng chy qua van hai l Sng E, A v t l E/A Thi gian gim tc sng E

Dng chy qua TM phi Sng S, D, Ap

Doppler m qua vng van hai l

NGHIN CU V HUYT NG

nhgi p lcythttri


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Dng chy qua van hai l:

E/A > 2(BT >1)

DT < 130 ms (BT > 150 ms)

Dng chyqua tnhmchphi: dApdAm > 20 ms(BT < 0)

Vntclan truyndng yqua van hai l:

Em /Vp > 2,5 (BT < 1,5) Vntcvng van hai l:

Em/Ea > 15(BT < 8)

NHNG THNG S CH RA TNH TRNG TNGP LC Y THT TRI


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p lc tht tri

p lc nh tri

0

E A Dng chy qua van hai l

Dng chy quaTM phiApDT

79+-26 cm/s 48+-22 cm/s

184+-24 ms 19+-4 cm/s

E/A =1,7+-0,6

A p su

DT


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TM chdi:K < 11.5 mm/m2

xp> 50%

BN bthadch:p lcycaop lcnhphi= 15 mmHg

TM chdi:K > 11.5 mm/m2

xp< 50%

BN khng bthadch:p lcythpp lcnhphi= 5 mmHg

P LC Y TIM PHI


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TNH MCH CH DI


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TNH HUNG LM SNG


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VAI TR PHT HIN CA SIU M: Ri lon chc nng tht tri

Ri lon y tht:

Gim th tch tun hon

Ri lon chc nng tht phi

Bin chng van tim cp tnh p tim cp do TDMNT

SC, TT P


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RI LON CHC NNG THT TRI

NGUYN NHN:

Hichngvnh cp

Gimthtch tunhon nghim trng

Rilonnhpkhng kimsot c

Tnthngctim khng do thiumu ccb

Vim ctim cp

Cpcungngtunhon ko di

Thiuoxy trmtrng, toan mu trmtrng

Do thuc: qu liuchnb ta, chncanxi


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RI LON CHC NNG TM THU THT TRI

THNG S SIU M DOPPLER:

Phn stngmu thttri (EF): Teicholz, Simpson

Cung lngtim (CO, CI): CI = 2,54,2 l/ph/m2

Chschcnngctim (Tei index): TI < 0,4

Chcnng EF

Bnh thng 55%

Gimnh 4554%

Gimva 3044%

Gimnng < 30 %


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RI LON Y THT TRI

NGUYN NHN:

Mtthtch tunhon do nn, xuthuyt, achy

Ti phn blidchtrong lng mch: scphnv, sc

nhimtrng, tngp lctrong lngngc

Mtthtch tunhon vo khoang th3: ph ton

thn, cchng.

Phihpgiagimchcnngtm thu/rilony

tht: NMCT cp


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GIM TH TCH TUN HON

THNG S SIU M DOPPLER:

Kch thctim: nh, tngng.

ChsE/A qua van hai l: E/A < 1

K TM chdithay itrn 50% khi h hp

A.Chenzbraun, Emergency Echocardiography, 2009


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TRONG THC HNH LM SNG:

Trcmtbnhnhn ttp, E/A c vai tr quan trng:

E/A < 1: BN c gimthtch tunhon (ngay ckhi c phihpRL chcnngthttri).

E/A > 1: t khnnghn.

E/E: c gi trtrong nhgi p lcythttri

Hnch: Khng nhgi cchnh xc khi:

Nhptim qu nhanh hocqu chm Rung nh

E/A thay itheo tui

Bnhvan hai l


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TthuytpGimcung lngtim

E/A < 1 hocE/E < 8

PLC Y TT

E/A > 1 v/hocE/E = 8 - 15

E/A >> 1 v/hocE/E > 15

DT < 140 ms

GIM THTCH TUN

HON

PLC Y TT

PLC Y TT


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P TIM CP

THNG S SIU M :

Chnondchmng tim: khongtrngsiu m

Chnontnh trngp tim trn siu m:

Duhiuxpthtphi, nhphi

TM chdigin, khng thay itheo h hp

Thay isng E van hai l > 20% theo h hp

Slng KTSA(sau TSTT th TTr)

ctnhlngdch

T < 10 mm < 300 mlVA 1020 mm 300700 ml

NHIU > 20 mm > 700 ml


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TDMT t

TDMT va

TDMT nhiu


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1. Siu m tim hng dn chc dn lu mng ngoi tim

- u d siu m t di b sn hoc mm tim,

gip xc nh v tr chnh xc v hng i ca catheter.2. Siu m cn m c thc hin khi:

Dch mu ng

Nghi ng kim chc i qua vch tim vo trong bung tim.

S dng NaCl 9 + 0, 5ml khng kh to bt cn m, bmqua kim chc d trong khi t u d siu m:nu bt cn

m khng xut hin trong khoang mng ngoi tim m xut hintrong bung tim:chc qu su vo trong bung tim:nhnhng rt kim, dng th thut, hi sc tch cc:chuyn

phng phu thut m mng tim ti thiu.


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BNH CNH LM SNG:

Thiu oxy khng p ng vi iu tr, khng c km

theo bnh l ti tim v phi.

Cn tm tn ti l bu dc vi shunt phi - tri

PHNG THC SIU M:

S cn m qua thnh ngc

S qua thc qun

THIU OXY


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BNH CNH LM SNG:

Ph phi cp ko r nguyn nhn, au ngc, ngt

Tm ting thi mi xut hin, hoc ting van nhn to

CC THNG S SIU M DOPPLER:

Dng h van tim trn Doppler mu

Tht tri: tng ng

Tng p lc MP, TP c th gin, gim ng

Chnh p qua van o trn Doppler lin tc

Nguyn nhn: thng phi lm S qua thc qun

BNH L CP CU CA VAN TIM

NGUYN NHN


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NGUYN NHN:

Van t nhin

H van hai l cp do:

t dy chng ct c t pht/do vim NTMNK

Thng l van

Bin chng cp ca NMCT

H van MC cp do:

Vim ni tm mc nhim khun

Tch thnh MC Stanford A, chn thng

Van nhn to Van c hc: Tc nghn van do cc mu ng, pannus,

si. H cnh van

Van sinh hc: H cnh van. Thoi ha van. Si van.


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tdy

chngVHL

Hvan MC

do si

HcnhVHL

chc


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NH GI CHC NNG VAN NHN TO

THNG S SIU M:

Doppler mu: nhgi dng hqua van nhn to

Doppler lin tc:

Chnh p trung bnh qua van

Thigian bn gimp lc(PHT)

Dintch lvan hiudng


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NH GI CHC NNG VAN NHN TO

GII HN BNH THNG:

Van ngmchchnhn to

Van hai l nhn to

Vntctia(m/s)

Chnh p trung bnh(mmHg)

Dintch lvan(pt lin tc: cm2 )

1,44 530 1 - 3

Vntctia(m/s)

Chnh p trung bnh(mmHg)

PHT(ms)

1,22 18 60 - 160

AU NGC V HI CHNG VNH CP


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CH NH SIU M CP CU:

Khng c s tng hp gia lm sng, T v cc du n sinhhc.

T hoc cc du n sinh hc khng r rng khng nh hay

loi tr HC vnh cp.

au ngc cp + huyt ng khng n nh

VAI TR CA S CP CU:

Chn on v tr ri lon vn ng vng

nh gi mc nng: RL vng nng, EF gim

Pht hin cc bin chng c hc, hoc bnh phi hp

AU NGC V HI CHNG VNH CP


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tctcl

trcVHL

Thngvchlin tht

Vthnh t

do thttriA.Chenzbraun, Emergency Echocardiography, 2009


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VAI TR CA SIU M:

Pht hin:

Tch thnh MC: v tr, lan rng

Huyt khi trong lng MC Lot thnh MC

Cc thng s khc:

Mc gin ca MC

Mc h ch (Stanford A)

Dch mng tim, dch mng phi

HI CHNG MC CP


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European Journal of Echocardiography (2009) 10, i31i39


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VAI TR PHT HIN CA SIU M:

Ch cn S cm tay.

Pht hin nhanh nhng nguyn nhn c th gii quyt

BN c ngng hot ng in hc tim:

Tc mch phi

p tim cp

Trn kh mng phi p lc

Mt th tch tun hon (v phnh MC, chy mu nng)

TRONG V SAU HI SINH TIM PHI

BS HSTP


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BS.cpcuHSTP yu cuS cpcu

TiptcHSTP

Btmy SChunbud

Dng5s khi

cy. cu

Btuiutrchiu

NgngHSTP

TiptcHSTP

Yu cudngp tim, nhgi nhanh

Dchmng tim, thtphi, thttri

tud vo mtctdibsntud thcqun(BN tng)

Dchmng tim va: p timTP gin, gimng: TcmchphiTT nh, tngng: GimV tunhon

TT gin, gimng: RLCN TT nng

Bs.cpcuhisinh tim phi BS. siu m tim


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Siu m Doppler tim trong cp cu:

Nhanh chng thc hin

Khng cn my S nhiu chc nng (ch cn S cmtay)

Khng cn kho st t m

C hiu qu rt cao:

Cu tnh mng bnh nhn

Trnh sai lm khi cp cu

Yu cu:

Cn c o to

KT LUN


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SA Doppler Tim Cap Cuu