ThS. BS TRN TH D THOLAO H THNG THN KINH TRUNG NGB MN LAO V BNH PHI

MC TIU HC TPBit cch tip cn hng n chn on lao mng no trong vng 48h sau nhp vin

2. Nm vng gi tr cc cn lm sng gip chn on bnh, nht l phn tch dch no ty

3. Bit r nguyn tc iu tr ni khoa v ch nh can thip ngoi khoa.

4. Bit c tin lng v cc di chng ca bnh.

NI DUNG

1. i cng v dch t hc 2. Lm sng3. Cn lm sng4. Chn on xc nh v phn bit5. iu tr ni khoa v ch nh ngoi khoa6. Tin lng v di chng

MNG NO: MNG BAO PH QUANH NO V DY THN KINH TY SNG

VIM MNG NO

p ng vim ca mng no v dch no ty vi tnh trng nhim trng, do: vi trng, siu vi, nm, v cc sinh vt khc nh protozoa, ritkettsia

PHN LOI VIM MNG NO1. Vim mng no m do vi trng (PBM)2. Lao mng no (TBM)3. Vim mng no v trng (siu vi, nm, k sinh trng, t min

1. I CNG V DCH T HC

Lao h thng thn kinh trung ng (CNS)1. Vim lao mng no: nng nht, thng gp nht2. u lao ni s 3. vim lao mng ty sng

Vn quan trng nht: chn on v iu tr sm nht khi c th

DCH T HC: LAO MNG NO VN L MT TRONG NHNG TH LAO NGOI PHI THNG GP

Lao CNS: 6% lao ngoi phi, 1% lao chung.

Trc thi i HIV : tui (0-4 tui), vng dch t lao thp: ngi ln

Thi i HIV: ngi trng thnh mc bnh

Yu t nguy c: HIV, nghin ru, i tho ng, suy dinh dng, bnh c tnh, corticoids

BKKHOANG DI NHNP VIM MNH VIM MNG NHN TNG SINHCHN P DY TK SXM LN MCH MUVIM QUANH MCH MU,HUYT KHI, NHI MUNO NG THYTC NGHN CNG NO TI NHIM NGOI SINHTI NHIM NI SINHYU T NGUY Ct quHn mDi chng thn kinhChn p dy TK sXm ln mch mu

THNG GP NHT

BNH NHN LAO MNG NO IN HNH thng din tin bn cp ko di qua ba giai on ring bit:1. Giai on tin triu, t 2-3 tun, xut hin t t cm gic kh chu ton thn, u oi, st nh, thay i tnh tnh.2. Giai on mng no: triu chng thn kinh r hn, nh cng gy, Kernig (+), Brudzinski (+), nhc u dai dng, i, ng lm, l ln, v nhiu nhiu du hiu tn thng dy thn kinh s v triu chng thp khc nhau.3. Giai on lit: bnh din tin tc nhanh, l ln chuyn thnh n v hn m, co git, thng kiu na bn cu. Hu ht bnh nhn khng c iu tr t vong trong vng 5-8 tun sau khi bnh.iu tr sm khi BN giai on 1: lnh bnh, khng di chng

Cc bin chng thn kinh ca lao mng no: a dng. Lit dy thn kinh s : 30% trng hp (III, VI, VII)Lit 1 chi hoc lit 1 bn : 20% trng hp, lit 2 chi di: 1-5% trng hp.

Tc nghn dch no ty dn n tng p lc ni s, no ng thy v thay i tri gic.

Co git him gp ngi ln, c th gy ra bi no ng thy, u lao hoc h Natri mu.

H natri mu : 50% bnh nhn lao mng no, c th gy ra l ln, co git,hn m. Cn chn on phn bit vi cc bin chng thn kinh ca lao mng no.

CC GIAI ON LM SNG

Phn giai on lm sng c ch cho tin lng v iu tr, da vo tnh trng tm thn v du thn kinh khu tr.Giai on I: tnh to, khng du thn kinh khu tr, khng bng chng no ng thy.Giai on II: mt , l ln, c du thn kinh khu tr nh, nh l lit dy s hay lit nh na ngi.Giai on III: sng, n, hn m, co git, lit nhiu dy s, v/hoc lit na ngi.

LAO NGOI H THN KINH TRUNG NG- Lao k : 30 %- Tn thng phi : 50%- Lao ct sng chim 25% trng hp. - Lun lun tm hch ngoi vi, tn thng dng abces lnh c km hoc khng km x d xung quanh.

Phi tm lao cc c quan khc i km khi nghi ng lao h thn kinh trung ng cng nh lao 1 c quan kh chn on khc

V PHNG DIN LM SNG, PHI BIT NGHI NG N LAO MNG NO KHI:1. St ko di > 14 ngy khng chn on c nguyn nhn2. C triu chng tm thn kinh xut hin m thm, t t v m nht: NG G, MT NG3. Nhng trng hp triu chng mng no + st cp tnh nhng khng p ng vi khng sinh thng (ceftriaxone liu cao)4. Tm hiu k tin cn tip xc ngun ly lao, nu c: rt quan trng cho hng chn on5. C lao mt c quan khc chn on c

3. CN LM SNG

1. CHC D DCH NO TY2. X QUANG PHI3. 3 AFB/M, DCH D DY4. CT NO, MRI NO5. CTM, VS, TST (IDR)6. HIV

Chng ch nhSuy h hpTng p lc ni s (nguy c thot v)Vim m t bo ti vng chc dRi lon ng mu nng1. CHC D DCH NO TYGii quyt nhanh chng cc ri lon chc d DNT ngay khi c thV tr:L3-L4Hoc L4-L5

DCH NO TY: CHA KHA LAO MNG NO

CN CH NH CHC D MNG NO KHI:ST KO DI KHNG R NGUYN NHNC DU MNG NORI LON TRI GIC CHA R NGUYN NHNRI LON TM THN KINH CHA R NGUYN NHNLAO K KM BIU HIN MNG NO

Lu :Hi chng mng no c st: chc d ngay trong vng 30 pht sau nhp vin iu tr khng sinh sm.Cn nhc nhng trng hp phi chp CTScan no trc: nghi ng c tng p ni s, xut huyt no (ngoi tr xut huyt di nhn: khng ch KQ CTSan no)

PHN TCH dch no ty

ConditionWBCProtein (mg/dL)Glucose (mg/dL)Normal50Bacterial, acute100 60K 100-500LowBacterial, part rxd1 10,000100+Low to normalTB10 500100-500

Tin hnh chc dch no ty:- Quan st mu- o p lc (m s git/pht)- Xt nghim:Sinh ha (m, ng, LDH)T boPCR laoAFB thun nht, BK cy MGITNm: soi, cyTp trng: soi cy khng sinh

DCH NO TY IN HNH CA LAO MNG NODch trong, nh vng, vng nht, vng chanhp lc tng vaSinh ha: m tng va :100 500 mg/dlng: di 45 mg/dl trong 80% trng hp. LDH tng va (khng quan trng)T bo:Tng lng bch cu thng trong khong 100 500/L.Thnh phn lympho chim u th ngay t ln chc u tin, hoc chuyn u th lympho vo ln chc th 2

PCR lao: dng tnh vi nhy 80-90%, l bng chng vng cho chn on lao mng no nhanh chng

AFB v BK cy MGIT: thng m tnh trong ln chc u

Ch :1. Giai on cp: khi bnh < 7 ngy: DNT ca lao mng no v vim mng no m c th hon ton ging nhau ln chc d u tin. Phn bit bng cch chc d ln 2 sau 48g iu tr cetriaxon v theo di din tin lm sng.

2. Phi hp thm vi bch cu mu, din tin ca ng trong DNT, thnh phn t bo/DNT chn on lao mng no.

Lu chn on phn bit lao mng no (LMN) vi vim mng no m (VMNM) lc nhp vin

Lu chn on phn bit lao mng no (LMN) vi vim mng no m (VMNM) 48 gi sau dng ceftriaxone nhng bnh nhn khng c iu tr khng lao t u

PCRCc nghin cu v PCR trong lnh vc ny cho thy nhy v c hiu bin thin ng k. Do , nn gi lm PCR tm vi khun lao nu lm sng nghi ng lao mng no cn iu tr theo kinh nghim v cc ln nhum tm vi khun lao u tin cho kt qu m tnh. iu quan trng nht l kt qu m tnh khng loi tr c chn on lao mng no.

ADA/DNT : CHA C KHUYN CO

3. CN LM SNG

1. CHC D DCH NO TY2. X QUANG PHI3. 3 AFB/M, DCH D DY4. CT NO, MRI NO5. CTM, VS, TST (IDR)6. HIV

2. X QUANG PHI THNG: TM TN THNG GI LAO- Lao k- Tn thng dng nt t m, dng hang, ng c to hangc BS CK lao khng nh chn on ngh nhiu lao phi

3. XT NGHIM 3AFB M, DCH D DY- Nn lun lun thc hin- BN HIV thng c Xquang phi thng bnh thng nhng AFB dng tnh

4. CTSCAN NO- Tng m nn no cng vi bt k mc no ng thy no rt gi lao mng no.CT bnh thng 30% bnh nhn giai on I, v bnh nhn c CT bnh thng hu nh lun hi phc hon ton.No ng thy km tng tng m nn no gi bnh tin nng v tin lng xu. Tng m nn no tng quan tt vi vim mch mu, do c nguy c nhi mu hch nn.

MRI NO: C GI TR HN

5. CTM, VS, TSTnhng xt nghim gip hng n bnh laoCTM: BC tng nh, thng

CHN ON XC NH:

Lm sng: khi bnh bn cp hoc > 14 ngyDNT ngh nhiu n lao: m tng va, ng gim nng, t bo tng va u th lymphoCng vi PCR lao dng tnh, hocAFB dng tnh, hocBK cy dng tnh (nn cy MGIT kt qu c th dng tnh sm nht sau ngy th 8)

Nn lm t nht 3 ln xt nghim DNT trong ba ngy lin tip, song song vi iu tr theo kinh nghim. nhy cm ca nhum tm AFB tng ln nu ch n cc im sau:1. Tt nht nn dng phn DNT cui cng chy ra. Mi ln chc ly nhiu dch, khong 10 15 ml.2. Vi khun d pht hin trong pht cc mu ng hoc cn lng. Nu khng c cc mu ng, c th thm vo 2 ml cn 95 tng ta protein, qua ko theo vi khun xung y ng nghim khi quay ly tm.3. Nn tri 0,02 ml dch quay ly tm trn lam, ng kch ca dch trn lam khng qu 1 cm, nhum theo phng php Ziehl Neelson.4. Nn c lam phng i 200 500, bi t nht hai ngi c.

CHN ON V IU TR SM THEO KINH NGHIMLm sng v dch no ty ngh nhiu n LMNKt hp vi mt trong cc yu t sau:1. Xquang c hnh nh lao k hoc tn thng ngh nhiu n lao phi: XN m hoc dch d dy tm AFB, BK2. C lao 1 c quan khc c d chn on xc nh hn: lao hch, lao ct sng, d hu mn, p xe lnh.3. TST dng tnh mnh4. C tin cn tip xc ngun ly lao, HIV, T5. Khng p ng KS thng trn LS v DNT sau 48g iu tr6. CTScan no c tn thng in hnh ca lao

U LAOLM SNG- Ty thuc vo v tr gii phu ca u. Hu ht bnh nhn than nhc u, st v st cn

- ngi ln, hu ht l vng trn lu v biu hin co git.Yu lit khu tr v ph gai th l nhng du hiu thng gp khi khm lm sng.

- U lao no xut hin nhiu hn bnh nhn ng nhim lao HIV.

DCH NO TYTng protein ton phn hu ht bnh nhn v tng bch cu trong khong 10-100 TB/mm3 trong 50% trng hp.

CT SCAN NO Pht hin tn thng dng u trong nhu m no, trn, c nhiu thy vi phn trung tm c, 15% trng hp c to hang.

CHN ON PHN BIT quan trng nht l ung th

SINH THIT TN THNG L TIU CHUN VNG k thut sinh thit bng kim nh v 3 chiu (stereotaxy) nng cao an ton cho th thut ny, cho kh nng chn on xc nh c th t n 94%.

A 27 year-old man with headache, visual field loss and right side weakness

BN C CHN ON : LAO NHU M NO NHANH CHNG BNG K THUT STEREOTAXY

IU TR1. KHNG LAO CNG SM CNG TT2. CHNG PH NO3. CORTICOIDS: DEXAMETHAZONE4. CAN THIP NGOI KHOA KP THI5. H TR: IU CHNH RI LON NC IN GII, CO GIT, SUY H HP, CHNG LOT, DINH DNG TCH CC, HY VNG CU C BNH NHN

PHC : 2 -3 SHRZ/6 HE (HR)2 RHZ/4 RH (CN NHC SM)

TIN LNG V DI CHNGLun lun l tin lng nng. Kt cc ca bnh ty thuc ch yu vo thi gian bt u iu tr, cng iu tr sm, tin lng cng tt. Di chng ca bnh nh hng gn 50% trng hp, bao gm lit cc dy s, m, ic, lit na ngi, ng kinh ton th hay cc b, ri lon tri gic vnh vin hoc ri lon pht trin tm thn.Bnh nhn qu nh hoc qu ln tui, nhp vin tr hay chn on tr, c nhi mu bt k, ng nhim HIV, a khng thuc l nhng yu t tin lng t vong.

TRC NGHIM

1. Bnh nhn nam, 45t, b vy nn + hen suyn 10 nm, ang iu tr bng corticoid liu duy tr, xut hin ho khan ko di nhiu thng nay, t mua thuc ung khng gim. Gn y n ung km, st v chiu, mt mi. 1 tun trc nhp vin, BN st cao, au u nhiu, bun nn ho nhiu m c. Xquang c tn thng dng ht k lan ta 2 ph trng. Ch nh no l quan trng nht trong chn on v iu tr:3 AFB trc tip / mChc d dch no tySoi ph qunChp CTScan s noCTScan ngc c cn quang

TRC NGHIM

1. Bnh nhn nam, 45t, b vy nn + hen suyn 10 nm, ang iu tr bng corticoid liu duy tr, xut hin ho khan ko di nhiu thng nay, t mua thuc ung khng gim. Gn y n ung km, st v chiu, mt mi. 1 tun trc nhp vin, BN st cao, au u nhiu, bun nn ho nhiu m c. Xquang c tn thng dng ht k lan ta 2 ph trng. Ch nh no l quan trng nht trong chn on v iu tr:3 AFB trc tip / mChc d dch no tySoi ph qunChp CTScan s noCTScan ngc c cn quang

2. Nguyn tc no quan trng nht trong iu tr lao mng no: chn cu ng nhtA. iu tr lao ngay khi bnh nhn c du mng no v tn thng trn X quang phiB. iu tr lao khi c bng chng vng l tm thy vi trng lao trong dch no tyC. iu tr cng sm cng tt, tt nht l lun lun cho iu tr thuc lao sau 48g nhp vinD. iu tr lao nn c tin sm ngay khi bc s lm sng nghi ng n chn on lao mng noE. iu tr lao c tin hnh khi bnh nhn khng p ng vi ceftriaxon liu cao

2. Nguyn tc no quan trng nht trong iu tr lao mng no: chn cu ng nhtA. iu tr lao ngay khi bnh nhn c du mng no v tn thng trn X quang phiB. iu tr lao khi c bng chng vng l tm thy vi trng lao trong dch no tyC. iu tr cng sm cng tt, tt nht l lun lun cho iu tr thuc lao sau 48g nhp vinD. iu tr lao nn c tin sm ngay khi bc s lm sng nghi ng n chn on lao mng noE. iu tr lao c tin hnh khi bnh nhn khng p ng vi ceftriaxon liu cao

3. B nam 6 tui. Bnh 2 tun, b st v chiu, bing n, than nhc u, thng ng g. B c nhp vin Nhi ng 1 v chc d dch no ty: dch trong, p lc tng nh, m 235 mg/dl, ng 3,2mmol/l (ng huyt cng lc 7 mmol/l), t bo: 200/mm3 (74% neutrophile, 36% lymphocyte), PCR lao (-). Bnh nhn c chn on vim mng no m, iu tr vi ceftriaxone liu cao. Sau 72 gi, b st cao, nn i, c chc d dch no ty ln 2: dch vng nht, p lc tng, m: 359 mg/dl, ng 1,2 mmol/l (ng huyt cng lc: 6 mmol/l), t bo: 230/mm3 (90% lympho, 20% neutro), PCR (-), AFB (-). Bnh l mng no c kh nng nht lc ny l:A. Vim mng no m khng p ng iu trB. Vim mng no nc trong do siu viC. Vim mng no m ct uD. Vim mng no do nmE. Vim mng no do vi trng lao

3. B nam 6 tui. Bnh 2 tun, b st v chiu, bing n, than nhc u, thng ng g. B c nhp vin Nhi ng 1 v chc d dch no ty: dch trong, p lc tng nh, m 235 mg/dl, ng 3,2mmol/l (ng huyt cng lc 7 mmol/l), t bo: 200/mm3 (74% neutrophile, 36% lymphocyte), PCR lao (-). Bnh nhn c chn on vim mng no m, iu tr vi ceftriaxone liu cao. Sau 72 gi, b st cao, nn i, c chc d dch no ty ln 2: dch vng nht, p lc tng, m: 359 mg/dl, ng 1,2 mmol/l (ng huyt cng lc: 6 mmol/l), t bo: 230/mm3 (90% lympho, 20% neutro), PCR (-), AFB (-). Bnh l mng no c kh nng nht lc ny l:A. Vim mng no m khng p ng iu trB. Vim mng no nc trong do siu viC. Vim mng no m ct uD. Vim mng no do nmE. Vim mng no do vi trng lao

4. Trn lm sng, A S chn on xc nh lao mng no SM thng da vo:A. T bo trong dch no ty tng, vi lympho chim u thB. CTScan s no c ph no km u nhu m noC. Th phn ng lao t (TST) dng tnh mnhD. PCR lao (+) trong dch no tyE. Albumin tng cao, ng gim nhiu trong dch no ty

4. Trn lm sng, A S chn on xc nh lao mng no SM thng da vo:A. T bo trong dch no ty tng, vi lympho chim u thB. CTScan s no c ph no km u nhu m noC. Th phn ng lao t (TST) dng tnh mnhD. PCR lao (+) trong dch no tyE. Albumin tng cao, ng gim nhiu trong dch no ty

5. Bnh nhi nam 10 tui, khi bnh 2 ngy vi st cao 39-40oC, km nn i, nn vt, nn tt c nhng g n vo. Tin cn cha ang iu tr lao phi AFB (+), c chch nga BCG. Bnh nhn c nhp vin, khm v chc d dch no ty ngay. Kt qu dch no ty sau 30 pht: dch trong, p lc 32 cmH2O, m: 500mg/dl, ng 50 mmol/l (ng huyt cng lc 102 mmol/l), LDH 573U/l, T bo:600/mm3, 80% neutro, 2% t bo thoi ha, 18% lymho, cha c kt qu PCR lao, AFB v tp trng trong dch no ty. Vi vai tr bc s iu tr, phi lm g ngay cho bnh nhn ny?A. Ch kt qu PCR lao v AFB trong dch no tyB. Chp CTSCan s no tm tn thng nghi laoC. Chng ph no, sau 48h chc dch no ty ln 2D. Chp ngay Xquang phi thng tm tn thng laoE. iu tr vi ceftriaxon liu cao sau 48g nh gi li

5. Bnh nhi nam 10 tui, khi bnh 2 ngy vi st cao 39-40oC, km nn i, nn vt, nn tt c nhng g n vo. Tin cn cha ang iu tr lao phi AFB (+), c chch nga BCG. Bnh nhn c nhp vin, khm v chc d dch no ty ngay. Kt qu dch no ty sau 30 pht: dch trong, p lc 32 cmH2O, m: 500mg/dl, ng 50 mmol/l (ng huyt cng lc 102 mmol/l), LDH 573U/l, T bo:600/mm3, 80% neutro, 2% t bo thoi ha, 18% lymho, cha c kt qu PCR lao, AFB v tp trng trong dch no ty. Vi vai tr bc s iu tr, phi lm g ngay cho bnh nhn ny?A. Ch kt qu PCR lao v AFB trong dch no tyB. Chp CTSCan s no tm tn thng nghi laoC. Chng ph no, sau 48h chc dch no ty ln 2D. Chp ngay Xquang phi thng tm tn thng laoE. iu tr vi ceftriaxon liu cao sau 48g nh gi li

*RBC traumatic vs CNS bleeding. After a few hours, CSF will be xanthrochromic; if traumatic it will be clear with centrifugation.Latex agglutination has high false negative rate.