1. Héi chøng h«n mª PGS. TS Ph¹m NhËt An

2. Môc tiªu 1. Tr×nh bµy ®­îc định nghĩa, c¬ chÕ bÖnh sinh cña h«n mª 2. Tr×nh bµy ®­îc ph©n lo¹i theo nguyªn nh©n (träng t©m theo løa tuæi) 3. §¸nh gi¸ ®­îc møc ®é h«n mª theo kinh ®iÓn vµ theo Glasgow 4. ChÈn ®o¸n ®­îc c¸c h«n mª th­êng gÆp ë trÎ em 5. ¸p dông ®iÒu trÞ ®­îc c¸c h«n mª th­êng gÆp ë trÎ em

3. 1.§Þnh NghÜa vµ mét sè thuËt ng÷: 1.§Þnh NghÜa: H«n mª lµ t×nh tr¹ng mÊt ý thøc kh«ng thÓ ®¸nh thøc Coma is a state of unconsciousness whereby a patient cannot react with the surrounding environment. The patient cannot be wakened with outside physical or auditory stimulation. The inability to waken differentiates coma from sleep. Patients can have different levels of unconsciousness and unresponsiveness Coma is a state of unconsciousness whereby a patient cannot react with the surrounding environment. The patient cannot be wakened with outside physical or auditory stimulation. The inability to waken differentiates coma from sleep. Patients can have different levels of unconsciousness and unresponsivenesssleep

4. 2.Mét sè thuËt ng÷: Mª s¶ng (Delirium) Mª s¶ng (Delirium) L¬ m¬ (Stupor) L¬ m¬ (Stupor) Ngñ lÞm (Lethargy) Ngñ lÞm (Lethargy) B¸n mª (Semi Coma) B¸n mª (Semi Coma)

5. 2.Sinh bÖnh häc 1. §iÒu kiÖn duy tr× ý thøc/ sù tØnh t¸o: Lµ sù liªn l¹c th«ng suèt gi÷a 2 b¸n cÇu Lµ sù liªn l¹c th«ng suèt gi÷a 2 b¸n cÇu (nhê c¸c ho¸ chÊt trung gian nh­ Acetylcholin, Norepinephrin, Serotonin...) víi th©n n·o vµ ®åi thÞ (hÖ thèng l­íi ho¹t ho¸ - RAS; vµ c¸c Neuron) (hÖ thèng l­íi ho¹t ho¸ - RAS; vµ c¸c Neuron)

6. 3. C¨n nguyªn: a/ Tæn th­¬ng b¸n cÇu (trùc tiÕp hay gi¸n tiÕp) TT b¸n cÇu lan to¶ 2 bªn TT 1 bªn, Fï, ®Ì Ðp c¶ bªn kia TT 1 hoÆc 2 bªn, ®Ì Ðp th©n n·o, n·o trung gian(RAS) b/ TT th©n n·o g©y h­ h¹i hÖ RAS trùc tiÕp hay gi¸n tiÕp (th­êng do RL chuyÓn ho¸). - RL ®iÖn gi¶i - RL toan kiÒm - RL ®­êng m¸u - ThiÕu m¸u, oxy - Ngé ®éc - Viªm nhiÔm - H«n mª gan… - RL ®iÖn gi¶i - RL toan kiÒm - RL ®­êng m¸u - ThiÕu m¸u, oxy - Ngé ®éc - Viªm nhiÔm - H«n mª gan…

7. Causes of coma Generally, coma is commonly a result of: Generally, coma is commonly a result of: - Trauma - Trauma - Bleeding and/or swelling affecting the brain. - Bleeding and/or swelling affecting the brain. - Inadequate oxygen or blood sugar (glucose) - Inadequate oxygen or blood sugar (glucose) - various poisons can also directly injure the brain to cause coma. - various poisons can also directly injure the brain to cause coma.

8. 4. Ph©n lo¹i 1.Ph©n theo nguyªn nh©n NhiÔm khuÈn (N·o, Mµng N·o, C¸c nhiÔm trïng kh¸c) ChÊn th­¬ng BÖnh m¹ch m¸u n·o T×nh tr¹ng cuèi cña nhiÒu bÖnh (Postictal State) RLCH Ngé ®éc (theo Russman – Neurologic Diseases, Pediatrics, 1994)

9. Ph©n lo¹i (tiÕp theo) Theo CÊp cøu Nhi Khoa,1999 - Do RLCH, néi tiÕt - Do nhiÔm khuÈn, nhiÔm ®éc - Do TT hÖ TKTW - Do thiÕu Oxy n·o Ph©n theo løa tuæi - TrÎ SS: - TrÎ SS: Sang chÊn - NhiÔm khuÈn - TrÎ nhò nhi - TrÎ nhò nhi NhiÔm trïng - XH - ChÊn th­¬ng -Ngé ®éc - TrÎ lín - TrÎ lín RLCH, Néi tiÕt, ngé ®éc ChÊn th­¬ng NhiÔm trïng U n·o

10. Ph©n lo¹i (TiÕp theo) Theo c¸c triÖu chøng kÌm theo - Sèt vµ c¸c biÓu hiÖn nhiÔm trïng - C¸c bÖnh kÌm Theo c¸c biÓu hiÖn TK khu tró: HCMN, C¸c HC liÖt, Co giËt.... - Cã hay kh«ng c¸c bÖnh lý : Viªm gan, Tiªu ch¶y, §¸i ®­êng... - Cã hay kh«ng c¸c bÖnh lý : Viªm gan, Tiªu ch¶y, §¸i ®­êng... - §ét ngét hay tiÕn triÓn tõ tõ - §ét ngét hay tiÕn triÓn tõ tõ

11. 5.§¸nh gi¸ møc ®é h«n mª - Theo 3 ®é - Theo 4 hoÆc 5 ®é - Theo c¸c thang ®iÓm kh¸c Glasgow Glasgow Liege Liege Simpson, Reilly Simpson, Reilly Jacobi Jacobi Bicetre Bicetre

12.  In the initial assessment of coma, it is common to gauge the level of consciousness by spontaneously exhibited actions, response to vocal stimuli ("can you hear me"?), and painful stimuli; this is known as the AVPU (alert, vocal stimuli, painful stimuli, unconscious) scale. More elaborate scales, such as the Glasgow coma scale level of consciousnessGlasgow coma scalelevel of consciousnessGlasgow coma scale

13. Thang ®iÓm GLASGOW Më m¾t: - Tù ®éng: 4 - Theo lÖnh: 3 - Khi ®au: 2 - Kh«ng ®¸p øng: 1 - Khi ®au: 2 - Kh«ng ®¸p øng: 1 VËn ®éng: - Chñ ®éng:6 - Ph¶n øng ®óng:4-5 - §¸p øng: 2-3 - Kh«ng ®¸p øng: 1 - §¸p øng: 2-3 - Kh«ng ®¸p øng: 1 Tr¶ lêi - §óng: 5 - LÉn: 4 - Sai: 3 - Cã nhËn biÕt:2 - Sai: 3 - Cã nhËn biÕt:2 - Kh«ng ®¸p øng: 1 - Kh«ng ®¸p øng: 1 3-7: NÆng 8-11: Võa 12-14: NhÑ

14.  Glasgow Coma Scale: -Eye Opening: Spontaneous 4; To loud voice 3; To pain 2; None 1 -Eye Opening: Spontaneous 4; To loud voice 3; To pain 2; None 1 -Verbal Response: Oriented 5; Confused, Disoriented 4;Inappropriate words 3; Incomprehensible words 2;None 1 -Verbal Response: Oriented 5; Confused, Disoriented 4;Inappropriate words 3; Incomprehensible words 2;None 1 -Motor Response: Obeys commands 6; Localizes pain 5; Withdraws from pain 4; Abnormal flexion posturing 3; Extensor posturing 2; None 1

15. Glasgow Coma Scale score Criteria Age >5 years Age 5 years Age <5 years Eye opening 4 Spontaneous 4 Spontaneous 3 To voice 3 To voice 2 To pain 2 To pain 1 None 1 NoneVerbal 5 Oriented Alert, babics, coos, words or 5 Oriented Alert, babics, coos, words or sentences – normal for age sentences – normal for age 4 Confused Less than usual ability, irritable cry 3 Inappropriate words Cries to pain 2 Incomprehensive sounds Moan to pain 1 No response to pain Motor 6 Obey commands Normal spontaneous 5 Localize supraorbital pain (>9 months old)Withdraws to touch 4 Withdraws from nailbed pain 3 Flexion to supraorbital pain 2 Extension to supraorbital pain 1 No response to supraorbital pain

16. 6.ChÈn ®o¸n Hái bÖnh Kh¸m LS - Cã TT th©n n·o: RL ®ång tö, LiÖt vËn nh·n, D/h m¾t bóp bª... - Cã TT th©n n·o: RL ®ång tö, LiÖt vËn nh·n, D/h m¾t bóp bª... - D/h liÖt b¸n cÇu - D/h liÖt b¸n cÇu - Kh«ng cã D/h TK khu tró - Kh«ng cã D/h TK khu tró XÐt nghiÖm Tæng hîp, ph©n tÝch ChÈn ®o¸n

17. First assessment of coma etiologies. Clinical examination / Possible causes Intact brainstem function, no meningism and no lateralizing signs: Intoxication (alcohol, carbon monoxide or neuroleptic drugs) Extrapiramidal (malignant neuroleptic syndrome) Seizures (status epilepticus) Metabolic (hypoglycemia, hepatic encephalopathy or Addison`s disease) Electrolytic disequilibrium (hyponatremia or hypermagnesemia) Intoxication (alcohol, carbon monoxide or neuroleptic drugs) Extrapiramidal (malignant neuroleptic syndrome) Seizures (status epilepticus) Metabolic (hypoglycemia, hepatic encephalopathy or Addison`s disease) Electrolytic disequilibrium (hyponatremia or hypermagnesemia) Meningism: Infection( Meningitis or encephalitis) Vascular (subarachnoid hemorrhage) Vascular (subarachnoid hemorrhage) Lateralizing signs: Asymmetrical signs (hemorrhage, venous thrombosis, abscess or tumor) Symmetrical (diffuse axonal injury or bilateral subdural hematoma) Focal brainstem dysfunction: Herniation syndrome, posterior fossa tumor or vertebrobasilar occlusion

18. 7.§iÒu trÞ Nguyªn t¾c chung: - B¶o ®¶m c¸c chøc n¨ng sèng: HH, TH - KiÓm so¸t ¸p lùc néi sä - C©n b»ng néi m«i - Ch¨m sãc - Dinh d­ìng - §iÒu trÞ ®Æc hiÖu: Tuú theo c¨n nguyªn Tuú theo c¨n nguyªn

19. Kiểm soát áp lực nội sọ  Nguyên tắc chung  Theo căn nguyên

20. 8.Tµi liÖu tham kh¶o Nhi khoa tËp 2,2000 Pediatrics, 1992, 1998 CÊp cøu nhi khoa, 1999 Emedicine.com.MedicineNet.com…