Hướng dẫn chẩn đoán điều trị bệnh tay - chân - miệng

Bệnh nhi bị bệnh Tay - Chân - MiệngNgày 16/5/2008 Bộ Y tế đã ra quyết định số 1732/QĐ-BYT ban hành “hướng dẫn chẩn đoán điều trị bệnh tay – chân – miệng”. Năm nay bệnh tay – chân – miệng đến sớm hơn mọi năm chỉ trong tháng 4 và đầu tháng 5 đã có nhiều ca bệnh nhập viện ở cả 3 miền Bắc Trung Nam. Tại BV Nhi Đồng 1 so với tháng 3-2008 số ca bệnh tay chân
miệng tăng 21% vào tháng 4-2008 và ước tính trung bình có 50 trẻ nằm viện. Nhưng đến nay số trẻ nằm điều trị tại BV Nhi Đồng 1 TPHCM đã tăng lên 60 ca mỗi ngày trong đó có đến 45% bệnh nhi đến từ các tỉnh khác.
Bệnh nhi tay – chân – miệng đang được
cấp cứu tại BV Nhi đồng 1.
Ảnh: Thiên Chương (Vnexpress)

Dưới đây là hướng dẫn Chẩn đoán điều trị bệnh tay - chân- miệng

HƯỚNG DẪN

Chẩn đoán điều trị bệnh tay-chân-miệng

I. ĐẠI CƯƠNG

- Bệnh tay-chân-miệng là bệnh truyền nhiễm lây từ người sang người dễ gây thành dịch do vi rút đường ruột gây ra. Hai nhóm tác nhân gây bệnh thường gặp là Coxsackie virus A16Enterovirus 71 (EV71). Biểu hiện chính là tổn thương da niêm mạc dưới dạng phỏng nước ở các vị trí đặc biệt như niêm mạc miệng lòng bàn tay lòng bàn chân mông gối. Bệnh có thể gây nhiều biến chứng nguy hiểm như viêm não-màng não viêm cơ tim phù phổi cấp dẫn đến tử vong nếu không được phát hiện sớm và xử trí kịp thời. Các trường hợp biến chứng nặng thường do EV71.

- Bệnh lây chủ yếu theo đường tiêu hoá. Nguồn lây chính từ nước bọt phỏng nước và phân của trẻ nhiễm bệnh.

- Bệnh tay-chân-miệng gặp rải rác quanh năm ở hầu hết các địa phương. Tại các tỉnh phía Nam bệnh có xu hướng tăng cao vào hai thời điểm từ tháng 3 đến tháng 5 và từ tháng 9 đến tháng 12 hàng năm.

- Bệnh thường gặp ở trẻ dưới 5 tuổi đặc biệt tập trung ở nhóm tuổi dưới 3 tuổi. Các yếu tố sinh hoạt tập thể như trẻ đi học tại nhà trẻ mẫu giáo là các yếu tố nguy cơ lây truyền bệnh đặc biệt là trong các đợt bùng phát.

II. CHẨN ĐOÁN

1. Lâm sàng:

1.1. Triệu chứng lâm sàng:

a) Giai đoạn ủ bệnh: 3-7 ngày.

b) Giai đoạn khởi phát: Từ 1-2 ngày với các triệu chứng như sốt nhẹ mệt mỏi đau họng biếng ăn tiêu chảy vài lần trong ngày.

c) Giai đoạn toàn phát: Có thể kéo dài 3-10 ngày với các triệu chứng điển hình của bệnh:

- Loét miệng: vết loét đỏ hay phỏng nước đường kính 2-3 mm ở niêm mạc miệng lợi lưỡi.

- Phát ban dạng phỏng nước: Ở lòng bàn tay lòng bàn chân gối mông; tồn tại trong thời gian ngắn (dưới 7 ngày) sau đó để lại vết thâm.

- Sốt nhẹ.

- Nôn.

- Nếu trẻ sốt cao và nôn nhiều dễ có nguy cơ biến chứng.

- Biến chứng thần kinh tim mạch hô hấp thường xuất hiện sớm từ ngày 2 đến ngày 5 của bệnh.

d) Giai đoạn lui bệnh: Thường từ 3-5 ngày sau trẻ hồi phục hoàn toàn nếu không có biến chứng.

1.2. Các thể lâm sàng:

- Thể tối cấp: Bệnh diễn tiến rất nhanh có các biến chứng nặng như suy tuần hoàn suy hô hấp hôn mê co giật dẫn đến tử vong trong vòng 48 giờ.

- Thể cấp tính với bốn giai đoạn điển hình như trên.

- Thể không điển hình: Dấu hiệu phát ban không rõ ràng hoặc chỉ có loét miệng hoặc chỉ có triệu chứng thần kinh tim mạch hô hấp mà không phát ban và loét miệng.

2. Cận lâm sàng:

2.1. Các xét nghiệm cơ bản:

- Công thức máu: Bạch cầu thường trong giới hạn bình thường.

- Protein C phản ứng (CRP) (nếu có điều kiện) trong giới hạn bình thường (< 10 mg/L).

2.2. Các xét nghiệm theo dõi phát hiện biến chứng:

- Đường huyết điện giải đồ X quang phổi.

- Khí máu khi có suy hô hấp

- Troponin I siêu âm tim khi nhịp tim nhanh ≥ 150 lần/phút nghi ngờ viêm cơ tim hoặc sốc.

- Dịch não tủy:

+ Chỉ định chọc dò tủy sống khi có biến chứng thần kinh.

+ Xét nghiệm protein bình thường hoặc tăng nhẹ số lượng tế bào trong giới hạn bình thường hoặc tăng nhẹ bạch cầu đơn nhân. Trong giai đoạn sớm có thể tăng bạch cầu từ 100-1000 bạch cầu/mm3 với tỉ lệ đa nhân chiếm ưu thế.

- Chụp cộng hưởng từ não: Tổn thương tập trung ở thân não. Chỉ thực hiện khi có điều kiện và khi cần chẩn đoán phân biệt với các bệnh lý ngoại thần kinh.

2.3. Xét nghiệm phát hiện vi rút: Lấy bệnh phẩm hầu họng phỏng nước trực tràng dịch não tuỷ để thực hiện xét nghiệm RT-PCR hoặc phân lập vi rút chẩn đoán xác định nguyên nhân do EV71 hay Coxsackievirus A16.

3. Chẩn đoán xác định: Chủ yếu dựa vào triệu chứng lâm sàng và dịch tễ học.

- Yếu tố dịch tễ: Căn cứ vào tuổi mùa vùng lưu hành bệnh số trẻ mắc bệnh trong cùng một thời gian.

- Lâm sàng: Sốt kèm theo phỏng nước điển hình ở miệng lòng bàn tay lòng bàn chân gối mông.

- Xét nghiệm xác định có vi rút gây bệnh.

4. Chẩn đoán phân biệt:

4.1. Các bệnh có biểu hiện loét miệng:

Viêm loét miệng (áp-tơ): Vết loét sâu có dịch tiết hay tái phát.

4.2. Các bệnh có phát ban da:

- Sốt phát ban: hồng ban xen kẽ ít dạng sẩn thường có hạch sau tai.

- Dị ứng: hồng ban đa dạng không có phỏng nước.

- Viêm da mủ: Đỏ đau có mủ.

- Thuỷ đậu: Phỏng nước nhiều lứa tuổi rải rác toàn thân.

- Nhiễm khuẩn huyết do não mô cầu: mảng xuất huyết hoại tử trung tâm

- Sốt xuất huyết Dengue: Chấm xuất huyết bầm máu xuất huyết niêm mạc.

4.3. Viêm não-màng não:

- Viêm màng não do vi khuẩn

- Viêm não-màng não do vi rút khác

5. Biến chứng:

5.1. Biến chứng thần kinh: Viêm não viêm thân não viêm não tủy viêm màng não.

- Rung giật cơ (myoclonic jerk): Từng cơn ngắn 1-2 giây chủ yếu ở tay và chân trong cơn trẻ vẫn còn ý thức.

- Ngủ gà bứt rứt chới với đi loạng choạng run chi mắt nhìn ngược.

- Yếu liệt chi (liệt mềm cấp).

- Liệt dây thần kinh sọ não.

- Co giật hôn mê là dấu hiệu nặng thường đi kèm với suy hô hấp tuần hoàn.

5.2. Biến chứng tim mạch hô hấp: Viêm cơ tim phù phổi cấp tăng huyết áp suy tim trụy mạch.

- Mạch nhanh > 150 lần/phút.

- Thời gian đổ đầy mao mạch chậm trên 3 giây.

- Da nổi vân tím vã mồ hôi chi lạnh.

- Giai đoạn đầu có huyết áp tăng (HA tâm thu: trẻ dưới 2 tuổi ≥ 115 mmHg trẻ trên 2 tuổi ≥ 120 mmHg) giai đoạn sau mạch huyết áp không đo được.

- Khó thở: Thở nhanh rút lõm ngực thở rít thanh quản thở không đều.

- Phù phổi cấp: Sùi bọt hồng khó thở tím tái phổi nhiều ran ẩm.

6. Phân độ lâm sàng:

6.1. Độ 1: Chỉ loét miệng và/hoặc tổn thương da.

6.2. Độ 2: Biến chứng thần kinh hoặc tim mạch mức độ trung bình.

Rung giật cơ: Kèm theo 1 trong các dấu hiệu sau:

- Đi loạng choạng.

- Ngủ gà.

- Yếu liệt chi.

- Mạch nhanh >150 lần/phút (khi trẻ nằm yên và không sốt).

- Sốt cao ≥ 39o5C (nhiệt độ hậu môn).

6.3. Độ 3: Biến chứng nặng về thần kinh hô hấp tim mạch.

- Co giật hôn mê (Glasgow < 10 điểm).

- Khó thở: Thở nhanh rút lõm ngực SpO2 < 92% (không oxy hỗ trợ).

- Mạch nhanh >170 lần/phút hoặc tăng huyết áp.

6.4. Độ 4: Biến chứng rất nặng khó hồi phục

- Phù phổi cấp.

- Sốc truỵ mạch.

- SpO2 < 92% với oxy qua gọng mũi 6 lít/phút.

- Ngừng thở.

III. ĐIỀU TRỊ

1. Nguyên tắc điều trị:

- Hiện nay chưa có thuốc điều trị đặc hiệu chỉ điều trị hỗ trợ (không dùng kháng sinh khi không có bội nhiễm).

- Theo dõi sát phát hiện sớm và điều trị biến chứng.

- Bảo đảm dinh dưỡng đầy đủ nâng cao thể trạng.

2. Điều trị cụ thể:

2.1. Độ 1: Điều trị ngoại trú và theo dõi tại y tế cơ sở.

- Dinh dưỡng đầy đủ theo tuổi. Trẻ còn bú cần tiếp tục cho ăn sữa mẹ.

- Hạ sốt khi sốt cao bằng Paracetamol liều 10 mg/kg/lần (uống) mỗi 6 giờ hoặc lau mát.

- Vệ sinh răng miệng.

- Nghỉ ngơi tránh kích thích.

- Tái khám mỗi 1-2 ngày trong 5-10 ngày đầu của bệnh

- Dặn dò dấu hiệu nặng cần tái khám ngay:

+ Sốt cao ≥ 39oC.

+ Thở nhanh khó thở.

+ Rung giật cơ chới với run chi quấy khóc bứt rứt khó ngủ.

+ Co giật hôn mê.

+ Yếu liệt chi.

+ Da nổi vân tím.

- Chỉ định nhập viện:

+ Biến chứng thần kinh tim mạch hô hấp (từ độ 2).

+ Sốt cao ≥ 39oC.

+ Nôn nhiều.

+ Nhà xa: không có khả năng theo dõi tái khám.

2.2. Độ 2: Điều trị nội trú tại bệnh viện huyện hoặc tỉnh

- Điều trị như độ 1.

- Nằm đầu cao 30° cổ thẳng.

- Thở oxy qua mũi 3-6 lít/phút khi có thở nhanh.

- Chống co giật: Phenobarbital 10 mg/kg/lần tiêm bắp hay truyền tĩnh mạch. Lặp lại sau 6-8 giờ khi cần.

- Immunoglobulin (nếu có).

- Theo dõi mạch nhiệt độ huyết áp nhịp thở tri giác ran phổi mạch mỗi 4- 6 giờ.

- Đo độ bão hòa oxy SpO2 và theo dõi mạch liên tục (nếu có máy).

2.3. Độ 3: Điều trị nội trú tại bệnh viện tỉnh hoặc bệnh viện huyện nếu đủ điều kiện.

- Thở oxy qua mũi 3-6 lít/phút. Đặt nội khí quản giúp thở sớm khi thất bại với thở oxy.

- Chống phù não (xem điều trị biến chứng).

- Chống co giật: Phenobarbital 10-20mg/kg pha trong Glucose 5% truyền tĩnh mạch trong 30- 60 phút. Lặp lại 8-12 giờ nếu cần.

- Hạ đường huyết: Glucose 30% 2 ml/kg/lần lặp lại khi cần.

- Điều chỉnh rối loạn nước điện giải toan kiềm.

- Dobutamin được chỉ định khi suy tim mạch > 170 lần/phút liều khởi đầu 5µg/kg/phút truyền tĩnh mạch tăng dần 1-2 5µg/kg/phút mỗi 15 phút cho đến khi có cải thiện lâm sàng; liều tối đa 10µg/kg/phút.

- Immunoglobulin (nếu có).

- Theo dõi mạch nhiệt độ huyết áp nhịp thở tri giác ran phổi SpO2 mỗi 1- 2 giờ.

2.4. Độ 4: Điều trị nội trú tại bệnh viện trung ương hoặc bệnh viện tỉnh huyện nếu đủ điều kiện.

- Xử trí tương tự độ 3.

- Điều trị biến chứng (xem phần điều trị các biến chứng).

3. Điều trị các biến chứng:

3.1. Phù não:

- Nằm đầu cao 30° cổ thẳng.

- Thở oxy qua mũi 1- 4 lít/phút. Đặt nội khí quản sớm để giúp thở khi SpO2 < 92% hay PaCO2 > 50 mmHg.

- Thở máy: Tăng thông khí giữ PaCO2 từ 25-35 mmHg và duy trì PaO2 từ 90-100 mmHg.

- Hạn chế dịch: tổng dịch bằng 1/2-3/4 nhu cầu bình thường.

3.2. Sốc: Sốc do viêm cơ tim hoặc tổn thương trung tâm vận mạch ở thân não.

- Thở oxy qua mũi 3-6 lít/phút.

- Đo và theo dõi áp lực tĩnh mạch trung ương.

- Truyền dịch Natri clorid 0 9% hoặc Ringer lactat: 5 ml/kg/15 phút điều chỉnh tốc độ theo hướng dẫn CVP và đáp ứng lâm sàng. Trường hợp không có CVP cần theo dõi sát dấu hiệu quá tải phù phổi cấp.

- Dopamin là thuốc được chọn lựa liều khởi đầu 5µg/kg/phút tăng dần 1- 2 5µg/kg/phút mỗi 15 phút cho đến khi có hiệu quả liều tối đa 10 µg/kg/phút. Trường hợp không đáp ứng với Dopamin phối hợp Dobutamin liều khởi đầu 5µg/kg/phút tăng dần 1- 2 5µg/kg/phút mỗi 15 phút cho đến khi có hiệu quả liều tối đa 20 µg/kg/phút.

3.3. Suy hô hấp: Suy hô hấp do phù phổi cấp hoặc viêm não.

- Thông đường thở: hút sạch đờm rãi.

- Thở oxy 3- 6 lít/phút duy trì SpO2 > 92%.

- Đặt nội khí quản nếu có cơn ngừng thở hoặc thất bại với thở oxy.

- Thở máy: Tăng thông khí giữ PaCO2 từ 25- 35 mmHg và duy trì PaO2 từ 90- 100 mmHg.

3.4. Phù phổi cấp:

- Ngừng ngay dịch truyền nếu đang truyền dịch.

- Dùng Dobutamin liều 5-20 µg/kg/phút.

- Furosemide 1-2 mg/kg/lần tiêm tĩnh mạch chỉ định khi quá tải dịch.

4. Immunoglobulin (nếu có):

- Chỉ định từ độ 2 và độ 3.

- Liều: 1g/kg/ngày truyền tĩnh mạch trong 6- 8 giờ x 2 ngày liên tiếp.

- Riêng độ 2 cần đánh giá lại lâm sàng trước chỉ định liều thứ 2. Không dùng liều 2 nếu lâm sàng cải thiện tốt.

5. Kháng sinh:

- Kháng sinh không có chỉ định trong bệnh tay-chân-miệng.

- Chỉ dùng kháng sinh khi có bội nhiễm.

- Có thể dùng các kháng sinh sau đây:

+ Amoxicillin

+ Cephalosporin thế hệ 3:

Cefotaxim 200 mg/kg/ngày chia 4 lần (tĩnh mạch)

Hoặc Ceftriaxon 100 mg/kg/ngày chia 1-2 lần (tĩnh mạch)

IV. PHÒNG BỆNH

1. Nguyên tắc phòng bệnh:

- Hiện chưa có vắc xin phòng bệnh đặc hiệu.

- Áp dụng các biện pháp phòng bệnh đối với bệnh lây qua đường tiêu hoá đặc biệt chú ý tiếp xúc trực tiếp với nguồn lây.

2. Phòng bệnh tại các cơ sở y tế:

- Cách ly theo nhóm bệnh.

- Nhân viên y tế: Mang khẩu trang rửa sát khuẩn tay trước và sau khi chăm sóc.

- Khử khuẩn bề mặt giường bệnh buồng bệnh bằng Cloramin B 2%.

- Xử lý chất thải theo quy trình phòng bệnh lây qua đường tiêu hoá.

3. Phòng bệnh ở cộng đồng:

- Vệ sinh cá nhân rửa tay bằng xà phòng (đặc biệt sau khi thay quần áo tã sau khi tiếp xúc với phân nước bọt).

- Rửa sạch đồ chơi vật dụng sàn nhà.

- Lau sàn nhà bằng dung dịch khử khuẩn Cloramin B 2%.

- Cách ly trẻ bệnh tại nhà. Không đến nhà trẻ trường học trong tuần đầu tiên của bệnh.

KT. BỘ TRƯỞNG

THỨ TRƯỞNG

(đã ký)

Nguyễn Thị Xuyên


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