兒科學(xué)教學(xué)課件：09-驚厥

1、Acute convulsion in ChildrencontentsDefinitionsCauses of acute convulsion Febrile seizuresExams and Tests for convulsionTreatment of acute convulsionAcute convulsion in ChildrenDefinitionsEpileptic Seizures（癲癇發(fā)作，癇性發(fā)作） transient excessive abnormal electrical activity of cortical neurons manifestation

2、 depends on the areas of the brain affected (motor, sensory, autonomic, cognitive, or psychic disturbance) manifestation is apparent either to the subject or an observerBe divided into partial seizures (affect only a part of the body) and generalized seizures (affect the whole body)Acute convulsion

3、in ChildrenClassification of seizures (International League against Epilepsy, 1981 ) SeizuresPartial Simple Partial Complex Partial secondary generalisationGeneralizedAbsenceTonic-clonicTonicClonicMyoclonicAtonic Infantile spasmsUnclassifiedDefinitionsConvulsive seizures (驚厥性癲癇發(fā)作，convulsion 驚厥): a s

4、ubtype of epileptic seizure, violent uncontrollable contractions of musclesEpilepsy（癲癇）: a chronic disorder of the brain characterized by recurrent, unprovoked epileptic seizures.Acute convulsion in Children癲癇發(fā)作（癇性發(fā)作，epileptic seizures 或 seizures）大腦皮層神經(jīng)元異常同步放電引起的暫時(shí)性腦功能異常 臨床可有多種發(fā)作癥狀（包括運(yùn)動(dòng)、感覺異常、行為認(rèn)知、植物

5、神經(jīng)功能障礙等）分為驚厥性癇樣發(fā)作（驚厥）、非驚厥性癇樣發(fā)作發(fā)作性、并有自限性、大多短暫可發(fā)生于急性疾病、慢性疾病驚厥（Convulsion）神經(jīng)元異常放電：起源于大腦皮層運(yùn)動(dòng)區(qū)腦功能障礙基本表現(xiàn)：抽搐（全身或局部骨骼肌的不自主收縮）可伴有不同程度意識(shí)障礙定 義excessive abnormal discharges of cortical neuronsEpileptic Seizuresconvulsive seizure (convulsion) nonconvulsive seizureAcute epileptic seizure(provoked in acute disorde

6、rs) epilepsy (recurrent, unprovoked epileptic seizures)Acute convulsion in Children癲癇發(fā)作、驚厥、癲癇癲癇發(fā)作(Epileptic Seizures)：發(fā)作性大腦皮層功能異常所引起的多種臨床癥狀驚厥(convulsion) ：伴有骨骼肌強(qiáng)烈、不自主收縮的癇性發(fā)作癲癇(epilepsy) ：臨床呈長(zhǎng)期反復(fù)癇性發(fā)作的疾病過程Acute convulsion in ChildrenCharacteristics of acute convulsion in childrenHigh incidence: 4-6% i

7、n the children younger than 6yrEasily with prolonged convulsion or status convulsion Status convulsion（驚厥持續(xù)狀態(tài)): a convulsion lasting longer than 30 minutes or repeated convulsion without a return to normal in between them Usually with minim or subtle seizure in the babies Etiological factors are var

8、iedAcute convulsion in ChildrencontentsDefinitionsCauses of acute convulsions Febrile seizuresExams and Tests for convulsionTreatment of acute convulsionAcute convulsion in ChildrenCommon causes of acute convulsionCNS infection: Meningitis or encephalitisFebrile convulsions（ Febrile seizures）Head tr

9、aumaCNS malformationsBrain tumorsMetabolic disorders: Hypoglycemia, Hyponatremia, hypernatremia, Hyperosmolar states, HypocalcemiaIdiopathic or cryptogenic epilepsy Acute convulsion in ChildrenInfectionNon-infectionIntra-cranial MeningitisEncephalitisHead traumaCerebral dysgenesis/ malformationCereb

10、ral tumourHypoxic-ischaemic encephalopathyHaemorrhage/ IschaemiaEpilepsyExtra-cranial Febrile SeizuresInfectious-toxic encephalopathy Metabolic: Hypoglycaemia Hypocalcaemia Hypomagnesaemia Hypo/hypernatraemiaPoisons/toxinsCauses of ConvulsionIntracranial infectionUsually with infectious symptoms（fev

11、er、drowsiness、irritation、delirium）Recurrent, severe, prolonged seizure Common occur in early stage or the most serious stage of diseaseUsually with the disturbance of impairment of consciousnessWith the manifestations of intracranial hypertensionUseful lab test: CSF Causes of acute seizurescontentsD

12、efinitions Causes of acute convulsion Febrile seizures（熱性驚厥）Exams and Tests for convulsionTreatment of acute convulsionAcute convulsion in ChildrenFebrile seizures An event in infancy or childhood usually occurring between three months and five years of age, associated with fever, but without eviden

13、ce of intracranial infection or an identifiable neurological disorder”Febrile seizuresFebrile seizuresMost common seizure disorder in childhood （25%），usually with good prognosisAge dependent: 6mon-5yr ( peak age of onset: 6mo-3yr)Genetic predisposition gene location: SFS: 19p 13-3; FS with TLE: 8q 1

14、3-21; FS+: 2q21-q33 , 19q13.1 Associated with febrile illness：upper respiratory infection, otitis media, viral syndromeWithout evidence of brain infection, severe metabolic disturbance, or other known neurological cause，no afebrile seizure historyDivided into simple febrile seizures, complex febrile

15、 seizuresFebrile seizuresSimple febrile Seizure (SFS)Age of seizure onset: 6 months to 5 yearsType of seizure: generalized (tonic-clonic)Duration of seizure: a few seconds to 15minOnly has once or twice of seizures during a period of disease Febrile seizuresComplex febrile Seizure(CFS)Age of seizure

16、 onset: 5yrsType of seizure: focal seizure Duration of seizure: prolonged, more than 15 min Repeated convulsions during a febrile period (multiple seizures occur in close succession).Recurrent seizure ( 5 times) Febrile seizuresSimple FS Complex FS incidence 8020Age 6 mo to 5 yr 5 yrOnset timeIn 24

17、hr after fever onset24 hr after fever onsetSeizure typeGeneralized Partial Duration 15 min 15 min FrequencyNo recurrence in 24 h Recurs in 24 h Post neurological abnormalitiesNo May abnormalNeurological developmentNormalMay abnormalClassification of FSRisk factors for recurrent febrile seizuresYoung

18、 age at time of first febrile seizure: 15mo or 18moFamily history of a febrile seizure in a first degree relative Complex febrile SeizureBrief duration between fever onset and initial seizure Febrile seizuresRisk factors for epilepsyComplex febrile seizure (a prolonged, or focal, or recur seizure in

19、 the same illness) Family history of epilepsyNeurological abnormality, and developmental delay. Febrile seizuresManagementIdentification and treatment of underlying infectionKeeping the patient cool with regular antipyreticsTermination of a prolonged convulsion ( diazepam, iv or rectally) Parental e

20、ducationEffective drugs for preventing recurrent febrile seizure: Phenobarbital, Sodium valproate, diazepamFebrile seizuresInfectionNon-infectionIntra-cranial MeningitisEncephalitisHead traumaCerebral dysgenesis/ malformationCerebral tumourHypoxic-ischaemic encephalopathyHaemorrhage/ IschaemiaEpilep

21、syExtra-cranial Febrile SeizuresInfectious-toxic encephalopathy Metabolic: Hypoglycaemia Hypocalcaemia Hypomagnesaemia Hypo/hypernatraemiaPoisons/toxinsCauses of ConvulsioncontentsDefinitions (Seizure, Convulsion, Epilepsy) Causes of acute convulsion Febrile seizuresExams and Tests for convulsionTre

22、atment of acute convulsion History of patientThe course of current seizure activity Time and nature of onset of seizure activity Involvement of extremities or other body parts Nature of movements (eg, eye movements, flexion, extension, stiffening of extremities), including any focal movements and de

23、tails of postictal neurologic deficit Incontinence Cyanosis (perioral or facial) Duration of seizure activity prior to medical attention Mental status after cessation of seizure activityExams and TestsHistory of patientFever or intercurrent illnesses Prior history of seizures Head injury (recent and

24、 remote) CNS infection or disease (eg, meningitis, neurocutaneous syndrome) Intoxication or toxic exposure Birth history and developmental delay Exams and TestsPhysical ExaminationObtain temperature and vital signs ( important in the initial evaluation) Examine for signs suggestive of trauma or the

25、presence of an intracranial shuntExamine for papilledema (suggesting increased intracranial pressure)Examine for nuchal rigidity (suggesting meningitis) Exams and Tests for seizuresPhysical ExaminationExamine skin for findings suggestive of neurocutaneous syndromeExamine features of appropriate neur

26、odevelopmentIdentify any focal neurologic deficits (may beindicative of an underlying focal structural lesionor postictal Todd paresis)Exams and Tests for seizuresHistory： Age relatedageCommon causesneonateTrauma, Metabolic, CNS infection, Cerebral malformation16 moCNS infection, Hypocalcaemia, etc7

27、mo3yrFebrile Seizures, CNS infection, Infectious-toxic encephalopathy3yrCNS infection, Infectious-toxic encephalopathy, TraumaDiagnosis病因?qū)W診斷提示病史-年齡新生兒期：顱腦損傷、顱內(nèi)畸形、顱內(nèi)感染、代謝紊亂1-6月：顱內(nèi)感染、低鈣、嬰兒痙攣-3歲：熱性驚厥、顱內(nèi)感染、中毒性腦病、癲癇3歲以上：顱內(nèi)感染、中毒性腦病、癲癇、顱腦外傷病因?qū)W診斷提示病史-季節(jié)夏秋季節(jié)：中毒性痢疾 流行性乙型腦炎 低血糖癥冬春季節(jié)：流行性腦脊髓膜炎 肺炎中毒性腦病 VitD缺乏性低鈣驚

28、厥病因?qū)W診斷提示病史-是否伴發(fā)熱無熱者大多非感染性，但3月幼嬰、新生兒以及休克者例外發(fā)熱者大多為感染性，但驚厥持續(xù)狀態(tài)可致體溫升高病史-驚厥嚴(yán)重程度Lab investigationRoutine analysis of blood, urine, and stoolBlood test: selective metabolic screening (glucose, electrolytes, calcium, and magnesium and toxicology studies )Analysis of CSFEEG (electroencephalo-graph )Neuroimag

29、ing : head CT or MRI Exams and Tests病因?qū)W診斷提示實(shí)驗(yàn)室檢查三大常規(guī)：白細(xì)胞計(jì)數(shù)、大便（中毒性菌痢）選擇性生化檢查：血糖、Ca+、Mg+、Na+、 肝腎功能腦脊液檢查：疑有顱內(nèi)病變者其它：EEG、頭CT/MRIcontentsDefinitions(Seizure,Convulsion,Epilepsy) Causes of acute convulsion Febrile seizuresExams and Tests for convulsionTreatment of acute convulsionDZP（地西泮，安定）LZP（勞拉西泮，氯羥安定） PHT（苯妥因）PB（苯巴比妥）成人（mg/kg)iv0.150.250.1152020小兒(mg/kg)iv0.3-0.5mg/kg0.050.52020小兒直腸用(mg/kg)0.5最大輸注速率(mg/min)1250100最早止驚時(shí)間(min)1 361010302030藥效維持時(shí)間(h)0.250.512242448半