儿科学课件（重庆医科大学）13惊厥7七年制儿科2015

Acute convulsion in Children JIANG Li Professor, Doctorial tutor Department of Neurology Childrens Hospital of CMU contents Definitions Causes of acute convulsion Febrile seizures Bacterial Meningitis Exams and Tests for convulsion Treatment of acute convulsion Acute convulsion in Children Definitions Epileptic Seizures（癫痫发作） manifestation of transient excessive abnormal hypersynchronous discharges of cortical neurons Clinical signs or symptoms of seizures depend on the location of the epileptic discharges in the cortex and the extent and pattern of the propagation of the epileptic discharge in the brain. May be manifested as a motor, sensory, autonomic, cognitive, or psychic disturbance manifestation is apparent either to the subject or an observer Different types of seizures may occur in different parts of the brain and may be localized (affect only a part of the body) or widespread (affect the whole body). Acute convulsion in Children Definitions Convulsive seizures (惊厥性癫痫发作， convulsion 惊厥): is a subtype of seizure in which abnormal motor activity occurs, noted by uncontrollable muscle jerking Epilepsy（癫痫）: a chronic disorder of the brain characterized by recurrent, unprovoked epileptic seizures. Acute convulsion in Children 癫痫发作癫痫发作（痫性发作，痫性发作，epileptic seizures epileptic seizures 或或 seizuresseizures） l大脑皮层神经元异常同步放电引起的暂时性脑 功能异常 临床可有多种发作症状（包括运动、感觉异常、行为 认知、植物神经功能障碍等） l分为惊厥性痫样发作（惊厥）、非惊厥性痫样 发作 l发作性、并有自限性、大多短暂 l可发生于急性疾病、慢性疾病 惊厥（Convulsion） 神经元异常放电：神经元异常放电：起源于大脑皮层运动区起源于大脑皮层运动区 脑功能障碍基本表现：抽搐（全身或局脑功能障碍基本表现：抽搐（全身或局 部骨骼肌的不自主收缩）部骨骼肌的不自主收缩） 可伴有不同程度意识障碍可伴有不同程度意识障碍 定定 义义 Classification of Epileptic Seizures (International League Against Epilepsy,1981) 一、Focal seizures (局灶性发作) 1、单纯局灶性发作（simple focal seizures, consciousness not impaired) 运动性发作 (with motor signs) 感觉性发作(with somatosensory or special-sensory symptoms) 植物神经症状发作(with autonomic symptoms or signs) 精神症状性发作(with psychic symptoms) 2、复杂局灶性发作（complex focal seizures, with impairment of consciousness) 3 、局灶性发作继发全面性发作（focal seizures evolving to secondarily generalized seizures) 二、Generalized seizures(全面性发作) 1、强直-阵挛性发作( tonic-clonic seizures) 2、强直性发作(Tonic seizures) 3、阵挛性发作(Clonic seizures) 4、失神发作(Absence seizures) 5、肌阵挛发作(Myoclonic seizures) 6、失张力发作(Atonic seizures seizures) 三、unclassified epileptic seizures (分类不明的发作) excessive abnormal discharges of cortical neurons Epileptic Seizures convulsive seizure (convulsion) nonconvulsive seizure Acute epileptic seizure (provoked in acute disorders) epilepsy (recurrent, unprovoked epileptic seizures) Acute convulsion in Children 癫痫发作、惊厥、癫痫 癫痫发作(Epileptic Seizures)：大脑神经元异常放 电所致发作性大脑皮层功能异常所引起的多种临床 症状 惊厥(convulsion) ：伴有骨骼肌强烈、不自主收缩 的痫性发作 癫痫(epilepsy) ：临床呈长期反复痫性发作的疾病 过程 Acute convulsion in Children Characteristics of acute convulsion in children High incidence: 4-6% in the children younger than 6yr Easily with prolonged convulsion or status convulsion Status convulsion（惊厥持续状态): 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 Seizures may occur for many causes Acute convulsion in Children contents Definitions (Seizure, Convulsion, Epilepsy) Causes of acute convulsions Febrile seizuresFebrile seizures Bacterial Meningitis Exams and Tests for convulsion Treatment of acute convulsion Acute convulsion in Children Common causes of acute convulsion CNS infection: Meningitis or encephalitis Febrile convulsions（ Febrile seizuresFebrile seizures） Head trauma CNS malformations Brain tumors Metabolic disorders: Hypoglycemia, Hyponatremia, hypernatremia, Hyperosmolar states, Hypocalcemia Idiopathic or cryptogenic epilepsy Acute convulsion in Children Classfication of the causes of convulsion infectious diseases infectious diseases other disorders other disorders IntracranialIntracranial diseasedisease Bacterial Meningitis, , Tuberculous meningitisTuberculous meningitis, Viral meningitis/encephalitis fungal meningitis, parasitic disease,brain abscess Head trauma CNS malformations Brain tumors epilepsy ExtracranialExtracranial diseasedisease Febrile convulsions Infectious-toxic Infectious-toxic encephalopathyencephalopathy Anoxia, ischemia Metabolic disorders: Hypoglycemia Hyponatremia Hypernatremia Hypocalcemia ToxicosisToxicosis rodenticide organic pesticide Acute convulsion in Children Intracranial infection Usually with infectious symptoms（fever、 drowsiness、irritation、delirium） Recurrent, severe, prolonged seizure Common occur in early stage or the most serious stage of disease Usually with the disturbance of impairment of consciousness With the manifestations of intracranial hypertension Useful lab test: CSF Causes of acute seizures 颅内感染-脑膜炎、脑炎、脑寄生虫、脑脓 肿病 多有感染中毒症状（发热、嗜睡、烦躁、激惹、谵妄） 反复而严重的惊厥发作，持续时间长 常见于疾病初期或极期 多伴有进行性意识障碍 伴有不同程度颅内高压表现 脑脊液检查有助诊断 感染性病因感染性病因 颅外感染中毒性脑病 大多见于严重细菌感染过程中大多见于严重细菌感染过程中 与感染和毒素导致的脑水肿有关与感染和毒素导致的脑水肿有关 临床特征：原发疾病极期临床特征：原发疾病极期 反复惊厥发作反复惊厥发作 伴有意识障碍与颅内压增高症状伴有意识障碍与颅内压增高症状 脑脊液检查仅压力增高脑脊液检查仅压力增高 感染性病因感染性病因 Febrile seizuresFebrile seizures “An event in infancy or childhood usually occurring between three months and five years of age, associated with fever, but without evidence of intracranial infection or an identifiable neurological disorder” Febrile seizuresFebrile seizures Classfication of the causes of convulsion infectious diseases infectious diseases other disorders other disorders IntracranialIntracranial diseasedisease Bacterial Meningitis, , Tuberculous meningitisTuberculous meningitis, Viral meningitis/encephalitis fungal meningitis, parasitic disease,brain abscess Head trauma CNS malformations Brain tumors epilepsy ExtracranialExtracranial diseasedisease Febrile convulsions Infectious-toxic Infectious-toxic encephalopathyencephalopathy Anoxia, ischemia Metabolic disorders: Hypoglycemia Hyponatremia Hypernatremia Hypocalcemia ToxicosisToxicosis rodenticide organic pesticide Acute convulsion in Children 非感染性病因-颅内病变 颅脑损伤（产伤、外伤、出血）颅脑损伤（产伤、外伤、出血） 伤后立即起病伤后立即起病 反复惊厥发作反复惊厥发作 伴有意识障碍与颅内压增高症状伴有意识障碍与颅内压增高症状 头颅影像学检查（头颅影像学检查（CTCT、MRIMRI）有助诊断）有助诊断 非感染性病因非感染性病因 非感染性病因-颅内病变 颅脑发育畸形（颅脑发育异常、脑积水）颅脑发育畸形（颅脑发育异常、脑积水） 常呈反复发作常呈反复发作 伴有智力和运动发育落后伴有智力和运动发育落后 肿瘤肿瘤 常呈反复发作常呈反复发作 伴有颅内压增高伴有颅内压增高 定位体征定位体征 病情进行性加重病情进行性加重 头颅影像学检查确诊头颅影像学检查确诊 非感染性病因非感染性病因 非感染性病因-颅外病变 缺氧缺血（窒息、溺水、休克、阿斯氏综合征等）缺氧缺血（窒息、溺水、休克、阿斯氏综合征等） 缺血缺氧后立即起病缺血缺氧后立即起病 反复惊厥发作反复惊厥发作 伴有意识障碍与颅内压增高症状伴有意识障碍与颅内压增高症状 非感染性病因非感染性病因 非感染性病因-颅外病变 代谢性疾病（水电解质紊乱、遗传代谢性）代谢性疾病（水电解质紊乱、遗传代谢性） 低钙血症（低钙血症（1.75-1.88mmol/L1.75-1.88mmol/L，游离钙，游离钙1.0mmol/L1.0mmol/L） 低血糖症（低血糖症（2.2mmol/L2.2mmol/L） 低镁血症（低镁血症（0.8-1.2mmol/L0.8-1.2mmol/L） 低钠或高钠血症（低钠或高钠血症（136-146mmol/L136-146mmol/L） 遗传代谢性病（苯丙酮尿症等）遗传代谢性病（苯丙酮尿症等） 非感染性病因非感染性病因 非感染性病因-颅外病变 中毒性（杀鼠药、有机磷农药、中枢兴奋药）中毒性（杀鼠药、有机磷农药、中枢兴奋药） 顽固性惊厥发作顽固性惊厥发作 意识障碍意识障碍 肝、肾功能损伤肝、肾功能损伤 非感染性病因非感染性病因 contents Definitions (Seizure, Convulsion, Epilepsy) Causes of acute convulsion Febrile seizures Bacterial Meningitis Exams and Tests for convulsion Treatment of acute convulsion History of patient The 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 details of postictal neurologic deficit Incontinence Cyanosis (perioral or facial) Duration of seizure activity prior to medical attention Mental status after cessation of seizure activity Exams and Tests for seizures History of patient Fever or intercurrent illnesses Prior history of seizures Head injury (recent and remote) CNS infection or disease (eg, meningitis, neurocutaneous syndrome) Intoxication or toxic exposure Birth history and developmental delay Exams and Tests for seizures Physical Examination Obtain temperature and vital signs ( important in the initial evaluation) Examine for signs suggestive of trauma or the presence of an intracranial shunt Examine for papilledema (suggesting increased intracranial pressure) Examine for nuchal rigidity (suggesting meningitis) Exams and Tests for seizures Physical Examination Examine skin for findings suggestive of neurocutaneous syndrome Examine features of appropriate neurodevelopment Identify any focal neurologic deficits (may be indicative of an underlying focal structural lesion or postictal Todd paresis) Exams and Tests for seizures 病因学诊断提示 病史病史-年龄年龄 新生儿期：颅脑损伤、颅内畸形、颅内感染、代谢紊乱 1-6月：颅内感染、低钙、婴儿痉挛 -3岁：热性惊厥、颅内感染、中毒性脑病、癫痫 3岁以上：颅内感染、中毒性脑病、癫痫、颅脑外伤 病因学诊断提示 病史病史-季节季节 夏秋季节：中毒性痢疾 流行性乙型脑炎 低血糖症 冬春季节：流行性脑脊髓膜炎 肺炎中毒性脑病 VitD缺乏性低钙惊厥 病因学诊断提示 病史病史-是否伴发热是否伴发热 无热者大多非感染性，但无热者大多非感染性，但3 3月幼婴、新生儿以及月幼婴、新生儿以及 休克者例外休克者例外 发热者大多为感染性，但惊厥持续状态可致体温发热者大多为感染性，但惊厥持续状态可致体温 升高升高 病史病史-惊厥严重程度惊厥严重程度 Laboratory Evaluation Initial laboratory evaluation can include: blood analysis (WBC count), urinalysis , stool examination Serum studies for glucose, electrolytes, calcium, and magnesium and toxicology studies Exams and Tests for seizures Laboratory Evaluation Perform a CT scan or MRI if the patient has had a recent head trauma, significantly altered mental status, a significant headache, papilledema, or a bulging fontanel. Consider a lumbar puncture (LP) in patients who have fever and a stiff neck or who have fever and are unconscious. Others: EEG Exams and Tests for seizures 病因学诊断提示 实验室检查实验室检查 三大常规：三大常规：白细胞计数、大便（中毒性菌痢）白细胞计数、大便（中毒性菌痢） 选择性生化检查：选择性生化检查：血糖、血糖、CaCa + + 、MgMg + + 、NaNa + + 、 肝肾功能肝肾功能 脑脊液检查：脑脊液检查：疑有颅内病变者疑有颅内病变者 其它其它：EEGEEG、头、头CT/MRICT/MRI contents Definitions(Seizure,Convulsion,Epilepsy) Causes of acute convulsion Febrile seizures Bacterial Meningitis Exams and Tests for convulsion Treatment of acute convulsion DZPDZP （地西泮，安定（地西泮，安定 ） LZPLZP （劳拉西泮，（劳拉西泮， 氯羟安定）氯羟安定） PHTPHT （苯妥因）（苯妥因） PBPB （苯巴比妥）（苯巴比妥） 成人（成人（mg/kg)ivmg/kg)iv0.150.150.250.250.1152020 小儿小儿(mg/kg)iv(mg/kg)iv0.3-0.5mg/kg0.3-0.5mg/kg0.050.050.50.520202020 小儿直肠用小儿直肠用(mg/kg)(mg/kg)0.50.5 最大输注速率最大输注速率(mg/min)(mg/min) 1 1 250100 最早止惊时间最早止惊时间(min)(min)1 1 3 361010302030 药效维持时间药效维持时间(h)(h)0.250.250.50.512242448 半衰期半衰期(h)(h)30301424100 可能副作用可能副作用: : 意识抑制意识抑制约约101030min30min数小时无可数日 呼吸抑制呼吸抑制偶见偶见偶见偶见少见少见偶见偶见 低血压低血压少见少见少见少见偶见偶见少见少见 心律失常心律失常心脏病者 抢救惊厥发作常用药物表抢救惊厥发作常用药物表 Treatment of seizures prompt cessation of seizure activity Diazepam - Intravenously administered (0.3-0.5 mg/kg/dose); - Has rapid onset and short duration of seizure control; - Do not administer 1mg/min IVP in children; - Monitor for respiratory depression acute seizures Treatment of seizures prompt cessation of seizure activity Phenobarbital - Has slow onset and long duration of seizure control; - Major disadvantages are significantly depresses mental status and causes respiratory difficulty Diazepam + Phenobarbital acute seizures Treatment of seizures Others Secure the airway Administer supplemental 100% oxygen Infuse intravenous fluids and glucose Increased intracranial pressure controlling Identification and treatment of underlying disease acute seizures contents Definitions (Seizure,Convulsion,Epilepsy) Causes of acute convulsion Febrile seizuresFebrile seizures（热性惊厥）（热性惊厥） Bacterial Meningitis Exams and Tests for convulsion Treatment of acute convulsion Acute convulsion in Children General Introduction “An event in infancy or childhood usually occurring between three months and five years of age, associated with fever, but without evidence of intracranial infection or an identifiable neurological disorder” Febrile seizures are the most common seizure disorder in childhood, affecting 25% of children. Febrile seizuresFebrile seizures General Introduction Associated with upper respiratory infection, otitis media, viral syndrome Genetic predisposition clearly contributes to the occurrence of this disorder Be divided into simple febrile seizures, complex febrile seizures Among children with febrile seizures, about 70- 80% have only simple febrile seizures, others have complex febrile seizures Febrile seizuresFebrile seizures Features of Febrile Seizure Most common cause of seizures in childhood, usually with good prognosis Associated with fever, usually occur when body temperature rises rapidly Febrile seizuresFebrile seizures Features of Febrile Seizure Occur in the absence of intracranial infection or an identifiable neurological disorder. Age dependent: 6mon-3yr ( peak age of onset:18-22mo of age) With normal CNS structure and function Febrile seizuresFebrile seizures Features of Febrile Seizure No afebrile seizure history Most underlying infection cause the fever may be a viral infection Genetic predisposition gene location: SFS: 19p 13-3; FS with TLE: 8q 13-21; FS+: 2q21-q33 , 19q13.1 Febrile seizuresFebrile seizures Simple febrile Seizure (SFS) The setting is fever in a child aged 6 months to 3 years Typically seizure is generalized (tonic-clonic) Duration of seizure: a few seconds to 15min Only has once or twice of seizures during a period of disease Febrile seizuresFebrile seizures Complex febrile Seizure(CFS) Age of seizure onset: 6 months to 5 years; 6yrs prolonged seizure: persisting for more than 15 min Repeated convulsions during a febrile period (multiple seizures occur in close succession). A focal seizure. Recurrent seizure ( 5 times) Febrile seizuresFebrile seizures 单纯性FS（SFS）复杂性FS（CFS） 发病率FS中80%FS中20% 发作形式全身性发作，发作后不留任何异 常神经征 局限性或不对称性发作。发 作后可留异常神经征 发作次数在一次热程中仅有一次惊厥发作 （2/3）， 少数2次（1/4-1/3） 反复多次（丛集式发作：24 小时内反复发作2次） 持续时间发作时间短暂，多数515分钟内发作时间长（ 15分钟） 复发 总次数 4次以内5次以上 热性惊厥的分类及基本临床特征 Risk factors for recurrent febrile seizures Young age at time of first febrile seizure: 15mo or 18mo Family history of a febrile seizure in a first degree relative Complex febrile Seizure Brief duration between fever onset and initial seizure Patients with all 4 risk factors have greater than 70% chance of recurrence. Patients with no risk factors have less than a 20% chance of recurrence. Febrile seizuresFebrile seizures Risk factors for epilepsy Complex febrile seizure (a prolonged, or focal, or recur seizure in the same illness) Family history of epilepsy Neurological abnormality, and developmental delay. Children with a febrile seizure have a slight increase in the incidence of epilepsy compared with the general population (1% vs 0.5%). Patients with 2 risk factors have up to 10% chance of developing afebrile seizures. Febrile seizuresFebrile seizures Management Identification and treatment of underlying infection Keeping the patient cool with regular antipyretics Termination of a prolonged convulsion (