儿科学教学课件：09-惊厥

1、Acute convulsion in ChildrencontentsDefinitionsCauses of acute convulsion Febrile seizuresExams and Tests for convulsionTreatment of acute convulsionAcute convulsion in ChildrenDefinitionsEpileptic Seizures（癫痫发作，痫性发作） 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 (惊厥性癫痫发作，convulsion 惊厥): a s

4、ubtype of epileptic seizure, violent uncontrollable contractions of musclesEpilepsy（癫痫）: a chronic disorder of the brain characterized by recurrent, unprovoked epileptic seizures.Acute convulsion in Children癫痫发作（痫性发作，epileptic seizures 或 seizures）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

5、神经功能障碍等）分为惊厥性痫样发作（惊厥）、非惊厥性痫样发作发作性、并有自限性、大多短暂可发生于急性疾病、慢性疾病惊厥（Convulsion）神经元异常放电：起源于大脑皮层运动区脑功能障碍基本表现：抽搐（全身或局部骨骼肌的不自主收缩）可伴有不同程度意识障碍定 义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癫痫发作、惊厥、癫痫癫痫发作(Epileptic Seizures)：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 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（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 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（热性惊厥）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病因学诊断提示病史-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-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

28、厥病因学诊断提示病史-是否伴发热无热者大多非感染性，但3月幼婴、新生儿以及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升高病史-惊厥严重程度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病因学诊断提示实验室检查三大常规：白细胞计数、大便（中毒性菌痢）选择性生化检查：血糖、Ca+、Mg+、Na+、 肝肾功能脑脊液检查：疑有颅内病变者其它：EEG、头CT/MRIcontentsDefinitions(Seizure,Convulsion,Epilepsy) Causes of acute convulsion Febrile seizuresExams and Tests for convulsionTreatment of acute convulsionDZP（地西泮，安定）LZP（劳拉西泮，氯羟安定） PHT（苯妥因）PB（苯巴比妥）成人（mg/kg)iv0.150.250.1152020小儿(mg/kg)iv0.3-0.5mg/kg0.050.52020小儿直肠用(mg/kg)0.5最大输注速率(mg/min)1250100最早止惊时间(min)1 361010302030药效维持时间(h)0.250.512242448半