儿科学全套课件(英文版)

PSYCHOLOGICALDEVEOPEMENT

&MENTALHEALTHINCHILDREN

小兒心理衛生LearningTheory-Watson,BanduraPsychoanalyticTheory-Freud,EriksonCognitiveDevelopment-PiagetMAINTHEORIESONPSYCHOLOGICALDEVELOPMENTMAINTHEORIESONPSYCHOLOGICALDEVELOPMENTFreudEriksonPiaget0-18mOral口欲期Basictrust-mistrust信任－不信任Sensorymotor感知運動18m-3yAnal肛欲期Autonomy自主-shame,doubt羞怯懷疑Symbolic象徵(preoperational)3-6yOedipal性器期Initiative-guilt主動－內疚Intuition直覺思維(preoperational)6-11yLatency潛伏期Industry-inferiority勤奮－自卑Concreteoperation具體運算12-17yAdolescence青春期Identity同一感-roleconfusion角色混亂Formaloperation形式運算PerceptiondevelopmentVisualperceptionAuditoryperceptionTaste,smellandcutaneoussensationLanguagedevelopmentReceptivelanguage

9mo—followone-stepcommands18mo—followtwo-stepcommands2ye—understandshortstories6-7ye—doubledeniedsentences,passivesentenceExpressivelanguage12mo—Oneword18-24mo—two-wordphrase3ye—completedsentence,1000words4ye—talkfreely,1600-2000wordsPsychologicaldevelopmentAttentiondevelopmentMemorydevelopmentEmotionaldevelopmentBehavioralproblemsandPsychologicaldisordersinchildrenTantrum，nailbiting，thumbsuckDevelopmentaldisorders:autism,mentalretardation,learningdisordersAttentiondeficithyperactivitydisorders,conductdisorders,ticdisordersEating,sleep,excretiondisordersMooddisorders,anxietydisorders,OCDSomatoformdisordersSchizophreniaAffectedfactorsofchildmentalhealthGeneticinfluencesAcquiredbraindisordersPersonalityandtemperamentmaritalstatus,parentsmentalhealth,parentingSeparation,deprivation,griefAssessmentanddiagnosisBothphysicalandbehavioralaspectsDevelopmentalissuesPsychosocialproblemsClinicalinterview,ratingscales,psychologicaltest,physicalexaminationandtestSystemsofclassificationofmentaldisordersDSM-IV《精神障礙診斷和統計手冊》第4版ICD-10《國際疾病分類》第10版CCMD-3

《中國精神疾病分類方案和診斷標準》第三版TreatmentandpreventionFamilyinvolvedIntegrativeDeleteremotecauseIndividuationMedicationPsychotherapy:Behaviortherapy,BCT,Familytherapy,PlaytherapyAttentiondeficiencyhyperactivedisorders

Epidemiology

prevalencerate4%-12%

male:female=3-4:1Etiology

multiplefactors:genetic,environmental

ClinicalmanifestationsPoorsustainedattentionInappropriateorexcessiveactivityDifficultiesininhibitingimpulsesDifficultiesgettingalongwithothersSchoolunderachievementlowself-esteemDiagnosisBehaviorratingscalesClinicalinterviewPhysicalexaminationNeuropsychologicalexaminationDSM-IVDiagnosticcriteriaforADHD6ormoresymptomsofinattention6ormoresymptomsofhyperactivity-impulsivitySymptomswerepresentbefore7yrofageSymptomspersistedatleast6mo.Symptomswerepresentin2ormoresettingsSignificantfunctionimpairmentExcludeotherpsychoticdisordersDifferentialdiagnosis

Age-appropriateoveractivityAdjustmentdisorderConductdisorderLearningdisordersTicdisorderEmotionaldisordersDevelopmentaldisorders:Autism,MRVisualandauditoryproblems,physicaldiseasesTreatment

PsychosocialinterventionsBehaviormanagementtrainingMedicationPrognosis40%-80%persistintoadolescenceandadultshyperactivitydecreasedProminent:Inattention,impulsivity,disorganization,relationshipdifficultiesSymptomsaresignificantlyamelioratedaftereffectiveintervention

PSYCHOLOGICALDEVEOPEMENT

&MENTALHEALTHINCHILDREN

小兒心理衛生LearningTheory-Watson,BanduraPsychoanalyticTheory-Freud,EriksonCognitiveDevelopment-PiagetMAINTHEORIESONPSYCHOLOGICALDEVELOPMENTMAINTHEORIESONPSYCHOLOGICALDEVELOPMENTFreudEriksonPiaget0-18mOralBasictrust-mistrustSensorymotor18m-3yAnalAutonomy-shame,doubtSymbolic(preoperational)3-6yOedipalInitiative-guiltIntuition(preoperational)6-11ylatencyIndustry-inferiorityConcreteoperation12-17yAdolescence(genital)Identity-roleconfusionFormaloperationPerceptiondevelopmentVisualperceptionAuditoryperceptionTaste,smellandcutaneoussensationLanguagedevelopmentReceptivelanguage

9mo—followone-stepcommands18mo—followtwo-stepcommands2ye—understandshortstories6-7ye—doubledeniedsentences,passivesentenceExpressivelanguage12mo—Oneword18-24mo—two-wordphrase3ye—completedsentence,1000words4ye—talkfreely,1600-2000wordsPsychologicaldevelopmentAttentiondevelopmentMenmorydevelopmentEmotionaldevelopmentBehavioralproblemsandPsychologicaldisordersinchildrenTantrum，nailbiting，thumbsuck,Developmentaldisorders:autism,mentalretardation,learningdisordersAttentiondeficithyperactivitydisorders,conductdisorders,ticdisordersEating,sleep,excretiondisordersMooddisorders,anxietydisorders,OCDSomatoformdisordersSchizophreniaAffectedfactorsofchildmentalhealthGeneticinfluencesAcquiredbraindisordersmaritalstatus,parentsmentalhealth,parenting,Separation,deprivation,griefPersonalityandtempermentAssessmentanddiagnosisBothphysicalandbehavioralaspectsDevelopmentalissuesPsychosocialproblemsClinicalinterview,ratingscales,psychologicaltest,physicalexaminationandtestSystemsofclassificationofmentaldisordersDSM-IVICD-10CCMD-3

TreatmentandpreventionFamilyinvolvedIntegrativeDeleteremotecauseIndividuationMedicationPsychotherapy:Behaviortherapy,BCT,Familytherapy,PlaytherapyAttentiondeficiencyhyperactivedisorders

Epidemiology

prevalencerate4%-12%

male:female=3-4:1Etiology

multiplefactors:genetic,environmental

ClinicalmanifestationsPoorsustainedattentionInappropriateorexcessiveactivityDifficultiesininhibitingimpulsesDifficultiesgettingalongwithothersSchoolunderachievementlowself-esteemDiagnosisBehaviorratingscalesClinicalinterviewPhysicalexaminationNeuropsychologicalexaminationDSM-IVDiagnosticcriteriaforADHD6ormoresymptomsofinnattention6ormoresymptomsofhyperactivity-impulsivitySymptomswerepresentbefore7yrofageSymptomspersistedatleast6mo.Symptomswerepresentin2ormoresettingsSignificantfunctionimpairmentExcludeotherpsychoticdisordersDifferentialdiagnosis

Age-appropriateoveractivityAdjustmentdisorderConductdisorderLearningdisordersTicdisorderEmotionaldisordersDevelopmentaldisorders:Autism,MRVisualandauditoryproblems,physicaldiseasesTreatment

PsychosocialinterventionsBehaviormanagementtrainingMedicationPrognosis80%persistintoadolescenceandadultshyperactivitydecreasedProminent:Inattention,impulsivity,disorganization,relationshipdifficultiesSymptomsaresignificantlyamelioratedaftereffectiveinterventionNeonatology

1.GeneralConsiderations

2.RespiratoryDisorders

3.JaundiceandHemolyticDisease4.NeurologicalDisordersandInfectionNeonatalPeriod新生兒期

Neonate，Newborn新生兒

Neonatology新生兒學

PerinatalPeriod圍產期

PerinatalInfant圍產兒

Perinatology圍產醫學

PerinatalMedicine

Classification1.Bygestationalage(GA)胎齡

full-terminfant,maturebaby

37weeks

GA

42

weeks

pre-terminfant,premature(immature)baby

GA

<37

weeks

extremelyimmatureinfant

22weeks

GA

28

weeks

post-terminfant過期產兒

GA

42

weeks2.Bybirthweight(BW)Normalbirthweight

2500-3999gLowbirthweight(LBW)

<2500

gVerylowbirthweight(VLBW)

<1500

g

極低出生體重兒

Extremelylowbirthweight(ELBW)

<1000

g

超低出生體重兒Giantinfant

4000g巨大兒

3.BygestationalageandbirthweightSmallforgestationalage(SGA)

小於胎齡兒BW<the10thpercentilesAppropriateforgestationalage(AGA)

適於胎齡兒

the10thpercentiles<BW<the90thpercentiles

Largeforgestationalage(LGA)

大於胎齡兒

BW>the90thpercentiles

IntrauterineGrowthCurve

3.BygestationalageandbirthweightSmallforgestationalage(SGA)

小於胎齡兒BW<the10thpercentilesAppropriateforgestationalage(AGA)

適於胎齡兒

the10thpercentiles<BW<the90thpercentiles

Largeforgestationalage(LGA)

大於胎齡兒

BW>the90thpercentiles

4.BypostnatalageEarlynewborninfant:inthefirstoneofageLatenewborninfant：between2and4weeksofage5.Highrisknewborn高危新生兒NormalNewbornInfant

1.Physicalappearance

2.RespiratoryOnsetofrespirationPulmonarySurfactant

RespiratoryRate(RR)40-50/minAbdominalrespiration

3.CardiovascularSystemCessationoffetalcirculationDecreaseofpulmonarypressureCloseofforamenovaleandductusarteriosusVariationofheartrateFetalcirculationtoneonatalcirculation

4.GastrointestinalsystemImmaturegastrointestinalfunction

GastroesophagealReflux(GER)

胃食道返流Passmeconium胎糞5.RenalVoidwithin48hoursoflifeImmaturefunction

6.HematologicalsystemBloodvolume85ml/kgHighredbloodcellwithhighfetalhemoglobin(70-80%)LowactivityofClottingfactorsPhysiologicanemia

7.NeurologicalsystemNeonatalreflexes:Suckingreflex,Rootingreflex,Mororeflex,PalmargraspAnteriorfontanelle(前囟)8.ImmunologyImmatureTransplacentalIgGIgMIgA:highlevelinbreastmilk

9.TemperaturecontrolHeatproduction

bybrownfat

Heatloss

largebodysurfacearealittlesubcutaneousfatspecialpositionNeutraltemperatureEnvironmentaltemperature

newborn：33－35ºC

adult：25－26ºC

11.Specialphysicalconditions

Physicaljaundice

Blood-tingeddischargefromthevagina

Abnormallyenlargebreast10.Fluid,electrolyteandnutrition

PhysicalweightlossCareofNormalNewbornInfantLevelILevelIILevelIIISpecialCareNursery(SCN)NeonatalIntensiveCareUnit(NICU)CareofNormalNewbornInfant(Contd.)Environment：temperature22－26ºChumidity40－50％Infectioncontrol:sterilizationandwashKeepwarm:incubationandradiantSkincare:bathCareofumbilicusNeonatalIntensiveCareUnit(NICU)SpecialCareNurserySCNHandwashingCareofNormalNewborn(Contd.)6.Feeding:breastmilkandformula7.Vaccination：BCG,HepatitisB8.Neonatalscreening：PKU,hypothyroidism,galactosemia,hearingPreterminfant

1.PhysicalappearanceSkin,lanugo,plantarsurface,breastsize

2.RespiratorysystemImmatureIrregularbreathApneaofprematurityRespiratorydistresssyndrome(RDS)

3.GastrointestinalsystemVomitingandaspirationGastroesphagealreflux(GER)

胃食道返流FeedingintoleranceNECJaundice

4.NeurologicalsystemRelatetothegestationalageWeakreflexandlowmuscletoneIntraventricularhemorrhage(IVH)andperiventricularleukomalacia(PVL)5.TemperaturecontrolImmaturecenterLessheatproductionLargeheatloss

6.CardiovascularsystemPDA7.OthersMetabolicdisordersVitamindeficiencyAnemiaofprematurityProblemsofpreterminfantTemperatureHypoglycemiaCardiovasculardisordersRespiratorydisordersFluidandelectrolyteRenaldisordersHemelogicaldisordersInfectionGastrointestinaldisordersJaundiceNeurologicaldisordersROPFeedingproblemsHearingandvisualproblemsTemperatureRespirationFeedingJaundiceInfection

……CareofPretermInfant

1.Environment：cleaning,sterile,hand-washing

2.Feeding：Breastmilkorpretermformula，carefulfeeding，nasogastricfeeding

3.Temperaturecontrol：incubator

4.Monitoring：respiration,acid-basebalance、bloodsugar,infection,bilirubin,bloodpressure、renalfunction

5.DevelopmentalsupportivecareofpretermPostnatalinfantSGAGiantInfant

PrematurebirthBirthasphyxiaNeurologicaldisordersTwin-twintransfusionCongenitalannomalieTwinsNeonatalTransportFollow-upofhigh-riskinfantsRespiratoryDisordersNeonatalRespiratoryDistressSyndrome(NRDS)

新生兒呼吸窘迫綜合症

HyalineMembraneDisease(HMD)

肺透明膜病NeonatalPneumonias

新生兒肺炎MeconiumAspirationSyndrome(MAS)

胎糞吸入綜合症

Asphyxia窒息TransientTachypneaofNewborn(TTN)WetLung濕肺Apnea呼吸暫停ChronicLungDisease(CLD)

慢性肺部疾病

BronchopulmonaryDysplasia(BPD)

支氣管肺發育不良Case

,GA29W,prolongedruptureofmembranes(胎膜早破)

FetalheartmonitoringisnormalManagement：terminatepregnancy？orcontinuepregnancy？HyalineMembraneDiseaseHMD

肺透明膜病NeonatalRespiratoryDistressSyndrome(NRDS)

新生兒呼吸窘迫綜合症PulmonarySurfactant（PS）

肺表面活性物質SynthesizedbyalveolartypeIIepithelialcellsFunction1.Tostabilizethelungduringdeflationbyreducingthesurfacetension2.Topreventhighsurfacetensionpulmonary3.ToprovideadefenseagainstinfectionIncreaseswithadvancinggestationalage1.Etiologies

DeficiencyofsurfactantPretermInfantsofdiabeticmothers(IDM)PerinatalasphyxiaElectivecesareansection(剖宮產)SevereRhhemolyticdiseaseGeneticfactors2.Pathophysiologylackofsurfactant

atelectasis

DysfunctionofV/QmismatchTypeIIcellsHyalinemembrane

PaCO2、PaO2

PoorperfusionendothelialinjurymixedacidosispulmonaryvasoconstrictionPulmonaryhypertension3.Pathology

HyalineMembrane

Atelectasis

肺不張4.ClinicalPresentation

Preterm

Onsetwithin6hoursofage

ProgressivelysevereTachypnea呼吸增快Retraction吸氣凹陷Grunting呻吟Cyanosis青紫Apnea呼吸暫停Patentductus

arteriosusPDA

動脈導管開放Respiratoryfailure新生兒持續肺動脈高壓

PersistentPulmonaryHypertensionofNewborn(PPHN)5.ChestradiographsOpacityDiffusereticular-granularinfiltrates

Bronchograms(支氣管充氣征)

Atelectasis

“white-out”(白肺)

GradeI,II,IIIandIVNRDSOpacityDiffusereticular-granularinfiltrates

“whiteout”GradeIV6.DiagnosisandDifferentialDiagnosisClinicalfeaturesChestradiographs:X-rayDifferentiatewithinfectiouspneumonia,wetlungandaspirationpneumonia7.Management(1)Surfactantreplacement

Timing:Prophylacticorrescue

Dosage：100－200mg/kg/dose

Interval：Q10－12h

2or3times

Administration:

endotrachealtube(ETT)SurfactantadministrationbyETT

(2)ContinuousPositiveAirwayPressure

CPAP

持續氣道正壓通氣(3)MechanicalventilationMode：

IMV＋PEEPSetting：

FiO2,PIP,PEEP,I:T,RRPStreatment(4)ManagementofPPHN:inhalednitricoxide(5)ClosureofPDA

(6)SupportivetherapyTemperature,acidosis,circulation，

fluidsandnutrition,possibleinfection8.Prevention

(1)

Antenatalcorticosteroids：

Dexamethasoneorbetamethasone

(2)Afterbirth:surfactant

GA<30weeks,BW<1500gNeonatalPneumoniaClassification：1.Aspirationpneumonia：Amniotic-fluid,meconiumormilk2.Infectiouspneumonia：prenatal,intrapartumorpost-natalinfectionMeconiumAspirationSyndrome

MAS

胎糞吸入綜合症1.CausesFull-termandpost-terminfantIntrauterineasphyxia(窒息)BirthAsphyxia

2.Pathogenesis

(1)Airwayobstruction:air-trappingandAirleak(pneumothorax

氣胸),atelectasis

(2)Inflammatoryandchemicalpneumonia(3)InactivationofPS

3.Pathogenesis(Contd.)

(4)Acuterespiratorydistresssyndrome

(ARDS)(5)PersistentpulmonaryhypertensionofNewborn(PPHN)4.ClinicalPresentationSignsofpost-termRespiratorydistress:tachypnea(呼吸增快),nasalflaring(鼻煽),intercostalretractions(肋間隙凹陷)Cyanosis

Increaseintheanterior-posteriordiameterofthechestAirleakPPHNRespiratoryfailure5.ChestradiographsHyperinflationofthelungfieldCoarse,irregularpatchyinfiltratesPneumothoraxorpneumomediastinum

氣胸或縱隔積氣MASIrregularpatchyinfiltratesMASPneumothoraxPneumomediastinum6.Management1.Clearairway：mostimportant2.Oxygentherapy3.Mechanicalventilation：conventionalofhighfrequencyventilation4.Surfactant5.ManagementofPPHN:inhalednitricoxide(NO)6.Others:Pneumothorax,hypotention,acidosisApnea呼吸暫停Absenceofbreathingfor>20secondscyanosisBradycardia心率減慢

heartrate<100beats/min慢性肺部疾病ChronicLungDisease(CLD)支氣管肺發育不良BronchopulmonaryDysplasia(BPD)濕肺WetLungTransientTachypneaofNewborn(TTN)NeonatalHyperbilirubinemia

新生兒高膽紅素血症Bilirubin(膽紅素)Jaundice(黃疸)Hyperbilirubinaemia(高膽紅素血症)Unconjugated(indirect)bilirubin(未結合膽紅素)Conjugated(direct)bilirubin(結合膽紅素)Freebilirubin(游離膽紅素)Glucuronyltransferase

葡萄糖醛酸轉移酶

-glucuronidase-葡萄糖醛酸苷酶EnterohepaticCirculation

腸肝迴圈NeonatalbilirubinmetabolismIncreasedbilirubinloadonlivercellIncreasedRBCvolumeDecreasedRBCsurvivalIncreasedearly-labeledbilirubinIncreasedenterohepaticcirculationofbilirubinNeonatalbilirubinmetabolism(Contd.)Defectivehepaticuptakeofbilirubinfromplasma1.Decreasedligandin(YandZprotein)2.Bindingofligandinbyotheranions

Neonatalbilirubinmetabolism(Contd.)Defectivebilirubinconjugation1.Decreaseduridine

diphosphateglucuronyltransferase(UDPG-T)activity

2.Increaseduridinediphosphoglucosedehydrogenenase(

-glucuronidase)activity

DecreasedexcretionofbilirubinNeonatalbilirubinmetabolism(Contd.)IncreasedbilirubinproductionDecreasedclearanceofbilirubinSummaryPhysicalJaundiceOnsetofjaundice:2-3daysofageThetimeofpeaklevel:4-6daysofageTheresolvingtimeFullterm:2weeksofage

Preterm:3-4weeksofageLeveloftotalserumbilirubin:<12mg/dLLevelofconjugatedbilirubin:<1.5mg/dLNonphysiologicalJaundiceOnsetofjaundicebefore24hoursofageAnyelevationofserumbilirubinthatrequiresphototherapyAriseofserumbilirubinlevelsofover5mg/dL/daySignsofunderlyingillnessPersistjaundiceCausesandClinicalFeaturesUnconjugatedhyperbilirubinemiaFetomaternalbloodgroupincompatibilityInfectionBreastjaundiceDelayedmeconiumpassageOthers:asphyxia,hemorrhage,polycythemia(紅細胞增多症)CausesandClinicalFeaturesConjugatedHyperbilirubinemiaHepatitisObstructivedisordersMetabolicandendocrineconditionCholestasis(膽汁淤積)BreastfeedingandJaundice

母乳性黃疸

Breast-milkjaundice1.Lateonsetbyday5-7oflife2.Risetopeaklevelby2weeksofage3.Bilirubinfallrapidlyifstopbreastfeeding4.Ruleoutpathologicalcondition5.MechanismisunknownBreastfeedingandJaundiceBreastfeedingjaundiceEarlyonsetHighbilirubinlevelsafter3daysoflifeRelatedtoadecreasedintakeofmilkBilirubinEncephalopathy

膽紅素腦病Kernicterus(核黃疸)CellulartoxicityofbilirubinBlood-BrainBarrierpermeabilityHemolyticdiseaseofthenewborn

新生兒溶血病

Rhincompatibility

ABOincompatibility

Onsetinfetalandneonatalperiod

RhesusHemolyticDisease

Rh溶血病Rh

bloodgroupRh-positive：Dantigen，DDorDdRhnegative：dd

一、Pathogenesis

MotherRhD(－),FetusRhD(＋)

fetal

RBC

maternalcirculationIgMSecondpregnancyplacentaIgGPrimarysecondarySensitizedfetalRBCSensitizedRBCbindtotheFcreceptorHemolysisFirstpregnancyMother:RhD(－)neonate:RhD(＋)

RhE(－)RhE(＋)

RhC(－)RhC(＋)

MayoccurinneonatewhosemotherisRh-positive二、ClinicalManifestations

1.Fetalhydrops(胎兒水腫)2.Jaundice：earlyonset,riserapidlyandsevere

3.Anemia

4.Hepatosplenomegaly(肝脾腫大)5.Bilirubinencephalopathy三、Diagnosis1.Clinicalfeatures2.LaboratoryfindingsBloodgroupofmotherandinfantCoombs’test(抗人球蛋白試驗)

DirectCoombs’test:identifysensitizedRBC

ABOHemolyticDiseaseMother:typeOFetus:typeAorB:O型胎兒:

A或B型最多見的新生兒溶血病一、PathogenesisA、BsubstancesEntermaternalcirculationAntiA、AntiBantibodyIgGPregancyplacentafetausSensitizeredbloodcellsHemolysis

二、Clinicalfeature

Jaundice,anemia

andHepatosplenomegaly

三、Diagnosis

1.Bloodgroup

2.Coombs’Test

DirectCoombs’testElutiontest

Management

1.

Phototherapy(光療)

(1)Indication：full-term>15mg/dl

(2)Light：bluelamps，wavelength450～460nm

(3)Mechanism：photochemicalreaction

Structuralisomerization

(4)Technique：singleordoublephototherapyPhototherapy2.Decreasingfreebilirubin

Albumin,plasma3.Inhibitingbilirubinproduction

competitiveinhibitorsofhemeoxygenase

(血紅素加氧酶)4.Increasingbilirubinconjugation

Phenobarbital5.Inhibitinghemolysis

High-doseintravenousimmuneglobulin(IVIG)靜脈丙種球蛋白6.Exchangetransfusion(交換輸血)(1)IndicationInRhhemolyticdisease,total

bilirubin>20mg/dl(2)Mechanisms

Removeantibodies,antibody-coatedRBCs(sensitizedredbloodcells)andbilirubin，correctanemia

(3)Blood

Rh

hemolyticdisease:Rhcross-matchedagainstthemother,ABOcross-matchedagainsttheinfant

ABOhemolyticdisease:typeOcellswithABplasma(4)VolumeDoublethevolumeoftheinfant’sblood(two-volumeexchange),160ml/kg(5)Complications

Hypocalcemia,hypoglycemia,Acid-basebalance,hyperkalemia,embolization,bleeding,infectionsNeonatalNeurologicalDiseaseChildren’sHospitalofFudanUniversityCAOYUNNeonatalHypoxic-IschemicEncephalopathy新生兒缺氧缺血性腦病NeonatalIntracerebralHemorrhage新生兒顱內出血

Sequela(後遺症)：cerebralpalsy(腦癱)、mentalretardation、visualdeficitHypoxic-IschemicEncephalopathy,HIE

Hypoxic-IschemicBrainDamage,HIBD

Hypoxia

Perinatalasphyxia,

apnea,respiratoryfailure,righttoleftshunt

Ischemia

Heartfailure,ShockCausesOnsetofHIETimingofInsultsPercentageAntepartum20Intrapartum35Antepartum

antepartum35Postnatal101.Cerebralhemodynamicalteration：

Initialchanges：redistributionofcirculation(divingreflex)

cerebralbloodflow↑

Continueinsult：lossofvascularautoregulation,systemichypotension,cerebralbloodflow↓，cerebralischemiaPathogenesisPathogenesis(Cont’s)2.EffectsofHypoxic-IschemicInsultsonEnergyMetabolism

(1)

Brainglucose

(2)Lactateproduction

(3)ATP

(4)Energyfailure(5)NeuronaldeathPathogenesis(Cont’s)3.RoleofFreeRadicals(自由基)Perioxidation(過氧化)ofmembrane

phospholipids(2)DamagetoDNA(3)Activationofproapoptotic(促凋亡)genesPathogenesis(Cont’s)4.CalciumReflux

Activatephospholipases(磷脂酶)

Activateproteases(蛋白酶)

Activatenucleases(核酸酶)

neurotransmitterreleaseActivatenitricoxidesynthetases

(一氧化氮合成酶)Pathogenesis(Cont’s)5.NeurotoxicityofExcitatoryAminoAcids(興奮性氨基酸)Na+entrywithH2Ocellswellingandlysis(2)Ca+entryCa+-mediatedeventstocelldeathPathogenesis(Cont’s)6.DelayedCellDeath(遲發性神經元死亡)Celldeath:Necrosis(壞死)andApoptosis(凋亡)NecrosisoccursinminutesApoptosis:delayedcelldeathoccursoverhoursordaysormonthsNeuropathology1.Selectiveneuronalnecrosis

選擇性神經細胞壞死2.Parasagittalcerebralinjury

矢狀旁區損傷Periventricularleukomalacia

腦室周圍白質軟化Periventricular-intraventricularhemorrhage

腦室周圍-腦室內出血5.Focalischemicbrainnecrosis

局灶缺血性腦壞死ClinicalAspectsLevelofconsciousness

Hyperalertness(興奮),irritability(激惹),lethargy(嗜睡),stupororcomaBrainstemdisfunction

Respiratorydisturbance,abnormalpupillaryresponsetolightSeizure(Jitteriness抖動)Muscletone

Hypertonia,weakness,hypotonia5.PrimitivereflexHyperactive,depress,absenceSeverityofHIEinFull-termNeonate

MildModeratesevereLevelofHyperalertnessLethargyComaconsciousnessSeizure-,JitterinessVariable+PrimitivereflexesExaggeratedSuppressedAbsentBrainstem__+dysfunctionMuscletoneHypertoniaWeaknessFloppyNormalDiagnosisHistoryofhypoxiaorischemiaClinicalfeaturesNeuroimagingElectrodiagnostictechniquesNeuronalbiochemistryNeuroimagingCranialUltrasound(頭顱超聲)DiffuseincreasedechogenicityofparenchymaEffacementofcorticalsulciIncreasedperiventricularechoesNeuroimagingComputedTomography(CT)1Focalorgeneralizedlowtissueattenuation(低密度)2Focalorgeneralizedcerebralatrophy3Multicyst