医学精品课件：09 惊厥.ppt

1、Acute convulsion in ChildrenJIANG LiProfessor,Doctorial tutorDepartment of NeurologyChildrens Hospital of CMUcontents Definitions Causes of acute convulsion Febrile seizures Exams and Tests for convulsion Treatment of acute convulsionAcute convulsion in ChildrenDefinitionsEpileptic Seizures（癫痫发作）（癫痫

2、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 manife

3、sted as a motor,sensory,autonomic,cognitive,or psychic disturbance manifestation is apparent either to the subject or an observerDifferent 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 convul

4、sion in ChildrenDefinitions Convulsive seizures(惊厥性癫痫发作惊厥性癫痫发作，convulsion 惊厥惊厥):is a subtype of epileptic seizure in which abnormal motor activity occurs,noted by uncontrollable muscle jerking Epilepsy（癫痫）（癫痫）:a chronic disorder of the brain characterized by recurrent,unprovoked epileptic seizures.A

5、cute convulsion in Childrenl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、慢性疾病惊厥惊厥（Convulsion）excessive abnormal discharges of cortical neuronsEpileptic Seizuresconvulsive seizure(convulsion)nonconvulsive seizureAcute epileptic seizure(p

6、rovoked in acute disorders)epilepsy(recurrent,unprovoked epileptic seizures)Acute convulsion in Children癫痫发作、惊厥、癫痫癫痫发作、惊厥、癫痫 癫痫发作癫痫发作(Epileptic Seizures)：发作性大脑皮层功能异常所引起的多种临床症状 惊厥惊厥(convulsion)：伴有骨骼肌强烈、不自主收缩的痫性发作 癫痫癫痫(epilepsy)：临床呈长期反复痫性发作的疾病过程Acute convulsion in ChildrenCharacteristics of acute conv

7、ulsion 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（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 sei

8、zure in the babies Seizures may occur for many causesAcute convulsion in Childrencontents Definitions(Seizure,Convulsion,Epilepsy)Causes of acute convulsions Exams and Tests for convulsion Treatment of acute convulsionAcute convulsion in ChildrenCommon causes of acute convulsion CNS infection:Mening

9、itis or encephalitis Febrile convulsions（Head trauma CNS malformations Brain tumors Metabolic disorders:Hypoglycemia,Hyponatremia,hypernatremia,Hyperosmolar states,Hypocalcemia Idiopathic or cryptogenic epilepsy Acute convulsion in ChildrenClassification of the causes of convulsionBacterial Meningit

10、is,Viral meningitis/encephalitis fungal meningitis,parasitic disease,brain abscessHead traumaCNS malformationsBrain tumorsepilepsyFebrile convulsions Anoxia,ischemiaMetabolic disorders:Hypoglycemia Hyponatremia Hypernatremia Hypocalcemiarodenticide organic pesticideAcute convulsion in ChildrenIntrac

11、ranial 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

12、Useful lab test:CSF Causes of acute seizures颅外感染颅外感染中毒性脑病中毒性脑病contents Definitions(Seizure,Convulsion,Epilepsy)Causes of acute convulsion Exams and Tests for convulsion Treatment of acute convulsionAcute convulsion in ChildrenGeneral Introduction An event in infancy or childhood usually occurring be

13、tween 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.General Introduction Associated with upper respiratory in

14、fection,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 seizuresFe

15、atures of Febrile Seizure Most common cause of seizures in childhood,usually with good prognosis Associated with fever,usually occur when body temperature rises rapidlyFeatures of Febrile Seizure Occur in the absence of intracranial infection or an identifiable neurological disorder.Age dependent:6m

16、on-3yr(peak age of onset:18-22mo of age)With normal CNS structure and functionFeatures 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 Simple

17、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 Complex febrile Seizure(CFS)Age of seizure onset:6 months to 5 years;6yr

18、s 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)单纯性单纯性FS（SFS）复杂性复杂性FS（CFS）发病率发病率FS中中80%FS中中20%发作形式发作形式 全身性发作，发作后不留任何异全身性发作，发作后不留任何异常神经征常神经征局限性或不对称性发作。发局限性或不对称性发作。发作

19、后可留异常神经征作后可留异常神经征发作次数发作次数 在一次热程中仅有一次惊厥发作在一次热程中仅有一次惊厥发作（2/32/3），），少数少数2 2次（次（1/4-1/31/4-1/3）反复多次（丛集式发作：反复多次（丛集式发作：2424小时内反复发作小时内反复发作2 2次）次）持续时间持续时间 发作时间短暂，多数发作时间短暂，多数5 51515分钟内。分钟内。发作时间长（发作时间长（1515分钟）分钟）复发复发总次数总次数4次以内次以内5次以上次以上 热性惊厥的分类及基本临床特征热性惊厥的分类及基本临床特征Risk factors for recurrent febrile seizures Y

20、oung 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 factor

21、s have less than a 20%chance of recurrence.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 o

22、f epilepsy compared with the general population(1%vs 0.5%).Patients with 2 risk factors have up to 10%chance of developing afebrile seizures.Management Identification and treatment of underlying infection Keeping the patient cool with regular antipyretics Termination of a prolonged convulsion(diazep

23、am,iv or rectally)Parental education Effective drugs for preventing recurrent febrile seizure:Phenobarbital,Sodium valproate,diazepamClassfication of the causes of convulsionBacterial Meningitis,Viral meningitis/encephalitis fungal meningitis,parasitic disease,brain abscessHead traumaCNS malformatio

24、nsBrain tumorsepilepsyFebrile convulsions Anoxia,ischemiaMetabolic disorders:Hypoglycemia Hyponatremia Hypernatremia Hypocalcemiarodenticide organic pesticideAcute convulsion in Childrencontents Definitions(Seizure,Convulsion,Epilepsy)Causes of acute convulsion Febrile seizures Exams and Tests for c

25、onvulsion 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 movement

26、s 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 activityExams and Tests for seizuresHistory of patient Fever or intercurrent illnesses Prior history of seizures Hea

27、d 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 seizuresPhysical Examination Obtain temperature and vital signs(important in the initial evaluation)Examine for signs sug

28、gestive 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 seizuresPhysical Examination Examine skin for findings suggestive of neurocutaneous syndrome Examine fea

29、tures 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病因学诊断提示病因学诊断提示 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

30、病因学诊断提示 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因学诊断提示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 fo

31、r seizuresLaboratory 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 uncons

32、cious.Others:EEG Exams and Tests for seizures病因学诊断提示病因学诊断提示contents Definitions(Seizure,Convulsion,Epilepsy)Causes of acute convulsion Febrile seizures Exams and Tests for convulsion Treatment of acute convulsion0.10.11515202020202 250501001006 610101010303020203030121224242424484814142424100100数小时数

33、小时无无可数日可数日心脏病者心脏病者Treatment of seizuresprompt 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治疗治疗-惊厥的急救惊厥的急救Trea

34、tment of seizuresprompt 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 seizuresTreatment of seizuresOthers Secure the airway Administer supplemental 100%oxygen Infuse intravenous fluids and glucose Increased intracranial pressure controlling Identification and treatment of underlying diseaseacute seizures