小兒驚厥一、定義N是指大腦神經(jīng)元突然大量的異常放電而使全身或局部骨骼肌的不自主收縮，伴或不伴意識(shí)障礙。為小兒常見(jiàn)的急癥癥狀之一。二、發(fā)病機(jī)理N小兒驚厥發(fā)生率是成人的1015倍，與嬰幼兒大腦皮質(zhì)功能未完善，抑制差，興奮易擴(kuò)散，神經(jīng)髓鞘未完全形成，沖動(dòng)易泛化，血腦屏障不良，毒物易滲入腦組織及水電解質(zhì)代謝不穩(wěn)定等因素有關(guān)。三、病因N一感染性病因N1顱內(nèi)感染N2顱外感染N二非感染性病因N1顱內(nèi)疾病N2顱外全身性疾病一感染性病因N1顱內(nèi)感染如由細(xì)菌、病毒、寄生蟲(chóng)、真菌引起的腦膜炎或腦炎。N常表現(xiàn)為反復(fù)而嚴(yán)重的驚厥發(fā)作，大多出現(xiàn)在疾病初期或極期。伴有不同程度意識(shí)障礙和顱壓增高表現(xiàn)。腦脊液檢查對(duì)診斷和鑒別診斷有較大幫助。N2顱外感染非顱內(nèi)感染性疾病引起的驚厥發(fā)作。N1熱性驚厥是兒科最常見(jiàn)的急性驚厥。N2感染中毒性腦病大多并發(fā)于敗血癥、重癥肺炎、菌痢、百日咳等嚴(yán)重細(xì)菌性感染疾病中。一感染性病因二非感染性病因N1顱內(nèi)疾病N1顱腦損傷與出血如產(chǎn)傷、顱腦外傷和腦血管畸形等各種原因引起的顱內(nèi)出血。N2先天發(fā)育畸形如顱腦發(fā)育異常。N3顱內(nèi)占位性病變?nèi)缒[瘤、囊腫或血腫等。N4癲癇2顱外全身性疾病N水電解質(zhì)紊亂重度脫水、水中毒、低血鈣、低血鎂、低血鈉、高血鈉和低血糖癥。N遺傳代謝性疾病常見(jiàn)如苯丙酮尿癥、半乳糖血癥等N肝腎功能衰竭N中毒如殺鼠藥、農(nóng)藥和中樞神經(jīng)興奮藥中毒。二非感染性病因四、臨床表現(xiàn)N（一）典型表現(xiàn)N典型驚厥發(fā)作時(shí)患兒意識(shí)喪失，全身骨胳肌不自主、持續(xù)性、強(qiáng)直性收縮，繼之痙攣性收縮，呼吸暫停，口吐白沫，兩眼凝視、斜視或上翻，頭轉(zhuǎn)向一側(cè)或后仰。部分小兒有大小便失禁現(xiàn)象。四、臨床表現(xiàn)N（二）不典型表現(xiàn)N嬰幼兒驚厥常無(wú)強(qiáng)直性發(fā)作，只有肢體陣攣，但破傷風(fēng)則以強(qiáng)直性驚厥為主。N新生兒驚厥表現(xiàn)全身性抽搐者不多，往往僅一側(cè)肢體跳動(dòng)、強(qiáng)直、下頜抖動(dòng)，頻繁眨眼，兩眼凝視，呼吸暫停。N早產(chǎn)兒驚厥可表現(xiàn)為陣發(fā)性眼球轉(zhuǎn)動(dòng)、斜視、凝視或上翻，也可反復(fù)眨眼，面肌抽動(dòng)似咀嚼、吸吮動(dòng)作，也可表現(xiàn)為陣發(fā)性面紅、蒼白、流涎、出汗或呼吸暫停而無(wú)抽搐，（三）高熱驚厥N1、單純型高熱驚厥N年齡6個(gè)月3歲，6歲后罕見(jiàn)；N多發(fā)生在體溫驟升之時(shí)，體溫385；N常為全身性抽搐、次數(shù)少、時(shí)間短（持續(xù)時(shí)間15，或反復(fù)多次發(fā)作，或局限性發(fā)作；N熱退后12周，腦電圖仍異常；N可有癲癇家族史；N預(yù)后差有陽(yáng)性癲癇家族史者，以后發(fā)生癲癇的可能性為3050；（四）驚厥持續(xù)狀態(tài)N驚厥持續(xù)超過(guò)30MIN或頻繁驚厥中間無(wú)清醒期，為危重型。五、診斷及鑒別診斷N（一）病史N1、首先了解有無(wú)發(fā)熱，可從前述病因中考慮N2、參考發(fā)病年齡驚厥病因與發(fā)病年齡的關(guān)系3、發(fā)病季節(jié)N有熱驚厥N夏秋季以乙腦及胃腸道傳染病如細(xì)菌性痢疾多見(jiàn)N冬春季以呼吸道傳染病如流腦多見(jiàn)N無(wú)熱驚厥N夏季低血糖多見(jiàn)N冬春季VITD缺乏性手足抽搐癥多見(jiàn)N食物中毒與食物上市的季節(jié)有關(guān)4、其他病因N分娩史N生長(zhǎng)發(fā)育史N喂養(yǎng)史N外傷史N家族史N預(yù)防接種史N當(dāng)?shù)貍魅静×餍惺種既往有無(wú)驚厥發(fā)作史（二）體檢N神志意識(shí)改變、血壓N頭圍、前囟N腦膜刺激癥、局灶性NS體征N局部感染灶（耳、皮膚）N抽搐后有無(wú)暫時(shí)性肢體癱瘓N眼底（三）輔助檢查N根據(jù)病史、體查及其他線索，有步驟的選擇檢查項(xiàng)目N感染性疾病血常規(guī)、血培養(yǎng)藥敏N腎炎、尿毒癥尿常規(guī)、血BUN、CRN腸道感染血常規(guī)、大便培養(yǎng)藥敏N代謝性疾病血生化（GLU、CA、MG、NA）NCNS感染CSF常規(guī)、生化、培養(yǎng)NEEGN頭顱CT、MRI、頭顱X線平片六、治療原則N驚厥為急診癥狀，必須立即緊急處理N安定首選N劑量0305MG/KG次或1MG/歲（10歲以?xún)?nèi)），總量不超過(guò)10MG。N用法靜推，速度1MG/MIN，脂溶性高，易入腦，注射后13分鐘即可起效，療程短，必要時(shí)20分鐘后可重復(fù)使用1次，24小時(shí)內(nèi)可重復(fù)應(yīng)用24次。N副作用抑制呼吸和血壓，可致嘔吐、共濟(jì)失調(diào)。N氯硝西泮N苯巴比妥1、控制驚厥N2、治療腦水腫N首選20甘露醇N呋塞米，清蛋白、地塞米松。3、一般處理側(cè)臥位，以防窒息及誤吸保持呼吸道通暢，及時(shí)清除口鼻分泌物如青紫或驚厥時(shí)間較長(zhǎng)者及時(shí)吸氧體溫升高應(yīng)退熱藥物口服或肌注或靜推；物理降溫3050酒精擦??；冰袋置頸部、腋下、腹股溝大血管處。4、病因處理N密切監(jiān)測(cè)驚厥發(fā)生持續(xù)時(shí)間，意識(shí)改變，生命體征變化和神經(jīng)系統(tǒng)體征，動(dòng)態(tài)觀察血清電解質(zhì)，血糖的變化。N無(wú)熱驚厥的新生兒可首先給予50葡萄糖12G/KG次，VITB625200MG/次，10葡萄糖酸鈣12ML/KG次，25硫酸鎂（稀釋成25）每次0204ML/KG。N持續(xù)驚厥伴高熱、昏迷，循環(huán)、呼吸功能障礙者，應(yīng)考慮CNS病變和全身性病變，給予脫水降顱壓、抗感染、抗休克等處理，原發(fā)性EP者應(yīng)長(zhǎng)期予抗EP治療5、驚厥持續(xù)狀態(tài)搶救原則N選擇強(qiáng)有力的抗驚厥藥，盡可能單藥足量，先緩慢靜注，一次負(fù)荷量后維持，不宜過(guò)度稀釋。所選藥物宜奏效快，作用長(zhǎng)，副作用少，根據(jù)發(fā)作類(lèi)型合理選擇。N維持生命功能，防止腦水腫，酸中毒，呼吸、循環(huán)衰竭，保持氣道通暢，吸氧。N積極尋找病因和控制原發(fā)疾病練習(xí)題N患兒，1歲半。半天來(lái)發(fā)熱、流涕、咳嗽，半小時(shí)突然抽風(fēng)1次，持續(xù)約5分鐘，為全身大抽。1歲時(shí)發(fā)熱曾發(fā)作一次，情況與本次類(lèi)似。查體神清，一般情況好，體溫39，咽紅，呼吸音稍粗，神經(jīng)系統(tǒng)檢查（），來(lái)院急診。N該患兒抽風(fēng)的原因最可能是NA化膿性腦膜炎B癲癇C維生素D缺乏性手足搐溺癥ND高熱驚厥E中毒性腦病N該患兒到醫(yī)院后的即刻處理應(yīng)是NA給止驚藥B給予抗生素治療C給予補(bǔ)充鈣劑ND在口腔放置壓舌板E給予約束N該患兒的預(yù)后NA患兒會(huì)越來(lái)越重B隨年齡增長(zhǎng)，多數(shù)會(huì)自愈NC需服用抗癲癇藥治療D需長(zhǎng)期服用鈣片、魚(yú)肝油治療E需加大抗生素的量治療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