1、朱翠平朱翠平广州市妇儿中心急诊科，广州市妇儿中心急诊科，2015.112015.11急诊抽搐，您处理到位了吗？急诊抽搐，您处理到位了吗？-儿科急诊抽搐管理儿科急诊抽搐管理病例呈现病例呈现吴xx，男，11m.主诉：主诉：反复抽搐伴发热1天余。现病史现病史：前一天余患儿单侧肢体阵挛，意识不清，较快缓解,随后发热，热峰38.8，稍咳嗽，外院予镇静处理后缓解。当天患儿再次出现抽搐，伴发热，共抽搐5次，急来我院。既往史既往史 半年余前因反复肢体抽动在我院就诊确诊“癫痫”一直口服药物治疗，间有抽搐发作，表现点头、肢体阵挛、双眼凝视等，数秒钟至数十分钟缓解。现药物德巴金2.5ml bid、硝基安定1mg b
2、id。病例呈现病例呈现查体查体 l精神倦l生命体征 T 38.40C HR 162/min RR（-）BP（-）处理处理 l急诊接诊医生考虑抽搐环境，病情尚稳定，犹豫是否留观；l但入急诊后出现右侧肢体阵挛、双眼向右侧凝视，很快意识不清转为全身性强直阵挛发作；l予鲁米那、安定、力月西序贯镇静，35分左右抽搐缓解。诊断诊断 癫痫持续状态 急性上呼吸道感染进一步治疗进一步治疗 抗炎对症，未出现抽搐，2天后出观。用药情况生命体征家长质疑家长质疑l首诊医生处理不及时？首诊医生处理不及时？l因处理不及时导致多次用药因处理不及时导致多次用药问问 题题抽搐病人留观抽搐病人留观l留观指征？留观指征？l留观时间？
3、留观时间？抽搐病人紧急处理指征？抽搐病人紧急处理指征？紧急处理原则？紧急处理原则？合理用药合理用药l首选药物？首选药物？l给药途径？给药途径？现状思考现状思考当前国内外指南了解？当前国内外指南了解？日常工作中救治流程日常工作中救治流程/指引？指引？概念更新？概念更新？癫痫持续状态的止惊药物选择？癫痫持续状态的止惊药物选择？抽搐后期？抽搐后期？家长健康教育？家长健康教育？临床研究状况？临床研究状况？1.1.抽搐简介抽搐简介2.2.脑损伤与并发症脑损伤与并发症3.3.常见临床类型常见临床类型4.4.急诊管理急诊管理-评估与救治评估与救治5.5.抽搐管理改进抽搐管理改进6.6.参考文献参考文献9主要
4、内容 抽搐简介抽搐简介Return to Table of Contents10异常神经元活动异常神经元活动突然的细胞膜生化失衡突然的细胞膜生化失衡 重复性的异常放电重复性的异常放电 临床运动、感觉、行为和临床运动、感觉、行为和/或自主神经功能的异常或自主神经功能的异常 11抽搐概念抽搐概念指南指南/指引指引/流程流程/临床路径临床路径NICE clinical guideline 137(2012).NICE clinical guideline 137(2012).www.nice.org.uk/cg137www.nice.org.uk/cg137AHRQ guidelines for t
5、he evaluation and management AHRQ guidelines for the evaluation and management ofofstatusstatusepilepticus.epilepticus.Date Released Date Released 2012 Apr 24 http:/www.guideline.gov/content.aspx?id=37274&search=status+epilepticus+in+childrenChildren and Infants with Seizures-Acute ManagementChildre
6、n and Infants with Seizures-Acute ManagementReview date 16-Oct-2014Review date 16-Oct-2014http:/www.health.http:/www.health.nsw.govnsw.gov.au/policies/.au/policies/Seizure Acute Management:Emergency DepartmentSeizure Acute Management:Emergency Department 2012,2012,Seattle Childrens HospitalSeattle C
7、hildrens HospitalLast Updated:6/11/2013Last Updated:6/11/2013Valid until:6/19/2015Valid until:6/19/201512抽搐院前抽搐院前/院内规范管理情况院内规范管理情况1 1抽搐院前抽搐院前/院内规范管理情况院内规范管理情况2 2指南指南/指引指引/流程流程/临床路径使用临床路径使用44%44%of responding facilities had a of responding facilities had a protocol/policy/guideline/clinical pathway p
8、rotocol/policy/guideline/clinical pathway In the prehospital management of pediatric seizures,In the prehospital management of pediatric seizures,blood glucose assessments were documented in only blood glucose assessments were documented in only 34%34%of of SFS patients and slightly over half of UnS
9、/SE patientsSFS patients and slightly over half of UnS/SE patients For UnS/SE patients,seizure precautions were either not For UnS/SE patients,seizure precautions were either not taken or not documented in more thantaken or not documented in more than 1/3 1/3rdrd of the cases of the cases(Source:Ill
10、inois EMSC Pediatric Seizures in the Emergency Department Summary Report,May 2011)l 躯体运动异常躯体运动异常重复性无目的运动重复性无目的运动凝视凝视吸吮吸吮跌倒跌倒四肢或单一肢体强直四肢或单一肢体强直四肢或单一肢体节奏性抖动四肢或单一肢体节奏性抖动14临床表现临床表现抽搐抽搐过过程不被声音或躯体刺激干程不被声音或躯体刺激干扰扰或阻止或阻止l 感觉与自主神经异常感觉与自主神经异常恶心恶心大小便失禁大小便失禁麻木，刺痛麻木，刺痛 幻听，幻嗅幻听，幻嗅l意识状态意识状态 无反应和意识丧失无反应和意识丧失 下降下降 正
11、常正常窒息或呼吸暂停窒息或呼吸暂停憋气憋气晕厥晕厥肌阵挛肌阵挛假性惊厥假性惊厥心因性抽搐心因性抽搐寒战寒战颤栗颤栗短暂性脑缺血发作短暂性脑缺血发作15鉴别诊断鉴别诊断 16抽搐分类抽搐分类全身性全身性部分性部分性复杂性复杂性简单性简单性涉及两侧大脑半球涉及两侧大脑半球涉及运动或自主神涉及运动或自主神经症状、伴有经症状、伴有意识意识状态改变状态改变可涉及运动或自主神经症可涉及运动或自主神经症状，或感觉异常症状状，或感觉异常症状常有常有意识丧失意识丧失可一组肌群开始可一组肌群开始可一组肌群开始可一组肌群开始类型类型:强直或阵挛或两者同时强直或阵挛或两者同时 存在存在33 失神发作失神发作 1010
12、 肌阵挛肌阵挛 失张力失张力 婴儿痉挛症婴儿痉挛症症状类型症状类型:1)1)运动异常运动异常 头头/眼异常运动眼异常运动,抽动抽动,强直强直2)2)自主神经自主神经#-瞳孔扩大瞳孔扩大,流涎流涎,苍白苍白,心率或呼吸频率改变心率或呼吸频率改变3)3)感觉异常感觉异常+-嗅觉嗅觉,认知改变认知改变 临床类型临床类型热性惊厥热性惊厥（febrile seizure)febrile seizure)症状性症状性抽搐抽搐（acute symptomatic seizure)acute symptomatic seizure)l急性症状性急性症状性l远期症状性远期症状性原因未明抽搐原因未明抽搐(unpr
13、ovoked seizure)(unprovoked seizure)癫痫癫痫 (epilepsy)(epilepsy)18何时抽搐属危急情况何时抽搐属危急情况?首次抽搐发作首次抽搐发作抽搐时间抽搐时间 5 5 重复抽搐意识未恢复重复抽搐意识未恢复 较平时抽搐频繁或发作形式改变较平时抽搐频繁或发作形式改变 有意外伤害、糖尿病、怀孕的学龄儿有意外伤害、糖尿病、怀孕的学龄儿水中出现抽搐发作水中出现抽搐发作抽搐后不能恢复正常呼吸抽搐后不能恢复正常呼吸父母要求急诊评估父母要求急诊评估Return to Table of Contents脑损伤与并发症脑损伤与并发症Return to Table of
14、Contents 抽搐引起脑损伤抽搐引起脑损伤再发性抽搐再发性抽搐Recurrent,Unprovoked Recurrent,Unprovoked SeizuresSeizures急性重复性急性重复性Acute Repetitive Seizures(ARS)*持续抽搐持续抽搐Prolonged SeizuresProlonged SeizuresSE孤立性抽搐孤立性抽搐*Also known as cluster,crescendo,multiple-recurrent,serial,or sequential seizures脑损伤脑损伤动物模型提示抽搐持续动物模型提示抽搐持续90-12
15、090-120脑损伤不可逆脑损伤不可逆 长时间强直长时间强直-阵挛发作导致低氧、低血糖、高血阵挛发作导致低氧、低血糖、高血钾、高颅压钾、高颅压 即使控制上述异常，脑细胞死亡同样出现即使控制上述异常，脑细胞死亡同样出现 required urgently.Lowquality(NICE,2012)癫痫持续状态癫痫持续状态（Status Epilepticus,SE)定义定义抽搐持续超过抽搐持续超过5 min 5 min 两次或多次抽搐，期间意识状态未完全恢复两次或多次抽搐，期间意识状态未完全恢复通常出现在癫痫患儿通常出现在癫痫患儿(9-27%)(9-27%)并发症与抽搐致全身反应和脑细胞损伤有关
16、并发症与抽搐致全身反应和脑细胞损伤有关快速终止抽搐可保护脑免于损伤快速终止抽搐可保护脑免于损伤 为为危及生命的急症，需立即危及生命的急症，需立即处处理！理！SESE病理生理分期病理生理分期持续持续5 5 可出现全身性反应可出现全身性反应根据持续时间可分为根据持续时间可分为3 3个阶段个阶段lPhase I(5-30)Phase I(5-30)早期早期SESElPhase II(30-60)SE Phase II(30-60)SE 难治性难治性SESE早期早期lPhase III(60)Phase III(60)难治性难治性SESEExpertOpinion(E)(Glauser,2007;Ma
17、,2010;NICE,2012)TypeIncidenceDescription远期症状性远期症状性 Remote Symptomatic SE33%Status Epilepticus(SE)with no immediate event but the child had a previous history of CNS malformation,traumatic brain injury or chromosomal disorder急性症状性急性症状性Acute Symptomatic SE26%SE with concurrent acute illness(e.g.,menin
18、gitis,encephalitis,hypoxia,trauma,intoxication)热性惊厥性热性惊厥性Febrile SE22%SE with a febrile illness but not a Central Nervous System infection(e.g.,sinusitis,sepsis,upper respiratory infection)特发性特发性Cryptogenic SE15%SE with no identifiable cause25SESE临床类型临床类型Return to Table of Contents急诊管理急诊管理-评估与救治评估与救
19、治急诊管理原则急诊管理原则基本原则基本原则l稳定生命稳定生命 维持呼吸维持呼吸/循环功能循环功能l止惊治疗止惊治疗 l明确抽搐可能原因明确抽搐可能原因 急救时机急救时机l正在抽搐正在抽搐(actively seizuring)(actively seizuring)伴有意识状态改变伴有意识状态改变抽搐抽搐55分钟或短期内重复抽搐分钟或短期内重复抽搐3 3次以上（次以上（1hr1hr内）内）)到达医院仍在抽搐应作为到达医院仍在抽搐应作为SESE救治救治l抽搐后期抽搐后期(postictal state)(postictal state)关键因素关键因素 时间时间(Time)(Time)治疗时间与
20、病人对一线药物反应有负相关，治疗时间与病人对一线药物反应有负相关，3030-30 综合治疗综合治疗 3030分钟分钟 评估是否难治评估是否难治SESE四剂止惊药物？！四剂止惊药物？！二线二线RSIRSI？！？！机械通气机械通气NSNS扩容？！扩容？！血管活性药？！血管活性药？！生命体征监测生命体征监测 Q10Q10纠正酸碱、电解质紊乱纠正酸碱、电解质紊乱救治步骤救治步骤-抽搐后抽搐后管理管理(postictal stage)(postictal stage)维持生命体征维持生命体征/内环境稳定内环境稳定l容量管理容量管理l血管活性药物使用血管活性药物使用?!?!l呼吸管理呼吸管理l生命体征监测
21、生命体征监测 l纠正酸碱、电解质紊乱纠正酸碱、电解质紊乱查找病因查找病因 CT CT 腰穿腰穿 EEG/MRI EEG/MRI 院内与院外健康教育院内与院外健康教育救治要点救治要点抽搐时间越长，控制越难！抽搐时间越长，控制越难！终点目标是临床控制或终止脑细胞放电，非药物浓度高低！终点目标是临床控制或终止脑细胞放电，非药物浓度高低！给药时间、途径和强度比特定药物选择更重要！给药时间、途径和强度比特定药物选择更重要！早期治疗远较后期强力治疗更有效！早期治疗远较后期强力治疗更有效！及早插管，避免全身并发症出现！及早插管，避免全身并发症出现！Return to Table of Contents 抽搐
22、管理改进抽搐管理改进临床指引与培训临床指引与培训 院前院前/院内院内健康教育健康教育/指引指引 家庭家庭/患儿患儿/学校学校临床研究临床研究 多中心多中心1.Epilepsy and Seizure Statistics.EpilepsyFoundation.org.Retrieved October 16,2013 from http:/www.epilepsyfoundation.org/aboutepilepsy/whatisepilepsy/statistics.cfm.2.National Survey of Childrens Health.NSCH 2007.Data query
23、 from the Child and Adolescent Health Measurement Initiative,Data Resource Center for Child and Adolescent Health website.Retrieved October 16,2013 from http:/www.childhealthdata.org.3.Pillow MT,Howes DS,Doctor,SU.Seizures.eM.Updated Jan 22,2010.4.Fisher,PG.First and second seizure:what to do and kn
24、ow.Contemporary Pediatrics.2007;24(4):80-89.5.Steering Committee on Quality Improvement and Management,Subcommittee on Febrile Seizures.Febrile seizures:clinical practice guideline for the long-term management of the child with simple febrile seizures.Pediatrics.2008;121:1281-1286.6.Freedman SB,Powe
25、ll EC.Pediatric seizures and their management in the emergency department.Clin Ped Emerg Med.2003;4:195-206.7.(AAP),Subcommittee on Febrile Seizures,American Academy of Pediatrics.Neurodiagnostic evaluation of the child with a simple febrile seizure.Pediatrics IBD.2011;127(2):389-394.8.Baumer,JH.(20
26、04).Evidence based guideline for post-seizure management in children presenting acutely to secondary care.Arch Dis Child;89:278-280.9.(BC),Febrile seizures.(2010).Clinical Practice Guidelines and Protocols in British Columbia10.Batra,P.,Gupta,S.,Gomber,S.,&Saha,A.(2011).Predictors of meningitis in c
27、hildren presenting with first febrile seizures.Pediatric Neurology,44(1),35-39.11.Fetveit,A.(2008).Assessment of febrile seizures in children.European Journal of Pediatrics,167(1),17-27.12.Harden,C.,Huff,J.,Schwartz,T.,et.al.(2007).Reassessment:Neuroimaging in the emergency patient presenting with s
28、eizure(an evidence-based review).Neurology 2007;69:1772-1780.13.Kimia,A.,Ben-Joseph,E.P.,Rudloe,T.,Capraro,A.,Sarco,D.,Hummel,D.,et al.(2010).Yield of lumbar puncture among children who present with their first complex febrile seizure.Pediatrics,126(1),62-69.14.Ma,L.,Yung,A.,Kwong,K.,et al.(2010).Cl
29、inical Guidelines on Management of Prolonged Seizures,Serial Seizures and Convulsive Status Epilepticus in Children.HK J Paediatr(new seeries)2010;15:52-63.15.NICE clinical guideline 137(2012).The epilepsies:the diagnosis and management of the epilepsies in adults and children in primary and seconda
30、ry care.www.nice.org.uk/cg13716.Riviello,JJ.,Ashwal,S.,Hirtz,D.,et.al.(2006).Practice Parameter:Diagnostic assessment of the child with status epilepticus(an evidence-based review).Neurology 2006;67:1542-1550.17.Seltz LB,Cohen E,Weinstein M.Risk of bacterial or herpes simplex virus meningitis/encephalitis in children with complex febrile seizures.Pediatr Emerg Care.2009;25(8):494-49741参考文献参考文献谢谢 谢！谢！
