Seizures in newborns are common (up to 1%). They are a symptom of various pathological processes in the central nervous system, humoral, endocrine, metabolic, electrolyte disorders and often represent an etiological, prognostic and therapeutic problem. Newborns are prone to seizures due to the known immaturity of the central nervous system, which can be explained by insufficient myelination, increased water content in nerve tissue And rapid development electrolyte, acid-base and other humoral disorders. Family background also matters. Convulsions can be clonic (with muscle twitching, usually accompanied by loss of consciousness) or tonic (with prolonged muscle contraction without twitching). With tonic convulsions, the upper limbs are in semiflexion, the hands are in extension, the arms are bent with the fingers in adduction, the lower limbs are in extension, extended with muscle hypertonicity. Convulsions can be generalized or spread only to certain parts of the body. Their sudden appearance is typical.
For diagnosis, not only the anamnesis and clinical picture are important, but also fundus examination, skull radiography, ionogram, acid-base balance, ECG, examination of cerebrospinal fluid in cases of suspected inflammatory processes in the meninges and brain, blood cultures in sepsis, etc. EEG is also of considerable importance, which in many cases is pathological during and after an attack. With short-term EEG changes and normal neurological status even in the first days after seizures, the prognosis is good. It should be borne in mind that seizures in a newborn may be the first sign of epilepsy in family-measured children, and only long-term observation can confirm the suspicion.
Convulsions in a newborn are observed when:
B. Encephalitis is usually caused by viruses. Clinical picture characterized by sudden onset, high fever and generalized tonic-clonic seizures, which are sometimes quite prolonged. Consciousness is impaired from doubt to coma. When sedatives are prescribed (luminal, chlorazine), the seizures go away.
4. Hypocalcemia(hypocalcemic tetany). The regulation of calcium levels in the blood of a newborn depends on the parathyroid gland, on kidney function, and also on the resorption of calcium and phosphorus in the intestines. If total serum calcium falls below 1.99 µmol/L (8 mg%) and ionized calcium below 1.09 µmol/L (4 mg%), symptoms of hypocalcemic tetany can be expected. In this regard, known insufficiency of the parathyroid glands, weak elimination ability of the kidneys for phosphates, pathological pregnancy (nephropathy), serious illnesses newborn (sepsis, syndrome respiratory failure etc.), which can cause a decrease in the content of ionized calcium and tetany. Alkalosis is also essential for the occurrence of tetanic convulsions.
Carpo-pedal spasms and known muscle twitching, most often with continued consciousness, are characteristic of hypocalcemic tetany. Intravenous or intramuscular administration of 3-5 ml of 10% calcium gluconate quickly eliminates tetanic convulsions. Treatment should be continued by mouth, prescribing a 5% solution of calcium chloride, one teaspoon three times a day; if unsuccessful, hypomagnesemia should be considered.
To facilitate the excretion of phosphorus by the kidneys, large amounts of fluids are prescribed and the child is not overfed with cow's milk.
5. Hypoglycemic seizures. In the first hours and days after birth, many newborns have low blood sugar levels. This is due to low glycogen content in the liver, especially in low weight children. This transient physiological hypoglycemia, as a rule, occurs without clinical manifestations, as an exception with symptoms such as pallor, sweating, movement disorder, and even seizures.
Hypoglycemia (below 1.5 mmol/l - 30 mg%, in full-term infants and below 0.80 mmol/l -20% mg, in premature infants) is observed mainly in children born from diabetic mothers or from mothers with prediabetes, not treated with insulin during pregnancy. Hypoglycemia in these cases is probably associated with a compensatory increase in insulin production and a decrease in glycogen content in the fetal liver. This hyperinsulism causes in the newborn a rapid drop in blood sugar after birth and phenomena of hyperexcitability, tremors, rhythmic myoclonus of the limbs, clonic convulsions and even coma. If there is a coma, other causes should be looked for, for example, cerebral hemorrhages, toxemia in the mother. Other signs of hypoglycemia are apnea, temporary cyanosis, and yawning.
Hypoglycemia also develops in cases where insulin is administered immediately before a cesarean section.
In differential diagnostic terms, one should keep in mind spontaneous hypoglycemia, renal glucosuria, galactosemia, myxedema.
Treatment of seizures in case of hypoglycemia, it is reduced to intravenous infusion of 10 ml of 20% glucose, early feeding.
6. Hypomagnesemia. It's about about an extremely rare disease. The clinical picture is similar to that of hypocalcemia with tetanic convulsions. Treatment consists of administering 0.1 ml per kg of body weight of a 50% magnesium sulfate solution, at most twice a day. After 6 hours, monitoring of magnesium levels in the blood is necessary due to the risk of developing a state of hypermagnesemia, characterized by peripheral neuromuscular blockade with pronounced muscle hypotension and central depression.
7. Water intoxication and hyponatremia. It develops during infusion large quantities glucose parenterally. Due to the weak elimination ability of the kidneys, water in these cases is retained in the cells (water intoxication), and the sodium concentration in the extracellular space decreases (hyponatremia). Water intoxication is initially accompanied by oliguria and isolated muscle twitching, later by convulsions, which, in all likelihood, are the result of retention large quantity water in cells.
Adrenogenital syndrome with loss of salt as a result of prolonged vomiting also leads to depletion of the body in trusted salt and hyponatremia. In severe crises it is also accompanied by convulsions.
Treatment for seizures associated with hyponatremia consists of intravenous infusion of 3-5 ml of hypertonic solution (3% solution table salt). The cramps disappear immediately.
8. Hypernatremia. Hypernatremia develops with prolonged infusion of table salt solution or if salt is mistakenly added to milk instead of sugar. It should be borne in mind that with prolonged infusions of solutions of table salt, water is also lost through perspiratio insensibilis and thus hypernatremic dehydration develops. Such iatrogenic hypernatremia can cause the development of a subdural hematoma or cerebral hemorrhage. With rapid intravenous administration of 8.4% NaHCO3 solution, hypernatremia with convulsions also develops. Clinical symptoms range from minor to very severe and can even result in death. Children are very excited at first. Muscle tone is increased, reflexes are strengthened. Later, uncoordinated muscle twitching and spasms appear. Finally the child falls into lethargy and coma. Not only hypernatremia matters, but also hyperosmolarity. In the cerebrospinal fluid, the protein content is increased, the cell content is almost not increased (protein-cell dissociation). The hematocrit and concentration of sodium ions in the blood are increased.
Treatment. For mild forms, 5% glucose or levulose is prescribed, and for more severe forms, a hypotonic solution of glucose with saline is prescribed, which covers the basic needs of sodium. For intact kidneys, additional potassium is prescribed.
9. Acute infections. Any septic disease in the neonatal period can occur with convulsions. The seizures are usually tonic-clonic. Meningoencephalitis of viral origin is sometimes accompanied by prolonged tonic-clonic seizures. Of the anthropozoonoses in the foreground, toxoplasmosis and, less commonly, listeriosis, in which convulsions are also observed. The clinical picture of the latter is described in detail in the section on congenital infections.
10. Tetanus in a newborn. The disease is very rare in Bulgaria. Characterized by tonic spasms that begin with the masticatory muscles, then spread to the rest facial muscles and gradually throughout the entire musculature of the body, without affecting eye muscles. Sometimes tonic convulsions spread to the respiratory muscles and diaphragm, accompanied in this case by cyanosis and attacks of asphyxia.
11. Seizures due to congenital disorders of amino acid metabolism:
A. Hyperglycinemia. This is an extremely rare disease, first described in 1961 in a newborn who began vomiting 18 hours after birth and developed severe acidosis and ketosis. Later, convulsions appeared. The disease is characterized by athetotic hyperkinesia. The glycine content in plasma and urine is increased (hyperglycinuria). The levels of serine, alanine, isoleucine and valine in the blood serum are also increased. The gamma globulin content is reduced, so these children are prone to infections. When prescribing food that is poor in proteins (0.5 g per kg of body weight per day), but rich in carbohydrates, acetone crises and, in general, clinical and biological disorders disappear.
B. Maple syrup disease. We are talking about a congenital abnormality in the metabolism of amino acids: leucine, isoleucine and valine. The disease was observed for the first time in 4 children from one Canadian family. Later, other cases were reported in the USA, England, and Germany. The disease is transmitted recessively. In plasma and urine, the content of amino acids is increased: leucine, isoleucine and valine.
The clinical picture is characterized by severe neurological phenomena even in the first days after birth. Children are apathetic and refuse food. Muscle tone is increased to the point of rigidity and only at times children are lethargic. Convulsions give way to comatose states. Eventually severe breathing problems occur and children die between the 2nd week and 20th month. Urine smells like maple syrup or burnt sugar. If treatment is started early by prescribing food poor in these amino acids, satisfactory results can be obtained.
B. Prolinemia. Congenital encephalopathy with impaired proline metabolism. Seizures appear on the first day after birth. Children are lagging behind in mental development. There is an increased content of proline and glycine in the plasma, and the amount of proline in the urine is also increased (hyperprolinuria).
G. Hop disease. The disease is characterized by convulsions in the neonatal period and urine with the smell of hops. Urine contains leucine, methionine, alanine and tyrosine.
D. Tyrosinase. This is characterized by an increased release of amino acids, predominantly tyrosine. The disease occurs in early infancy (by the 3rd month) with generalized convulsions, hypertension of the extremities, and delayed physical and psychomotor development.
A certain improvement can be achieved by limiting the content of tyrosine and phenylalanine in food.
All of the listed diseases associated with disturbances in amino acid metabolism are extremely rare and have not been observed by us.
12. Convulsions due to vitamin B6 deficiency. In newborns and young infants, with prolonged feeding with powdered milk, in which the content of vitamin B6 is significantly reduced (excessive heating), conditions of pyridoxine deficiency may develop, accompanied by increased excitability and even convulsions.
A characteristic feature is pyridoxine dependence, in which the newborn has an increased need for vitamin B6. The disease was described by Hunt. With a normal content of vitamin B6 in food and normal resorption, the child has an increased need for vitamin B6. We are talking about a metabolic-genetic metabolic disorder. The cause of this condition is believed to be a deficiency of glutamic acid decarboxylase in the cortex followed by a deficiency of gamma-aminobutyric acid. If pyridoxine is not added, there is a decrease in the synthesis of gamma-aminobutyric acid and serotonin, which are necessary for the normal function of the nervous system.
In the presence of vitamin B6 dependence, the first sign is severe anxiety, and a few hours after birth, rarely later, generalized convulsions appear. It is characteristic that these convulsions are not affected by ordinary anticonvulsants.
Treatment. Only a single intramuscular injection of 50-100 mg of vitamin B6 instantly eliminates cramps. To prevent further seizures, long time Give the child 5-10 mg of vitamin B6 per day. When treatment is started early, children develop normally.
13. Kernicterus. Excluding hyperbilirubinemia in hemolytic disease of the newborn, any hyperbilirubinemia above 350 µmol/l (20 mg%), in which indirect bilirubin is increased and exchange transfusion is not undertaken in a timely manner, leads to damage basal ganglia and kernicterus. Symptoms usually appear towards the end of the first week. In addition to symptoms of the eyes, paresis, rigidity of all muscles, etc., in severe cases, convulsions also appear, most often generalized tonic-clonic. Kernicterus is now very rare.
Treatment of seizures here is purely symptomatic.
14. Pathological polyglobulia. Severe forms of polyglobulia can occur with convulsions.
15. Hyperpyretic seizures. We are talking about convulsions that appear at high temperatures of a non-infectious nature. When a newborn is overheated in incubators, thermophores, or swaddled in many diapers (which, unfortunately, is still practiced by some parents), the child may become very ill. heat, he becomes restless and sometimes spontaneous tremors and convulsions appear, which disappear at normal temperature. In some newborns with severe hydrolability, between the 3rd and 6th day after birth, the temperature rises to 39-40°C and, among other symptoms (pallor, lethargy, sunken eyes, restlessness), convulsions, mainly clonic, sometimes appear. The cause of this transient fever is a food rich in proteins and salts - colostrum. After administering 5% glucose and saline solution to the child in an amount of 200 ml per day, the temperature returns to normal within a few hours and all symptoms, including convulsions, quickly disappear. If this condition is accompanied by vomiting, these solutions are administered parenterally - intravenously, 30-40 ml twice a day.
16. Seizures during treatment with cortisone drugs. Treatment with cortisone drugs can be accompanied by a variety of side effects. When the dose is exceeded or when treated with cortisone drugs for a long time, some children may experience seizures associated with swelling of the brain. Stopping treatment with cortisone (but not immediately, but gradually) eliminates all phenomena.
17. Seizures during treatment with tetracycline. Treatment of newborns and young infants with tetracycline can cause not only the well-known yellowish-brown color of baby teeth, dysbacteriosis, etc., but, as an exception, increased intracranial pressure (hydrocephalus) with bulging of the fontanelle, opisthotonus, and even convulsions. Currently, newborns are not treated with tetracycline.
18. Seizures in children born to mothers with eclampsia. Severe forms of nephropathy with eclampsia in pregnant women are currently observed very rarely. With late-onset eclampsia, the child may be born alive, but, as a rule, with low weight and with lesions caused by seizures in the mother, causing cyanosis and asphyxia. In the first 24 hours after birth, a newborn may experience tonic-clonic convulsions of individual muscle groups or generalized ones. Sometimes the urine of newborns contains albumin, etc.
Treatment of seizures in a newborn is reduced to intramuscular injection of 5 ml of a 10% solution of calcium gluconate and 0.02-0.04 g of luminal.
19. Placental insufficiency syndrome. Most common cause fetal malnutrition, dysmaturia, postmaturity of the fetus is placental insufficiency. In these cases, newborns are often very excited, with a lively look, and sometimes they have convulsions.
20. Sturge-Weber disease. We are talking about a congenital malformation of blood vessels, which is characterized by a unilateral nevus on the face, angiomatous changes in the choroid (formation of glaucoma), often with the presence of meningeal angiomas on the same side. Angiomatosis of the meninges causes circulatory disorders of the cerebral cortex, degenerative changes up to atrophy of the hemisphere with the deposition of calcium stones in this area. As a consequence, tonic-clonic seizures appear with opposite side, spastic hemiplegia, etc., manifesting itself during the neonatal period and early infancy in cases where angiomatous changes are quite pronounced.
Treatment. Convulsive phenomena are eliminated symptomatically. Treatment of the underlying disease is, if possible, surgical.
21. Familial seizures of unknown etiology. Familial seizures in newborns without proven hereditary disease metabolism have been described by a number of authors. It is possible that these seizures are associated with initial form epilepsy.
22. Seizures in Di George syndrome. We are talking about congenital agenesis of the parathyroid glands with aplasia of the thymus.
Shortly after birth, the baby develops severe and frequent attacks of generalized tetanic seizures. The diagnosis is confirmed by the absence of a thymic shadow on X-ray examination and low calcium levels in the blood serum. In the presence of severe tetanic convulsions and the absence of a thymic shadow, one should think about this syndrome.
Treatment consists of calcium and parathyroid hormone.
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Cramps are a pathological condition manifested by involuntary muscle contractions that occur suddenly in the form of paroxysms and is clinical manifestation damage to the central nervous system (CNS). Convulsions can occur with or without impaired consciousness.
In children, the main causes of seizures may be:
- hypoxia, ischemic brain damage
- intracranial hemorrhages;
- metabolic disorders (hypoglycemia, hypocalcemia, hyper- or hyponatremia, hypomagnesemia, hyperbilirubinemia, hyperammonemia, acidosis)
infections (meningitis, encephalitis, sepsis); - genetic and congenital malformations of the brain (chromosomal abnormalities,
- Phakomatoses, familial epilepsy, tumors, encephalocele, hydro- and microcephaly, etc.);
withdrawal of medications (withdrawal syndrome in the child) if the mother is dependent on opiates, alcohol, sedatives and antidepressant drugs;
congenital metabolic abnormalities (Emiya acid, galactosemia, congenital amaurotic idiocy, etc.); - other causes (hypothermia or hyperthermia, polyglobulia, “fifth era attacks”, familial convulsions of unknown origin in newborns).
Presence in newborns and children early age a greater tendency to develop seizures than in adults is explained by immaturity of the brain, increased vascular permeability, the blood-brain barrier, increased hydration of brain tissue, insufficient myelination of the nervous system, lability and generalization of excitation with weakness of inhibitory processes in the cerebral cortex, imbalance of the autonomic nervous system and metabolic processes.
Diagnostic criteria
In the clinical aspect of assessing seizures in children, the time of their appearance and the type of course of the paroxysm are important.
The occurrence of paroxysms on the 2-3rd day of life most often indicates brain damage of hypoxic, ischemic origin, hemorrhage, withdrawal syndrome; on days 2-3 - about metabolic disorders; in the second half of the 1st week of life - about infection, malformations of the brain, metabolic abnormalities.
Local and generalized convulsions are distinguished. Convulsions in newborns are often polymorphic in nature.
J. Volpe (1988), G. Calciolari et al. (1988) identified the following clinical variants of seizures in newborns:
- minimal (convulsive equivalents)
- focal clonic;
- myoclonic.
Minimal convulsions in newborns manifest themselves in the form of ocular paroxysms (gaze fixation, tonic or vertical deviation of the eyeballs with or without trembling, opening of the eyes, paroxysmal dilatation of the pupils), trembling of the eyelids, oral automatism (sucking, smacking, chewing, protruding and trembling of the tongue) , general muscle tension or paroxysmal movements of the limbs (upper in the form of “swimmer’s movements”, lower - in the form of cyclist’s movements). Manifestations of minimal pain may include changes in the rhythm of breathing, primarily in the form of apnea, less often tachypnea, as well as attacks of unemotional screaming.
Generalized tonic convulsions - long-term (up to 3 minutes or more) contraction large group muscles with the formation of a forced position of the body and limbs. Tonic convulsions occur with increased activity of the brain stem and are more often observed in premature newborns, in the presence of severe hypoxic-ischemic brain damage, hypoglycemia.
In the case of clonic convulsions, short-term contractions and relaxations are observed. separate groups rhythmic muscles. Multifocal clonic convulsions are characterized by contractions of the facial muscles and limbs, either in the right or left parts. Such seizures occur more often in full-term newborns in the presence of metabolic disorders, hypoxia, infection and malformations of the brain.
Focal clonic convulsions are manifested by rhythmic (1-3 per 1 s) contractions of the muscles of half the face and limbs on one side. On the side where the cramps occurred, there may be signs of hemiparesis. Manifestations of the hemitype often indicate damage to the cerebral hemisphere (hematoma, ischemic stroke, developmental defects), less often - an infectious process.
Myoclonic spasms are characterized by irregular contractions various groups limb muscles. They are possible in newborns with severe abnormalities of brain development, congenital abnormalities of metabolism, and hypoxia.
Depending on the frequency, we can talk about episodic and constant seizures. If seizures are repeated one after another, then this condition is considered convulsive status.
More often, convulsions have mixed character. An attack of convulsions is characterized by a sudden onset, phenomena of motor excitation, during which partial or general manifestations of seizures and changes in consciousness (from barely noticeable to loss of consciousness) can be observed. In the event of an attack, the child suddenly loses contact with environment. The gaze becomes wandering and, after repeated movements of the eyeballs, is fixed upward or to the side. The chair is thrown back, the torso freezes, the upper limbs contract at the elbow and wrist joints, the lower limbs straighten, the jaws close. Breathing may stop for a short period of time, and the pulse slows down. This tonic stage of clonic-tonic convulsions often lasts no more than 1 minute, after which the child takes a deep breath. The clonic stage begins with contractions of the facial muscles, which spread to the limbs and become generalized. Breathing becomes noisy and foam may appear on the lips. Cyanosis decreases, but the child remains pale. The duration of the clonic stage varies. Sometimes it can lead to a new tonic phase and fatal outcome. After the end of the seizure, the child remains in a state of oblivion and more often falls asleep.
M. Dehan et al. (1977) from 98 newborns with seizures identified 20 children with the same type of manifestations, which they called “convulsions of the 5th day of a child’s life.” It was noted that in such patients, convulsions occurred on the 5th day of life during the normal course of maternal pregnancy and childbirth. In the first days of life, the children showed no signs of neonatal pathology. The convulsions occurred acutely, were clonic (myoclonic) in nature and repeated after 20 hours. The electroencephalogram (EEG) showed the same type of manifestations in the form of Q-waves. After the attack, hypotension, drowsiness, and unresponsiveness were noted until 6 days after the paroxysm. Observation of this category of children for 30 months showed that they subsequently normal development and normalization of the EEG.
Neonatal hypocalcemia (serum calcium levels in newborns<1,75 ммоль / л, а ионизированного кальция <0,87-0,75 ммоль / л) может сопровождаться признаками гипервозбудимости - гиперестезией, тремором подбородка и конечностей, клонусы стопы, неэмоциональным пронзительным постоянным криком, тахикардией с приступами цианоза. Нарушение дыхания фиксируются в виде ларингоспазма, инспираторного стридора, тахипноэ с чередованием приступов апноэ. Сухожильные рефлексы повышены, хоботковый симптом и феномен Люст часто положительные. В случае прогрессирования гипокальциемии возникают тонические судороги, рвота, застойная сердечная и почечная недостаточность, кишечно желудочные кровотечения. В диагностике важным является установление низкого уровня кальция в плазме крови, а также удлинение интервала QT на электрокардиограмме (ЭКГ).
In the presence of neonatal hypoglycemia (blood glucose level<2,2 ммоль / л) на начальных этапах появляются глазные симптомы (нистагм), снижается тонус глазных яблок, исчезает окулоцефальний рефлекс, крик становится слабее и неэмоциональным, ребенок срыгивает. В дальнейшем отмечаются приступы тахикардии, тахи пное, цианоза, тремор, бледность кожи, потливость. Прогрессируют слабость, гипотония, гипотермия, анорексия, приступы автомобильные дыхания и апноэ, возможны клонико-тонические судороги. Базовым в диагностике гипогликемии у новорожденных является регулярное определение уровня глюкозы крови. Менингит у новорожденных проявляется чаще глазными симптомами, реже наблюдаются выбухание или исполнения большого родничка, острое увеличение окружности головы, ригидность затылочных мышц, повторная рвота. С менингеальных знаков достаточно типичным является положительный симптом Лесажа (сгибание ног при подъеме ребенка). Судороги могут иметь тонический, клонический характер. Решающим в диагностике является оценка результатов люмбальной пункции (увеличение белка, клеток, снижение уровня глюкозы, посева возбудителя или определения его при бактериоскопии при наличии гнойного менингита). Клинические проявления внутричерепных кровотечений в новонаро Джен разнообразные и зависят от локализации, массивности процесса, гестационного возраста, преморбидного фона. Общее состояние новорожденного резко ухудшается с развитием синдрома угнетения, иногда с признаками периодической гипервозбудимости, меняется характер крика, взрывается большой родничок. Отмечаются аномальные движения глазных яблок, псевдобульбарные и двигательные расстройства, судороги, парезы, расстройства тонуса мышц. Прогрессируют вегетовисцеральных расстройства (срыгивания, тахипноэ, тахикардия), метаболические нарушения (ацидоз, гипогликемия, гипербилирубине емия). Важные для диагностики проявления пост геморрагической анемии, результаты офтальмологического обследования (застойные диски), люмбальной пункции (эритроциты в ликворе), рентгенологического и нейросонографического исследования головного мозга. Гипертермические () судороги характерны для детей раннего возраста. Возникают при гипертермии>38 ° C, have a clonic-tonic character, last from a few seconds to 15-20 minutes.
Convulsions with spasmophilia
They occur in young children, usually during the winter-spring period and are hypocalcemic in nature. The clinical picture of spasmophilic diseases is varied and can have local and generalized manifestations. The following symptoms of increased neuromuscular excitability are pathognomonic:
- Khvostek's symptom - contraction of the facial muscles during tapping with a finger between the zygomatic arch and the corner of the mouth;
- Trousseau's sign - flexion of the hand and adduction of the thumb ("obstetrician's hand") when pressing on the neurovascular bundle of the forearm
- Lust symptom - raising the outer edge of the foot and abduction of the lower limb when tapping in the area of the head of the fibula
- carpopedal spasm - tonic tension of the flexors of the foot and hand;
laryngospasm - in this case, a tonic contraction of the muscular apparatus of the larynx with a narrowing of the glottis; characterized by a loud, prolonged cry (a symptom of a cock's crow) followed by cessation of breathing for up to 1-2 minutes; at the height of laryngospasm, cyanosis of the lips and motor agitation or freezing with the head thrown back occur; after the attack, several noisy exhalations are observed; - generalized convulsions in spasmophilia are tonic in nature with short-term (up to 2 minutes) cessation of breathing.
Laboratory tests for spasmophilia show hypocalcemia (decrease in total calcium<1,2 ммоль / л и ионизированного <0,9 ммоль / л), респираторный или смешанный алкалоз.
Affective and hysterical convulsions (affective-respiratory attacks) occur in children under 3 years of age at the height of crying or in older children with increased emotional excitability. Characterized by a tonic component with breath holding during inhalation. Due to hysteria, possible clonus of the feet and hands.
Convulsions on a residual organic background are observed in cerebral palsy, Tay-Sachs, Neman-Pick diseases, etc. and are characterized by epileptic attacks against the background of delayed psychomotor development.
To verify the diagnosis by the court, it is necessary to conduct a complete clinical, laboratory, and instrumental examination of the child with a detailed assessment of the course of pregnancy and childbirth, and family history; neurological examination; biochemical blood test (level of glucose, electrolytes, CBS, bilirubin, urea, etc.); general blood test, PO 2 and PCO 2 levels; if necessary, reviews by an ophthalmologist, an infectious disease specialist, according to indications - examination to identify an infectious or other pathogen, ECG, neurosonography, electroencephalogram, skull radiography, nuclear magnetic resonance.
Urgent Care
Treatment of a child with seizures should be etiopathogenetic. Since seizures themselves can lead to brain damage, even death, early administration of drugs that suppress the excitability of the central nervous system (anticonvulsants, anticonvulsants) is vital.
Emergency help for seizures:
- check airway patency
- provide the child with the correct body position (turn him on his side to prevent possible aspiration); protect him from mechanical injuries by placing soft things under his head and back; in order to prevent biting the tongue between the molars, place a spatula or the handle of a spoon wrapped in a layer of bandage or a knot of a handkerchief;
- to prevent the patient’s tongue from retracting, push the lower jaw forward and, fixing it, clear the upper respiratory tract;
- oxygen support with 100% humidified heated oxygen, if necessary, artificial ventilation;
- ensure reliable venous access (preferably central venous catheterization)
administer anticonvulsants.
The first-line drugs for the treatment of seizures in children are benzodiazepines (Seduxen, Relanium, Sibazon, Diazepam, Valium, Librium). Seduxen is administered intravenously (less frequently intramuscularly) in the form of a 0.5% solution in a single dose of 0.2-0.35-0.5 mg/kg body weight (one ampoule of Seduxen 10 mg in 2 ml). The rate of administration is 1-5 mg per 1 minute. The frequency and duration of administration of seduxen provides for the possibility of repeated (2-3 times) administration of the drug after 5-15-20 minutes in case of recurrent seizures. For children 15 kg - 10-20 mg. Possible complications of treatment with benzodiazepines include arrhythmia and respiratory arrest, laryngospasm, arterial hypotension, arrhythmias and cardiac arrest. There may be other relative disadvantages when using benzodiazepines: short duration of action, sedation, muscle relaxation, tolerance.
If the anticonvulsant effect of seduxen is ineffective, water-soluble hydantoin (phenytoin, fengidan) is used in a single dose of 10-15-(20) mg/kg. The rate of administration is 1-3 mg/kg per 1 min. Total dose - no more than 30 mg/kg; sodium hydroxybutyrate - 20% solution in a single dose of 50-100 mg/kg i/v slowly.
- If hydantoin therapy is ineffective, use water-soluble phenobarbital at a dose of 5-10-(15) mg/kg. A single dose can be administered every 20-30 minutes up to a total dose of 30-40 mg/kg;
- It is possible to administer other benzodiazepines (clonazepam at a dose of 0.05-1 mg/kg, lorazepam at a dose of 0.1 mg/kg slowly IV).
If previous drugs are ineffective, as well as if convulsions last more than 30 minutes, it is necessary to prescribe general anesthesia using an artificial respiration apparatus. The drugs of choice are short-acting barbiturates (sodium thiopental). In the intensive care unit (intensive care ward), sodium thiopental is simultaneously administered intravenously and intramuscularly in a total dose of 8-10 mg/kg (no more than 15-20 mg/kg). For intravenous administration, a 0.25-0.5-1% solution of the drug is used, and for intramuscular administration, a 2-5% solution is used (solutions of higher concentrations can cause aseptic necrosis).
The criteria for the effectiveness of the prescribed treatment is the disappearance of seizure and epileptic activity when monitoring the bioelectrical activity of the brain.
For resistant seizures in newborns - lidocaine IV at a dose of 2 mg/kg, followed by a dose of 6 mg/kg over 1 hour and a duration of therapy of 1-3 days.
In the presence of hypoglycemia - 20% glucose solution at a dose of 2 ml/kg intravenously slowly, followed by intravenous drip administration of a 10% glucose solution at a dose of 2.4-4.8 ml/kg 1 hour before the manifestations of hypoglycemia are eliminated.
In the presence of hypocalcemia - 10% solution of calcium gluconate at a dose of 0.5-1-2 ml/kg per day in 2-3 divided doses slowly, followed by administration of the drug enterally or parenterally as needed.
In children with manifestations of hypomagnesemia - 25% magnesium sulfate solution at a dose of 0.2-0.4 ml/kg IM every 8-12 hours on the first day and 1 time per day thereafter.
Pyridoxine-dependent seizures require intramuscular or intravenous administration of 50-100 mg of vitamin B6.
In cases where seizures are accompanied by severe disturbances in breathing, blood circulation, and water-electrolyte metabolism, the effectiveness of anticonvulsant therapy is largely determined by the possibility of eliminating these manifestations (with the help of oxygen therapy, correction of hemodynamic disorders, metabolic processes, etc.).
Dehydration therapy for seizures is not mandatory. The choice of fluid therapy depends on the cause of seizures and should ensure adequate cerebral perfusion. If there is existing cerebral edema, dehydration therapy is prescribed:
- - Lasix 1% solution at a dose of 1-2 mg/kg IV;
- - Osmotic diuretics: sorbitol at a dose of 1 g/kg, mannitol at a dose of 1-2 g/kg in the form of a 15-20% solution in a drip (50-60 drops/min);
- - Diacarb orally at a dose of 50-80 mg/kg/day;
- - Albumin 10-15%, plasma at a dose of 5-10 ml/kg/day intravenously;
- - Eufillin, if necessary, 2% solution 3-5 mg/kg intravenously.
Any seizure is a life-threatening condition that can cause brain damage to the child or even be fatal in the case of convulsive status, so emergency care should begin as early as possible and continue while the child is being transported to the hospital.
1. Associated with metabolic disorders
A. Hypocalcemic (spasmophilia, hypoparateriosis).
b. Hypoglycemic.
V. Hypomagnesemic.
d. Pyridoxine dependent.
2. Non-exchangeable
Epileptic reaction.
a) febrile convulsions;
b) affective-respiratory convulsions.
Epileptic syndrome
a) organic brain damage;
b) traumatic brain injury;
c) neuroinfections;
d) poisoning;
e) vascular lesions of the brain;
e) brain tumors.
Epilepsy.
SPASMOPHILIA
Age - up to 1 year. Background - the nature of feeding is “artificial”, the time of year is spring, if rickets is not prevented with vitamin “D” with the simultaneous administration of calcium supplements.
Clinic - the presence of a triad of symptoms:
carpopedal spasm (“obstetrician’s hand”, foot clonus).
laryngospasm (“cock crow”).
tetany (generalized clonic-tonic convulsions).
Consciousness is preserved.
Treatment: - with normal access to the vein, intravenous administration of calcium supplements:
Ca gluconate 10% - 1.0 ml/year of life, up to 10 ml at a rate of 1 ml/min.;
Ca chloride 10% - 0.5 ml/year of life (administer only intravenously, as the drug causes necrosis of soft tissues).
In the absence of the possibility of intravenous administration - Ca gluconate 10% - 0.5 ml/kg/intramuscularly.
To potentiate the effect of calcium preparations, we administer magnesium sulfate 25% intramuscularly (under the age of 5 years - 0.2 ml/kg, for older ages - 1.0 m/year, but not more than 10 ml, diluted 2 times with a 0.5% solution novocaine). After relieving convulsions, hospitalization.
Hospital management tactics:
1) monitoring of hemodynamics (pulse, blood pressure, ECG).
2) examination by an ophthalmologist (“shock disks”).
3) checking the symptoms of latent spasmophilia (Chvostek, Trousseau, Lyust symptoms).
4) laboratory:
With rickets, the levels of Ca and phosphorus decrease; metabolic acidosis; alkaline phosphatase activity increases;
With hypoparateriosis - a tendency to alkalosis, the level of alkaline phosphatase is normal, the level of Ca is reduced, phosphorus is increased or normal;
With spasmophilia, the Ca level is reduced, and alkalosis is more often observed.
In older children, hypocalcemia may be caused by intense muscle activity and hyperventilation.
Induced hypocalcemia can occur in children receiving anticonvulsant therapy (phenobarbital, diphenine).
Treatment in hospital:
Rickets, spasmophilia: vitamin D3 and calcium supplements.
Preferably calcium carbonate in tablets up to 1.0 grams per day or calcium gluconate 5%, 1 teaspoon - 1 dessert spoon three times a day, or combination preparations; "Vigantol." In parallel, asparkam is given (contains magnesium).
The treatment tactics for hypoparateriosis are determined empirically by an endocrinologist.
HYPOGLYCEMIC SEIZURES
Hypoglycemic conditions are dangerous due to the rapid onset of coma! Any age. Background – fasting, taking medications (insulin, salicylates, supphonamides), alcohol, the presence of metabolic and endocrine diseases (fructosemia, galactosemia, cerebral and pituitary insufficiency, chronic adrenal insufficiency), pancreatic tumor, type II diabetes.
Neurohypoglycemia
Sympathoadrenal reactions
Drowsiness/disorientation in space,
Noise in ears,
Dizziness,
Feeling of hunger (in older people)
Refusal to eat and monotonous screaming (in younger ones)
Pallor,
sweating,
Tachycardia,
High blood pressure,
Arterial increase in tendon reflexes and muscle tone,
Jaw tremor/trismus,
Feeling of fear and aggressiveness.
Hypoglycemic seizures are characterized by the absence of hypersalivation, involuntary urination and defecation; the seizures are clonicotonic in nature with loss of consciousness.
Treatment: glucose solution 40% - 20-40 ml or 20% - 40-80 ml, if you hit the mark, then consciousness returns during administration or immediately after the glucose infusion. If you are sure that hypoglycemia is provoked by the administration of insulin, then if there is no effect, repeat the administration of the glucose solution after 10-15 minutes at the same dose. If there is no effect, then switch to intravenous drip administration of a 5% glucose solution, at the rate of 5.0 grams of dry matter glucose per 1 unit of insulin administered
Hospitalization.
Tactics in the hospital:
1) evaluation of the clinic.
2) assessment of laboratory parameters (blood sugar, sugar and acetone in urine, acid-base acid, blood electrolytes). With ketotic hypoglycemia (fructosemia, galactosemia, cerebral and pituitary insufficiency, chronic adrenal insufficiency), acetone is present in the urine; with non-ketotic hypoglycemia, there is no acetone in the urine.
3) ECG - signs of hypokalemia: inversion and thickening of T, decreased voltage.
4) consultation with an endocrinologist.
Hypomagnesemic seizures
Occur when the level of magnesium in the blood decreases below 0.62 mmol/l. Characteristic of the neonatal period.
Clinically: the most characteristic symptoms are generalized and focal convulsions, hyperexcitability, tremor, muscle tremors. In premature infants, the disorders are usually more severe and are additionally characterized by an unusual cry, muscle hypotonia, hypotension, edema, bradycardia, and respiratory rhythm disturbances.
Treatment: hypomagnesemia is treated with intramuscular injection of a 25% solution of magnesium sulfate, 0.4 ml/kg every 6 hours and further as indicated, but at least once a day.
Pyridoxine-dependent seizures
They develop as a result of a lack of pyridoxine or its coenzyme pyridoxal-5-phosphate in the blood. These seizures can occur in utero or during the first 72 hours of a child's life. Characterized by generalized muscle twitching, myoclonic contractions in the form of nods and generalized winces.
The use of large doses of pyridoxine, at least 100 mg per day, leads to relief of attacks.
Affective-respiratory convulsions
These are attacks of apneic convulsions that occur when a child cries. At the height of crying, apnea and cyanosis of the skin and oral mucosa develop. Clonic or clonic-tonic convulsions develop less frequently, and sometimes seizures are limited to short-term loss of consciousness. The mechanism of seizures is anoxic. They are typical for children aged 6 months to 3 years with increased affective excitability, a tendency to hysteroid reactions, and are provoked by fear, anger, and dissatisfaction.
The treatment uses a gentle regimen, sedative therapy (collections of soothing herbs). If generalized tonic or tonic-clonic convulsions develop at the time of an attack, assistance is provided (similarly) according to the scheme for relieving febrile convulsions.
FEBRILE SEIZURES
Age - 5 months - 5 years. Background - fever.
single episodes up to 15 minutes,
generalized
In neurologically healthy children.
duration more than 15 minutes,
repeat throughout the day
are focal in nature
can lead to complications (paresis of the limbs, development of febrile epistatus)
Treatment: it is necessary to ensure a passable, as “short” airway as possible. To do this, place the patient with his back on a flat, horizontal surface, free the oral cavity and nasopharynx from mucus, vomit, saliva, foreign bodies, unbutton clothes, shirt collar, turn his head to the side (to prevent aspiration). Give oxygen through a mask or catheter, or at least provide an influx of fresh air (open a window). Wrap the entire scalp and forehead with a large terry towel soaked in cold water; water. When heating the towel, cool it by wetting it again.
When stopping seizures before a doctor appears, it is necessary, if possible, to carry out the same measures.
Drug treatment: the drug of choice is diazepam (Seduxen), or sibazon, Relanium, at a dose of 0.5 mg/kg (up to 2 years 0.1 ml/kg, but not more than 2.0 ml, from 2 to 5 years up to 2.0 ml, from 5 and older up to 4.0 ml). At the first moment, we administer the drug deep into the muscles (this method allows you to immediately begin administering the drug to the patient, as well as create a depot that maintains a stable concentration in the blood). In parallel or after this, we begin to “look” for a vein so that further administration of medications can be carried out intravenously. If there is no effect after 10-15 minutes. repeat at the same dose IV or administer GHB 20% at a dose of 100 mg/kg in saline in a 1:1 ratio IV slowly. A good option is to start therapy with a slow intravenous injection of 0.25% droperidol, at a dose of 0.1-0.5 ml/kg at 5 - 10% glucose, or intramuscularly. Repeated administration if there is no effect after 10-15 minutes.
If it was not possible to get into a vein, then it is possible to introduce solutions into the sublingual area in a volume of 5.0 - 5.0 ml, depending on the age of the patient. The injection can be made both from the oral cavity and through the skin in the sublingual area to a depth of at least 2.5 cm.
For complex febrile convulsions, we administer prednisolone 2-3 mg/kg IV, IM, hydrocortisone hemisuccinate 10 mg/kg, IV, IM.
In the presence of hyperthermia, a nutritional mixture is administered: analgin 50% 0.1 - 0.15 ml/year of life + di-medrol 1% 0.1 ml/year of life up to 1.0 ml or diprazine 2.5% 0.1-0.15 ml/year of life + novocaine 0.25% 0.1 ml/year life. If prednisolone was administered, then the lytic mixture can be omitted. For marbled, “pale” hyperthermia, no-spa 0.1 MP/year is prescribed.
Hospitalization.
NONFEBRAL. Convulsions due to intracranial hypertension.
Any age. Background - residual - organic lesions, neuroinfection, tumors, trauma, cerebrovascular accident. Clinic - hypertensive syndrome: headache (in small children - screaming), regurgitation, vomiting, characteristic posture (head tilting), eye symptoms, focal symptoms, hyperthermia, hyperesthesia, hemodynamic disorder (relative bradycardia).
Treatment: according to the scheme for stopping febrile seizures. Along with anticonvulsants, dehydration is carried out. For these purposes, Lasix is administered intravenously or intramuscularly at a dose of 1 mg/kg. In addition, you can use a 25% solution of magnesium sulfate, 1 ml per year of life, up to 1 year - 0.2 ml per kg of body weight.
In case of CRANIOUS BRAIN INJURIES, seizures are the only sign of compression of the brain.
Treatment: syndromic.
EPILEPSY
Any age. Background: heredity, perinatal brain damage, history of brain injury.
Minor seizure - without loss of consciousness.
Grand seizure - the presence of an aura, clonic-tonic convulsions with loss of consciousness, the pupils are immobile, the face is cyanotic, foamy discharge from the mouth, trismus of the jaws, biting the tongue, involuntary urination and defecation (less often). After a seizure, he usually falls asleep and has amnesia. Transient paresis.
Treatment: according to the scheme for stopping febrile seizures.
Indications for hospitalization in the neurological department.
1. primary seizure
2. presence of several attacks during the day
3. appearance of focal neurological symptoms
4. threat of status epilepticus (duration more than 10 minutes)
NEUROINFECTION
Any age. Background - seasonality, previous or current viral infections (measles, influenza, chicken pox, herpes and others). Clinic: fever, headache, vomiting (symptoms of intracranial hypertension), positive meningeal symptoms, convulsions in meningoecephalitis and encephalitis.
Treatment: according to the scheme for stopping febrile seizures. Hospitalization in the infectious diseases department.
HYSTERICAL SEIZURES
Hysterical attacks in their clinical manifestations can resemble any type of epileptic paroxysms. However, there are a number of differences that, with careful observation, provide a “key” to establishing the correct diagnosis.
Symptoms
Hysterical convulsions
Epileptic convulsions
Time and conditions of occurrence
At any time of the day, in the presence of emotionally “significant” people
Often associated with a specific time of day, regardless of the presence of people
Beginning of the attack
Sudden
Both sudden and gradual
Type of attack
Characterized by great variability and the ability to imitate paroxysms that patients had previously observed among the people around them
More stereotypical, similar to one another
Falling during a seizure
Gradual, slow and “soft” fall, injuries are rare
Sudden and rapid fall, high risk of injury
Pupil reaction to light
Normal
Reduced or absent
Involuntary urination
Absent
Characteristic
Post-attack sleep
Not typical
Characteristic
Duration of attack
Changeable
More permanently
POISONING.
Causes: CO, amitriptyline, and poisoning with substances that cause cerebral edema (FOS).
In case of poisoning, antidotes are administered: as a rule, atropine, adrenaline, methipene blue solution, nalorphine (drug overdose).
Treatment of convulsive syndrome should not blur the picture of poisoning.
Seizures (sudden and involuntary muscle contractions) in newborns, according to various sources, occur with a frequency of 1.5 to 14 cases per 1000 children, and in premature infants in a modern intensive care unit, their frequency reaches 25%.
The main causes of seizures in newborns:
1. Hypoxic-traumatic brain damage (without or with hemorrhage in the brain and - or its membranes, thrombosis of the cortical veins, cerebral edema).
2. Metabolic disorders
- hypoglycemia
- hypocalcemia
- hypo or hypernatremia
- hyperammonemia
- amnioacidopathy
- pyridoxyl dependence
- hyperbilirubinemia with kernicterus
3. Infections
- meningitis
- meningoencephalitis
4. Congenital anomalies (brain dysginesia)
5. Withdrawal syndrome (children of mothers who are drug addicts or alcoholics)
6. Drug poisoning
7. Familial seizures (hereditary syndromes with mental retardation, benign familial epilepsy)
In 50% of cases, convulsions in newborns occur on the first day of life, in 75% of cases before the 3rd day. In the first 48 hours of life, the most common causes of seizures are asphyxia and birth trauma, hypoglycemia.
On days 3-5 - metabolic disorders (uncomplicated primary hypocalcemia); in the period older than 5 days, infectious and genetic factors are of greatest importance in the development of seizures.
Clinic:
The following types of seizures in newborns are distinguished:
1. minimal, elusive
2. tonic - generalized, focal
3. clonic - focal (focal), multifocal (multifocal)
4. myoclonic
Difficulties in diagnosis are caused by minimal seizures or seizure equivalents. These are seizures with minimal peripheral manifestations and seizures in the form of deviations from normal behavior. They manifest themselves in the form of fixation of gaze, deviation of the eyes (sometimes with nystagmus), twitching, movements of the lips, tongue (sucking, smacking, chewing), tonic tension of the limbs, pedaling, swimming, circular movements of the limbs, attacks of apnea and unemotional screaming.
Required scope of laboratory examination:
(in addition to a thorough analysis of the nature of labor and the clinical picture)
1. Clinical blood test
2. Determination of the level of glucose, calcium (Ca), magnesium (Mg), sodium (Na), chlorine (Cl) in the blood, as well as urea nitrogen, creatinine, bilirubin, acid-base balance.
3. Lumbar puncture
4. Neurosonography
5. Electroencephalography (EEG)
6. For persistent convulsive syndrome, computed tomography
TREATMENT TACTICS
Treatment of a child with seizures should be etiopathogenetic. During the examination period, the following medications are prescribed:
- seduxen (diazepam, relanium), 0.5% IV or IM 0.04 ml/kg, the dose can be increased to 0.1 ml/kg 0.5% solution. If there is no effect, the injection can be repeated after 30 minutes.
- sodium hydroxybutyrate (GHB) IV slowly (2ml/min), - 20% solution at a dose of 0.5 - 0.75 ml/kg (100-150 mg/kg), pre-diluted in 10% glucose solution in a 1:1 ratio.
Less commonly, drugs are administered intramuscularly.
- droperidol IV or IM 0.25% solution 0.04 - 0.08 ml/kg (especially good for children with fever and peripheral circulatory disorders)
- phenobarbital 20 mg/kg IV for 15 minutes - loading dose, then maintenance dose per os 4-5 mg/kg - day (if a solution for parenteral administration is available)
- to increase the effectiveness of phenobarbital, diphenine is prescribed 5-10 mg/kg - daily in 1-2 doses per os.
In case of neonatal convulsions caused by metabolic disorders, their correction is carried out:
1. Hypocalcemia (level of total calcium< 1,9 ммоль/л, ионизированного < 0,9 ммоль/л; на ЭКГ - удлинение интервала QТ): в/в струйно 10% р-р кальция глюконата из расчета 1 мл/кг медленно (1мл/мин). При отсутствии эффекта инъекцию повторяют через 20-30 минут.
2. Hypomagnesemia (often combined with hypocalcemia). The critical level of magnesium is -0.5 mmol/l. A 25% solution of magnesium sulfate IM is indicated at a dose of 0.4 ml/kg (in addition to hypomagnesemia, the drug is indicated for seizures caused by cerebral edema and intracranial hypertension). For intravenous administration, a 25% solution of magnesium sulfate is diluted to a 1% concentration with 10% glucose and 6-10 ml of a 1% solution is administered slowly (1 ml/min). Complications from intravenous administration - respiratory depression, bradycardia.
3. Hypoglycemia
The diagnosis is established when the level of glucose in the blood of a full-term baby is less than 2.2 mmol/l. Clinical manifestations of hypoglycemia are pallor, sweating, weak cry, apathy, refusal to feed, lethargy (in the beginning, on the contrary, irritability, tremor, spontaneous Moro reflex may be noted), decreased tone of the eyeballs, general muscle hypotonia, vomiting, attacks of shortness of breath, cyanosis , bradycardia, respiratory and cardiac arrest, hypothermia, convulsions.
To relieve convulsive syndrome, the following is administered intravenously: IV 10% glucose solution 2 ml/kg for 1 minute, then 1 ml/min, then switch to IV drip infusion of 10% glucose solution at a rate of 5 ml/kg per hour.
4. Pyridoxine-dependent seizures: IV or IM 50-100 mg of vitamin B6, i.e. 1-2 ml of 5% solution of pyridoxine hydrochloride.