Febrile convulsions, or febrile convulsions, commonly known as “convulsions”, are sudden increases in body temperature that cause cortical movements, abnormal discharge of nerve cells and temporary involuntary contractions of the whole body or local muscles, accompanied by impaired consciousness.
Pediatric febrile convulsions are one of the common critical illnesses in pediatrics, with a temperature of 38.5 to 39°C or higher, within 6 to 12 hours after the onset of fever, no later than 24 hours, between the ages of 3 months and 6 years, with a peak at 6 months to 3 or 4 years, and a high incidence, with 2% to 3% of children under 5 years of age having had at least one febrile convulsion, with a higher male to female ratio of 1.5:1 The recurrence rate is 40% to 50%, and the incidence is 10 to 15 times higher than that of adults.
The etiology of convulsions is still not fully understood, but recent studies have found that the disease has significant heredity, probably autosomal dominant, with age-related incomplete epistasis and expressivity, and the tendency to convulsions is determined by genetic factors. It may also be related to the imperfect development of the pediatric brain, which has poor analytical, discriminatory and inhibitory abilities, so that even weak stimuli can cause strong excitation and diffusion in the brain, resulting in sudden abnormal neural discharges and convulsions. This indicates that both genetic and developmental factors characterize the intrinsic basis of convulsions. However, the vast majority are caused by infections, among them, upper respiratory tract infections, acute tonsillitis, pneumonia and early infectious diseases, and other acute infectious diseases that induce high fever produce convulsions. All of these factors work together to cause febrile convulsions to occur.
A few febrile convulsions may be preceded by aura, such as extreme irritability, nervousness, panic, dramatic change of face; sudden rapid, irregular or suspended breathing (especially in newborns, otherwise serious brain damage will result). In most cases, when the body temperature rises suddenly in the early stage of fever, due to the imperfect development of motor nerve cells in the cerebral cortex, it causes abnormal neuronal discharge and overexcitation, resulting in episodic or transient brain dysfunction, often accompanied by disorders of consciousness, and also symptoms of sensory and behavioral abnormalities of the vegetative nerves. Typical clinical manifestations often include sudden loss of consciousness or fall, transient tonic or spastic involuntary jerking of the skeletal muscles of the limbs, trunk and face, irregular or suspended respiratory rhythm, accompanied by cyanosis of the lips and mouth, fixed or upturned eyes, staring or squinting, head tilted backward or to the side, foaming at the mouth, closed teeth, muscle tonicity, incontinence of urine and feces, lasting for a few seconds or minutes to relieve. The majority of them do not exceed 15 minutes, but in severe cases, febrile convulsions can occur. Febrile convulsions last for 30 minutes or repeatedly, and those who cannot regain consciousness between 2 convulsions are called convulsive persistence, which is a critical manifestation of the disease. Most children fall asleep after the convulsions have stopped, but most children are awake soon after the convulsions and are in good general condition with no neurological signs. In unilateral or restricted convulsions, some may develop Todd’s palsy and transient weakness of the affected limb after convulsion cessation, which can return to normal within 24 hours.
The diagnosis of febrile convulsions should be noted according to different age, season, medical history and temperature, type, and state of consciousness at the time of convulsions. The present medical history, personal history, family history, etc. should also be inquired promptly, with special attention to the presence of past febrile convulsions, epilepsy, etc. During the physical examination, it is best to witness the convulsive seizure and also to observe the vital signs, skin for bleeding spots, petechiae, trauma marks, etc. While completing the comprehensive physical examination, focus on detailed neurological examination.
Febrile convulsions are fierce and if not handled properly, they can cause damage to brain tissue, affect intellectual development, and may cause irreversible brain damage to the child, and multiple or repeated seizures can leave serious sequelae inducing epilepsy or even endangering life. It is especially important to collaborate with each other to give timely, appropriate and effective treatment and care.
First-aid care to keep the airway unobstructed
Convulsions should be rescued in situ to save time, the child immediately to the pillow lying flat, head to the side, loosen the clothes button, clear the mouth, nose, throat secretions, to prevent vomit accidental aspiration caused by asphyxia. For children with closed teeth, gauze wrapped mouthpiece and tongue depressor can be placed between the upper and lower molars to prevent tongue bite, and if necessary, tongue pliers can be used to pull out the tongue to prevent the tongue from falling back and blocking the airway causing asphyxia. If necessary, prepare sputum absorbers, tracheal intubation and other appliances to give sputum, and operate gently to avoid damage to the respiratory mucosa, which can also reduce the occurrence of convulsions.
Improve tissue hypoxia
Poor breathing during convulsions, combined with increased oxygen consumption, leads to tissue hypoxia. The degree and duration of hypoxia have a certain influence on the occurrence and prognosis of convulsive brain injury, so regardless of cyanosis, high concentration oxygen should be given immediately to improve blood oxygen concentration, reduce cerebral edema, and improve brain cell hypoxia. In order to avoid the stimulation of nasal catheter to aggravate the convulsion, we often give oxygen by face mask with the oxygen flow rate of 2~4L/min until the symptoms are relieved, and also to avoid the respiratory mucous membrane damage.
Establishing intravenous access
The medical staff should be quick and agile, methodical in the process of resuscitation, accurate establishment of intravenous access and keep it open, which is conducive to the use of anti-convulsant drugs, is a favorable guarantee to stop convulsions, and is also an important link to obtain successful resuscitation. Most children come to the hospital for emergency treatment because of convulsions, and the successful puncture technique of the nurse is required. It is best to apply the indwelling needle to choose a thick and straight easy-to-fix vein to facilitate the implementation of therapeutic measures such as the use of emergency drugs antibiotics, dehydrating agents and maintenance of water-electrolyte balance, and to record the time and dose of drugs in a timely and accurate manner after the use of drugs to provide a good basis for the repeated use of drugs in the future.
Stopping convulsions
Convulsions should be actively sought and treated when the cause of the attack, and the condition should be controlled as soon as possible with timely, accurate and effective use of sedatives and anti-convulsants. First, in the temporary lack of drugs to take emergency measures, finger pressure or acupuncture, acupuncture points such as Renzhong, Hegu, Baihui, etc. both simple and effective 2-3 minutes to stop the shock, pay attention not too hard to avoid damage to the skin. Secondly, on the basis of establishing intravenous access, anticonvulsant drugs with fast action, low toxicity and less impact on respiratory and circulatory functions are given quickly.
Diazepam (Valium) is the drug of choice for convulsions and is effective for all types of seizures, especially for the persistent state of convulsions. The dose is 0.3-0.5 mg/kg each time, the maximum amount of infants not more than no more than 5 mg/kg times, young children not more than 10 mg/kg, intramuscular injection or diluted and slowly IV, the speed should be less than 1 mg per minute, too fast can inhibit breathing, blood pressure decreased. 5 minutes to take effect, but the effect is short, if necessary, 15-20 minutes can be repeated.
Phenobarbital sodium is the drug of choice in neonatal convulsions, 10mg/kg intravenously, with a daily maintenance dose of 5mg/kg for a long duration of action. This drug has a longer anticonvulsant maintenance time, but the side effects are smaller than diazepam, and can be repeated once in 4-6 hours if necessary.
10% chloral hydrate 0.5ml/kg each time, the maximum amount at a time is not more than 10ml, administered by gastric tube or with equal amount of saline retention enema, the effect is faster, repeated once in 30 to 60 minutes if necessary.
Fever control
High fever can cause metabolic disorders and disorders of various functional systems, so temperature control is an important measure to prevent recurrent convulsions and complications, so the child with high fever convulsions should lower the body temperature as soon as possible, so that the body temperature is controlled below 38 ℃, and the child with high fever should be instructed to rest in bed absolutely, and all treatment and nursing operations should be carried out gently and centrally to minimize some unnecessary stimulation. And should choose appropriate cooling measures according to the condition, of which physical cooling, drug cooling, intravenous cooling is the most basic cooling methods.
1.Physical cooling
When the body temperature exceeds 39.5℃, place an ice bag or cold towel on the head, loosen the wrapping, encourage the child to drink more water, enter a high-calorie, high-protein, high-vitamin diet, and give patient feeding for a few times to let it cool down naturally. And use warm water to scrub the neck, axilla, groin of the large blood vessels, when the body temperature drops to 38.5 ℃ stop scrubbing or give 28 ~ 32 ℃ cold saline clean enema.
2.Drug cooling
If the above cooling effect is not good, you can use drugs to cool down the temperature according to medical advice. Oral administration, acetaminophen 15mg/kg once or ibuprofen 10mg/kg once, can be repeated once in 4-6 hours when the body temperature is repeated, for those who can not be taken orally, choose anal administration.
3.Liquid cooling
In case of good cardiac and renal functions, giving sufficient fluid 70-90ml/kg each time can not only correct the metabolic disorder but also replenish the required energy and facilitate the excretion of metabolites and bacterial toxins [1], so that the body temperature can drop smoothly to the normal range.
Application of dehydrating agents
The body in the state of convulsive hypoxic stress, due to endocrine changes can cause a decrease in dilute blood sodium, coupled with cerebral edema to depolarize brain cells and reduce the threshold of convulsions to convulsions. Frequent and recurrent convulsions are often complicated by cerebral edema, so intravenous pressurized sedative dehydration is often required to reduce intracranial pressure and control cerebral edema. Commonly used 20% mannitol 1 ~ 2g/kg rapid static drip, if necessary 6 hours can be repeated application. As well as dexamethasone to lower the cranial pressure, add diuretics if necessary, and carry out etiological treatment at the time of resuscitation, and give antibiotics to correct acidosis.
Nursing measures to do basic care
Keep the environment comfortable, quiet, fresh air, appropriate temperature and humidity, room temperature at 24-26℃, relative humidity of 65% is appropriate. All treatments and care should be centralized as much as possible, and the operation should be gentle to reduce the moving of the child and avoid unnecessary stimulation.
Oral and skin care
Do oral care, twice a day, scrub the mouth with saline or 1:5000 furacilin cotton balls to keep the oral hygiene and promote appetite. Children with high fever will sweat a lot during the cooling process, and skin rashes will easily appear. Change clothes in time to prevent cold and skin infection. Change the bedding in time for vomiting and incontinence. Turn the comatose child regularly to strengthen the massage of the pressure area, and if necessary, use an air mattress to prevent pressure sores from occurring and prevent skin breakdown causing infection. Children with high intracranial pressure should be turned axially, with the head elevated by 15° to 30° to avoid neck distortion.
Nutrition
Correctly assess the child’s temperature status and nutritional status. Encourage more water or choice of preferred juice for awake children, and eat a light, easily digestible, high-calorie diet (high-calorie food is prohibited in the case of hyperthermia). In case of convulsions, fast temporarily and feed after the condition has stabilized. When sweating a lot, attention should be paid to salt supplementation. Gastric tube can be inserted for nasal feeding or intravenous high nutrition if the patient is confused.
Observation of disease condition
Observe the child’s body temperature, blood pressure, respiration, pulse, consciousness and pupil changes, and notify the doctor if early symptoms of cerebral edema are detected. Pay attention to the type of convulsion, characteristics of the convulsion, the number of times and intervals, especially the recovery of sanity after the convulsion is relieved, the color of the skin, the special smell of the mouth, etc., and make nursing records, and report any abnormalities to the doctor immediately so that emergency resuscitation measures can be taken.
Prevention of trauma
During convulsions, place gauze in the child’s hands and under the armpits to prevent skin abrasion. When the teeth are tightly closed, do not pry them open to avoid damaging them. Install bedside protection rails to prevent the child from falling out of bed. Beds with rails should have quilts placed at the rails to prevent the child from being injured during a convulsion, and remove all hard objects from the bed to avoid injury. If the child falls to the ground during a convulsion, you should rescue the child in place, remove hard objects that may hurt the child, do not forcefully pull or press the child’s limbs to avoid fractures or dislocations. The children who are likely to have convulsions should be guarded by someone to prevent injuries during the seizure.
Psychological guidance and health education
The febrile convulsions often cause extreme panic among parents. The medical staff explains the causes, treatment and prognosis of the convulsions to the parents and patiently answers their questions to reduce or eliminate the tension. Parents are told that children with febrile convulsions may have convulsions in the future when they have fever, and the recurrence rate is 35% [3], so that they know that controlling body temperature is the key to preventing convulsions, and they are taught how to observe changes in body temperature and recognize early manifestations and signs of elevated body temperature in a timely manner, such as the child’s mental agitation, chills, chilled extremities, and increased respiration, which are mostly manifestations of rising body temperature, and how to use physical and pharmacological cooling The method. Demonstrate the methods of first aid in case of convulsions, such as pressing the acupuncture points of Renzhong and Hegu to maintain sedation, and transfer the child to the nearest hospital as quickly as possible when the convulsions are relieved. Let parents understand that transient disorders of consciousness generally do not cause major damage to the child’s brain and do not require preventive medication after discharge. However, parents need to always have cooling medications and anticonvulsant medications at home, and correctly grasp the dosage and usage of the medications, and take them in a timely manner when the fever is present to prevent the recurrence of convulsions by preventive administration. The use of antipyretic drugs to prevent insufficient doses of drugs, vomiting after taking the drugs, incorrect antipyretic bolus technique, etc. can not achieve the purpose of reducing fever, while observing the effect of using the drugs to achieve the purpose of cooling as soon as possible. Children with epilepsy should take their medication on time and should not stop taking it without permission. The child and parents should communicate frequently to relieve their anxiety and low self-esteem and to build confidence in overcoming the disease. We also emphasize the importance of regular outpatient visits, adjusting medication according to the condition, and actively cooperating with treatment.