Tema: Sindromul febril şi convulsiile febrile

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Febrile syndrome and febrile convulsionsDepartment of pediatrics


Febrile syndrome


The central temperature of human beings is, as in another animals with warm blood, a constant, which is naming homeothermia, in contrast with that of animals with cold blood (fish, reptiles, etc.) which is variable.Generalities


Homeothermia results from equilibrium between warmth production, or thermogenesis (alimentation, physical exercise…), and the means to combat it, or thermolysis (more or less abundant sweating, water intake). There are, however, variations of central temperature during one day by 0,6ºC, the most decreased temperature being registered in morning and the most increased evening.


It’s important to memorize that, normally, the children seems to have a temperature slightly more that the normal temperature of adults, and can sometimes achieve until 38ºC, and even 38,5ºC in evening.


Insufficient thermoproduction. Incapacity to increase the thermic losses in the case of hyperthermia and the thermoproduction in the case of overcooling. Incapacity to present a typical febrile reaction (caused by insufficient sensibility of hypothalamic neurons to the pyrogenic leucocytary substances and increased concentration of arginin-vasopressin which decreases the body temperature). Only at the age of 2-3 years the circadian rhythm of body temperature is installing in children.The thermic metabolism in newborns


The forms and basic mechanisms of body t0 increasingWe speak about fever when the body temperature is mai more than 38°C. A febrile sensation can appear when the temperature exceeds the medium normal value of 37°C. The febrile state appears when the function of de thermoregulation centers from hypothalamus is not disturbed, but under the action of pyrogenic substances (exogenous – lipopolysacharides, or endogenous – macrophages, granulocytes, neutrophils, eosinophils, in consequence of phagocytosis the genetically determined “point of body t” (set point) is changing. The febrile states have a positive biologic character of organism defense.


hyperthermic reaction (tº higher than 38,0 – 38,50 C), which appears on the background of disturbance and decompensation of thermoregulation mechanisms function (intensifying with metabolism decompensation, pathological disorders of thermoregulartion centers. The hyperthermic reactions are often met in pediatric practice, especially in neuroinfections, different viroses etc. and have not biologic sense for organism. They have only pathologic character. The forms and basic mechanisms of body t0 increasing (cont.)


Hyperthermia corresponds to central body temperature increasing provoked by thermogenesis increasing, in the time of some intense muscular exercise, for example, and/or diminishing thermolysis, having a connection with very high exterior temperature, diminishing of sweating and/or insufficiency of hydric intakes (overheating, dehydration, etc). The forms and basic mechanisms of body t0 increasing (cont.)


Due to hyperthermia all forms of metabolism are decompensating, the endogenous intoxication of organism increases(cascade of intermediary metabolits), the disorders of vital centers – respiratory and cardiovascular are observed, the convulsions appear, the cerebral edema increases. The hyperthermic reactions are not stopping with antipyretics, but the physical methods are useful: frictions of body with wet gauze and ensuring of local hypothermia in the region of head and magistral vessels (towels, wet swaddling clothes etc).


Etiology of feverInfectious causes Bacterial infections Mycoplasma Chlamidias Parasitoses Mycoses etc.


Noninfectious Immunopathological (collagenoses, systemic vasculites, allergies) Tumors (lymphogranulomatosis, lymphomas, neuroblastomas) Intracranial traumas Hemorrhages Endocrine diseases Vaccination Malignant hyperthermia etc.Etiology of fever (cont.)


Subfebrile (until 380C) Moderated fever (38,10C – 39,00C) High fever (39,00C - >) Hyperpyrexia (more than 410C)Levels of fever


Continuous fever– oscillation in 24 hrs no more than 10C (abdominal typhus) Remittent fever- oscillation in 24 hrs more than 10C (virotic and bacterial infections) Irregular or atypical fever– oscillations are irregular– the most frequent form of fever in different pathologies Hectic fever– correlation between remittent and irregular fever with oscillations more than 2-3 0C Intermittent fever– short periods of high temperature which correlates with the periods of physiological temperature (tuberculosis, purulent diseases) Recurrent fever– the alternation of febrile crisis in the time of 2-7 days with the periods of apyrexia by 1-2 days is characteristic (malaria).Thermic curves


Circulator system: pulse increasing with 8-10 beats at fever increasing with 1 degree. In the cases of long – term febrile states and manifested with high values the collapse, cardiac failure, DIC syndrome are determining. Nervous system: fatigue, headache, delirium, insomnia or somnolence. Clinical signs


Clinical signs (cont.)Respiration – in the first phase of fever the frequence of respiration decreases, then increases with 4 respiratory movements at each degree of fever. In the same time, the volume of respiration not increases, but even decreases being the cause of hypoxia appearance as pathogenetic mechanism of affection in fever. The digestive system is characterizing by motory and fermentative activity decreasing, gastric juice acidity decreasing.


Management The diagnosis is performing on the base of thermometria, clinical manifestations of basic disease and routine paraclinical examinations. The treatment includes the following measures: Diet Physical methods of cooling Using of antipyretics


Febrile convulsions


The peculiarities of nervous system in early age childrenThe immaturity of cellular elements and nervous fibers, which determine a diffuse affection of brain. Increased sensibility to noxious factors and decreased excitability threshold, which can provoke the convulsive status. Increased hydrophylia of nervous tissue which contributes to rapid development of cerebral edema. Intolerance of CNS to the immune system, which conditions the appearance of anticerebral autoantibodies in the case of hematoencephalic barrier affection. Plasticity and high compensatory possibilities of the brain.


The convulsions are paroxystic or rhythmic or saccadated muscular contractions, enclosed in tonic, clonic or tonico-clonic crises. The convulsions can have epileptic and nonepileptic (occasional) origin. The seconds are released by intercurrent events (fever, metabolic disorders, neuroinfections etc.). Definitions


They represent a critical disorders which appear in children between 6 months and 5 years, in association with fever, but without the signs of intracranian infection and without afebrile crises in antecedents. The majority of crises, until 90%, appear before 3 years age, with the incidence peak at 15 months. Febrile convulsions


Infections of nervous system. The fever can act as a trigger factor of convulsions. Febrile convulsions, as expression of some genetic predisposition connected with the age.The causes of febrile convulsions


Most frequently, the crises of febrile convulsions follow the virotic infections ofrespiratory tract, severe gastroenteritis caused by Shigella or another infections which provoke minimal fever by 37,80 – 38,5 0C. The crises appear usually with the first episode of fever or are the first symptom of fever manifestation in 25 – 42% of cases.


International classification of epilepsies, epileptic syndromes and critical disordersLocalized crises (focal, partial): I.1. Idiopathic (primary) I.2. Symptomatic (secondary) I.3. Criptogenic Generalized crises: II.1. Idiopathic II.2. Symptomatic II.3. Criptogenic or symptomatic Undetermined syndromes(with focal character or generalized undetermined): neonatal crises, myoclonic severe epilepsy of the child, acquired epileptic aphasia , epilepsy with peak – wave complexes continues in the time of sleeping. Special syndromes (situational, occasional crises).


Tonic crises– sudden disturbance of consciousness, hypertonia of axial musculature with the members in extension, apnea, perioronasal cyanosis, contracture of masseters, revulsioned eyes; Tonico-clonic crises are characterizing by tonic phase with duration of10-12 seconds, followed by clonic phase with muscular symmetrical and bilateral clonus, with short relaxations during until 2 minutes, the tongue wounding can appear, sanguinolent foam, elimination of urine and stools; the resolutive phase is characterizing by postcritical coma with ample, noisy respirations, bilateral midriasis; Atonic crises – sudden loss of muscular tonus during one or a few seconds, sudden falling of the head on the chest. Clinical manifestations


Clinical manifestations (cont.)Loss of consciousness authenticated by ocular revulsion . Neuro-vegetative disorders – respiratory, vasomotory (accesses of pallor), rhythm irregularities, cyanosis.

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Last Updated: 8th March 2018

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