医学精品课件以病程分期為依據之兒童腸病毒重症治療.ppt

以病程分期為依據之兒童腸病毒重症治療 The Stage Based Therapy ofCritically Ill Children with EV 71 Infection  林口長庚兒童醫院 兒童加護科 夏紹軒 吳昌騰 兒童心臟科 黃茂盛 鍾宏濤 兒童神經科 林光麟 王傳育 兒童呼吸胸腔科 黃健燊 兒童感染科 張鑾英 黃玉成 邱政洵 林奏延 A Cardiopulmonary disaster requiring multidisciplinary treatment Outbreaks (1) 民國八十七年五月初 一個一歲兩個月大的小女孩被帶到門診，主訴是 fever with oral ulcers and vesicles on hands, feet and knees. 母親對於小朋友的高燒不退、躁動不安、食慾減退、入睡困難、無力站立非常擔心。 Outbreaks (2) 醫生說：這是典型手足口病症狀，只要吃一些退燒藥，多休息、多喝水就好了。 第二天，小女孩被帶回急診，已經發生意識不清、發紺等症狀，當時，急診醫師為她插上氣管內管，大量粉紅色泡沫狀液體從氣管內冒出。 Outbreaks (3) 小女孩被送到 PICU. 發生心肺衰竭，CPR無效後，被宣布死亡。 此後一個月，共有七名兒童因同一症狀死在本院，醫師立即通報疾病管制局，並發現幾乎全台灣各大醫學中心都有類似案例。 EV 71 Outbreaks Enterovirus type 71 was firstly isolated from the stool of an infant with encephalitis in US in 1969 1975, 44/705 were killed in Bulgaria 1997, 30 were killed in Malaysia 1998, 78 were killed in Taiwan 1999, 8 were killed in Hong-Kong 1998 腸病毒流行之統計 估計約一百萬至兩百萬人口被感染？！ 查有實據者129106人為EV71感染 405人為重症 78人死亡 80%死於肺水腫與肺出血 腸病毒的傳染途徑 飛沫傳染 唾液與呼吸道分泌物在痊癒之後2-3 weeks仍可分離出EV71病毒 糞口傳染 糞便在痊癒之後6-8 weeks仍可分離出EV71病毒 病毒離開人體可存活8小時左右 Skin and Mucosa Lesions Oral ulcers distributed not on soft palate only as typical hand-foot mouth disease Vesicles on hand and foot were smaller (pin-point) than typical HFM disease Sometimes the skin lesion consisted of petechiae-like clusters Phases Based Therapy of Critical EV-71 Infection腸病毒重症之臨床分期 第一期：上呼吸道感染─手足口病 第二期：神經症狀─腦膜腦脊髓炎 第三A期：高血壓—肺水腫出血─自主神經失調 第三B期：低血壓─心臟衰竭？心肌炎？SIRS? 第四期：逐漸恢復─神經後遺症 分期標的 Stage 1: Oral ulcer, skin rash, fever Stage 2: Neurological symptoms myoclonic jerk, limb weakness, seizure, consciousness disturbance Stage 3A: Elevated BP Stage 3B: Decreased BP, use of catecholamines Stage 4: Cessation of catecholamines. Results We observed a majority of patients (58% 14/24) presented different five clinical phases. Two patients developed PE without a HFM prodrome One patient developed PE without previous CNS involvement signs In six patients, hypertension phases were not observed Three patients did not develop hypotens