小児の神経救急の現状

Current Emergency Medicine for Neurological Disorders in Children

はじめに

　少子化・情報化時代の保護者は育児・急病に対する不安が強く，一刻も早い完結医療を求めて時間外の小児救急外来に殺到する^1）。実際，小児の初期救急現場では外来患者の90％以上が受診後に軽症と判断されている^2）。しかし，多くの軽症患者の中に緊急度の高い重症患児が少数ながら存在することは事実であり，それらの重症患児を見逃さずに早期に的確な治療を開始することは小児救急医療に求められる重要な役割の1つである。特に，小児の救急疾患の中でも痙攣，意識障害などの神経症状を主訴とする疾患は生命の危険あるいは重度の後遺症を残す可能性があり，高次施設で複数のスタッフによる全身管理が不可欠で，症例によってはICUでの治療が早期より必要となる^3）。

　京都第二赤十字病院は京都市（人口146万人）のほぼ中央部に位置し，救命救急センターを併設する市内の基幹病院の1つである。当院小児科では単科連日当直体制を組み，地域の中核病院として小児の初期～二，三次救急に対応している。本稿では当科における小児救急診療および小児神経疾患入院患者の実態と後天性脳損傷児のリハビリテーションおよび入院長期化に伴う問題についての検討結果を示すことにより，小児の神経救急の現状報告に代えたい。

Abstract

　In 2006,the number of pediatric outpatients consulting our hospital during non-practice hours increased by 218.1% of that in 1996.　The number of pediatric inpatients during non-practice hours in 2006 increased by 71.3% of that in 1996.　In 2006,the number of patients who were admitted with neurological disorders in children during non-practice hours increased to 213.3% of that in 1996.　The proportion of these pediatric patients among those who were admitted during non-practice hours was 16.6% in our hospital,suggesting the importance of neurological disorders in pediatric emergency medicine.　More than 60% of inpatients with neurological disorders in children were 3 years old or younger.　The most common neurological symptoms observed at admission included convulsion (81.6%) and disturbance of consciousness (8.5%).　The disorders were mainly febrile seizure (41.4%) and epilepsy (29.0%).　Most patients with severe disorders requiring emergency medicine,such as head bruise,acute encephalitis/encephalopathy,purulent meningitis,and head trauma,were admitted during non-practice hours.　The prognoses of most neurological disorders in children were favorable.　However,patients with sequelae (especially,hypoxic encephalopathy,acute encephalitis/encephalopathy) showed an unfavorable neurological prognosis.　Early rehabilitation during admission was useful as a support method for their families.　In the future,a comprehensive rehabilitation program for children with acquired brain injury should be established and laws to promote home care must be passed.