Anoxic brain injury


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June, 2010 teaching presentation at JFK

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  • Skin peeling at birth and meconium staining are signs of intrauterine lack of oxygen to brain
  • Anoxic brain injury

    1. 1. Elinor A. Graham MD University of Washington Seattle, WA , USA
    2. 2. Case: Neonatal Anoxic Injury <ul><li>Term infant to primi-gravida mother </li></ul><ul><li>Obstructed labor </li></ul><ul><li>Vaginal delivery </li></ul><ul><li>Not breathing, mask/bag ventilation. </li></ul><ul><li>Floppy, no suck/reflex </li></ul><ul><li>Developed fever & seizures in 1 st 24 hours </li></ul><ul><li>Positive malaria smear </li></ul>
    3. 3. Definition <ul><li>Lack of oxygen to the brain due to respiratory or circulatory failure </li></ul><ul><li>Permanent brain damage after 3 minutes </li></ul><ul><li>Death after 4-5 minutes </li></ul><ul><li>Often has other associated organ injury: </li></ul><ul><ul><li>Kidneys (failure to concentrate urine or anuria) </li></ul></ul><ul><ul><li>Liver (elevated liver enzymes/can’t detoxify) </li></ul></ul><ul><ul><li>Intestines (ischemic injury/bloody stools) </li></ul></ul>
    4. 4. Causes in Infants/Children <ul><li>Perinatal Complications </li></ul><ul><li>Drowning </li></ul><ul><li>Head Injury: cerebral edema and increased ICP cut off brain circulation </li></ul><ul><li>Strangulation or choking </li></ul><ul><li>Respiratory Arrest </li></ul>
    5. 5. Epidemiology <ul><li>Neonatal Asphyxia: </li></ul><ul><ul><li>3% of NB require resuscitation </li></ul></ul><ul><ul><li>Globally 900,000 die each year due to asphyxia </li></ul></ul><ul><ul><li>Cause of 15-20% of neonatal deaths in Liberia </li></ul></ul><ul><li>Drownings: </li></ul><ul><ul><li>Globally 200,000 children ages 0-14 die of drowning each year </li></ul></ul>
    6. 6. Perinatal Causes of Hypoxia/Anoxia <ul><li>Antepartum conditions </li></ul><ul><ul><li>Maternal severe anemia, hypertension or severe hypotension </li></ul></ul><ul><ul><li>placental insufficiency </li></ul></ul><ul><ul><li>Congenital infection or anomalies </li></ul></ul>
    7. 7. Intrapartum <ul><ul><li>Interruption of umbilical blood flow </li></ul></ul><ul><ul><ul><li>knot, cord prolapse, cord avulsion) </li></ul></ul></ul><ul><ul><li>Inadequate placental perfusion: </li></ul></ul><ul><ul><ul><li>placental abruption, uterine rupture, abnormal uterine contractions </li></ul></ul></ul><ul><ul><li>Traumatic delivery </li></ul></ul><ul><ul><ul><li>shoulder dystocia, difficult breech extraction </li></ul></ul></ul>
    8. 8. Postnatal Causes of Anoxia <ul><ul><li>Congenital heart disease </li></ul></ul><ul><ul><li>Prematurity </li></ul></ul><ul><ul><li>Seizures with episodes of apnea </li></ul></ul><ul><ul><li>Severe circulatory insufficiency </li></ul></ul><ul><ul><ul><li>acute blood loss, </li></ul></ul></ul><ul><ul><ul><li>septic shock </li></ul></ul></ul>
    9. 9. Signs and Symptoms <ul><li>History of not breathing/need for resuscitation </li></ul><ul><li>Abnormal state of consciousness </li></ul><ul><ul><li>Hyper-alert, irritable, lethargic, obtunded </li></ul></ul><ul><li>Respiratory or sucking problems </li></ul><ul><li>Poor tone, lack of grimace, Moro, rooting, no or weak cry </li></ul><ul><li>Seizures </li></ul><ul><li>Intrauterine Anoxia: peeling of skin at birth and meconium staining </li></ul>
    10. 10. Case: Intrauterine Anoxia <ul><li>Mother in obstructed labor 3-4 days </li></ul><ul><li>Transferred to JFK for C-section delivery </li></ul><ul><li>Infant required mask/bag resuscitation in DR but breathing by 5 min </li></ul><ul><li>Died of respiratory failure from meconium aspiration on day 4 </li></ul>
    11. 11. Prognosis <ul><li>Normal motor function and sucking by 1 week: good prognosis for full recovery </li></ul><ul><ul><li>Subtle increased tone in lower extremities </li></ul></ul><ul><ul><ul><li>Toe walking; hip dislocation in late infancy/toddler </li></ul></ul></ul><ul><ul><li>Learning difficulties in school </li></ul></ul><ul><li>Still floppy tone and cannot suck at 1 week: </li></ul><ul><ul><li>severe brain injury </li></ul></ul><ul><ul><li>will have some impairment </li></ul></ul>
    12. 12. Long Term Prognosis <ul><li>Cerebral Palsy </li></ul><ul><li>Seizures </li></ul><ul><li>Orthopedic problems related to poor muscle tone: hip dislocation, spasticity at ankles/hips </li></ul><ul><li>Poor respiratory effort: tracheomalacia </li></ul><ul><ul><li>Increased susceptibility to pneumonia </li></ul></ul><ul><ul><li>Likely to have significant gastro-esophageal reflux </li></ul></ul><ul><li>Speech and Learning disabilities </li></ul><ul><li>Visual impairment </li></ul>
    13. 13. Immediate Management <ul><li>In the delivery room: good resuscitation </li></ul><ul><li>In the NICU: </li></ul><ul><ul><li>Sniffing position with support under upper back </li></ul></ul><ul><ul><li>Oxygen by nasal cannula & suction </li></ul></ul><ul><ul><li>Bag/Mask resuscitation if O2 saturation drops </li></ul></ul><ul><ul><li>Frequent monitoring of vital signs </li></ul></ul><ul><ul><li>Blood glucose </li></ul></ul><ul><ul><li>Sepsis treatment; consider malaria smear </li></ul></ul>
    14. 14. Management First 1-3 days <ul><li>Adequate ventilation </li></ul><ul><li>Adequate organ perfusion ( urine output, stool output, blood in stools) </li></ul><ul><li>Normal metabolism </li></ul><ul><ul><li>Blood sugar (check q 6 h 1 st day) </li></ul></ul><ul><ul><li>Temperature control (treat fever immediately) </li></ul></ul><ul><ul><li>Nutrition: breast milk by NG tube </li></ul></ul><ul><li>Control seizures </li></ul><ul><li>Control brain edema: avoid fluid overload </li></ul>
    15. 15. Management after 72 hours <ul><li>Establish breast feeding </li></ul><ul><ul><li>Stimulation of palate to encourage sucking </li></ul></ul><ul><ul><li>Finger feeding with syringe/breast milk/palate stimulation </li></ul></ul><ul><ul><li>Feeding at breast with supplemental nursing system until strong enough to suck at breast </li></ul></ul><ul><li>Range of motion exercises/physical and mental stimulation </li></ul><ul><li>Close follow-up in chronic disease clinic </li></ul>
    16. 16. Finger feeding
    17. 17. Supplemental Nursing System
    18. 18. Case Outcomes <ul><li>Severe anoxic injury </li></ul><ul><ul><li>No suck/cry for 1 wk </li></ul></ul><ul><ul><li>Improved week 2 </li></ul></ul><ul><li>Rx for sepsis & malaria </li></ul><ul><li>Seizures treated prn with phenobarbital </li></ul><ul><li>NG tube breast milk </li></ul><ul><li>Finger feeding; then breast feeding on own </li></ul><ul><li>Home at 3 weeks on no meds & full breast feeding </li></ul>
    19. 19. Hypothermia: ? Treatment of the Future <ul><li>Whole body or just head cooling started by 6 hrs of age X 72 hours can decrease the severity of neurologic outcomes </li></ul><ul><li>Body temperature reduced to 33-34.5 degrees </li></ul><ul><li>In severe anoxia, rate of death or outcomes may not be improved </li></ul><ul><li>Arrhythmias and low platelets are complications but not clinically significant </li></ul>
    20. 20. Prevention <ul><li>Neonatal hypoxia </li></ul><ul><ul><li>Prenatal care for 100% of women; preventive Rx for malaria </li></ul></ul><ul><ul><li>Access to improved delivery care </li></ul></ul><ul><ul><li>Essential Newborn Care training of delivery personnel </li></ul></ul><ul><ul><ul><li>Training birth attendants decreased rate of stillbirth and moderately or severely abnormal neurologic findings </li></ul></ul></ul><ul><li>Drowning </li></ul><ul><ul><li>Safe swim areas with lifeguards </li></ul></ul><ul><ul><li>Teaching swimming skills </li></ul></ul>