Anoxic brain injury

21
Elinor A. Graham MD University of Washington Seattle, WA , USA

description

June, 2010 teaching presentation at JFK

Transcript of Anoxic brain injury

Page 1: Anoxic brain injury

Elinor A. Graham MD

University of Washington

Seattle, WA , USA

Page 2: Anoxic brain injury

Case: Neonatal Anoxic InjuryTerm infant to primi-

gravida motherObstructed laborVaginal deliveryNot breathing,

mask/bag ventilation.Floppy, no suck/reflex Developed fever &

seizures in 1st 24 hoursPositive malaria smear

Page 3: Anoxic brain injury

DefinitionLack of oxygen to the brain due to respiratory or

circulatory failurePermanent brain damage after 3 minutesDeath after 4-5 minutesOften has other associated organ injury:

Kidneys (failure to concentrate urine or anuria)Liver (elevated liver enzymes/can’t detoxify)Intestines (ischemic injury/bloody stools)

Page 4: Anoxic brain injury

Causes in Infants/ChildrenPerinatal ComplicationsDrowningHead Injury: cerebral edema and increased ICP cut

off brain circulationStrangulation or chokingRespiratory Arrest

Page 5: Anoxic brain injury

EpidemiologyNeonatal Asphyxia:

3% of NB require resuscitationGlobally 900,000 die each year due to asphyxiaCause of 15-20% of neonatal deaths in Liberia

Drownings:Globally 200,000 children ages 0-14 die of drowning

each year

Page 6: Anoxic brain injury

Perinatal Causes of Hypoxia/AnoxiaAntepartum conditions

Maternal severe anemia, hypertension or severe hypotension

placental insufficiency Congenital infection or anomalies

Page 7: Anoxic brain injury

IntrapartumInterruption of umbilical blood flow

knot, cord prolapse, cord avulsion)Inadequate placental perfusion:

placental abruption, uterine rupture, abnormal uterine contractions

Traumatic deliveryshoulder dystocia, difficult breech extraction

Page 8: Anoxic brain injury

Postnatal Causes of Anoxia– Congenital heart disease– Prematurity – Seizures with episodes of apnea– Severe circulatory insufficiency

– acute blood loss, – septic shock

Page 9: Anoxic brain injury

Signs and Symptoms• History of not breathing/need for resuscitation• Abnormal state of consciousness

– Hyper-alert, irritable, lethargic, obtunded

• Respiratory or sucking problems• Poor tone, lack of grimace, Moro, rooting, no or

weak cry• Seizures• Intrauterine Anoxia: peeling of skin at birth and

meconium staining

Page 10: Anoxic brain injury

Case: Intrauterine AnoxiaMother in obstructed

labor 3-4 daysTransferred to JFK for

C-section deliveryInfant required mask/bag

resuscitation in DR but breathing by 5 min

Died of respiratory failure from meconium aspiration on day 4

Page 11: Anoxic brain injury

PrognosisNormal motor function and sucking by 1 week:

good prognosis for full recoverySubtle increased tone in lower extremities

Toe walking; hip dislocation in late infancy/toddler

Learning difficulties in schoolStill floppy tone and cannot suck at 1 week:

severe brain injury will have some impairment

Page 12: Anoxic brain injury

Long Term Prognosis• Cerebral Palsy• Seizures• Orthopedic problems related to poor muscle tone:

hip dislocation, spasticity at ankles/hips• Poor respiratory effort: tracheomalacia

– Increased susceptibility to pneumonia– Likely to have significant gastro-esophageal reflux

• Speech and Learning disabilities• Visual impairment

Page 13: Anoxic brain injury

Immediate ManagementIn the delivery room: good resuscitationIn the NICU:

Sniffing position with support under upper backOxygen by nasal cannula & suctionBag/Mask resuscitation if O2 saturation dropsFrequent monitoring of vital signsBlood glucoseSepsis treatment; consider malaria smear

Page 14: Anoxic brain injury

Management First 1-3 days• Adequate ventilation• Adequate organ perfusion ( urine output, stool

output, blood in stools)• Normal metabolism

– Blood sugar (check q 6 h 1st day)– Temperature control (treat fever immediately)– Nutrition: breast milk by NG tube

• Control seizures• Control brain edema: avoid fluid overload

Page 15: Anoxic brain injury

Management after 72 hoursEstablish breast feeding

Stimulation of palate to encourage suckingFinger feeding with syringe/breast milk/palate

stimulationFeeding at breast with supplemental nursing system

until strong enough to suck at breastRange of motion exercises/physical and mental

stimulationClose follow-up in chronic disease clinic

Page 16: Anoxic brain injury

Finger feeding

Page 17: Anoxic brain injury

Supplemental Nursing System

Page 18: Anoxic brain injury

Case OutcomesSevere anoxic injury

No suck/cry for 1 wkImproved week 2

Rx for sepsis & malariaSeizures treated prn with

phenobarbital NG tube breast milkFinger feeding; then

breast feeding on ownHome at 3 weeks on no

meds & full breast feeding

Page 19: Anoxic brain injury

Hypothermia: ? Treatment of the FutureWhole body or just head cooling started by 6 hrs of

age X 72 hours can decrease the severity of neurologic outcomes

Body temperature reduced to 33-34.5 degreesIn severe anoxia, rate of death or outcomes may not

be improvedArrhythmias and low platelets are complications but

not clinically significant

Page 20: Anoxic brain injury

PreventionNeonatal hypoxia

Prenatal care for 100% of women; preventive Rx for malaria

Access to improved delivery careEssential Newborn Care training of delivery personnel

Training birth attendants decreased rate of stillbirth and moderately or severely abnormal neurologic findings

DrowningSafe swim areas with lifeguardsTeaching swimming skills

Page 21: Anoxic brain injury