Anoxic brain injury
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Transcript of Anoxic brain injury
Elinor A. Graham MD
University of Washington
Seattle, WA , USA
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
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)
Causes in Infants/ChildrenPerinatal ComplicationsDrowningHead Injury: cerebral edema and increased ICP cut
off brain circulationStrangulation or chokingRespiratory Arrest
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
Perinatal Causes of Hypoxia/AnoxiaAntepartum conditions
Maternal severe anemia, hypertension or severe hypotension
placental insufficiency Congenital infection or anomalies
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
Postnatal Causes of Anoxia– Congenital heart disease– Prematurity – Seizures with episodes of apnea– Severe circulatory insufficiency
– acute blood loss, – septic shock
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
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
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
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
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
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
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
Finger feeding
Supplemental Nursing System
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
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
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