Asphyxia of the newborn

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Asphyxia of the newborn
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Hellou !
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Definition

• WHO Asphyxia is incapacity of newborn to begin
  or to support of spontaneous respiration after
  delivery due to breaching of oxygenation during
  labor and delivery
• India Asphyxia is absent or ineffective
  respiration of newborn of 1 minute old with Apgar
  score less than 4

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Definition

• Great Britain Asphyxia is critical insufficiency
  of oxygen in fetus during delivery so severe that
  leads to development of metabolic acidosis and
  depression of spontaneous respiration

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Definition

• Canada Asphyxia is breach of gas exchange when
  hypoxia and hypercapnia, and considerable
  metabolic acidosis occur

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Definition

• Australia Asphyxia is a state with
• mother has complications in perinatal period that
  decrease provision with oxygen and leads to
  acidosis
• functional violation minimum 2 organs due to acts
  of acute hypoxia

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Definition

• Ukraine Asphyxia of newborn as a nosological
  form is conditioned by causes when fetus out and
  find (connect) with severe maternal-placental and
  (or) umbilical flow leads to increasing of oxygen
  approach to fetus tissue and hypoxia development

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Definition
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Asphyxia

• Asphyxia means to be pulse less, but more useful
  is a definition of impaired or interrupted gas
  exchange.
• These situations can take place
• a. Intrauterine the gas exchange depends on the
  function of placenta, and the blood-flow in the
  umbilical vessels.
• b. Intrapartum
• c. Postnatal after delivery the gas exchange
  takes place in the pulmonary vesicles or alveoli
  and depends on the function of the heart, lungs
  and brain.

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Causes of Asphyxia

• Fetal hypoxia
• Mother hypoventilation during anesthesia,
  cyanotic heart disease, respiratory failure or
  carbon monoxide poisoning.
• Low maternal blood pressure as a result of the
  hypotension that may compression of the vena cava
  aorta by the gravid uterus
• Inadequate relaxation of the uterus to permit
  placental filling as a result of uterine tetany
  caused by excessive administration of oxytocin
• Premature separation of the placenta placenta
  previa
• Impedance to the circulation of blood through the
  umbilical cord as a result of compression or
  knotting of the cord
• Uterine vessel vasoconstriction by cocaine,
  smoking
• Placental insufficiency from numerous causes,
  including gestosis, eclampcia, toxemia,
  postmaturity
• Extremes in maternal age (lt 20 years or gt35
  years)
• Preterm or postterm gestation.

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Causes of Asphyxia

• Intrapartus asphyxia
• More frequently inadequate obstetric aid
• Using focerps, vacuum extraction, cresteller,
  cesaring cection
• Trauma narrow pelvis, presentation
• Extremely rapid or prolonged labor
• Multiple gestation
• Drags depression of CNS anaesthesia, sedatics
  analgetics
• Meconium stained amniotic fluid

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Causes of Asphyxia

• Postnatal hypoxia
• Anemia severe enough to lower the oxygen content
  of the blood to a critical level due to severe
  hemorrhage or hemolytic disease
• Shock severe enough to interfere with the
  transport of oxygen to vital cells from adrenal
  hemorrhage, intraventricular hemorrhage severe
  enough to age, overwhelming infection or massive
  blood loss
• A deficit in arterial oxygen saturation resulting
  from failure to breathe adequately postnatally
  due to a cerebral defect, narcosis, or injury
• Failure of oxygenation of an adequate amount of
  blood resulting from of cyanotic congenital heart
  disease of deficient pulmonary function

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Gas exchange.
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Cell pathology
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Cell pathology
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Cell pathology
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Cell pathology
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Cell pathology
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Cell pathology
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Heart rate, breath movements and blood pressure
in fetus during primary and secondary apnea
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Virginia Apgar
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Apgar Score of the Newborn

• SIGNSCORE 0 1
  2
• Heart rate Absent lt100 beats/min gt100
  Respiratory
• effort Absent Weak,irregular Strong
  cry
• Muscle tone Flaccid Some flexion Well
• Reflex irritability (response to catheter in
  nostril)
• No Grimace
  Cough or sneeze
• Skin colour Blue, pale extremities blue pink

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CRITERIAS OF SEVERE ASPHYXIA

• Severe metabolic or mix acidosis pH 7.00 in
  arterial blood of umbilical vessels
• Assessment by Apgar is 0-3 during more than 5
  minutes
• Neurological symptoms such as general
  hypotonic, lethargy, coma, seizures
• Damage of vital organs (lungs, heart and other)
  in fetus or newborn

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Acute complications associated with Asphyxia

• hypotension
• hypoxic encephalopathy
• seizures
• persistent pulmonary hypertension
• hypoxic cardiomyopathy
• ileum and necrotizing enterocolitis
• acute tubular necrosis
• adrenal hemorrhage and necrosis
• hypoglycemia
• polycytemia
• disseminated intravascular coagulation

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Brain Edema
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Periventricular leukomalacia
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Morphologic substrate of Cerebral palsy due to
Asphyxia
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DIAGNOSIS

• Clinical symptoms
• Metabolic derangement
• Renal and/or cardiac failure
• Assessment of the brain
• a.. EEG EEG is useful particulary in the
  asphyxiated term newborn.Serial recordings are
  almost necessary.
• Low voltage. Burst-suppression patterns or
  electrical inactivity are associated with bad
  prognosis.
• Rapid resolution of EEG abnormalities and/or
  normal interictal EEG are associated with a good
  prognosis.
• b. Ultras onography Ultrasound can be useful in
  premature newbomsbut is of more limited value in
  the term newborn.
• c. Computed tomography CT is of major value both
  acutely during theneonatal period and later in
  childhood. The optimal timing of CT scanning
  isbetween 2 and 4 days.

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DIAGNOSIS

• I. Intrauterine assessment
• A. Ultrasound and Doppler technique
• Ultrasound to measure the growth of the fetus.
  For this reason it is important have a reliable
  gestational age. Early during pregnancy an
  ultrasound will be done to date the fetus. This
  method safer than common clinical methods. The
  growth retarded fetus is in a great risk of
  developing asphyxia.
• Doppler techniques to measure the blood flow in
  the umbilical vessels or aorta. A low flow or
  decreasing flow indicates a fetus in risk of
  asphyxia.
• B.Electrofysiological
• Severe pathological fetus heart rate will lead to
  cessation of the delivery with Caesarean section.
• Fetal heart rate Episodes of bradycardia can be
  dangerous and lead to brain damage. The problem
  is to do this type of measurement during long
  periods and on every pregnant woman.
• II. Extrauterine assessment
• C. Biochemical
• - C blood sample drawn from the umbilical artery
  is an ideal way to evaluate whether an
  intrapartum asphyxia exist or not. Low pH (lt 7,
  00) indicates the intrapartum asphyxia.
• PC02 and P02 will also be deranged as you have a
  diminished gas exchange. The low pH is the result
  of an increased level of H and lactate.

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EEG
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ABC resuscitation

• A- Airways (maintenance of passable ness of
  airway)
• B- breathing (stimulation of breathing)
• C- circulation (to support of circulation)
• D-drug

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ABC resuscitation

• Step A- immediately after delivery the infants
  head should be placed in a neutral or slightly
  extended position
• Rolled towel under the shoulders

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Step A- immediately after delivery the infants
head should be placed in a neutral or slightly
extended position
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And airway established by clearing the mouth,
then the nose by rubber bag

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If meconium is present in amniotic fluid, after
sucking of mouth and nose we must suck a pharynx
by tube after laryngoscopes
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If it is inadequate we must use step B. At first
the tactile stimulation should be given to
newborn, for example- gentle flicking of the feet
or heel

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ABC resuscitation

• or rubbing of the back

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If these measures are inadequate, mechanical
ventilation should be initiated, using mask and
bag ventilation
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If ventilation is adequate supplemental oxygen
may be given to improve heart rate or skin colour

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If mechanical ventilation does not improve the
respiration, heart rate or colour skin, the
following step is C-circulation. At first the
assessment of heart rate is necessary
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If heart rate is less than 60 beats/minute, or
between 60 and 80 beats and is not improving,
cardiac compression is a lower on/third of
sternum

• Chest compressions with two fingers

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ABC resuscitation

• Your big fingers must be lie on the sternum,
  other finder should lie under the back of newborn

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ABC resuscitation

• If heart rate is less then 80 beats per minute
  the cardiac compression should be continued. If
  heart rate is 80 beats per minute or more the
  cardiac compression should be stop .

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Brain death

• The clinical diagnosis of brain death is made on
  the basis of
• - coma manifested by lack of response to pain,
  light, or auditory stimulation
• - apnea confirmed by documentation of failure to
  breathe when pCO2 is greater then 60 mm Hg tested
  by 3 minutes
• - absent bulbar movements and brainstem reflexes
  (including midposition or fully dilated pupils
  with no response to light or pain and with absent
  oculocephalic, caloric, corneal, gag, cough,
  rooting and sucking reflexes, flaccid tone and
  absence of spontaneous or induced movements
  (excluding activity mediated at the spinal cord
  level)

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Different painless is possible
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PROGNOSIS.

• Prognosis is difficult because of the inability
  to establish the precise extent and duration of
  cerebral insult and injury. At the time of
  delivery low delayed Apgar scores between 0 and 3
  at 10, 15 and 20 minutes' of age are associated
  with significantly increased mortality and
  morbidity, e.g. cerebral palsy. The single most
  useful prognostic factor is the severity of the
  neonatal neurological syndrome.

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HI brain injure is the most impotent consequence
of perinatan Asphyxia

• Leads to increase lactate, fall in pH, ?ATP, ?
  glucose utilization, loss of cerebrovascular
  autoregulation
• Impairs ion pumps with accumulation Na,Cl,H2O, Ca
  intracellularly
• ? amino acid neurotransmitters (glutamate,
  aspartate)
• Generation of free radicals leukotriens wich
  they overwhelm endogeneous scavenger mechanism
• Damage nucleic acids, lipids proteins

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HIE
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Birth Trauma
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Development of the CNS
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Development of the CNS
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Development of the CNS
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Development of the CNS
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Birth trauma

• The term Birth trauma is used to denote
  mechanical and anoxic trauma incurred by the
  infant during labor and delivery.

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Birth trauma

• The incidence of B.T. has been estimated at 2 7
  per 1000 live births. Overall 5 - 8 per 100000
  infants die of B.T. and 25 per 100000 die of
  anoxic injuries.
• Some injuries may be latent initially but later
  result in severe illness or squealed

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Birth trauma

• The process of birth is blend of compressions,
  contractions, and tractions.

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Birth trauma

• When fetal size, presentation, or neurological
  immaturity complicate this event, such
  intrapartum forces may lead to tissue damage,
  edema, hemorrhage or fracture in the neonate.

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Birth trauma

• The use of obstetrical instruments may further
  amplify the effect of such forces or may induce
  injury by itself.
• Although breech presentation carries the
  greatest risk of injury, delivery by cesarean
  section does not guaranteed an injury free
  infant.

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The risk of birth injury

• Primiparity
• Small maternal stature
• Maternal pelvic anomalies
• Extremely rapid
• Prolonged labor
• Deep transverse arrest of descent of presenting
  part of fetus
• Oligohydramnions
• Abnormal presentation (i.e. breech)

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The risk of birth injury

• Use of mid-forceps or vacuum extraction
• Cesarean section
• Versions and extraction
• Very low birth weight infant or extreme premature
  
• Postmature infant (gt 42 week of gestation)
• Fetal macrosomia
• Large fetal head
• Fetal anomalies (see teratoma)

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Teratoma
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Classification of birth injuries

• I. Soft-tissue injuries
• - caput succedaneum
• - subcutaneous and retinal hemorrhage, petechia
• - ecchymoses and subcutaneous fat necrosis

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Classification of birth injuries

• II. Cranial injuries
• cephalohematoma
• fractures of the skull

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Classification of birth injuries

• III. Intracranial hemorrhage
• subdural hemorrhage
• subarachnoid hemorrhage
• intra- and peryventricular hemorrhage
• parenchyma hemorrhage

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Classification of birth injuries

• IV. Spine and spinal cord
• fractures of vertebra
• Erb-Duchenne paralysis
• Klumpke paralyses
• Phrenic nerve paralyses
• Facial nerves palsy

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Classification of birth injuries

• V. Peripheral nerve injuries
• VI. Viscera (rupture of liver, spleen and
  adrenal hemorrhage)
• VII. Fractures of bones.

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Birth trauma
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Birth trauma

• Petechiae and ecchymosis are common
  manifestation of birth trauma in the newborn. If
  the etiology is uncertain, studies to rule out
  coagulation disorders or infections etiology are
  indicated. This lesions resolve spontaneously
  within 1 week. Petechiae of the skin of the heard
  and neck are common. All are probably secondary
  to a sudden increase in intrathoracic pressure
  during passage of the chest through the birth
  canal. Parents should be assured that they are
  temporary and result of normal hazards of
  delivery.

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Birth trauma

• Subcutaneous fat necrosis. Although not
  detectable et birth this irregularly shaped, hard
  no pitting, subcutaneous plagues with overlying
  dusky, red purple discoloration may by caused
  by pressure during delivery. They appear during
  the first 2 weeks of life usually in large babies
  on the cheeks, arms, back, buttocks end thinks.

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Birth trauma

• Caput succedaneum is a subcutaneous
  extraperiosteal fluid collection with poorly
  defined margins it may extend across the midline
  over suture lines end is usually associated with
  heat molding the soft tissue edema will usually
  resolve over the few days post partum.

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Birth trauma

• Cephalohematoma is a subperiosteal collection of
  blood secondary to rupture of the blood vessels
  between the scull and pereostium, its extent will
  be delineated by suture lines over days. The
  extent of hemorrhage may be severe enough to
  present as anemia and hypotension with secondary
  hyperbilirubinemia. It may be a focus of
  infection leading to meningitis, particularly
  when there is a concominant skull fracture. Skull
  X-rays should be obtained if there are CNS
  symptoms, if the hematoma is very large or if the
  delivery was very difficult. Resolution occurs
  over 1 to 2 month, occasionally with residual
  calcification as a thrombus.

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Birth trauma

• INTRACRANIAL HEMORRHAGE occur in 20 to more
  than 40 of infants with birth weight under 1500
  gm but is less common among more mature infants.
• Intracranial hemorrhage may occur in the
  subdural, subarachnoid, intraventricular or
  intracerebral regions. Subdural and subarachnoid
  hemorrhage follow head trauma e.g., in breech,
  difficult and prolonged labor and after forceps
  delivery. Other forms of intracranial bleeding
  are associated with immaturity and hypoxia. With
  better obstetric care intracranial bleeding has
  become rare.

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Predisposing factors of IVH

• premature
• respiratory distress syndrome
• hypoxic ischemic or hypotensive injuries
• reperfusion of damaged vessels
• increased venous pressure
• pneumothorax
• hypervolemia, hypertensia

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The etiologic factors with IVH in
low-birth-weight infants (Intravascular inflow
factors)

• impaired autoregulation
• seizers
• manipulation with infant
• infusion of hyperosmotic solutions
• rapid colloid infusion
• apnea
• presents of patent ductus arteriosus
• hypertension and use of ECMO

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The etiologic factors with IVH in
low-birth-weight infants (Intravascular outflow
factors)

• respiratory distress
• pneumothorax
• congestive heart failure
• continuous positive airway pressure
• labor/delivery
• acute angle of the internal cerebral vein

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The etiologic factors with IVH in
low-birth-weight infants (Vascular and extra
vascular structural factors)

• normal regression of germinal matrix
• relatively large blood flow to deep cerebral
  structures
• hypoxic-ischemic injury to germinal matrix or its
  vessels
• present of fibrinolitic enzymes
• poor structural support of germinal matrix
  vessels
• abrupt termination of media in arteries proximal
  to germinal matrix

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Clinical manifestation IVH

• Absent Moro reflex
• Poor muscle tone
• Lethargy
• excessive somnolence
• Pallor or cyanosis
• Respiratory distress
• DIC
• Jaundice

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Clinical manifestation IVH

• Bulging anterior fontanel
• Hypotonia
• Weakness, seizures, muscular twitching
• Temperature instability
• Brain stem signs (apnea, lost extraocular
  movements, facial weakness, abnormal eye sing)

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Laboratory correlates of blood loss

• Metabolic acidosis
• Low hematocrit
• Hypoxemia, hypercarbia
• Respiratory acidosis
• Thrombocytopenia and prolongation of protrombin
  time (PT) and partial thromboplastin time (PTT)

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Diagnosis IVH

• History
• Clinical manifestation
• Transfontanel cranial ultrasonography
• Computed tomography
• Glucose level
• Coagulogramma, hematocrit
• Lumbal punction

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Outcomes and prognosis

• Patients with massive bleeding have a poor
  prognosis. About 10-15 infants may develop post
  hemorrhagic hydrocephalus and chronic
  neurological pathology

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Spinal cord

• Strong traction exerted when the spine is hyper
  extended or when the direction of pull is
  lateral, or forceful longitudinal traction on the
  trunk while the head is still firmly, engaged in
  the pelvic, especially when combined with
  flections and torsion of vertical axis, may
  produce fracture and separation of the vertebra.
  Tran section of the cord may occurs with or
  without vertebral fractures

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Clinical data

• Areflexia
• Loss of sensation
• Complete paralysis of voluntary motion below the
  level of injury
• Epidural hemorrhage
• Apnea

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Delivery room

• If cord injury is suspected, effort in the
  delivery room should immediately focus on
  resuscitation and prevention of further insult.
• The head should be made immobile relative to the
  spine and secured on a flat, firm surface with
  padding of pressure points.

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Duchenne-Erb paralysis

• Injury to the 5th and 6th cervical nerves
• Affected arm is adducted, internally rotated
• Forearm is in pronation
• Wrist is flexed
• Arm falls limply to the side of the body when
  passively adducted
• Moro, biceps and radial reflexes absent

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Cervix injury
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Klumpkes paralysis

• injury to the 7th and 8th cervical and 1st
  thoracic spinal nerves
• Horner syndrom (ipsilateral ptosis and miosis) if
  the thoraxic spinal nerve is involved
• Absent of movements of the wrist

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Phrenic nerve palsy

• Injury to the C3,C4 or C5
• Brachial plexur injury
• RDS
• Paradox (upward) movement during inspiration

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Clavicular fracture

• Most common
• Crepitus, palpable bony irregularity
• sternoclaidomastoid muscle spasm
• Cry during movement of upper extremities

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Long bone injures

• Loss of spontaneous arm or leg movement is
  usually the first sing of humeral or femoral
  injury, following by swelling and pain on passive
  motion

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Intraabdominal injures target organ

• Liver
• Spleen
• Adrenal gland (breach presentation)

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Intraabdominal injures

• Sudden presentation
• Shock
• Abdominal distension
• Bluish discoloration, jaundice, pallor
• Poor feeding
• Thachypnea, tachycardia
• history difficult delivery

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HIE

• Selective necrosis of the neurons of the deeper
  cerebral cortical layers is the hallmark of
  hypoxic injury to the perinatal brain in
  full-term babies, parasagittal cerebral injury
  occurs as a result of the generalized reduction
  in the cerebral blood flow. In preterm babies,
  the areas of infarction involve the deeper
  periventricular white matter. Neuronal necrosis
  may also entail basal ganglia.

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HIE

• Some of the ischemic infants with encephalopathy
  gradually improve while others deteriorate. If
  not treated promptly, 20 to 30 percent of infants
  with severe ischemia die.

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HIE
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HIE

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HIE
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HIE

• HYPOXIA-ISCHEMIA
• ANAEROBIC GLYCOLYSIS
• ATP
• ADENOSINE ?GLUTAMATE
• ? ?
• HYPOXANTHINE NMDA
• ? RECEPTOR
• XANTHINE ?
• Ca
• LIPASES NITRIC OXIDE
• ? SYNTHASE
• ?ARACHIDONIC INHIBITORS
• ACID
• ?
• FREE RADICALS

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Sarnat

• Level of consciousness
• Neuromuscular control
• Muscle tone
• Posture
• Stretch reflexes
• Segmental myoclonus
• Complex reflexes Suck, Moro, oculovestibular
  tonic neck
• Autonomic function

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Sarnat

• Pupils
• Respirations
• Heart rate
• Bronchial salivary secretions
• Gastrointestinal motility
• Seizures
• EEG
• Duration of symptoms

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Sarnat

• Outcome
• Mild About 100 normal
• Moderate 80 normal abnormal if symptoms more
  than 5 to 7 days
• Severe About 50 die remainder with severe
  sequel

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Sarnat
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Diagnosis.

• A thorough neurological examination combined
  with a careful history is helpful for the
  diagnosis. Ultrasound examination of the brain,
  EEG, intracranial pressure measurement and
  computed scanning arc is valuable.

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EEG
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EEG
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Treatment.

• Prevention of asphyxia remains the most important
  mode of treatment. Careful monitoring of the
  fetus during labor and prompt appropriate
  intervention at the earliest signs of fetal
  compromise is important in preventing perinatal
  asphyxia.
• The rapid responders from anoxia need observation
  in the nursery for only 12 to 24 hours. These
  babies become active, and start accepting feeds
  within a few hours. The slow responders need more
  aggressive management. Both hypoxemia and
  hyperoxemia as well as hypercapnia should be
  circumvented, since they affect cerebral blood
  flow. These babies should be kept in ward, with a
  minimal noise level or in the nursery.
  Intravenous fluids should be restricted to
  two-third of the maintenance requirements and
  blood glucose levels must be maintained at 75-100
  mg/dL. Acidosis, hypocalcaemia and hypoglycemia
  need correction. Seizures should be controlled
  with phenobarbitone but not in preterm babies who
  are severely disturbed and in those with
  decerebration.

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Treatmentcurative and protective regimen in
newborn

• Children with severe A or BT should be undergo
  strict regimen because the rest more frequently
  associated with emergency position if baby
• The infant must lie on the hard surface with
  fixated neck by collar
• The baby is observed in bed or incubator, is not
  washed and sometimes is turned side to side. The
  transport of this infant prohibitive.
• Oxygen (ingalation or mask or apparatus )
• Feeding throught catheter 40-50 daily calories

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Treatmentcurative and protective regimen in
newborn

• Baby with subcompensation of all function must be
  undergo spareing regimen.
• May be washed (in bad)
• Feeding through catheter and spoon. If he can
  suck he may be apply to mother brest
• Common (general) regimen is administrated for
  healthy child or reconvalescents

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Treatment

• Oxygenotherapy
• Hemostatics 1 vit K 1mg/kg, dicinone 12.5 mg/kg
  
• Hypovolemia 5 albumine, plasma, 5 glucose
  1-10 ml/kg
• Protect of nerve cells and anticonvulsants 20
  Natrium-oxybutirate 100 mg/kg, sibazone 0.3
  ml/kg, Phenobarbital 20 mg/kg (5-10)
• 25 Magnesia 0.2 ml/kg

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Treatment (underlying problems associated with BT)

• Hypoglycemia 5 glucose i/v 1-10 ml/kg
• Hypocalciemia10 Ca-gluconate 2 ml/kg
• Acidosis- 4.2 Sodium bicarbonate solution 2
  meq/kg

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Treatment (underlying problems associated with BT)

• RDS
• Hypoxia
• Hypothermia
• Hypotension
• Support cardiac output 0.5 dopamin 5 µg/kg/min
  speed is 1 ml/hour

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seizures
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seizures
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Treatment
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I dont want a trauma