Kasus Perdarahan Intrakranial Pada Bayi Baru Lahir

Presented by :Silvia P. Tarigan

Counsellor :H. Tisna Sukarna, dr., SpA, MBA

PATIENT IDENTITY Name : M Rafif Lathif

Age : 1 month old

Sex : Male

Date of hospitalized : January, 16th 2011

Date of examination : January, 16th 2011

Father : Name : Mr. Beni H

Age :36 years old

Education : Senior High School

Occupation :Entrepreneur

Address :

Sukamukti RT 3 RW 5, Katapang Bandung.

Mother : Name : Mrs. Siti M

Age :35 years old

Education : Senior

High School

Occupation : Housewife

Address : Sukamukti RT 3 RW 5, Katapang Bandung.

Heteroanamnesis was given by his mother on January, 16 th 2011

Chief complaint: convulsion

History of present illness:

One day before admission to the hospital patient had convulsion as many as 1 time for 2 minutes The convulsion are not preceded by fever. During the convulsion, suddenly became stiff and uprolling of the eyes for 1 minutes. He had a generalised tonic-clonic convulsion. Before and after the convulsion patient was conscious. Patient’s mother denied any historical information of falling from a baby box.

2 days before entering the hospital, patient experienced vomiting in each breast-feeding time. Patient has not ever cried again since the convulsion.

The big brother of patient had experience the convulsion at the age of 6 months old but was preceded by fever. Patient’s mother stated that when the patient was 1 week old, the baby was ikterik and it has still happened until today. The patient’s mother also said that the baby had not been given Vitamin K injection when the baby was born

Urine: the color, volume, and frequency was normal and no pain when urinate.

Defecation : the color, consistency, and frequency was normal

Medical Effort: 1 day ago went to the midwife and got some medicine.

Past Medical History: the patient never had sick like this before.

History of family illness: The big brother of patient had experience the convulsion at the age of 6 months old but was preceded by fever

Birth History The patient is the 3rd child from 3 children. No

stillbirth and no abortus.

Birth : aterm, spontaneous, directly cry and helped by a midwife.

Birth weight : 3500 grams. Birth length : 52 cm

Physical and Intelligence Development Turn over : - Sitting down : - Standing up : - Talking : - Walking : -

Immunization

VaccineBasic Vaccination

Booster Vaccination

RecommendedVaccination

BCG - - - - HiB : none

Polio - - - - - - MMR : none

DPT - - - - - - Hep A : none

Hep B - - - - - - Varicella : none

Measles - - - - Typhim/typha : none

Influenzae : none

Nutrition and Feeding Breastmilk

Past Illnesses Cough

Family history : Convulsion

General appearance Condition : severe sickness Consciousness : somnolen Activity and position : no force position General condition : weak

Vital signs Pulse : 143 times a minute, regular, equal,

strong

Respiration : 36 times a minute, thoracoabdominal type

Temperature : 35,7 ºC, aksiler

Measuring Weight : 4,9 kg Height : 65 cm (113,95 % standard Weight/Age ) (119,04 % standard Height/Age )

Nutrition status : (standard Weight/Height ) Rumple Leede : (-)

SYSTEMATIC EXAMINATION

4.1. Skin : rash (-), pale (+), icteric (+), turgor was immediately returns to normal position

Head Hair : black, disseminated, not easy to yanked out Fontanel ² : tense Eyes : conjunctiva anemic +/+, conjungtiva

hyperemic -/-, sclera icteric +/+, pupil anisokor (diameter pupil sinistra > dextra), light reflex : -/-

Nose : nostril breathing+/+, secret -/-, epistaxis -/-

Lips : wet, cyanosis + Mouth : moist mucosa Gums : no bleeding, no hyperemic Palate : no disparity Tongue: coated tongue -, hyperemic -, tremor –,

Koplik’s spot – Pharynx and tonsil : hyperemic -, T1=T1

Neck Nuchal rigidity : (-) Lymph node : not palpable

Thorax Lungs Inspection : shape and movement was simetric, right

was equal to left, retractions supraclavicle +

Palpation : vocal fremitus right was equal to left Auscultation : vesicular breath sound +/+, ronchi

-/-, wheezing -/- Heart Inspections : ictus cordis was not seen Palpations : ictus cordis was palpable at ICS 4

linea midclavicularis sinistra

Percussions : border on top ICS 2 linea parasternalis sinistra, border on left ICS 4 linea midclavicularis sinistra, border on right ICS 3 linea sternalis dextra

Auscultations : heart sounds regular, shuffle –

Abdomen : Inspections : flat Auscultations : bowel sound (+) Percussions : tympanic, Traube’s space : tympanic Palpations : , liver 4 cm below arch costarum,

tenderness (-), skin’s turgor was immediately returns to its normal position.

Liver and spleen inpalpable

Genital : male, normal Anus & Rectal: no disparity Extremities : no disparity Upper : left: active, right : active Lower : left: active, right: active Joint : no disparity Muscle : hypertrophy -, atrophy - Neurological Examination Reflex : physiological -/-, pathological +/+

On January 16,2011 On January 17,, 2011

22

Hb : 9,3 gr / dl Ht: 28,0% ↓Leu: 11700 / m3 Tc: 578000/m3 GDS : 94 mg/dl ↑Bilirubin total : 13,91 mg/dl ↑Bilirubin direk : 2,64 mg/dl ↑Bilirubin indirek: 11,2 mg/ dl ↑

Hb : 9,3 gr / dl Ht: 28,0% ↓Leu: 11700 / m3 Tc: 578000/m3 GDS : 94 mg/dl ↑Bilirubin total : 13,91 mg/dl ↑Bilirubin direk : 2,64 mg/dl ↑Bilirubin indirek: 11,2 mg/ dl ↑

Hb : 10,5 mg/dlHt : 32,6 %Leu : 8620/ m3

Tc : 517000/m3

Na : 124 mEq/L ↓K : 4,6 mEq/L

Ureum : 16 mEq/LPT : 11.5 secondaPTT : 30,4 secondFibrinogen : 396 mg/dl

Hb : 10,5 mg/dlHt : 32,6 %Leu : 8620/ m3

Tc : 517000/m3

Na : 124 mEq/L ↓K : 4,6 mEq/L

Ureum : 16 mEq/LPT : 11.5 secondaPTT : 30,4 secondFibrinogen : 396 mg/dl

CT- scan

On 16 January,2011

Trail:

Frontotemporoparietal left subdural haemorrhage is the cause of the shifted midline to the left by 1, 29 cm; and the constriction of the left lateral ventricle. There also appears the hemorrhage of intracerebral in areas right-side frontotemporoparietal.

1 month old boy, with 4,9 kg body weight, 60m body height, nutritional status (standard Weight/Height) came to Immanuel Hospital because convulsion.

One day before admission to the hospital patient had convulsion as many as 1 time for 2 minutes The convulsion are not preceded by fever. During the convulsion, suddenly became stiff and uprolling of the eyes for 1 minutes. He had a generalised tonic-clonic convulsion. Before and after the convulsion patient was conscious. Patient’s mother denied any historical information of falling from a baby box.

2 days before entering the hospital, patient experienced vomiting in each breast-feeding time. Patient has not ever cried again since the convulsion.

The big brother of patient had experience the convulsion at the age of 6 months old but was preceded by fever. Patient’s mother stated that when the patient was 1 week old, the baby was ikterik and it has still happened until today. The patient’s mother also said that the baby had not been given Vitamin K injection when the baby was born

Urine: the color, volume, and frequency was normal and no pain when urinate.

Defecation : the color, consistency, and frequency was normal

Medical Effort: 1 day ago went to the midwife and got some medicine.

Past Medical History: the patient never had sick like this before.

History of family illness: The big brother of patient had experience the convulsion at the age of 6 months old but was preceded by fever.

Immunization profile: the patient haven’t receive all basic immunization.

Nutrition status : (standard Weight/Height)

General appearance Condition : severe sickness Consciousness : somnolen Activity and position : no force position General condition : weak

Vital signs Pulse : 143 times a minute, regular, equal,

strong

Respiration : 36 times a minute, thoracoabdominal type

Temperature : 35,7 ºC, aksiler

Skin : rash (-), pale (+), icteric (+), turgor was immediately returns to normal position

Head Eyes : conjungtiva anemic +/+, sklera ikteric +/+,

light reflex : -/-, pupil anisokor ; diameter pupil sinistra> dextra

Fontanel ² : tense Nose :nostril breathing+/+, secret -/-, Mouth : moist mucosa Tongue : Koplik’s spot – Pharynx and tonsil : hyperemic -, T1=T1

Neck Lymph node : not palpable

Thorax Lungs retractions supraclavicle + vesicular breath sound +/+, ronchi -/-, wheezing -/-

Abdomen

Liver 4 cm below arch costarum

On January 16,2011 On January 17,, 2011

32

Hb : 9,3 gr / dl Ht: 28,0% ↓Leu: 11700 / m3 Tc: 578000/m3 GDS : 94 mg/dl ↑Bilirubin total : 13,91 mg/dl ↑Bilirubin direk : 2,64 mg/dl ↑Bilirubin indirek: 11,2 mg/ dl ↑

Hb : 9,3 gr / dl Ht: 28,0% ↓Leu: 11700 / m3 Tc: 578000/m3 GDS : 94 mg/dl ↑Bilirubin total : 13,91 mg/dl ↑Bilirubin direk : 2,64 mg/dl ↑Bilirubin indirek: 11,2 mg/ dl ↑

Hb : 10,5 mg/dlHt : 32,6 %Leu : 8620/ m3

Tc : 517000/m3

Na : 124 mEq/L ↓K : 4,6 mEq/L

Ureum : 16 mEq/LPT : 11.5 secondaPTT : 30,4 secondFibrinogen : 396 mg/dl

Hb : 10,5 mg/dlHt : 32,6 %Leu : 8620/ m3

Tc : 517000/m3

Na : 124 mEq/L ↓K : 4,6 mEq/L

Ureum : 16 mEq/LPT : 11.5 secondaPTT : 30,4 secondFibrinogen : 396 mg/dl

CT- scan

On 16 January,2011

Trail:

Frontotemporoparietal left subdural haemorrhage is the cause of the shifted midline to the left by 1, 29 cm; and the constriction of the left lateral ventricle. There also appears the hemorrhage of intracerebral in areas right-side frontotemporoparietal.

Differential Diagnosis : Intracranial hemorrhage

Increased in Intracranial Pressure

Sepsis neonatorum

Working diagnosis :Intracranial hemorrhage (subdural and intraserebral hemorrhage)

Additional diagnosis : Anemia, Hiperbilirubin neonatus, hiperglikemia neonatorum

Serial Lumbar Punctures Blood gas analysis CT Scan USG

Quo ad vitam : dubia ad bonam Quo ad functionam : dubia ad bonam

Non Medicamentous Treated in the PICU Fluid : Ringer Lactat 500cc / 24 hour O2 nasal 2Lpm Fasting

Medicamentous Amoxicillin : 3 x 500 mg iv Kalmethason : 2 x 1 mg iv Garamicine : 2 x10 mg iv Mannitol : 3 x 10 cc, drip Vit K : 2 x 1 mg, IM every day ( during 5 day) Diazepam : 1 mg prn PRC 50 cc during 3 hours FFP 50 cc during 3 hours

Jan 16 th, 2011 Subjective:

Groan (+) Convulsion (+) Pale (+)

Objective: Sklera ikteric (+/+), pupil

anisokor ( diameter pupil sinistra> dextra)

Skin : pale (+), ikteric (+) Fontanel ² : tense Bradipnoe RR:12 x/m SpO2 : 97 % Nastril breath +/+,

retraction +/+

Therapy

02 nasal 2 lpm Fluid : RL 500cc /24h Fasting Amoxillin 3 x 500 mg iv Garamisin 2 x 100 mg iv Diazepam 1 mg Mannitol 3 x 10 cc, drip Vit K : 1 mg IM, during 5

days Transfussion PRC 50 cc

during 3 hours Plan to transfussion FFP 50

cc during 3 hours

Jan 17th, 2011 Subjective:

Groan (-) Convulsion (+) Cry (+)

Objective: Sklera ikteric (+/+),

pupil anisokor ( diameter pupil sinistra> dextra)

Skin : ikteric (+) Fontanel : tense SpO2 : 100 % Nastril breath -/-,

retraction -/-

Plan: 02 nasal 2 lpm Diet : fasting IVF : Aminofuchsin ped

100cc/hour, D5 %+ valium 15 mg 400 cc/24 hour

Transfusi WB 50 cc Amoxillin 3 x 500 mg iv Garamisin 2 x 100 mg

iv Mannitol 3 x 10 cc, drip Vit K : 1 mg IM, during

5 days

Jan 18th, 2011 Subjective:

Convulsion (+) Objective:

Sklera ikteric (+/+), pupil anisokor ( diameter pupil sinistra> dextra)

Skin : ikteric (+) Fontanel : tense SpO2 : 100

%,spontaneus breathing

Nastril breath -/-, retraction -/-

Plan: Craniotomy

Diet : fasting IVF : Aminofuchsin ped

100cc/hour, D5 % 400 cc/24 hour

Amoxillin 3 x 500 mg iv Garamisin 2 x 100 mg

iv Kalmethason 2x1 mg Mannitol 3 x 10 cc, drip Phenitoin 2x 25 mg Diazepam 1 mg prn Vit K : 1 mg IM

Jan 19th, 2011 Subjective:

Convulsion (+) Eyelash (+) General condition :

improve Objective:

Sklera ikteric (+/+), pupil isokor , light reflex +/+

Skin : ikteric (+) Fontanel : soft spontaneus breathing Nastril breath -/-,

retraction -/-

Plan : Diet : D5 % 6 x 10 cc KaEN 1 B 100 cc Aminofucsin 100 cc

Amoxillin 3 x 500 mg iv Garamisin 2 x 100 mg iv Kalmethason 2x1 mg Phenitoin 2x 25 mg Vit K : 1 mg IM Novalgin 4x 50 mg Valium 1mg prn

The Diagnosis of based Intracranial Hemorrhage In the Newborn

on :

Anamnesis : Patient was 1 month year old Convulsion wasn’t preceded by fever never cry again since seizures vomitting ikteric had not been given Vitamin K injection when the baby was born. The big brother of patient had experience the convulsion at the

age of 6 months old

Physical Diagnostic Skin : pale (+), ikteric (+) Fontanel : Tense Eyes : conjungtiva anemic +/+, sklera ikteric +/+,

light reflex : -/-, pupil anisokor ; diameter pupil sinistra> dextra

Nose : Nostril breathing (+) Thorax : retractions supraclavicle +

CT Scan :

subdural and intraserebral haemorrhage

Vitamin K is one of the essential vitamins. The letter K in vitamin K actually comes from the word

"Koagulations", that means coagulation or clotting.

Without vitamin K, blood would be unable to clot. Deficiencies in vitamin K lead to clotting disorders,

bruising, and other blood disorders.

a coagulation disturbance in newborns due to vitamin K deficiency. As a consequence of vitamin K deficiency there is an impaired production of coagulation factors II, VII, IX, X, by the liver

Causes

Newborns are relatively vitamin K deficient for a variety of reasons. They have low vitamin K stores at birth, vitamin K passes the placenta poorly, the levels of vitamin K in breast milk are low and the gut flora has not yet been developed (vitamin K is normally produced by bacteria in the intestines).

Brain tumors Bleeding (hemorrhage) or blood clots (hematomas) from

injuries (subdural hematoma or epidural hematomas) Weaknesses in blood vessels (cerebral aneurysms) Damage to tissues covering the brain (dura) Pockets of infection in the brain (brain abscesses) Epilepsy

Definition Bleeding in the cranial cavity and its contents in infants

from birth until age 4 weeks.

Intracranial Hemorrhage includes epidural, subdural, subarachnoid, intra serebral/parenkim dan intraventrikuler hemorrhage

Epidemiology from 5 to 15 %, with a mortality of from 40 to 50 % low birth weight infants, weighing less than 1500 g)

Etiology

The chief cause is trauma Breech extraction, in which rapid or forceful delivery of the

after-coming head produces the injury. Precipitate labors, where there is sudden compression of

the head. Very difficult or prolonged labors, where there is excessive

molding of the head with injury. Instrumental deliveries

Cause not trauma• Prematurity of the infant

Grade I: hemorrhage limited to the germinal matrix (subependymal hemorrhage)

Grade II: hemorrhage which has extended into the ventricular system but without dilation of the lateral ventricles

Grade III: hemorrhage extending into the ventricular system with the blood resulting in ventricular dilatation

Grade IV: hemorrhage which extends into the brain tissue (this grade is also referred to as PVH and associated with intraparenchymal echodensity (IPE) by some

Epidural hemorrhage (extradural hemorrhage) which occur between the durameter and the skull, is caused by trauma It may result from laceration of an artery, most commonly the middle meningeal artery dangerous type of injury because the bleed is from a high-pressure system and deadly increases in intracranial pressure can result rapidly

Subdural hemorrhage results from tearing of the bridging veins in the subdural space between the dura and arachnoid mater

Subarachnoid hemorrhage which occur between the arachnoid and pia meningeal layers, can result either from trauma or from ruptures of aneurysms or arteriovenous malformations

Intraventrikuler hemorrhage↓

hypoxia ↓

vasodilatation blood vessel of the brain and venous congestion

↓increase blood flow

↓ elevated pressure of the brain blood

↓ Easily Ruptur

Onset of symptoms of intracerebral hemorrhage is usually during daytime activity, with progressive :

Alteration in level of consciousness (approximately 50%) Nausea and vomiting (approximately 40-50%) Headache (approximately 40%) Seizures Focal neurological deficits Cephalic cry Snake like flicking of the tongue Expiratory grunting

Physical exam:

unconscious individual should quickly assess the adequacy of the airway, breathing, pulse, and blood pressure before beginning a more detailed neurological and physical exam.

The latter includes an evaluation of level of consciousness, pupil response and vital signs, motor function, reflexes, and memory.

Serial Lumbar Punctures Blood gas analysis CT Scan USG

Treated in the incubator that allows continuous observation and O2 delivery

It should be observed carefully: body temperature, degree of consciousness, pupil size and reaction, motor activity, respiratory frequency, heart frequency, pulse rate and diuresis.

Keeping the airway to remain free.The baby lies on his side

Vitamin K and blood transfusions may be considered.

Valium / luminal if convulsion, valium dose from 0.3 to 0, 5 mg / kgBB

Corticosteroids such as dexamethasone 0.5 to 1 mg/kgBB/24 hours that have good effect against hypoxia and brain edema

Antibiotics can be given to prevent secondary infection Lumbar puncture to reduce intracranial pressure,

bleeding, prevent obstruction likuor flow and reduce the effects of irritation on the surface of the cortex

Emergency surgery Craniotomy

Staging I, II : mild Staging III, IV : severe

Intracranial hemorrhage is a serious medical emergency because the build up of blood within the skull can lead to increases in intracranial pressure

Severe increases in intracranial pressure can cause potentially deadly brain herniationin