123933672 Kasus Perdarahan Intrakranial Pada Bayi Baru Lahir

8/10/2019 123933672 Kasus Perdarahan Intrakranial Pada Bayi Baru Lahir

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Presented by :Silvia P. Tarigan

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


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PATIENT IDENTITY Name : M Rafif Lathif

Age : 1 month old

Sex : Male

Date of hospitalized : January, 16th 2011

Date of examination : January, 16th 2011


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Father :Name : Mr. Beni H

Age :36 years old

Education : Senior HighSchool

Occupation :Entrepreneur

Address : SukamuktiRT 3 RW 5, KatapangBandung.

Mother :Name : Mrs. Siti M

Age :35 years old

Education : Senior HighSchool

Occupation : Housewife

Address : Sukamukti RT 3RW 5, Katapang Bandung.


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Heteroanamnesis was given by his mother onJanuary, 16 th 2011

Chief complaint: convulsion


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History of present illness: One day before admission to the hospital patient had

convulsion as many as 1 time for 2 minutes The convulsionare not preceded by fever. During the convulsion, suddenly

became stiff and uprolling of the eyes for 1 minutes. Hehad a generalised tonic-clonic convulsion. Before and afterthe convulsion patient was conscious. Patients motherdenied any historical information of falling from a babybox.

2 days before entering the hospital, patientexperienced vomiting in each breast-feeding time. Patienthas not ever cried again since the convulsion.


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The big brother of patient had experience the

convulsion at the age of 6 months old but was precededby fever. Patients mother stated that when the patient

was 1 week old, the baby was ikterik and it has stillhappened until today. The patients mother also saidthat the baby had not been given Vitamin K injectionwhen the baby was born


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Urine: the color, volume, and frequency was normal and nopain when urinate.

Defecation : the color, consistency, and frequency wasnormal

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

Past Medical History: the patient never had sick like thisbefore.

History of family illness: The big brother of patient hadexperience the convulsion at the age of 6 months old butwas preceded by fever


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

Birth : aterm, spontaneous, directly cry and helped by amidwife.

Birth weight : 3500 grams. Birth length : 52 cm


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


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Immunization

Vaccine Basic Vaccination

Booster Vaccination

Recommended Vaccination

BCG - - - - HiB : none

Polio - - - - - - MMR : none

DPT - - - - - - Hep A : none

Hep B - - - - - - Varicella : none

Measles - - - - Typhim/typha : none

Influenzae : none


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Nutrition and Feeding Breastmilk

Past Illnesses Cough

Family history :Convulsion


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General appearance Condition : severe sicknessConsciousness : somnolenActivity and position : no force positionGeneral condition : weak


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

Respiration : 36 times a minute, thoracoabdominal type

Temperature : 35,7 C, aksiler


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Measuring Weight : 4,9 kgHeight : 65 cm (113,95 % standard Weight/Age ) (119,04 % standard Height/Age ) Nutrition status : (standard Weight/Height )Rumple Leede : (-)


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SYSTEMATIC EXAMINATION4.1. Skin : rash (-), pale (+), icteric (+), turgor wasimmediately returns to normal position


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HeadHair : black, disseminated, not easy to yanked outFontanel : tenseEyes : conjunctiva anemic +/+, conjungtiva hyperemic -/-,sclera icteric +/+, pupil anisokor (diameter pupil sinistra >dextra), light reflex : -/-Nose : nostril breathing+/+, secret -/-, epistaxis -/-Lips : wet, cyanosis +Mouth : moist mucosaGums : no bleeding, no hyperemicPalate : no disparityTongue : coated tongue -, hyperemic -, tremor ,Kopliks spot Pharynx and tonsil : hyperemic -, T1=T1


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

Thorax

Lungs Inspection : shape and movement was simetric, right was equalto left, retractions supraclavicle +


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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 lineamidclavicularis sinistra


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Percussions : border on top ICS 2 lineaparasternalis sinistra, border on left ICS 4 lineamidclavicularis sinistra, border on right ICS 3 lineasternalis dextra

Auscultations : heart sounds regular, shuffle


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Abdomen : Inspections : flatAuscultations : bowel sound (+)Percussions : tympanic, Traubes space : tympanic

Palpations : , liver 4 cm below arch costarum,tenderness (- ), skins turgor was immediately returns to itsnormal position.Liver and spleen inpalpable


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Genital : male, normalAnus & Rectal : no disparityExtremities : no disparity Upper : left: active, right : active

Lower : left: active, right: active Joint : no disparity Muscle : hypertrophy -, atrophy -Neurological Examination

Reflex : physiological -/-, pathological +/+


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On January 16 2011 On January 17 2011

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Hb : 9,3 gr / dl

Ht: 28,0% Leu: 11700 / m 3 Tc: 578000/m 3 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/m 3 Na : 124 mEq/L K : 4,6 mEq/L

Ureum : 16 mEq/LPT : 11.5 second

aPTT : 30,4 secondFibrinogen : 396 mg/dl


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CT- scanOn 16 January,2011Trail:

Frontotemporoparietal left subdural haemorrhage is the

cause of the shifted midline to the left by 1, 29 cm; andthe constriction of the left lateral ventricle. There alsoappears the hemorrhage of intracerebral in areas right-sidefrontotemporoparietal.


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

One day before admission to the hospital patient hadconvulsion as many as 1 time for 2 minutes The convulsionare not preceded by fever. During the convulsion, suddenlybecame stiff and uprolling of the eyes for 1 minutes. Hehad a generalised tonic-clonic convulsion. Before and afterthe convulsion patient was conscious. Patients motherdenied any historical information of falling from a babybox.

2 days before entering the hospital, patientexperienced vomiting in each breast-feeding time. Patienthas not ever cried again since the convulsion.


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The big brother of patient had experience the

convulsion at the age of 6 months old but was precededby fever. Patients mother stated that when the patientwas 1 week old, the baby was ikterik and it has stillhappened until today. The patients mother also saidthat the baby had not been given Vitamin K injectionwhen the baby was born


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Urine: the color, volume, and frequency was normal and nopain when urinate.

Defecation : the color, consistency, and frequency was

normal

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

Past Medical History: the patient never had sick like thisbefore.

History of family illness: The big brother of patient hadexperience the convulsion at the age of 6 months old but

was preceded by fever.

Immunization profile: the patient ha vent receive all basicimmunization.

Nutrition status : (standard Weight/Height)


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General appearance Condition : severe sicknessConsciousness : somnolenActivity and position : no force position

General condition : weak


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

Respiration : 36 times a minute, thoracoabdominal type

Temperature : 35,7 C, aksiler


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


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HeadEyes : conjungtiva anemic +/+, sklera ikteric +/+, lightreflex : -/-, pupil anisokor ; diameter pupil sinistra> dextraFontanel : tense

Nose :nostril breathing+/+, secret -/-,Mouth : moist mucosaTongue : Kopliks spot Pharynx and tonsil : hyperemic -, T1=T1


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Neck Lymph node : not palpable

Thorax

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

AbdomenLiver 4 cm below arch costarum


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On January 16 2011 On January 17 2011

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Hb : 9,3 gr / dl

Ht: 28,0%

Leu: 11700 / m 3 Tc: 578000/m 3 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/ m 3

Tc : 517000/m 3 Na : 124 mEq/L K : 4,6 mEq/L

Ureum : 16 mEq/LPT : 11.5 second

aPTT : 30,4 secondFibrinogen : 396 mg/dl


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CT- scanOn 16 January,2011Trail:

Frontotemporoparietal left subdural haemorrhage is the

cause of the shifted midline to the left by 1, 29 cm; andthe constriction of the left lateral ventricle. There alsoappears the hemorrhage of intracerebral in areas right-sidefrontotemporoparietal.


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Differential Diagnosis : Intracranial hemorrhageIncreased in Intracranial PressureSepsis neonatorum

Working diagnosis :Intracranial hemorrhage (subduraland intraserebral hemorrhage)

Additional diagnosis : Anemia, Hiperbilirubin neonatus,hiperglikemia neonatorum


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Serial Lumbar PuncturesBlood gas analysisCT ScanUSG


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


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Non Medicamentous

Treated in the PICUFluid : Ringer Lactat 500cc / 24 hourO2 nasal 2LpmFasting

Medicamentous Amoxicillin : 3 x 500 mg ivKalmethason : 2 x 1 mg ivGaramicine : 2 x10 mg iv

Mannitol : 3 x 10 cc, dripVit K : 2 x 1 mg, IM every day ( during 5 day)Diazepam : 1 mg prnPRC 50 cc during 3 hoursFFP 50 cc during 3 hours


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Jan 16 th , 2011 Subjective:

Groan (+)Convulsion (+)

Pale (+)Objective:Sklera ikteric (+/+), pupilanisokor ( diameter pupilsinistra> dextra)Skin : pale (+), ikteric (+)Fontanel : tenseBradipnoe RR:12 x/mSpO2 : 97 %Nastril breath +/+,retraction +/+

Therapy

02 nasal 2 lpmFluid : RL 500cc /24h

FastingAmoxillin 3 x 500 mg ivGaramisin 2 x 100 mg ivDiazepam 1 mgMannitol 3 x 10 cc, drip

Vit K : 1 mg IM, during 5 daysTransfussion PRC 50 ccduring 3 hoursPlan to transfussion FFP 50cc during 3 hours


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Jan 17 th , 2011Subjective:

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

Objective:Sklera ikteric (+/+), pupilanisokor ( diameter pupilsinistra> dextra)Skin : ikteric (+)

Fontanel : tense SpO2 : 100 %Nastril breath -/-,retraction -/-

Plan: 02 nasal 2 lpmDiet : fastingIVF : Aminofuchsin ped100cc/hour, D5 %+ valium

15 mg 400 cc/24 hour

Transfusi WB 50 ccAmoxillin 3 x 500 mg ivGaramisin 2 x 100 mg iv

Mannitol 3 x 10 cc, dripVit K : 1 mg IM, during 5days


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Jan 18 th , 2011 Subjective:

Convulsion (+)

Objective:

Sklera ikteric (+/+), pupilanisokor ( diameter pupilsinistra> dextra)Skin : ikteric (+)Fontanel : tense SpO2 : 100 %, spontaneusbreathingNastril breath -/-,retraction -/-

Plan:

Craniotomy

Diet : fasting

IVF : Aminofuchsin ped100cc/hour, D5 % 400 cc/24hourAmoxillin 3 x 500 mg ivGaramisin 2 x 100 mg iv

Kalmethason 2x1 mgMannitol 3 x 10 cc, dripPhenitoin 2x 25 mgDiazepam 1 mg prnVit K : 1 mg IM


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Jan 19 th , 2011Subjective:

Convulsion (+)Eyelash (+)General condition :improve

Objective:Sklera ikteric (+/+), pupilisokor , light reflex +/+Skin : ikteric (+)Fontanel : soft spontaneus breathingNastril breath -/-,retraction -/-

Plan : Diet : D5 % 6 x 10 ccKaEN 1 B 100 ccAminofucsin 100 cc

Amoxillin 3 x 500 mg ivGaramisin 2 x 100 mg ivKalmethason 2x1 mgPhenitoin 2x 25 mg

Vit K : 1 mg IM Novalgin 4x 50 mg

Valium 1mg prn


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The Diagnosis of based Intracranial Hemorrhage In the Newbornon :

Anamnesis :

Patient was 1 month year old

Convulsion wasnt 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


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Physical Diagnostic

Skin : pale (+), ikteric (+)

Fontanel : Tense

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

light reflex : -/-, pupil anisokor ; diameter pupil sinistra> dextraNose : Nostril breathing (+)

Thorax : retractions supraclavicle +

CT Scan :

subdural and intraserebral haemorrhage


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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, andother blood disorders.


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a coagulation disturbance in newborns due to vitamin Kdeficiency. As a consequence of vitamin K deficiency there is animpaired production of coagulation factors II, VII, IX, X, by theliver

Causes

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


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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


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Definition

Bleeding in the cranial cavity and its contents in infants frombirth until age 4 weeks.

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


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Epidemiologyfrom 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 thehead.

Very difficult or prolonged labors, where there is excessivemolding of the head with injury.

Instrumental deliveries

Cause not trauma Prematurity of the infant


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

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

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

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


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Epidural hemorrhage (extradural hemorrhage) which occurbetween the durameter and the skull, is caused by trauma Itmay result from laceration of an artery, most commonly themiddle meningeal artery dangerous type of injury because

the bleed is from a high-pressure system and deadl y increases inintracranial pressure can result rapidly

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

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


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Intraventrikuler hemorrhage

hypoxia

vasodilatation blood vessel of the brain and venous congestion

increase blood flow

elevated pressure of the brain blood

Easily Ruptur


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Onset of symptoms of intracerebral hemorrhage is usually duringdaytime 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 tongueExpiratory grunting


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Physical exam:

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

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


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Serial Lumbar PuncturesBlood gas analysisCT ScanUSG


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Treated in the incubator that allows continuous observation andO2 delivery

It should be observed carefully: body temperature, degree ofconsciousness, pupil size and reaction, motor activity, respiratoryfrequency, 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.


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

Corticosteroids such as dexamethasone 0.5 to 1 mg/kgBB/24hours 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 ofirritation on the surface of the cortex

Emergency surgery Craniotomy


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Staging I, II : mildStaging III, IV : severe

Intracranial hemorrhage is a serious medical emergency b ecausethe build up of blood within the skull can lead to increases inintracranial pressure Severe increases in intracranial pressure can cause potentiallydeadly brain herniationin


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123933672 Kasus Perdarahan Intrakranial Pada Bayi Baru Lahir