Documente Academic
Documente Profesional
Documente Cultură
onfirmed;
at methodical meeting
of hospital pediatrics 1 department
hief of department
professor _____________V. A. Kondratyev
______ _________________ 2013 y.
METHODICAL INSTRUCTIONS
FOR STUDENTS` SELF-WORK
WHILE PREPARING FOR PRACTICAL LESSONS
Educational discipline
module
Substantial module
Theme of the lesson
Course
Faculty
pediatrics
2
8
Dnepropetrovsk, 2013.
Definition
Pathological condition caused by gas disorders in the need of 02
2
baby
2. Hipoxic-ischemic
encephalopathy
3. Antenatal hypoxia
4. Intranatal hypoxia
5. Cardiac-respiratory
syndrome
6. Syndrome of increased
nervous anxiety
7. Syndrome of general
depression
8. Hypertension syndrome
9. Hydrocephalic
syndrome
- in gut
- in immune system
- in metabolism
13. Complications of reanimation and intensive care
14. Notion of hypoxic-ischemic encephalopathy
15. Pathogenesis in development of hypoxic-ischemic encephalopathy
16. Clinical signs of hypoxic-ischemic encephalopathy. Neurological, somatic and
metabolism disorders
17. Contemporary methods of diagnosing CNS disorders (neurosonography, CT, NMR,
etc.)
18. Classification of hypoxic-ischemic encephalopathy
19. Treatment and rehabilitation of children with hypoxic-ischemic encephalopathy
20. Principles of treatment and control on pediatrics regions and its effectiveness
21. Outcomes of hypoxic-ischemic encephalopathy
Clinical sign
Heart rate
Breathing
Muscular tone
The reflex
excitability
(reaction to the catheter)
Skin color
Grimace
Sneezing, cough
Skin color of
Pink
Generalised pallor or color of the body,
Pink
cyanosis
cyanosis of
color of the body
extremities..
6. To carry out short (no more than 2 times) tactile stimulation of the newborn (a percussion on a sole).
7. To estimate existence and character of independent breathing. In the absence of independent breath
or gasping breathing:
immediately to begin mechanical ventilation by the bag and the mask with the use of 90 100% of
oxygen (frequency 40-60 in 1 min.);
initial pressure of ventilation usually is 30-40 cm of water column, at children with the immature and
affected lungs and after the several first breaths inspiratory pressure has to be 20-40 cm of water
column.
If after mask putting on a child's face and carrying out several ventilations by the bag the thorax doesn't
move, such actions are recommended:
a) again to put a mask, providing its tight fitting to the person, and again to carry out ventilation; in the
absence of effect consistently to perform the actions provided below, each time checking efficiency of
ventilation;
b) to check the position of the head;
c) to check the presence of the secret in the oral cavity and if indicated to suck it;
d) to try to carry out ventilation with a half-open mouth with air duct use;
e) to increase inspiratory pressure.
In the absence of effect it is necessary to carry out an intubation of the trachea and to exclude existence
at the child of congenital anomalies. In 2 min. after initiating of mechanical ventilation by the bag and
the mask it is necessary to enter a probe into the stomach to prevent aspiration and stomach dilatation.
In the presence of adequate independent breath it is necessary to pass to item 9 at once.
8. To ventilate 15-30 times with 100% oxygen with the frequency of 40-60 in 1 min.
9 . To determine heart rate.
If heart rate is more than 100 in 1
min.
To evaluate skin color
Pink or local cyanosis
Central cyanosis
Increa
ses
oxygen
To begin indirect heart massage of with
a frequency of 90 in 1 min if
mechanical ventilation has been
already carried out by 100% oxygen
within 15-30 s.
To continue
mechanical
ventilation by100%
oxygen with a
frequency 30 per 1
min.
To continue
mechanical
ventilation
by 100%
oxygen with
a frequency
of 40-60 per
1 min.
- CNS:
hypoxic-ischemic encephalopathy, brain edema, seizures, a syndrome of inappropriate
secretion of antidiuretic hormone, cerebral spastic infantile paralysis.
- Respiratory system:
pulmonary hypertension, surfactant system disturbances, mekonium aspiration, pulmonary
hemorrhage.
- Urinary system:
proteinuria, gematuria, oliguria, acute renal failure.
- Cardiovascular system:
insufficiency of the tricuspid valve, myocardium necrosis, arterial hypotension, left
ventricular dysfunction, sinuse bradycardia, rigid heart rhythm, shock.
- Digestive system:
necrotic enterocolitis, hepatic dysfunction, gastric or intestinal bleeding, reduced tolerance to
an enteral nutrition.
- Blood system:
thrombocytopenia, DIC-syndrome, polycytemia.
- Metabolic disorders:
Metabolic acidosis, hypoglycemia, hypocacemia, hyponatremia; increased potassium.
7. Concept about a hypoxic-ischemic encephalopathy
Hypoxic-ischemic encephalopathy (GIE) - the brain disorder caused by perinatal hypoxia
which is manifested by morphological functional disorders and signs of cerebral failure.
Pathogenesis of HIE:
- to decrease in the cerebral brain flow caused by the loss of ability to its autoregulation,
arterial systemic hypotonia, reduced ejection fraction through owing to the hypoxemic injury
of the myocardium, disorders of the venous outflow from the brain and increase of cerebral
vascular resistance;
- influence of prostaglandins, excessive synthesis of leucotriens by vessels, and also the role
of the antidiuretic hormone (ADG)
- localization of the affection at the brain frontal and parietal regions the brain are mainly
damaged as the result of the the thinnest arterioles less developed net of capillaries. At the
chronic intranatal hypoxia typical changes in basal ganglia, thalamus occur which causes
increase of adaptational possibilities of haemodynamics. Ischemia occurs as the result of the
thromboses, hemorrhagic disorders, hematoencephalic barrier is damaged. These disorders
lead to edema, dystrophy and focal necroses of neurons of cerebral cortex, hypocampus, and
at preterms - periventricul regions;
- cytotoxic edema of the brain which can be caused by the cascade emission of aminoacids first of all, a glutamate combined with metabolic acidosis (PH less than 7,0);
- hemostatic disorders - low level of vitamins of K-dependent clotting factors and
trombocytic dysfunction, development of the DIC-syndrome can predispose to intracranial
hemorrhages.
Clinical signs of HIE. Neurologic, somatic and exchange disorders:
Clinical syndromes of the acute period of HIE:
1. Syndrome of increased neuroreflectory excitability is manifested by concern, disordered
sleep, eruction, constant cry, increase of the muscular tone, tremor of the extremities and the
chin, increased reflexes. These symptoms resolves within 5 days and corresponds to the light
form of HIE.
2. Syndrome of the general depression is observed at prematurely born children owing to
immaturity of CNS that is manifested by generalized depression. Characteristic signs are
weakness , adinamia, decreases reflexes, muscular hypotonia.
3. Hypertension syndrome. It is observed at almost 100% cases of HIE It is manifested by the
specific position of the child - the head is thrown back, extremities are flexed, the squeezed
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cams, "brain" cry, eruction and vomiting, increased tone and a tremor of extremities, vertical
and rotator nistagmus, Grefe symptom the lag of an upper eyelid at eyeball movements
with the emergence of the scleral strip which is defined in rest, a symptom of "the sun which
sets" - the same, but at changed position of the body. At extreme degree of hypertension
generalized clonic seizures occur.
4. The hydrocephalic syndrome occurs at the end of the acute period and is manifested by the
increase in the size of the head, prevalence of the brain skull over facial part, sunken nasal
bridge with an overhang of the frontal site, dilatation of subcutaneous veins over the head,
and also dilatation ventricles index according to ultrasonic investigation of the brain.
5. The seizure syndrome at HIE is the most often manifested by generalized clonical-tonic
seizures. Focal, multifocal and myoclonic seizures occur less frequently.
6. The comatous condition develops at brain edema and is characterized by unconsciousness,
absence of physical activity, cry, emotions and reaction to the pain. Degree of severity of the
coma is defined by the level of the brain affection.
HIE classification:
There are three GIE clinical forms of HIE:
At light HIE signs of HIE are observed no more than 2-5 days. Hyperexcitability symptoms
prevail.
At moderate HIE disorders of the breathing rhythm, attacks of bradipnoe or bradycardia,
decreased physical activity can be observed during the first hours of life. Seizures, high-pitch
cry, eruction, tremor, chaotic movements appear later. Apnea attacks, symptoms of
intracranial hypertension or brain edema can occur until the end of the second - the beginning
of the third week of life.
Severe HIE is characterized by the absence of consciousness during the first 12 hours of life,
further some improvement of the condition of the child can be noted, but then, on 2 - the 3rd
week, the coma and seizures occur again. Especially unfavorable sign is the development of
generalized tonic seizures which are accompanied by the attacks of the secondary asphyxia
(breathing and heart arrest) - these symptoms testify to the presence of intracellular brain
edema with the involvement of brain stem structures. Symptoms of "weakness of shoulders",
"a short neck", "a hanging-down hand", "a sharp-clawed paw", hypotonia, paralysis of the
upper extremities can be evident at accompanying hypoxic-ischemic disorder of the cervical
part of the spinal cord.
Course of the disease and prognosis
The most unfavorable symptoms are the preservation of the 3 points or lower by Apgar scale
at 5 minute for the first 8 hours of the life, persistent muscular hypotonia. Later the child can
suffer from cerebral paralysis, a delay of psychomotor and intellectual development, epilepsy
HIE diagnostics.
The diagnosis can be established by the complex of anamnestic data (the course of pregnancy
and delivery, interventions in labor, drug therapy of mother during pregnancy and in labor,
etc.), the analysis of dynamics of the clinical picture at the child and the assessment of results
of such methods of diagnostics:
- cranial ultrasonography - ultrasonic scanning of the brain through the big fontanel. This
method is highly informative, noninvasive; without radial damage and gives the image of
various structures of the brain in sagital and in frontal position;
- computer tomography of the brain which allows to analyze a condition of the cranial bones,
and brain parenchyma;
- nuclear magnetic resonance and emission tomography - very exact research method,
allowing to reveal pathological changes in the brain, to define differences between white and
gray substance of the brain and to specify degree of a miyelinization (maturity) of various
sites of the brain;
- Electroencefalograpy (EEG).
8. HIE treatment
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1. Organization of the regimen: decrease in intensity of sound and light irritants; careful
inspection, swaddling and performance of procedures; minimizing of painful manipulations;
"temperature protection" that prevents cooling and overheating, participation of mother in
care of the child.
2. Nutrition depending upon the condition: parenteral; through the constant or disposable
probe; from the small bottle. The child shouldn't starve. At parenteral administration of
nutrition it is important to adhere to the regimen, not to overload with volume, to prevent
hypovolemia, hypotension, dehydration, hyperviscosity; not to administer heparin as even its
small doses (1-2 U/kg) increase risk of intracranial hemorrhages.
3. Monitoring supervision over the main physiological parameters: heart rate, blood pressure,
rate of breathing, temperature, etc.
4. Restoration of potency of respiratory airways and adequate ventilation of lungs.
5. At HE - support of adequate cerebral perfusion, correction of pathological acidosis and
other biochemical parameters (hypoglycemia, hypocalcemia, etc.); intravenous
administration of 10% glucose solution (for the first days of life up to 50 ml/kg)
6. In case of comatous condition and at brain edema mechanical ventilation is indicated in the
regimen of hyperventilation; barbiturates (phenobarbital 3-5 mg/kg each 6-8 hours) or
sibazone 0,5 mg/kg each 8-12 hours are also administered. Barbiturates reduce increased
intracranial pressure at brain edema. Intravenous dehydration with plasma, 10% albumin
solution, mannitol or furosemid (at normal peripheral blood pressure) is carry out. These
should not be administered if the cranial hemorrhage is present. When the symptoms of brain
edema are progressing osmotic diuretics in connection with corticosteroids (dexamethasone
in an initial dose of 0,2 mg/kg, then - 0,1 mg/kg with an interval of 6 hours) should be used.
8. Preparations which improve microcirculation: curantil (dipiridamol), trental, cavinton,
xantinoli nicotinatis, instenon.
9. Antihypoxants: sodium oxybutiratis, piracetam, cocarboxylase, ascorbic acid, actovegin.
10. Antioxidants, stabilizers of cellular membranes: tocopherol, tocopherol acetate, selenium,
unithiol.
11. Nootropic preparations (pantogam, piracetam) for the purpose of improvement of trophic
processes in the brain. Drugs which improve trophic processes and miyelinization of nervous
cells (cerebrolisin, encephabol, solcoseril) are administered after stabilization of the
condition of the child, not earlier than after the 14th- the 20th day of life.
Treatment of seizures:
1. Standard therapy for urgent stopping the esizures: 100-150 mg/kg of 20% of solution of
sodium oxibutiratis intravenously slowly with 5% glucose solution, in the absence of the
effect - 0,5 mg/kg of 0,5% of sibasone solution intravenously; then 15-20 mg/kg of oral
phenobarbital; if the standard therapy isinefficient - barbiturates (thiopental sodium - 15
mg/kg/day intravenously slowly) under control of blood pressure and heart rate.
2. At hypoglycemic seizures - 10-20 ml/kg of 10-20% glucose solution intravenously,
maintenance dose - 3-5 ml of 10% solution/kg/1 hour intravenously before level of glycemia
normalizes.
3. At hypocalcemic seizures - 1 ml/kg of 10% of solution of calcium gluconate intravenously
slowly.
4. At hypomagnemic seizures - 0,2 ml/kg of 25% of solution of magnesium sulfate
intramuscular or intravenous administration simultaneously.
5. At the pyridoxine dependent seizures - 2 ml of 5% of piridoxin solution intravenously or
intramuscularly; maintenance dose of the pyridoxine - 25 mg/kg.
Haemostatic therapy:
1. Fresh frozen plasma 10-15 ml/kg intravenously 1 time per day.
2. Vikasolum 0,2-0,5 ml (2-5 mg) of 1% solution intravenously or intramuscularly.
3. Etamsylate-sodium (dicinon) - 1 ml of 12,5% solution intravenously for receiving fast
effect. To enter 0,3-0,5 ml for the 3-5 days further.
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13
Questions:
1. What is your preliminary diagnosis?
2. What additional investigations need to be carried out for the confirmation of the
diagnosis? What are the possible results?
3. What factors indicated the development of this pathology in the newborn?
4. What features of the hematoencephalic barrier at the newborns?
5. What compensatory mechanisms are developing at acute hypoxia of the newborn?
6. Name the cellular composition of the spinal liquid of the newborn.
7. Should this patient have consultation of the ophthalmologist? If so, what changes are
possible?
8. Administer treatment.
9. What drugs are used for the dehydration at treatment of brain edema?
10. What is prognosis for this child?
B. Tests
Question 1. In the child who has suffered a severe hypoxic ischemic injury, which of the
following is true?
A. Liver and kidney damage are irreversible
B. Isolated brainstem function might be preserved
C. CT scans do not reveal abnormalities until after 1 mo following Injury
D Intracranial pressure monitoring improves outcome
Answer B. Explanation: The brainstem may be preserved in the presence of cortical cell
death. This is a controversial point in the discussion of brain death. Today we agree on the
legal definition of whole brain death, which includes the brainstem and obviously precludes
effective spontaneous ventilation.
Cortical brain death proponents want to recognize cortical death alone as the criterion for
legal death. The controversy has not been resolved.
Question 2. The best description of the Apgar score is that it:
A. Accurately predicts who will develop cerebral palsy
B. Assesses neonates in need of resuscitation
C. Accurately predicts a low umbilical cord pH
D. Is unaffected by maternal opiate pain relief
E. Accurately predicts neonates who will die in the neonatal period
Answer B. Explanation: The Apgar score helps to rapidly assess the need to resuscitate
neonates after birth. Although it has some value in predicting neonatal mortality and cerebral
palsy, it has a poor positive predictive value. Most children with cerebral palsy have had
normal Apgar scores, while neonates with low Apgar scores do not universally get cerebral
palsy.
Question 3. A term female is born by spontaneous vaginal delivery to a primiparous woman
who received two doses of meperidine 30 min and 2 hr prior to an abrupt delivery. The baby
is apneic and limp. The most important, immediate management is to:
A. Administer naloxone in the umbilical vein
B. Perform bag-mask ventilation
C. Administer naloxone in the endotracheal tube
D. Begin chest compressions
E. Obtain a cord pH
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Answer B. Explanation: Apnea from any cause is treated with securing apatent airway and
instituting ventilation. If bag mask ventilation is ineffective, endotracheal intubation should
be performed. Naloxone (Narcan) can be given only after the baby is ventilated.
Question 4. Successful ventilation is determined by all of the following except:
A. Zero reading of end-tidal CO2 measurement
B. Pink color
C. Rising heart rate
D. Symmetric breath sounds
E. Good chest rise
Explanation: Indeed, one expects that with a successful intubation and ventilation, the endtidal (exhaled) CO2 will rise dramatically. This is now used in many neonatal resuscitations.
Complete cardiac onset with poor perfusion may also cause a low end-tidal CO2.
Question 5. An infant has the following findings at 5 min of life: pulse, 130/min; cyanotic
hands and feet; good muscle tone; and a strong cry and grimace. This infant's Apgar score is:
A. 7
B. 8
C. 9
D. 10
Answer C. Explanation: One point in the Apgar score is taken off for color.
Question 6. A girl is born via stat cesarean section to a 34-year-old mother whose pregnancy
was complicated by hypertension and abnormal fetal heart monitoring. At delivery she is
covered in thick, green meconium and is limp, apneic, and bradycardic. Which of the
following is the best
first step in her resuscitation?
A. Administer IV bicarbonate.
B. Administer IV naloxone.
C. Initiate bag-and-mask ventilation.
D. Initiate chest compressions immediately.
E. Intubate with an endotracheal tube and suction meconium from
the trachea.
Answer E. An attempt is made to remove the meconium from the oropharynx and the airway
prior to initiation of respirations. Ideally, the obstetrician will begin suctioning the meconium
upon delivery of the head, and the pediatrician will further remove meconium with an
aspirator or through endotracheal intubation with suction. Ventilation is initiated after
meconium is removed. The goal is to remove airway meconium and to prevent its aspiration
into the small airways where ventilation-perfusion mismatch may occur with deleterious
effects.
Question 7. A term male is delivered vaginally to a 22-year-old mother. Immediately after
birth he is noted to have a scaphoid abdomen, cyanosis, and respiratory distress. Heart
sounds are heard on the right side of the chest, and the breath sounds seem to be diminished
on the left side. Which of the
following is the most appropriate next step in his resuscitation?
A. Administer IV bicarbonate.
B. Administer IV naloxone.
C. Initiate bag-and-mask intubation.
15
Question 12. In the 43rd week of gestation a long, thin infant was delivered. He is apneic, limp,
pale, and covered with "pea soup" amniotic fluid. The first step in the resuscitation of this infant at
delivery should be:
A.Suction of the trachea under direct vision
B.Artificial ventilation with bag and mask
C.Artificial ventilation with endotracheal tube
D.Administration of 100\% oxygen by mask
E.Catheterization of the umbilical vein
Question 13. A full-term baby was born with body weight of 3200 g, body length of 50 cm, Apgar
score - 8-10 points. What is the optimum time for the first breast-feeding?
A.First 6 hours
B.First 24 hours
C.First 30 minutes
D.First 48 hours
E.After 48 hours
Question 14. The child had Apgar scale of 8-9 points at time of birth. When should he be
breastfed?
A. Right after birth
B.After processing of the umbilical cord and performing profilaxis of gonoblennorea
C.After umbilical cord processing
D.30 minutes after birth
E. 2 hours after birth
Question 15. What medication should be administered to the baby, born by Caesarean section, if
he is at asphyxia and independent breathing is absent on the first minute of life?
A.Etimizole
B.Caffeine sodium benzoate
C.Cordiamin
D.Sodium bicarbonate
E.Naloxone a hydrochloride
Question 16. Newborn child experienced intranatal asphyxia. While suctioning the mucus from
the upper respiratory tract miconium is reveaked. Independent breath is absent. The further actions of
17
neonatologist provide:
A.External heart massage
B.Tracheal intubation, sanation of respiratory tract
C.Application of 100 %oxygen.
D.Adrenaline introduction.
E.Tactile stimulation of breathing.
Question 17. After birth the child is pale, has arrhythmic breathing which doesn't improve against
oxygenotherapy. Pulse is weak, tachycardia is observed, arterial pressure it barely measured. Edema
is absent. What is the most likely cause of these symptoms?
A.Congestive heart failure
B.Intracranial hemorrhage
C.Intrauterine sepsis
D.Asphyxia
E.Intrauterine pneumonia
Question 18 . Overterm infant, which was born at 43 weeks` gestation, has apnoe, pallor, the child
is covered by greenish amniotic fluid. The first steps in the newborn resuscitations include:
A.Mechanical ventilation using the mask and a bag
B.Mechanical ventilation using the endotracheal tube
C.Application of 100 % of oxygen
D.Umbilical vein cateterisation
E.Aspiration of tracheal contents
Question 19. The newborn which had asphyxia at the birth had apnea and the bradycardia (heart rate
70 per minute). Mechanical ventilation using 100 % oxygen with application of a mask and a bag of
Ambu was applied urgently. In 30 seconds the heart rate without improvement. What should be the
next step of resuscitatory measures?
A.Undirect heart massage
B.Tactile stimulation
C.Continue ventilation
D.Sodium hydrocarbonate intravenously
E.Epinefrin intravenously
Question 20. The term infant with cord encirclement round the neck since 1 minute of life has total
cyanosis, apnea, heart rate - 80 in minute, muscular hypotonia and absent reflexes. Signs of
meconium aspiration are absent. After sanation of respiratory tract breathing hasnt restored. Your
following action?
A.Adrenaline introduction
B.Etamzilat introduction
C.Mechanical ventilation using the mask of 100 % 2
D. Intubation of trachea and mechanical ventilation
E.Irritation of the skin along the spinal cord
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5. Nelson Essentials of Pediatrics -5th ed. / Ed. by B.S.Siegel, J.J.Siegel. - Elsevier Inc.
2007.
6. Examination of the Newborn. A Practical Guide / Ed. by Helen Baston and Heather
Durward. - the Taylor & Francis e-Library. - 2005.
7. Fetal and neonatal secrets. - second edition . / Ed. by R.A.Polin, A.R.Spitzer. - Elsevier.2006.
8. Key Topics in Neonatology / Ed. by R.H. Mupanemunda, M. Watkinson. - Oxford
Washington DC. -1999.
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
19