1/29/2014. Kimberly Johnson Hatchett, MD PGY-4 11/15/13

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Kimberly Johnson Hatchett, MD PGY-4 11/15/13 History of Present Illness 14 month old previously healthy infant boy presented via EMS after being found by his mother to be breathing loudly and

1 Kimberly Johnson Hatchett, MD PGY-4 11/15/13 History of Present Illness 14 month old previously healthy infant boy presented via EMS after being found by his mother to be breathing loudly and non-responsive. Possibly co-sleeping and she awoke around 3 am to find him with blood tinged emesis and not moving. Patient would not open eyes, withdrawing to pain only. Patient found to have wheezing, and concern for airway protection, and intubated. Physical Exam and Labs General: Vitals: T 36.7, HR 150, RR 56, BP 145/83, 91% HEENT: NCAT Cardio: Regular rate and rhythm Respiratory: Not breathing over ventilator Neurological Mental status: No response to name, stimuli or movement of limbs Cranial Nerves: Doll s eye present, gag intact, Pupils weakly reactive to light Motor: No movement of limbs to stimuli DTR: Hyper-reflexic throughout, with several beats of clonus bilaterally 1

2 Physical Exam and Labs Labs CBC: WBC 39.5, Hgb11.2, Plt501, PT 22.8 BMP: Na 134, K 5.8, Creat0.66, Glu445, Lactic Acid 10.4 AST 2654, ALT 2150, Amylase 659 CSF studies: Protein 255, Glucose 130, RBC 37, WBC 92 (92% monocytic macrophages containing pigment consistent with hemosiderin) Toxicology screen: Venlafaxine and Norvenlafaxine MRI BRAIN on hospital day 1, 2

3 MRI BRAIN on hospital day 1, MRI BRAIN on hospital day 1, 10/14/13 Differential Infectious: Herpes, Varicella, Mycoplasma,WestNile, EBV Toxic injestion Post infectious cerebelitiswith septic emboli (Rhinovirus/Enterovirus was positive in respirations) Suffocation, Hypoxic Injury. 3

4 Continued story Interim Physical Exam Initial EEG completed After initial HSV PCR negative, and with OK from Infectious Disease started on High dose steroids for Cerebral Edema Follow up MRI scan on hospital Day 5. MRI BRAIN on hospital day 5, MRI BRAIN on hospital day 5, 4

MRI BRAIN on hospital day 5, Story continued Induced Hypothermia Pentobarbital coma with patient in burst suppression EVD placed to monitor intracranial pressure Warmed on Hospital Day 8 Stopped

5 MRI BRAIN on hospital day 5, Story continued Induced Hypothermia Pentobarbital coma with patient in burst suppression EVD placed to monitor intracranial pressure Warmed on Hospital Day 8 Stopped Pentobarbital Electrographic/clinical seizures noted Placed on additional Antiepileptic Trileptalat 50 mg/kg/day, Phenobarbital 10 mg/kg/day, Keppra87.5 mg/kg/day Developed left sided chorea, started on Clorazepate mg/kg/day (1.875 mg bid) Developed Rash ACHSS or DRESS Currently in ICU for treatment of skin lesion and systemic reaction MRI BRAIN on hospital day 8, 5

MRI BRAIN on hospital day 8, Hypoxic Ischemic Encephalopathy Clinical evidence of acute or sub-acute brain injury due to asphyxia Systemic hypoxemia and/or reduced cerebral blood

6 MRI BRAIN on hospital day 8, Hypoxic Ischemic Encephalopathy Clinical evidence of acute or sub-acute brain injury due to asphyxia Systemic hypoxemia and/or reduced cerebral blood flow Birth asphyxia = 23% of neonatal deaths world wide. Mild versus Moderate versus Severe Locations: Watershed, Basal Nuclei, can involve white matter and extend to the gray. 6

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8 Take home points, conclusions HIE, Hypoxic Ischemic Encephalopathy MRI findings and functional outcome Cooling and Outcomes, Not much difference? How soon should repeat scan be done? MRI scoring system gives tools to be able to predict future outcomes. 8

9 References SrinivasakumarP, ZempelJ, Wallendorf M, Lawrence R, InderT, MathurA. Therapeutic hypothermia in neonatal hypoxic ischemic encephalopathy: electrographic seizures and magnetic resonance imaging evidence of injury. J Pediatr. Aug 2013;163(2): Grow J, Barks JD. Pathogenesis of hypoxic-ischemic cerebral injury in the term infant: current concepts. Clin Perinatol. Dec 2002;29(4): , v. Shankaran S, Laptook AR, EhrenkranzRA, et al. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med. 2005; 353: [PubMed: ] Barkovich AJ, Hajnal BL, Vigneron D, et al. Prediction of neuromotor outcome in perinatalasphyxia: evaluation of MR scoring systems. AJNR Am J Neuroradiol. 1998; 19: [PubMed: ] Rutherford M, Ramenghi LA, Edwards AD, et al. Assessment of brain tissue injury after moderate hypothermia in neonates with hypoxicischaemic encephalopathy: a nested substudy of a randomised controlled trial. Lancet Neurol. 2010; 9: [PubMed: ] Thank you Questions????? 9

Hypothermia in Neonates with HIE TARA JENDZIO, DNP(C), RN, RNC-NIC

Hypothermia in Neonates with HIE TARA JENDZIO, DNP(C), RN, RNC-NIC Objectives 1. Define Hypoxic-Ischemic Encephalopathy (HIE) 2. Identify the criteria used to determine if an infant qualifies for therapeutic