This lecture will provide an overview of the neurologic exam of a neonate in the context of clinical cases.

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Amy Holmes
5 years ago
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1 A11a Neuro Nuggets from the Trenches Michael D. Weiss, MD Associate Professor Department of Pediatrics, Division of Neonatology University of Florida, Gainesville, FL The speaker has signed a disclosure form and indicated he has no significant financial interest or relationship with the companies or the manufacturer(s) of any commercial product and/or service that will be discussed as part of this presentation. Session Summary This lecture will provide an overview of the neurologic exam of a neonate in the context of clinical cases. Session Objectives Upon completion of this presentation, the participant will: be familiar with the entry criteria for therapeutic hypothermia; understand how serial neurologic exams may reveal changes in the neonate s status; recognize the basic patterns for aeeg; understand the differential diagnosis of the floppy neonate; know the arterial anatomy of a neonatal stroke. References Azzopardi, D.V., Strohm, B., Edwards, A.D., Dyet, L., et al. (2009). Moderate hypothermia to treat perinatal asphyxial encephalopathy. New England Journal of Medicine, 361(14): Bodensteiner, J.B. (2008). The evaluation of the hypotonic infant. Seminars in Pediatric Neurolology, 15(1): Carney, P.R., Geyer, J.D., Saxonhouse, M.A., Gomez, C.R. & Malaty, I. (2009). Pediatric stroke. In: Stroke. Philadelphia, PA: Lippincott. de Vries. L.S. & Toet, M.C. (2006). Amplitude integrated electroencephalography in the full-term newborn. Clinics in Perinatology, 33(3): , vi. Gunn, A.J., Wyatt, J.S., Whitelaw, A., Barks, J., et al. (2008). Therapeutic hypothermia changes the prognostic value of clinical evaluation of neonatal encephalopathy. Journal of Pediatrics, 152(1): 55-8, 58 e1. Hellstrom-Westas, L., Rosen, I., Svenningsen, N.W. (1995). Predictive value of early continuous amplitude integrated EEG recordings on outcome after severe birth asphyxia in full term infants. Archives of Disease in Childhood, Fetal Neonatal Edition, 72(1): F34-8. Ioroi, T., Peeters-Scholte, C., Post, I., Leusink, C., et al. (2002). Changes in cerebral haemodynamics, regional oxygen saturation and amplitude-integrated continuous EEG during hypoxia-ischaemia and reperfusion in newborn piglets. Exp Brain Res, 144(2): Shankaran, S., Laptook, A.R., Ehrenkranz, R.A., Tyson, J.E., et al. (2005). Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. New England Journal of Medicine, 353(15): A11a: NEURO NUGGETS FROM THE TRENCHES Page 1 of 11

2 Thoresen, M., Hellstrom-Westas, L., Liu, X. & de Vries, L.S. (xxxx). Effect of hypothermia on amplitude-integrated electroencephalogram in infants with asphyxia. Pediatrics, 126(1): e Volpe, J.J. (2001). Neurology of The Newborn. Philadelphia, PA: W.B. Saunders. Session Outline See presentation handout on the following pages. A11a: NEURO NUGGETS FROM THE TRENCHES Page 2 of 11

3 Neuro Nuggets from the trenches Michael D. Weiss, M.D. University of Florida Department of Pediatrics Division of Neonatology Mercy Me Memorial calls for a referral of a 1hour old, 3.49kg infant born at 40 weeks gestation via SVD to a 23 year old Gravida1, Para 0 mother with negative GBS/serology s. At delivery the patient was noted to have Meconium stained fluids and a nuchal cord times 1. Patient was flaccid, with no spontaneous breathing and heart rate was less than 100/minute. She was intubated at delivery and CPR was commenced. Apgars were 0 at 1 minute, 3 at 5 minutes and 4 at 10 minutes. Initial Arterial Blood Gas ph 6.8, PCO2 43mmHg and base deficit was -25. Patient lethargic and hypotonic with no suck and a poor moro reflex. requiring assisted ventilation with periodic respirations and a variable heart rate. Does the baby qualify for Hypothermia???? A11a: NEURO NUGGETS FROM THE TRENCHES Page 3 of 11

1. Gestational Age greater than or equal to 35 weeks gestation 2. Birth weight greater than or equal to 1.8 kg 3. less than or equal to 6 hours since insult occurred 4.

4 1. Gestational Age greater than or equal to 35 weeks gestation 2. Birth weight greater than or equal to 1.8 kg 3. less than or equal to 6 hours since insult occurred 4. Seizures or 3 of 6 of the following: Mercy Me Memorial calls for a referral of a 1hour old, 3.49kg infant born at 40 weeks gestation via SVD to a 23 year old Gravida1, Para 0 mother with negative GBS/serology s. At delivery the patient was noted to have Meconium stained fluids and a nuchal cord times 1. Patient was flaccid, with no spontaneous breathing and heart rate was less than 100/minute. She was intubated at delivery and CPR was commenced. Apgars were 0 at 1 minute, 3 at 5 minutes and 4 at 10 minutes. Initial Arterial Blood Gas ph 6.8, PCO2 43mmHg and base deficit was -25. Patient lethargic and hypotonic with no suck and a poor moro reflex. requiring assisted ventilation with periodic respirations and a variable heart rate. Clinical Staging of hypoxic-ischemic encephalopathy A11a: NEURO NUGGETS FROM THE TRENCHES Page 4 of 11

5 Birth to 12 hours Depressed level of consciousness-usually deep stupor or coma. Ventilatory disturbances- periodic breathing or respiratory failure. Intact pupillary responses. Intact oculomotor responses. Hypotonia, minimal movement Seizures Hours Variable change in level of alertness More seizures Apneic Spells Jitteriness Weakness Proximal limbs, upper>lower (full term) Hemiparesis (full term) Lower limbs (premature) hours Stupor or coma Respiratory arrest Brain stem oculomotor and pupillary disturbances Catastrophic deterioration with severe IVH and periventricular hemorrhage infarction (premature) >72 hours Persistent, yet diminishing stupor Disturbed sucking, swallowing, gag, g, and tongue movements. Hypotonia Weakness Proximal limbs, upper>lower (full term) Hemiparesis (full term) Lower limbs (premature) 38 week EGA neonate Mother reported decreased fetal movement for several hours. The amniotic fluid was foul smelling NRFHT which progresses to no fetal heart rate detected. Requires BMV, intubation, CPR and epinephrine First heart rate detected at 12 minutes of age. A11a: NEURO NUGGETS FROM THE TRENCHES Page 5 of 11

suck, pupils were dilated with no reaction

!!!!!! T1 Persistently elevated lactic acid.

6 Initial cord gas= 6.78/102 with a base deficit of -18. Neuro Exam- Lethargic, Increased tone, decerebrate posturing, no reflexes, no suck, pupils were dilated with no reaction to light. NEED EEG with video from EMU LAB!!!!!!! T1 Persistently elevated lactic acid. Worsening respiratory status requiring HFOV, ino, steroids, surfactant. Is this baby an ECMO candidate? DWI A11a: NEURO NUGGETS FROM THE TRENCHES Page 6 of 11

T1 Placental villitis with a microabscesses containing mostly neutrophils in a case of congenital infection with

with pre-eclampsia eclampsia and on MG Developed MG toxicity with level of 11 MSF and was intubated and suctioned

CPR, FiO2 increased to 100%. Epinephrine X1 via UVC.

7 T1 Placental villitis with a microabscesses containing mostly neutrophils in a case of congenital infection with Listeria monocytogenes T2 Case 3 Case 3 Case /7 weeks born via C-section due to failure to progress Mother with pre-eclampsia eclampsia and on MG Developed MG toxicity with level of 11 MSF and was intubated and suctioned below cords with no meconium noted Poor chest rise with PPV and no heart rate at 6 minutes of life. CPR, FiO2 increased to 100%. Epinephrine X1 via UVC. Baby transferred to NICU shortly after with ETT APGARs were Chest compressions stopped at 13 minutes of life Arterial cord gas 7.05/-12.4 A11a: NEURO NUGGETS FROM THE TRENCHES Page 7 of 11

8 Case 3 Normal pattern Initial PE Intubated Lethargic Poor tone No suck No gag Weak grasp Moderate (Discontinuous pattern) Severe Al Naqeeb A11a: NEURO NUGGETS FROM THE TRENCHES Page 8 of 11

9 Case 4 Case 4 35 week EGA neonate born via SVD APGARS 3, 4, 6 PPV and intubation ti 7.12/55/81/-12 Neuro Exam- No spont. Movement, pupils midsized and reactive, no gag or suck, no palmar grasp, no clonus or babisnki. T1 DWI What is the etiology? A11a: NEURO NUGGETS FROM THE TRENCHES Page 9 of 11

Case 4 Case 4 Differential diagnosis of the Floppy Baby Infection Central Cerebral

Gravis Muscular Myopathy Myotubular Myopathy Central Core Myopathy Nemaline Myopathy Myotonic

EGA neonate with APGARS of 8 and 9. Serologies all negative.

10 Case 4 Case 4 Differential diagnosis of the Floppy Baby Infection Central Cerebral malformations HIE Spinal SMA Genetic Prader-Willi Syndrome Neuromuscular Junction Myasthenia Gravis Muscular Myopathy Myotubular Myopathy Central Core Myopathy Nemaline Myopathy Myotonic Dystrophy Other Glycogen Storage Disease Case 4 Case 4 Case 5 Case 5 Layton week EGA neonate with APGARS of 8 and 9. Serologies all negative. Stat C-section due to decreased fetal movement. Right extremity white-purple with no pulse. A11a: NEURO NUGGETS FROM THE TRENCHES Page 10 of 11

11 Case 5 At 3 hours of age noted to be apneic and required intubation. HUS showed right occipital parenchymal hemorrhage. Had activity concerning for seizures. T2 DWI A11a: NEURO NUGGETS FROM THE TRENCHES Page 11 of 11

Too Cool? Hypoxic Ischemic Encephalopathy and Therapeutic Hypothermia. Lauren Sacco DNP, ARNP, NNP-BC

Too Cool? Hypoxic Ischemic Encephalopathy and Therapeutic Hypothermia Lauren Sacco DNP, ARNP, NNP-BC Pathophysiology of HIE Occurs in two energy failure phases: First phase happens during the initial insult