Neonates Cram Flashcards
Layers of the scalp and which bleeds occur between layers?
Skin Connective tissue - caput - Apneurosis Loose connective tissue - cephalohaematoma - Periosteum - subgaleal - Bone - subdural -
Complications of cephalohaematoma?
Underlying fracture in 10-25% Calcification of haematoma Skull deformity Infection - most commonly E Coli Hyperbilirubinaemia
Cause of subgaleal haemorrhage? Complications of subgaleal?
Shearing of emissary veins causing bleeding that crosses suture lines
Blood loss - 20-40% of circulating volume
Coagulopathy
Skull fracture
Hyperbilirubinaemia
Risk factors and complications of clavicle fracture?
Operative delivery
Shoulder dystocia
Breech
Erb’s palsy - c5-6 nerve roots “waiter’s tip”
Management of brachial plexus injuries?
Conservative
Physiotherapy
Splinting to reduce contractures
Surgical repair if absent biceps function at 6-12 weeks
Long term outcome following kernicterus with neurological signs?
75% mortality
Survivors have choreoathertoid CP
Mechanism of phototherapy?
Photochemical reaction
- reversible photo isomerisation converts toxic to non-toxic isomer
- formation of lumirubin which can be excreted by the kidneys
NAS peak onset RF and treatment
- Usually onset D3 of life
- 70% of of infants whose mothers on methadone
Reduce stimuli Barrier cream Demand feed Pharmacological treatment indicated in 3x scores >8 or 2x >12 Morphine NOT naloxone (rapid withdrawal)
Facial nerve injury risk factors, presentation and management?
Forceps birth
Usually only mandibular branch - lip weakness when crying
Usually spontaneous resolution 2-6 weeks
Phrenic nerve injury presentation and management?
Resp depression, reduced breath sounds and hemidiaphragm on CXR
Lie on affected side
Spontaneous recovery 1-3 months. May require plication if not resolved.
Causes of retinal haemorrhages in neonates?
Late onset HMD
Meningococcal meningitis
Moderate head injury in a child w vWD
Pertussis
NOT SIDS
Findings in retinopathy of prematurity and RFs?
Small intra-retinal haemorrhages in the neo vascular ridge, may extend to vitreous seen from 32-34/40 CGA onwards
Prematurity
Low birth weight/IUGR
Oxygen therapy
Male
Laser for Gr3 and above
Long term risk of retinal detachment , myopia. strabismus, glaucoma
Causes of cataracts in neonate?
Congenital glaucoma (most common) HSV/Varicella infection Birth trauma due to forceps Dermoid tumour Mucopolysaccharidoses Peters anomaly Sclerocornea
Cause of congenital glaucoma?
Improper development of aqueous outflow system
Tears in Descement membrane
Leads to raised intraocular pressure and risks loss of vision
Surgical management required
Key features of neonatal encephalopathy and risk factors?
- Reduced level of consciousness
- Difficulty initiating and maintaining respiration
- Depressed tone & reflexes
IUGR is strongest risk factor
70% associated with events prior to labour
- unemployment, FHx seizures/neurological disease, infertility, thyroid disease, PET, placental conditions
Neonatal markers of hypoxic ischaemic encephalopathy?
Apgar of <5 at 5min, 10min
Umbi artery acidaemia pH <7.0/base excess >12
Deep nuclear grey matter injury or watershed cortical injury on MRIB
Multi-system organ failure
Developmental outcomes associated with hypoxic ischaemic encephalopathy?
Spastic quadriplegia
Dyskinetic cerebral palsy
Death
Moderate: 5% mortality, 20% neuro sequalae
Severe: 75% mortality 90-100% neuro sequelae
Mechanism of therapeutic hypothermia and SEs?
Cooling to 33-35C within 6hrs of birth
Reduces cerebral metabolic rate, reduced apoptosis, lower nitric oxide production and free radicals and is neuroprotective
Improved survival/outcomes at 18mths
SEs:
thrombocytopenia, bradycardia, subcutaneous fat necrosis and hypercalcaemia
Periventricular injury outcome most associated?
Spastic diplegia
Neonatal stroke outcome most associated?
Spastic hemiplegia
Congenital infection CP associated?
Spastic quadriplegia
Severe perinatal asphyxia CP associated?
Dyskinetic CP
Grade IV intraventricular haemorrhage outcome?
Cerebral palsy with spastic hemiparesis if unilateral, quadriparesis if bilateral
Intellectual deficit
Risk factors for IVH and protective factors?
Chorioamnionitis
Very low birthweight or <32/40
Coag abnormalities, hypoxia, neonatal transport, CPR, mechanical ventilation
Intrapartum asphyxia
Protective:
Antenatal steroid therapy, term infant
Symptoms of IVH?
Usually asymptomatic until neurological sequqale evident in later infancy as spastic motor deficit
25-50% detected on routine CrUSS screening
Necrosis of cerebral white matter surrounding lateral ventricles and involving area adjacent to trigones/frontal horn?
Periventricular leukomalacia
Usually asymptomatic until later infancy - may have lower limb weakness
Area of most arterial ischaemic stroke in neonates?
MCA distribution
Arm and face affected > lower limb
Most common presentation is focal seizures
Risk factors for TTN
Prematurity
Cesarean
Infants of diabetic mothers
Maternal asthma
Risk factors for meconium aspiration?
Post-dates
SGA
Signs of severe mechanism asp syndrome?
Pneumothorax/pneumomediastinum
PPHN
Pre-post ductal SpO2 difference due to R->L shunting
Severe hypoxia in 100% FiO2
R -> L shunt. Normal heart structure on TTE
Single loud S2 +/- gallop rhythm of systolic regard murmur
Persistent Pulmonary Hypertension
PPHN
Reversible causes of PPHN?
Alveolar hypoxia (eg mec asp) Sepsis Birth asphyxia LV dysfunction/CHD Polycythemia Hypoglycaemia/hypocalcaemia
Difficult/irreversible causes of PPHN?
Intrauterine asphyxia
Maternal prostaglandin use, SSRI use resulting in early duct closure
Congenital diaphragmatic hernia
Primary pulmonary hypoplasia
Management of PPHN?
Lower pulmonary vascular resistance by O2, respiratory alkalosis, pulmonary vasodilators
Nitric oxide - reduces PPHN by 40%
Incidence of unilateral pneumothorax in all newborns?
1-2%
Subcutaneous emphysema in neonate?
Pneumomediastinum
Ventilated VLBW infant with hyperaemia and hypercarbia within first 4 days of life? May progress to reduced cardiac output
Pulmonary interstitial emphysema
Decrease MAP - consider HFOV - position with affected side down
Risk factors for prev delivery?
Maternal age - young/old Cervical incompetence Uterine malformation Substance use (cocaine) Maternal medical illness Multiple pregnancy Polyhydramnios Fetal anomaly Antepartum haemorrhage Chorio HTN/PET
Benefit of Magnesium sulphate in premature delivery?
Decreases risk of cerebral palsy
PDA incidence in prev infants?
30% of very low birth weight
Complications of NEC?
Growth delay
Neurodev disability
Increased mortality
Organisms most commonly associated with late onset sepsis in prems?
70% gram-positive organisms
50% coagulase negative staph (S epidermis, S haemolytic, S Capitis)
Most important indicator f severity in retinopathy of prematurity?
Presence of plus disease
- vessel tortuosity
- vessel engorgement
- pupil rigidity
- vitreous haze
Retinal vascularisation occurs when in gestation?
15-18 weeks
Vessels extend from optic disc and grow peripherally
VEGF contributes to abnormal development
Physiology contributing to osteopenia of prematurity?
- Passage of Ca/Phos via placenta >24/40 peaks 32-36
- GIT absorption is poor
- Renal loss
Risk factors for metabolic bone disease?
Prematurity Inactivity Delay in establishment of enteral feeding >4/52 Short gut/NEC CLD - steroid/diuretic treatment
Best biochem marker for bone turnover?
ALP
>750 osteopenia
>1000 rickets
Risk factors for bronchopulmonary dysplasia?
Infants < 1250g (97%) Prematurity Male sex PDA Increased pulmonary artery pressure
Prevention of BPD?
Prevention of prev birth Antenatal steroids CPAP rather than mechanical ventilation Early caffeine therapy Supplemental vit A
Complications of BPD?
Pulmonary artery hypertension Systemic hypertension Asthma like symptoms Sleep disordered breathing/sleep hypoxia Resp infections
Ear shape for gestation?
24 – 33 weeks: Flat, shapeless. No cartilage
34 – 35 weeks: Minor superior incurving. Minimal cartilage
36 – 38 weeks: Upper 2/3 incurving. Thin cartilage
>39 weeks: Full incurving. Cartilage.
Sole creases for gestation?
24 – 31 weeks: No anterior creases 32 – 33 weeks: 1 or 2 anterior creases 34 – 35 weeks: 3 or 4 anterior creases 36 – 37 weeks: Creases covering 2/3 of anterior sole >38 weeks: Heel creases
Lanugo for gestation?
22 - 32 weeks: entire body and face
32 - 37 weeks: body only
>38 weeks: shoulders only
>42 weeks: none
34 week infant renal function vs term infant?
Reduced glomerular filtration rate
Sugars in breastmilk?
Glucose
Galactose
Ex-prem infant with resp distress and CXR shows reticular, bubbly appearance?
Interstitial pulmonary fibrosis
Resp distress and scaphoid abdomen?
Congenital diaphragmatic hernia
Benefits of volume guarantee ventilation?
Consistent tidal volume delivered
Prevents frequent desaturation
Disadvantages of volume guarantee ventilation?
Volutrauma (if volume is too high)
Barotrauma if excess PIP is required to reach the volume target
Can’t be auto-weaned
Benefits of pressure control ventilation?
Limits PIP - reduces barotrauma Adjustable IT Reduces WOB Improves V/Q mismatch as the pressure is achieved throughout the inspiratory cycle Allows for spont resp
Disadvantages of pressure control ventilation?
Higher variation in volume delivered
Increased WOB with spont resps
Factors influencing oxygenation?
PEEP
FiO2
Factors influencing ventilation (removal of CO2)?
MAP - increase PIP - increase PEEP (makes the most difference) - increase inspiratory time Resp rate
Maternal smoking increases risk of which long term outcomes?
SIDS T2DM Obesity HTN Nicotine dependance Asthma, LRTI, reduced lung function Impaired academic performance ADHD, behavioural problems Psychiatric illness
Jaundice
Poor tone
Large anterior fontanelle
Umbi hernia
Hypothyroidism
What GA can infants co-ordinate suck and swallow?
From 33-34 CGA
