Presented by : Silvia P. Tarigan Counsellor : H. Tisna Sukarna, dr.

, SpA, MBA

PATIENT IDENTITY Name

: M Rafif Lathif : 1 month old : Male : January, 16th 2011 : January, 16th 2011

Age Sex Date of hospitalized Date of examination

Father : Name

: Mr. Beni H :36 years old : Senior High School

Mother : Name

: Mrs. Siti M :35 years old : Senior High School : Housewife

Age Education

Age Education

Occupation :Entrepreneur

Occupation

Address : Sukamukti RT 3 RW 5, Katapang Bandung.

Address : Sukamukti RT 3 RW 5, Katapang Bandung.

 Heteroanamnesis

was given by his mother on January, 16 th 2011

complaint: convulsion

Chief

History of present illness: One day before admission to the hospital patient had convulsion as many as 1 time for 2 minutes The convulsion are not preceded by fever. During the convulsion, suddenly became stiff and uprolling of the eyes for 1 minutes. He had a generalised tonic-clonic convulsion. Before and after the convulsion patient was conscious. Patients mother denied any historical information of falling from a baby box. 2 days before entering the hospital, patient experienced vomiting in each breast-feeding time. Patient has not ever cried again since the convulsion.

The big brother of patient had experience the convulsion at the age of 6 months old but was preceded by fever. Patients mother stated that when the patient was 1 week old, the baby was ikterik and it has still happened until today. The patients mother also said that the baby had not been given Vitamin K injection when the baby was born

Urine: the color, volume, and frequency was normal and no pain when urinate.
Defecation : the color, consistency, and frequency was normal Medical Effort: 1 day ago went to the midwife and got some medicine.

Past Medical History: the patient never had sick like this before.
History of family illness: The big brother of patient had experience the convulsion at the age of 6 months old but was preceded by fever

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

Birth : aterm, spontaneous, directly cry and helped by a midwife. Birth weight : 3500 grams. Birth length : 52 cm

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

 Immunization
Booster Vaccination
Vaccine Basic Vaccination Recommended Vaccination

BCG Polio DPT Hep B Measles

HiB MMR Hep A Varicella Typhim/typha

: : : :

none none none none

: none

Influenzae

: none

Nutrition and Feeding Breastmilk

Past Illnesses Cough Family history : Convulsion

General appearance Condition Consciousness Activity and position General condition

: severe sickness : somnolen : no force position : weak

Vital signs Pulse

: 143 times a minute, regular, equal, strong : 36 times a minute, thoracoabdominal type

Respiration

Temperature : 35,7 C, aksiler

Measuring Weight : 4,9 kg Height : 65 cm (113,95 % standard Weight/Age ) (119,04 % standard Height/Age )

Nutrition status Rumple Leede

: (standard Weight/Height ) : (-)

SYSTEMATIC EXAMINATION 4.1. Skin : rash (-), pale (+), icteric (+), turgor was immediately returns to normal position

Head Hair : black, disseminated, not easy to yanked out Fontanel : tense Eyes : conjunctiva anemic +/+, conjungtiva hyperemic -/-, sclera icteric +/+, pupil anisokor (diameter pupil sinistra > dextra), light reflex : -/ Nose : nostril breathing+/+, secret -/-, epistaxis -/ Lips : wet, cyanosis + Mouth : moist mucosa Gums : no bleeding, no hyperemic Palate : no disparity Tongue : coated tongue -, hyperemic -, tremor , Kopliks spot Pharynx and tonsil : hyperemic -, T1=T1

Neck Nuchal rigidity : (-) Lymph node : not palpable Thorax Lungs Inspection : shape and movement was simetric, right was equal to left, retractions supraclavicle +

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 linea midclavicularis sinistra

Percussions : border on top ICS 2 linea parasternalis sinistra, border on left ICS 4 linea midclavicularis sinistra, border on right ICS 3 linea sternalis dextra Auscultations : heart sounds regular, shuffle

Abdomen : Inspections : flat Auscultations : bowel sound (+) Percussions : tympanic, Traubes space : tympanic Palpations : , liver 4 cm below arch costarum, tenderness (-), skins turgor was immediately returns to its normal position. Liver and spleen inpalpable

Genital : male, normal Anus & Rectal: no disparity Extremities : no disparity Upper : left: active, right : active Lower : left: active, right: active Joint : no disparity Muscle : hypertrophy -, atrophy Neurological Examination Reflex : physiological -/-, pathological +/+

On January 16,2011

On January 17,, 2011

Hb : 9,3 gr / dl Ht: 28,0% Leu: 11700 / m3 Tc: 578000/m3 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/dl Ht : 32,6 % Leu : 8620/ m3 Tc : 517000/m3 Na : 124 mEq/L K : 4,6 mEq/L Ureum : 16 mEq/L PT : 11.5 second aPTT : 30,4 second Fibrinogen : 396 mg/dl

22

CT- scan On 16 January,2011 Trail: Frontotemporoparietal left subdural haemorrhage is the cause of the shifted midline to the left by 1, 29 cm; and the constriction of the left lateral ventricle. There also appears the hemorrhage of intracerebral in areas right-side frontotemporoparietal.

1 month old boy, with 4,9 kg body weight, 60m body height, nutritional status (standard Weight/Height) came to Immanuel Hospital because convulsion. One day before admission to the hospital patient had convulsion as many as 1 time for 2 minutes The convulsion are not preceded by fever. During the convulsion, suddenly became stiff and uprolling of the eyes for 1 minutes. He had a generalised tonic-clonic convulsion. Before and after the convulsion patient was conscious. Patients mother denied any historical information of falling from a baby box. 2 days before entering the hospital, patient experienced vomiting in each breast-feeding time. Patient has not ever cried again since the convulsion.

The big brother of patient had experience the convulsion at the age of 6 months old but was preceded by fever. Patients mother stated that when the patient was 1 week old, the baby was ikterik and it has still happened until today. The patients mother also said that the baby had not been given Vitamin K injection when the baby was born

Urine: the color, volume, and frequency was normal and no pain when urinate. Defecation : the color, consistency, and frequency was normal Medical Effort: 1 day ago went to the midwife and got some medicine. Past Medical History: the patient never had sick like this before. History of family illness: The big brother of patient had experience the convulsion at the age of 6 months old but was preceded by fever.

Immunization profile: the patient havent receive all basic immunization.

Nutrition status : (standard Weight/Height)

General appearance Condition Consciousness Activity and position General condition

: severe sickness : somnolen : no force position : weak

Vital signs Pulse

: 143 times a minute, regular, equal, strong : 36 times a minute, thoracoabdominal type

Respiration

Temperature : 35,7 C, aksiler

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

Head Eyes : conjungtiva anemic +/+, sklera ikteric +/+, light reflex : -/-, pupil anisokor ; diameter pupil sinistra> dextra Fontanel : tense Nose :nostril breathing+/+, secret -/-, Mouth : moist mucosa Tongue : Kopliks spot Pharynx and tonsil : hyperemic -, T1=T1

Neck Lymph node : not palpable

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

Abdomen Liver 4 cm below arch costarum

On January 16,2011

On January 17,, 2011

Hb : 9,3 gr / dl Ht: 28,0% Leu: 11700 / m3 Tc: 578000/m3 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/dl Ht : 32,6 % Leu : 8620/ m3 Tc : 517000/m3 Na : 124 mEq/L K : 4,6 mEq/L Ureum : 16 mEq/L PT : 11.5 second aPTT : 30,4 second Fibrinogen : 396 mg/dl

32

CT- scan On 16 January,2011 Trail: Frontotemporoparietal left subdural haemorrhage is the cause of the shifted midline to the left by 1, 29 cm; and the constriction of the left lateral ventricle. There also appears the hemorrhage of intracerebral in areas right-side frontotemporoparietal.

Differential Diagnosis : Intracranial hemorrhage Increased in Intracranial Pressure Sepsis neonatorum Working diagnosis :Intracranial hemorrhage (subdural and intraserebral hemorrhage)
: Anemia, Hiperbilirubin neonatus, hiperglikemia neonatorum

Additional diagnosis

Serial Lumbar Punctures Blood gas analysis CT Scan USG

 Quo

ad vitam Quo ad functionam

: dubia ad bonam : dubia ad bonam

Non Medicamentous Treated in the PICU Fluid : Ringer Lactat 500cc / 24 hour O2 nasal 2Lpm Fasting Medicamentous Amoxicillin : 3 x 500 mg iv Kalmethason : 2 x 1 mg iv Garamicine : 2 x10 mg iv Mannitol : 3 x 10 cc, drip Vit K : 2 x 1 mg, IM every day ( during 5 day) Diazepam : 1 mg prn PRC 50 cc during 3 hours FFP 50 cc during 3 hours

Jan 16 th, 2011

Therapy

Subjective: Groan (+) Convulsion (+) Pale (+) Objective: Sklera ikteric (+/+), pupil anisokor ( diameter pupil sinistra> dextra) Skin : pale (+), ikteric (+) Fontanel : tense Bradipnoe RR:12 x/m SpO2 : 97 % Nastril breath +/+, retraction +/+

02 nasal 2 lpm Fluid : RL 500cc /24h Fasting Amoxillin 3 x 500 mg iv Garamisin 2 x 100 mg iv Diazepam 1 mg Mannitol 3 x 10 cc, drip Vit K : 1 mg IM, during 5 days Transfussion PRC 50 cc during 3 hours Plan to transfussion FFP 50 cc during 3 hours

Jan 17th, 2011 Subjective: Groan (-) Convulsion (+) Cry (+) Objective: Sklera ikteric (+/+), pupil anisokor ( diameter pupil sinistra> dextra) Skin : ikteric (+) Fontanel : tense SpO2 : 100 % Nastril breath -/-, retraction -/-

Plan: 02 nasal 2 lpm Diet : fasting IVF : Aminofuchsin ped 100cc/hour, D5 %+ valium 15 mg 400 cc/24 hour Transfusi WB 50 cc Amoxillin 3 x 500 mg iv Garamisin 2 x 100 mg iv Mannitol 3 x 10 cc, drip Vit K : 1 mg IM, during 5 days

Jan 18th, 2011

Plan: Craniotomy Diet : fasting IVF : Aminofuchsin ped 100cc/hour, D5 % 400 cc/24 hour Amoxillin 3 x 500 mg iv Garamisin 2 x 100 mg iv Kalmethason 2x1 mg

Subjective: Convulsion (+) Objective: Sklera ikteric (+/+), pupil anisokor ( diameter pupil sinistra> dextra) Skin : ikteric (+) Fontanel : tense SpO2 : 100 %,spontaneus breathing Nastril breath -/-, retraction -/-

Mannitol 3 x 10 cc, drip

Phenitoin 2x 25 mg Diazepam 1 mg prn Vit K : 1 mg IM

Jan 19th, 2011

Plan :
Diet : D5 % 6 x 10 cc KaEN 1 B 100 cc Aminofucsin 100 cc Amoxillin 3 x 500 mg iv Garamisin 2 x 100 mg iv Kalmethason 2x1 mg Phenitoin 2x 25 mg Vit K : 1 mg IM Novalgin 4x 50 mg Valium 1mg prn

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

Objective: Sklera ikteric (+/+), pupil isokor , light reflex +/+ Skin : ikteric (+) Fontanel : soft spontaneus breathing Nastril breath -/-, retraction -/-

The Diagnosis of based Intracranial Hemorrhage In the Newborn

on : 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

Physical Diagnostic

Skin : pale (+), ikteric (+)

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

light reflex : -/-, pupil anisokor ; diameter pupil sinistra> dextra

Nose : Nostril breathing (+)

Thorax : retractions supraclavicle +

CT Scan : subdural and intraserebral haemorrhage

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, and other blood disorders.

a coagulation disturbance in newborns due to vitamin K deficiency. As a consequence of vitamin K deficiency there is an impaired production of coagulation factors II, VII, IX, X, by the liver Causes Newborns are relatively vitamin K deficient for a variety of reasons. They have low vitamin K stores at birth, vitamin K passes the placenta poorly, the levels of vitamin K in breast milk are low and the gut flora has not yet been developed (vitamin K is normally produced by bacteria in the intestines).

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

Definition

Bleeding in the cranial cavity and its contents in infants from birth until age 4 weeks. Intracranial Hemorrhage includes epidural, subdural, subarachnoid, intra serebral/parenkim dan intraventrikuler hemorrhage

Epidemiology

from 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 the head. Very difficult or prolonged labors, where there is excessive molding of the head with injury. Instrumental deliveries

Cause not trauma

Prematurity of the infant

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

Grade II: hemorrhage which has extended into the ventricular system but without dilation of the lateral ventricles Grade III: hemorrhage extending into the ventricular system with the blood resulting in ventricular dilatation

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

Epidural hemorrhage (extradural hemorrhage) which occur between the durameter and the skull, is caused by trauma It may result from laceration of an artery, most commonly the middle meningeal artery dangerous type of injury because the bleed is from a high-pressure system and deadly increases in intracranial pressure can result rapidly Subdural hemorrhage results from tearing of the bridging veins in the subdural space between the dura and arachnoid mater Subarachnoid hemorrhage which occur between the arachnoid and pia meningeal layers, can result either from trauma or from ruptures of aneurysms or arteriovenous malformations

Intraventrikuler hemorrhage hypoxia vasodilatation blood vessel of the brain and venous congestion increase blood flow elevated pressure of the brain blood Easily Ruptur

Onset of symptoms of intracerebral hemorrhage is usually during daytime 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 tongue

Expiratory grunting

Physical exam:
unconscious individual should quickly assess the adequacy of the airway, breathing, pulse, and blood pressure before beginning a more detailed neurological and physical exam. The latter includes an evaluation of level of consciousness, pupil response and vital signs, motor function, reflexes, and memory.

Serial Lumbar Punctures Blood gas analysis CT Scan USG

Treated in the incubator that allows continuous observation and O2 delivery

It should be observed carefully: body temperature, degree of consciousness, pupil size and reaction, motor activity, respiratory frequency, 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.

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

Corticosteroids such as dexamethasone 0.5 to 1 mg/kgBB/24 hours 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 of irritation on the surface of the cortex
Emergency surgery Craniotomy

Staging I, II : mild
Staging III, IV : severe Intracranial hemorrhage is a serious medical emergency because the build up of blood within the skull can lead to increases in intracranial pressure Severe increases in intracranial pressure can cause potentially deadly brain herniationin