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PENGENALAN

KEGAWATAN
PADA
NEONATUS

Dr. Aris Primadi,


Sp.A(K)
RSHS/ FK UNPAD BANDUNG

D a n g e r signs
Asphyxia Abdominal
Lethargy distension Yellow
Hypothermi palms/soles
Bleeding
a
Excessive weight
Respiratory loss Vomiting
distress Cyanosis Diarrhea
Convulsion
APGAR
Scores
Sign Score = 0 Score = 1 Score = 2
---------------------------------------------------------------------------------------------------
APPEARANCE Blue all over, Acrocyanosis Pink all over or
(color) pale
PULSE Absent Below 100 Above 100
(heart rate)
GRIMACE No response Grimace or Good cry
(reflex irritability) weak cry
ACTIVITY Flaccid Some flexion of Well flexed, or active
(muscle tone) extremities movements of extremities
RESPIRATIONS Absent Weak, irregular, Good crying
or gasping
============================================
The APGAR score should be assigned at one minute and five minutes, finding the total
score (0-10) at each time by adding up points from the table above.
Continue to assign scores every five minutes thereafter as long as the APGAR score is
less than 7.

Ya
DIAGRAM ALUR
Ber nap as atau m en an g i s? P e r a w a t a n rutin:
To n u s b a i k ?  Pastikan bayi tetap hangat
 K e r i n g k a n ba y i
Ti dak
 L anj ut k an o bs e rv as i p e r n a p as a n ,
BANTUAN?
PADASETIAP LANGKAH TANYAKAN: APAKAH ANDAMEMBUTUHKAN

L a n g k a h awal: (ny alakan pencatat waktu) l aj u d e n y u t j a n t u n g, d a n t o n u s RESUSITASI NEONATUS


 P a s t i k a n b ay i t e t a p h a n g a t
detik
30

 A t u r po s i s i d a n b e r s i hk a n j a l a n n a p a s
 Keringkan
 Pos is ikan k em bal i
d a n s t i m u l as i
Keteran gan:
P a d a b a y i d e n g a n be r at DI
≤ 1 5 0 0 g r a m , ba y i l a n g s u n g
d i b u n g k u s plastik b en i n g
O b s e r v a s i u s a h a n a p a s , l aj u d e n y u t j a n t u n g ( L D J ) , d a n t o n u s o t o t t a n p a di k er i ng k a n t e r l eb i h
dahulu kecuali wajahnya,
FASILITAS
k e m u d i a n d i p a s a n g t opi .
Tid ak bernap as/
m e g a p -m e g a p , d an atau
Bernapas spontan
B ay i tetap d apa t distimulasi
wa l a u p u n d i b u n g k u s plastik
PELAYANA
atau L D J < 100x/ m enit

Distres n ap a s
( Ta k i p n u , r e t r a k s i , a t a u
S i a n o s i s s en t r al
persisten
N
detik

merintih)
30

` Ve n t i l as i
t e k a n a n positif
(VTP)
Co n ti n uo us positive
P e rt i m ba ngk a n
s uplementasi ok sigen
KESEHATAN
a i r w a y p r e s s u r e ( C PA P )
P E E P 5-8 c m H 2O
Pemantauan SpO 2
Pemantauan SpO2
Pemantauan SpO 2
RUJUKAN
K eterangan:
G ag al C PA P
Bila LDJ te t ap A pa b i l a L D J > 1 0 0 k al i p e r
< 1 00 kali/ m e n i t P E E P 8 c m H 2O

F iO2 > 4 0 %
m e n i t d a n t ar g et s at ur a s i
o k s i g e n t er c ap ai :

FASILITAS
Setiap 30 detik sekali nilai laju denyut jantung, usaha napas dan tonus

D e n g a n d i s t r es n a p a s  Ta n p a a la t  kanutLanj k e
P e rti m b an g ka n intubasi peraw atan observasi

LENGKAP
 D e n g a n a la t  kanutLanj
ke per aw ata n pask a-
Peng embang an dada adekuat?
resusitasi

Ya T id a k Wa k t u d a r i
Target S p O 2
Lahir
Preduktal

D ad a me n ge mb an g adekuat Bila d a d a tidak 1 menit 60-70%


n a m u n L D J < 60x/ me ni t men g emb a ng adekuat
2 menit 65-85%
VT P (O2 1 00 %) +
komp resi d ad a
( 3 k o m p r e s i t i ap 1 n a p a s )
Evaluasi:
 Posisi kepala bayi
3 menit 70-90% UKK Neonatologi
 Obstruksi jalan n ap as 4 menit 75-90%
Pert imbangk an Intubasi
 Kebocoran s un gk up
 Te k a n a n p u n c a k 5 menit 80-90% IDAI 2014
Observasi L D J d an us ah a i ns p i r a s i c u k u p a t a u
tidak 10 menit 85-90%
na pa s tiap 3 0 detik

K eterangan:
I nt u ba s i e n d o t r a k e a d a p a t
dipertimbangkan pa da
L D J < 60/ m en i t? l a n g k a h ini ap a b i l a V T P t i d ak
ef ek t i f a t a u t el a h d i l a k u k a n
s elam a 2 menit
P e r t i m b a n g k a n p e m b e r i a n o b a t d a n c a i r a n i n t r av e n a
Lethargy and poor sucking

 In a term baby who was feeding earlier


 indicates neonatal illness (as perceived by mother)

 In a preterm baby
 needs careful assessment
because it may be due to cold stress or immaturity

VOLPE,
Level of Penampila 2008
Respo Respon Motorik
Alertnes n Bayi n Kuantitas Kualitas
s Bangu
n

Normal Bangun Normal Normal High Level


Stupor
Ringan Mengantuk Berkurang Berkurang High Level
(slight) (slight)
Sedang Tidur Berkurang Berkurang High Level
(sedang) (sedang)
Berat Tidur Tidak ada Berkurang High Level
(jelas)
Koma Tidur Tidak ada Berkurang Low Level
(jelas)/ tak ada
Primitive gut formed

Gut rotation

Structure
Villi

Digestive enzymes

Small intestine mature

F Swallow
u
n
c Gastrointestinal motor activity
t
i
o Organized motility
n

Post-menstrual age (wk)


The ontogenic timetable showing structural and functional gastrointestinal development

Clin Perinatol 2000

Nutritive sucking and swallowing

Body temperature in newborn infant (oC)

37.5o
Normal range

36.5o
Cold stress
Cause for concern
36.0o
Moderate hypothermia
Danger, warm baby

32.0o
Severe hypothermia Outlook grave, skilled
care urgently needed
Respiratory problems

 RR > 60 / min*
 Retractions
 Grunting
 Central cyanosis
 Apnea

* R a t e s h o u l d be c o u n t e d in a q u i e t
s t a t e a n d n o t immediately a f t e r f e e d
Cyanosis

Peripheral
 Normal at birth
 Seen in extremities
due to cold

Central
 Always needs te referral
appropria
 Seen on lips and
mucosa
 Indicates cardiac
or pulmonary
disease

Respiratory Distress Evaluation

Silverman Anderson retraction


score
Score Upper Lower Xiphoid Nasal Grunt
chest chest retractio dilatatio
restraction retraction n n

0 Synch None None None None


1 Lag on Just visible Just visible Minimal Stethoscop
inspiratio e only
n
2 See-Saw Marked Marked Marked Naked ear
A score of > 6 is indicative of impending respiratory
failure
Silverman WC, Anderson DH. Controlled clinical trial on effects of water mist on obstructive respiratory signs, death rate
and necropsy findings among premature infants. Pediatrics 1956; 17: 1-4.
Respiratory Distress Evaluation

Classification of breathing difficulty (WHO – Depkes)

Respiratory Distress Evaluation


Downes’ score

Score Respirator Cyanosis Air entry Grunt Retraction


y rate
0 <60/min Nil Normal None Nil
1 60-80/min In room air Mild ? Aus Mild
c
with
stet
hosc
ope
2 >80/min In >40%
Audible Marked ? Moderate
Score with naked
< 3 Minimal respiratory distress
ear
Score 4 – 5 Moderate respiratory distress
Score >6 Severe respiratory distress

Wood DW, Downes’ JJ, Locks HI. A clinical score for the diagnosis of respiratory
failure. Amer J Dis Child 1972; 123: 227-9.
Convulsion

17

ABDOMINAL DISTENSION

Feeding Intolerance
Stop enteral feeds and reassess:
 Bilious (or greenish residuals)
 Vomiting
 Acute increase in abdominal girth >2 cm
 Frankly bloody or very watery stool
 Increased residuals
 Other signs of illness
Yellow staining of soles

19

Clinical assessment of severity of jaundice

• Cephalocaudal progression
– face 5 mg/dL (approximately)
– upper chest 10 mg/dL (approximately)
– abdomen and upper thighs 15 mg/dL (approximately)
– soles of feet 20 mg/dL (approximately)

• Visual inspection may be misleading


20
Kernicterus - Neuropathology

Yellow staining and neuronal


necrosis
• Basal ganglia:
– globus pallidus
– subthalamic nucleus
• Cranial nerve nuclei:
• vestibulocochlear
• oculomotor
• facial
• Cerebellar nuclei
21

BLEEDING

Disseminated Intravascular
Coagulation

22
Bleeding infant

Screening tests
Activated partial thromboplastin time (aPTT)
Thrombin clotting time (TCT)
Prothrombin Time (PT)
Fibrinogen (Fbg)
Platelet Count
Bleeding Time (BT)

All tests aPTT aPTT, BT abnormal,


PT prolonged Thrombocytopenia
prolonged PT, TCT, Platelet count
normal Fbg normal
abnormal

CAPILLARY REFILL TIME


(CRT)
 Indicates tissue perfusion
Normal CRT < 3
seconds Prolonged CRT > 3
seconds *
* Hypotension, hypothermia,
acidosis
Excessive
weight loss pattern

 > 10 percent of birth weight in term


 > 15 percent in preterm
 > 5 percent acute weight loss

Failure to pass
meconium &
urine

F a i l u r e t o pass meconium
Majority pass within 24 hrs
 Delayed passage
 May have passed in –utero
 Suspect obstruction

F a i l u r e t o pass u r i n e
Majority pass within 48 hrs
 Delayed passage
 Exclude obstructive uropathy or renal
agenesis
Vomiting*

 Ingestion of meconium stained amniotic


fluid
 Systemic illness
 Raised ICP – IVH, asphyxia

• Persistent, projectile or bile stained


 intestinal obstruction

Diarrhea

 Infective diarrhea*
(often non breast fed baby)
 Metabolic disorders
 Maternal drug addiction

* Infective diarrhea needs


treatment with systemic antibiotics