Morning Rounds \u00b7 Birth Asphyxia & HIE<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n#neo04 *,#neo04 *::before,#neo04 *::after{box-sizing:border-box;margin:0;padding:0}\n#neo04{\n --ter:#8B3A3A;\n --ter-light:#A85050;\n --ter-pale:#F9EDED;\n --ter-dark:#5C1E1E;\n --correct:#2D6B47;--correct-bg:#EAF6EF;--correct-border:#3A9960;\n --wrong:#B83232;--wrong-bg:#FDF0F0;--wrong-border:#E53935;\n --ink:#2A1010;--ink-mid:#5A3030;--ink-soft:#9A7070;\n --line:#EDD8D8;--cream:#FDF4F4;--warm:#FFFAFA;\n font-family:'Source Serif 4',Georgia,serif;\n font-size:16px;color:var(--ink);background:var(--cream);\n line-height:1.7;padding:0 0 64px;\n}\n#neo04 .mr-header{background:var(--ter);color:#FFFAFA;padding:34px 24px 28px;text-align:center}\n#neo04 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style=\"width:100%;max-width:620px;display:block;margin:0 auto\" aria-label=\"Sarnat grading of hypoxic-ischaemic encephalopathy\">\n <rect width=\"620\" height=\"196\" rx=\"6\" fill=\"#FFFAFA\"\/>\n \n <rect x=\"8\" y=\"8\" width=\"148\" height=\"28\" rx=\"4\" fill=\"#E8C0C0\"\/>\n <rect x=\"166\" y=\"8\" width=\"142\" height=\"28\" rx=\"4\" fill=\"#C97A7A\"\/>\n <rect x=\"318\" y=\"8\" width=\"142\" height=\"28\" rx=\"4\" fill=\"#8B3A3A\"\/>\n <rect x=\"470\" y=\"8\" width=\"142\" height=\"28\" rx=\"4\" fill=\"#5C1E1E\"\/>\n <text x=\"82\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#5C1E1E\">Feature<\/text>\n <text x=\"237\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#FFFAFA\">Grade I (Mild)<\/text>\n <text x=\"389\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#FFFAFA\">Grade II (Moderate)<\/text>\n <text x=\"541\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#FFFAFA\">Grade III (Severe)<\/text>\n \n <rect x=\"0\" y=\"44\" width=\"620\" height=\"26\" fill=\"#FDF4F4\"\/>\n <rect x=\"0\" y=\"70\" width=\"620\" height=\"26\" fill=\"#FFFAFA\"\/>\n <rect x=\"0\" y=\"96\" width=\"620\" height=\"26\" fill=\"#FDF4F4\"\/>\n <rect x=\"0\" y=\"122\" width=\"620\" height=\"26\" fill=\"#FFFAFA\"\/>\n <rect x=\"0\" y=\"148\" width=\"620\" height=\"26\" fill=\"#FDF4F4\"\/>\n <rect x=\"0\" y=\"174\" width=\"620\" height=\"26\" fill=\"#FFFAFA\"\/>\n \n <text x=\"6\" y=\"62\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Consciousness<\/text>\n <text x=\"6\" y=\"88\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Tone<\/text>\n <text x=\"6\" y=\"114\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Seizures<\/text>\n <text x=\"6\" y=\"140\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Reflexes<\/text>\n <text x=\"6\" y=\"163\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Autonomic<\/text>\n <text x=\"6\" y=\"192\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Outcome \/ TH<\/text>\n \n <text x=\"237\" y=\"62\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Hyperalert<\/text>\n <text x=\"237\" y=\"88\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Normal \/ mild ↑<\/text>\n <text x=\"237\" y=\"114\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">None<\/text>\n <text x=\"237\" y=\"140\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Brisk<\/text>\n <text x=\"237\" y=\"163\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Sympathetic<\/text>\n <text x=\"237\" y=\"185\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Good; TH not indicated<\/text>\n \n <text x=\"389\" y=\"62\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Lethargic<\/text>\n <text x=\"389\" y=\"88\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Mild ↓ (hypotonia)<\/text>\n <text x=\"389\" y=\"114\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Present<\/text>\n <text x=\"389\" y=\"140\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Decreased<\/text>\n <text x=\"389\" y=\"163\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Parasympathetic<\/text>\n <text x=\"389\" y=\"185\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Variable; TH indicated<\/text>\n \n <text x=\"541\" y=\"62\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Stupor \/ coma<\/text>\n <text x=\"541\" y=\"88\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Flaccid<\/text>\n <text x=\"541\" y=\"114\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Absent or prolonged<\/text>\n <text x=\"541\" y=\"140\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Absent<\/text>\n <text x=\"541\" y=\"163\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Depressed<\/text>\n <text x=\"541\" y=\"185\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Poor; TH indicated<\/text>\n \n <line x1=\"156\" y1=\"8\" x2=\"156\" y2=\"196\" stroke=\"#EDD8D8\" stroke-width=\"1\"\/>\n <line x1=\"308\" y1=\"8\" x2=\"308\" y2=\"196\" stroke=\"#EDD8D8\" stroke-width=\"1\"\/>\n <line x1=\"460\" y1=\"8\" x2=\"460\" y2=\"196\" stroke=\"#EDD8D8\" stroke-width=\"1\"\/>\n \n <line x1=\"0\" y1=\"44\" x2=\"620\" y2=\"44\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"70\" x2=\"620\" y2=\"70\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"96\" x2=\"620\" y2=\"96\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"122\" x2=\"620\" y2=\"122\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"148\" x2=\"620\" y2=\"148\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"174\" x2=\"620\" y2=\"174\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <\/svg>\n <figcaption>\n <strong>Sarnat grading of HIE<\/strong> (modified). Therapeutic hypothermia (TH) is indicated for\n <strong>Grade II and III<\/strong> in neonates ≥36 weeks, provided criteria are met and cooling begins within 6 hours of birth.\n Grade I (mild HIE) generally has a good prognosis and TH is not currently standard of care.\n Grade III carries the highest mortality and risk of severe neurodisability even with TH.\n <\/figcaption>\n <\/figure>\n<\/div>\n\n\n\n<div id=\"neo04\">\n\n <div class=\"mr-header\">\n <div class=\"mr-eyebrow\">Morning Rounds · Neonatology Series<\/div>\n <div class=\"mr-title\">\n Birth Asphyxia & HIE<br><em>Clinical Reasoning<\/em>\n <\/div>\n <div class=\"mr-subtitle\">Five cases · Read carefully · Trust your instinct<\/div>\n <div class=\"mr-chips\">\n <span class=\"mr-chip\">5 Cases<\/span>\n <span class=\"mr-chip\">+4 \/ −1 scoring<\/span>\n <span class=\"mr-chip\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n <div class=\"mr-sentinel\" id=\"neo04-sentinel\"><\/div>\n\n <div class=\"mr-progress\" id=\"neo04-progress\">\n <div class=\"mr-prog-inner\">\n <div class=\"mr-pips\" id=\"neo04-pips\"><\/div>\n <\/div>\n <\/div>\n\n <div class=\"mr-body\">\n <div id=\"neo04-cases\"><\/div>\n\n <div class=\"mr-submit-wrap\">\n <button class=\"mr-btn\" id=\"neo04-submit\">Submit for Debrief<\/button>\n <\/div>\n\n <div class=\"mr-score\" id=\"neo04-score\">\n <div class=\"mr-score-in\">\n <div class=\"mr-score-ey\">Round Complete<\/div>\n <div class=\"mr-ring\" id=\"neo04-ring\">\n <div class=\"mr-ring-in\">\n <span class=\"mr-ring-pct\" id=\"neo04-pct\">0%<\/span>\n <span class=\"mr-ring-sub\">net<\/span>\n <\/div>\n <\/div>\n <div class=\"mr-score-title\">Your Debrief<\/div>\n <div class=\"mr-score-net\" id=\"neo04-net\"><\/div>\n <div class=\"mr-verdict\" id=\"neo04-verdict\"><\/div>\n <div class=\"mr-bands\">\n <span class=\"mr-band mr-band-c\" id=\"neo04-ct-c\"><\/span>\n <span class=\"mr-band mr-band-w\" id=\"neo04-ct-w\"><\/span>\n <span class=\"mr-band mr-band-s\" id=\"neo04-ct-s\"><\/span>\n <\/div>\n <button class=\"mr-retry\" id=\"neo04-retry\">↻ New Round<\/button>\n <\/div>\n <\/div>\n\n <\/div>\n<\/div>\n\n\n<script>\n(function () {\n 'use strict';\n\n var NS = 'neo04';\n var TOTAL = 5;\n var MAX = 20;\n var LTRS = ['A','B','C','D'];\n\n var QS = [\n\n {\n id: 1,\n tag: 'HIE — Therapeutic Hypothermia Criteria',\n stem: 'A <strong>term neonate (40 weeks)<\/strong> is born after an acute cord prolapse. Apgar scores are 1 at 1 minute and 4 at 5 minutes. Cord arterial pH is <strong>6.95<\/strong> and base deficit is <strong>18 mmol\/L<\/strong>. At 2 hours of life the infant has <strong>seizures, generalised hypotonia, and reduced level of consciousness<\/strong>. HIE is graded as <strong>moderate (Sarnat Grade II)<\/strong>. The infant is now 3 hours old. What is the most appropriate neuroprotective intervention?',\n correct: 'Whole-body cooling to 33–34°C for 72 hours, commenced within 6 hours of birth',\n opts: [\n 'Whole-body cooling to 33–34°C for 72 hours, commenced within 6 hours of birth',\n 'High-dose IV phenobarbitone to suppress all electrical activity and prevent secondary neuronal injury',\n 'Therapeutic hypothermia is contraindicated once seizures have occurred — magnesium sulphate should be used instead',\n 'Defer cooling until MRI brain confirms cortical injury, as unnecessary hypothermia worsens coagulopathy'\n ],\n exp: '<strong>Therapeutic hypothermia (TH)<\/strong> is the only evidence-based neuroprotective treatment for <strong>moderate-to-severe HIE<\/strong> in neonates ≥36 weeks. It exploits the <em>secondary energy failure window<\/em> (6–72 hours post-asphyxia) during which excitotoxicity and apoptosis can be attenuated by reducing cerebral metabolic demand. Criteria: ≥36 weeks, evidence of perinatal asphyxia (cord pH ≤7.0 or base deficit ≥16 mmol\/L, or need for resuscitation at birth) <em>plus<\/em> clinical or aEEG evidence of encephalopathy. Target rectal temperature is <strong>33–34°C for exactly 72 hours<\/strong>; must start within 6 hours of birth. Seizures are <em>not<\/em> a contraindication. NNT to prevent one death or major neurodisability is approximately 7.',\n imgId: 'neo04-img1'\n },\n\n {\n id: 2,\n tag: 'Apgar Score — Interpretation',\n stem: 'A neonate is born at term by emergency LSCS for fetal bradycardia. At 1 minute: <strong>heart rate 90\/min, gasping respirations, some flexion of limbs, grimace only to stimulation, blue peripheries with pink trunk<\/strong>. At 5 minutes, after positive-pressure ventilation, the baby is crying, heart rate 130\/min, and well flexed. What are the correct 1-minute and 5-minute Apgar scores?',\n correct: '1-minute Apgar 4; 5-minute Apgar 8–9',\n opts: [\n '1-minute Apgar 4; 5-minute Apgar 8–9',\n '1-minute Apgar 2; 5-minute Apgar 10',\n '1-minute Apgar 6; 5-minute Apgar 10',\n '1-minute Apgar 3; 5-minute Apgar 7'\n ],\n exp: '<strong>Apgar scoring<\/strong> at 1 minute: Heart rate 90\/min = <strong>1<\/strong> (slow, <100); gasping = <strong>1<\/strong> (weak effort); some flexion = <strong>1<\/strong> (reduced tone); grimace only = <strong>1<\/strong> (some response); blue peripheries, pink trunk (acrocyanosis) = <strong>1<\/strong> (body pink). Total = <strong>4<\/strong>. At 5 minutes after PPV: crying = <strong>2<\/strong>; HR 130 = <strong>2<\/strong>; well flexed = <strong>2<\/strong>; vigorous cry implies good reflex = <strong>2<\/strong>; colour likely pink body, possibly acrocyanosis = <strong>1<\/strong>. Total <strong>8 or 9<\/strong>. Key point: a <strong>low 1-minute score<\/strong> reflects the need for resuscitation; it is the <strong>5-minute score<\/strong> (and beyond) that correlates with neurological outcome. A neonate who responds rapidly to resuscitation is not at risk for HIE.',\n imgId: null\n },\n\n {\n id: 3,\n tag: 'Neonatal Resuscitation — NRP Algorithm',\n stem: 'A <strong>term neonate<\/strong> is delivered and is <strong>floppy, apnoeic, and pale<\/strong> at birth. Initial steps (warmth, drying, stimulation) fail to establish respirations. Positive-pressure ventilation (PPV) is commenced via a bag-mask. After 30 seconds of effective PPV the heart rate is <strong>55\/min<\/strong>. What is the correct next step according to the NRP algorithm?',\n correct: 'Begin chest compressions at a 3:1 ratio with ventilation and reassess heart rate after 60 seconds',\n opts: [\n 'Begin chest compressions at a 3:1 ratio with ventilation and reassess heart rate after 60 seconds',\n 'Administer IV adrenaline 0.1 mg\/kg immediately without chest compressions',\n 'Switch to CPAP and observe for spontaneous improvement over 2 minutes',\n 'Intubate first, then begin chest compressions at a 15:2 ratio as in adult CPR'\n ],\n exp: 'In the <strong>NRP (Neonatal Resuscitation Program) algorithm<\/strong>, chest compressions are indicated when heart rate remains <strong><60\/min despite 30 seconds of effective positive-pressure ventilation<\/strong>. The neonatal compression:ventilation ratio is <strong>3:1<\/strong> (not 15:2 as in adults) — 90 compressions and 30 breaths per minute — because neonatal arrest is almost always respiratory in origin and ventilation takes priority. Compressions are delivered with two thumbs encircling the chest. Reassess heart rate after 60 seconds of coordinated CPR. <strong>Adrenaline<\/strong> (epinephrine) is indicated only if HR remains <60\/min after 60 seconds of coordinated compressions + ventilation; preferred route is IV (umbilical vein), not endotracheal. Intubation is recommended but should not delay starting compressions.',\n imgId: null\n },\n\n {\n id: 4,\n tag: 'HIE — Seizure Management',\n stem: 'A <strong>term neonate with confirmed moderate HIE<\/strong> on therapeutic hypothermia develops <strong>clinical and electrographic seizures<\/strong> at 8 hours of life. The seizures are confirmed on amplitude-integrated EEG (aEEG). What is the correct first-line anticonvulsant and the key prescribing consideration in this setting?',\n correct: 'Phenobarbitone IV 20 mg\/kg loading dose — first-line for neonatal seizures; dose is the same whether on hypothermia or not, but drug clearance is reduced during cooling',\n opts: [\n 'Phenobarbitone IV 20 mg\/kg loading dose — first-line for neonatal seizures; dose is the same whether on hypothermia or not, but drug clearance is reduced during cooling',\n 'Diazepam IV 0.5 mg\/kg — benzodiazepines are first-line for all neonatal seizures and are safe during hypothermia',\n 'Phenytoin IV 20 mg\/kg — preferred over phenobarbitone during hypothermia as it is not renally cleared',\n 'Levetiracetam IV 50 mg\/kg — now first-line in all neonatal units; phenobarbitone is obsolete'\n ],\n exp: '<strong>Phenobarbitone<\/strong> remains the <strong>first-line anticonvulsant for neonatal seizures<\/strong> at a loading dose of <strong>20 mg\/kg IV<\/strong>; a further 10 mg\/kg may be given if seizures persist, up to 40 mg\/kg total. During therapeutic hypothermia, drug metabolism is slowed — phenobarbitone clearance falls by approximately 20–30% — increasing the risk of toxicity (respiratory depression, sedation). The loading dose is <em>not<\/em> reduced, but maintenance dosing and drug levels require close monitoring. <strong>Levetiracetam<\/strong> is increasingly used as second-line or even first-line at some centres (NEOLEV2 and PHENOBARB trials), but phenobarbitone remains the global standard. Benzodiazepines (midazolam, clonazepam) are second- or third-line; diazepam is generally avoided in neonates.',\n imgId: null\n },\n\n {\n id: 5,\n tag: 'HIE — Prognostication & MRI Timing',\n stem: 'A <strong>term neonate with severe HIE (Sarnat Grade III)<\/strong> completes 72 hours of therapeutic hypothermia. Rewarming is performed over 6 hours. The parents ask about prognosis and when imaging will be most informative. Which statement about MRI brain in HIE is MOST CORRECT?',\n correct: 'MRI at 5–7 days post-injury (after rewarming) gives the most accurate prognostic information; diffusion-weighted imaging is most sensitive in the first week',\n opts: [\n 'MRI at 5–7 days post-injury (after rewarming) gives the most accurate prognostic information; diffusion-weighted imaging is most sensitive in the first week',\n 'MRI should be performed within the first 6 hours of life to guide the decision to start therapeutic hypothermia',\n 'MRI at 3 months of age is the only reliable prognostic tool; early imaging is uninformative in HIE',\n 'CT scan is preferred over MRI in the first week as MRI cannot detect haemorrhage in the neonatal brain'\n ],\n exp: 'MRI brain is the gold-standard prognostic tool in HIE, but <strong>timing is critical<\/strong>. <strong>Diffusion-weighted imaging (DWI)<\/strong> is most sensitive for ischaemic injury in the <strong>first 7 days<\/strong> (peaks at 3–5 days); it reflects cytotoxic oedema and can show restricted diffusion in basal ganglia, thalami, and cortex. <strong>Conventional T1\/T2<\/strong> imaging is most informative at <strong>7–14 days<\/strong> when signal changes in the posterior limb of the internal capsule (PLIC) become reliable predictors of motor outcome. MRI is <em>not<\/em> used to make the initial decision to cool — that decision is clinical. CT is generally avoided in neonates (radiation, inferior soft-tissue resolution). Injury to the <strong>basal ganglia and thalami<\/strong> on MRI predicts dyskinetic cerebral palsy; <strong>watershed cortical injury<\/strong> predicts spastic quadriplegia and cognitive impairment.',\n imgId: null\n }\n\n ];\n\n\n var answers = {};\n var answered = 0;\n var shuffled = {};\n var done = false;\n\n function byId(id) { return document.getElementById(id); }\n function gid(suffix) { return byId(NS + '-' + suffix); }\n\n function shuffleArr(arr) {\n var a = arr.slice(), i, j, tmp;\n for (i = a.length - 1; i > 0; i--) {\n j = Math.floor(Math.random() * (i + 1));\n tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n }\n return a;\n }\n\n function countVal(val) {\n var k, n = 0;\n for (k in answers) {\n if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n }\n return n;\n }\n\n function buildPips() {\n var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n cont.innerHTML = '';\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n if (i > 0) {\n wLine = document.createElement('div');\n wLine.className = 'mr-pip-wrap';\n line = document.createElement('div');\n line.className = 'mr-pip-line';\n line.id = NS + '-pl' + q.id;\n wLine.appendChild(line);\n cont.appendChild(wLine);\n }\n wPip = document.createElement('div');\n wPip.className = 'mr-pip-wrap';\n pip = document.createElement('div');\n pip.className = 'mr-pip';\n pip.id = NS + '-pip' + q.id;\n pip.textContent = String(q.id);\n wPip.appendChild(pip);\n cont.appendChild(wPip);\n }\n }\n\n function build() {\n var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n optEl, ltrSpan, txtSpan;\n\n cont = gid('cases');\n cont.innerHTML = '';\n answers = {}; answered = 0; shuffled = {}; done = false;\n gid('score').style.display = 'none';\n buildPips();\n\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n opts = shuffleArr(q.opts);\n shuffled[q.id] = opts;\n\n card = document.createElement('div');\n card.className = 'mr-case';\n\n top = document.createElement('div');\n top.className = 'mr-case-top';\n\n numDiv = document.createElement('div');\n numDiv.className = 'mr-num';\n numDiv.textContent = q.id < 10 ? 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4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#5C1E1E\">Feature<\/text>\n <text x=\"237\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#FFFAFA\">Grade I (Mild)<\/text>\n <text x=\"389\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#FFFAFA\">Grade II (Moderate)<\/text>\n <text x=\"541\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#FFFAFA\">Grade III (Severe)<\/text>\n \n <rect x=\"0\" y=\"44\" width=\"620\" height=\"26\" fill=\"#FDF4F4\"\/>\n <rect x=\"0\" y=\"70\" width=\"620\" height=\"26\" fill=\"#FFFAFA\"\/>\n <rect x=\"0\" y=\"96\" width=\"620\" height=\"26\" fill=\"#FDF4F4\"\/>\n <rect x=\"0\" y=\"122\" width=\"620\" height=\"26\" fill=\"#FFFAFA\"\/>\n <rect x=\"0\" y=\"148\" width=\"620\" height=\"26\" fill=\"#FDF4F4\"\/>\n <rect x=\"0\" y=\"174\" width=\"620\" height=\"26\" fill=\"#FFFAFA\"\/>\n \n <text x=\"6\" y=\"62\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Consciousness<\/text>\n <text x=\"6\" y=\"88\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Tone<\/text>\n <text x=\"6\" y=\"114\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Seizures<\/text>\n <text x=\"6\" y=\"140\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Reflexes<\/text>\n <text x=\"6\" y=\"163\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Autonomic<\/text>\n <text x=\"6\" y=\"192\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Outcome \/ TH<\/text>\n \n <text x=\"237\" y=\"62\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Hyperalert<\/text>\n <text x=\"237\" y=\"88\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Normal \/ mild ↑<\/text>\n <text x=\"237\" y=\"114\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">None<\/text>\n <text x=\"237\" y=\"140\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Brisk<\/text>\n <text x=\"237\" y=\"163\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Sympathetic<\/text>\n <text x=\"237\" y=\"185\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Good; TH not indicated<\/text>\n \n <text x=\"389\" y=\"62\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Lethargic<\/text>\n <text x=\"389\" y=\"88\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Mild ↓ (hypotonia)<\/text>\n <text x=\"389\" y=\"114\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Present<\/text>\n <text x=\"389\" y=\"140\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Decreased<\/text>\n <text x=\"389\" y=\"163\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Parasympathetic<\/text>\n <text x=\"389\" y=\"185\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Variable; TH indicated<\/text>\n \n <text x=\"541\" y=\"62\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Stupor \/ coma<\/text>\n <text x=\"541\" y=\"88\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Flaccid<\/text>\n <text x=\"541\" y=\"114\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Absent or prolonged<\/text>\n <text x=\"541\" y=\"140\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Absent<\/text>\n <text x=\"541\" y=\"163\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Depressed<\/text>\n <text x=\"541\" y=\"185\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Poor; TH indicated<\/text>\n \n <line x1=\"156\" y1=\"8\" x2=\"156\" y2=\"196\" stroke=\"#EDD8D8\" stroke-width=\"1\"\/>\n <line x1=\"308\" y1=\"8\" x2=\"308\" y2=\"196\" stroke=\"#EDD8D8\" stroke-width=\"1\"\/>\n <line x1=\"460\" y1=\"8\" x2=\"460\" y2=\"196\" stroke=\"#EDD8D8\" stroke-width=\"1\"\/>\n \n <line x1=\"0\" y1=\"44\" x2=\"620\" y2=\"44\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"70\" x2=\"620\" y2=\"70\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"96\" x2=\"620\" y2=\"96\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"122\" x2=\"620\" y2=\"122\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"148\" x2=\"620\" y2=\"148\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"174\" x2=\"620\" y2=\"174\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <\/svg>\n <figcaption>\n <strong>Sarnat grading of HIE<\/strong> (modified). Therapeutic hypothermia (TH) is indicated for\n <strong>Grade II and III<\/strong> in neonates ≥36 weeks, provided criteria are met and cooling begins within 6 hours of birth.\n Grade I (mild HIE) generally has a good prognosis and TH is not currently standard of care.\n Grade III carries the highest mortality and risk of severe neurodisability even with TH.\n <\/figcaption>\n <\/figure>\n<\/div>\n\n\n\n<div id=\"neo04\">\n\n <div class=\"mr-header\">\n <div class=\"mr-eyebrow\">Morning Rounds · Neonatology Series<\/div>\n <div class=\"mr-title\">\n Birth Asphyxia & HIE<br><em>Clinical Reasoning<\/em>\n <\/div>\n <div class=\"mr-subtitle\">Five cases · Read carefully · Trust your instinct<\/div>\n <div class=\"mr-chips\">\n <span class=\"mr-chip\">5 Cases<\/span>\n <span class=\"mr-chip\">+4 \/ −1 scoring<\/span>\n <span class=\"mr-chip\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n <div class=\"mr-sentinel\" id=\"neo04-sentinel\"><\/div>\n\n <div class=\"mr-progress\" id=\"neo04-progress\">\n <div class=\"mr-prog-inner\">\n <div class=\"mr-pips\" id=\"neo04-pips\"><\/div>\n <\/div>\n <\/div>\n\n <div class=\"mr-body\">\n <div id=\"neo04-cases\"><\/div>\n\n <div class=\"mr-submit-wrap\">\n <button class=\"mr-btn\" id=\"neo04-submit\">Submit for Debrief<\/button>\n <\/div>\n\n <div class=\"mr-score\" id=\"neo04-score\">\n <div class=\"mr-score-in\">\n <div class=\"mr-score-ey\">Round Complete<\/div>\n <div class=\"mr-ring\" id=\"neo04-ring\">\n <div class=\"mr-ring-in\">\n <span class=\"mr-ring-pct\" id=\"neo04-pct\">0%<\/span>\n <span class=\"mr-ring-sub\">net<\/span>\n <\/div>\n <\/div>\n <div class=\"mr-score-title\">Your Debrief<\/div>\n <div class=\"mr-score-net\" id=\"neo04-net\"><\/div>\n <div class=\"mr-verdict\" id=\"neo04-verdict\"><\/div>\n <div class=\"mr-bands\">\n <span class=\"mr-band mr-band-c\" id=\"neo04-ct-c\"><\/span>\n <span class=\"mr-band mr-band-w\" id=\"neo04-ct-w\"><\/span>\n <span class=\"mr-band mr-band-s\" id=\"neo04-ct-s\"><\/span>\n <\/div>\n <button class=\"mr-retry\" id=\"neo04-retry\">↻ New Round<\/button>\n <\/div>\n <\/div>\n\n <\/div>\n<\/div>\n\n\n<script>\n(function () {\n 'use strict';\n\n var NS = 'neo04';\n var TOTAL = 5;\n var MAX = 20;\n var LTRS = ['A','B','C','D'];\n\n var QS = [\n\n {\n id: 1,\n tag: 'HIE — Therapeutic Hypothermia Criteria',\n stem: 'A <strong>term neonate (40 weeks)<\/strong> is born after an acute cord prolapse. Apgar scores are 1 at 1 minute and 4 at 5 minutes. Cord arterial pH is <strong>6.95<\/strong> and base deficit is <strong>18 mmol\/L<\/strong>. At 2 hours of life the infant has <strong>seizures, generalised hypotonia, and reduced level of consciousness<\/strong>. HIE is graded as <strong>moderate (Sarnat Grade II)<\/strong>. The infant is now 3 hours old. What is the most appropriate neuroprotective intervention?',\n correct: 'Whole-body cooling to 33–34°C for 72 hours, commenced within 6 hours of birth',\n opts: [\n 'Whole-body cooling to 33–34°C for 72 hours, commenced within 6 hours of birth',\n 'High-dose IV phenobarbitone to suppress all electrical activity and prevent secondary neuronal injury',\n 'Therapeutic hypothermia is contraindicated once seizures have occurred — magnesium sulphate should be used instead',\n 'Defer cooling until MRI brain confirms cortical injury, as unnecessary hypothermia worsens coagulopathy'\n ],\n exp: '<strong>Therapeutic hypothermia (TH)<\/strong> is the only evidence-based neuroprotective treatment for <strong>moderate-to-severe HIE<\/strong> in neonates ≥36 weeks. It exploits the <em>secondary energy failure window<\/em> (6–72 hours post-asphyxia) during which excitotoxicity and apoptosis can be attenuated by reducing cerebral metabolic demand. Criteria: ≥36 weeks, evidence of perinatal asphyxia (cord pH ≤7.0 or base deficit ≥16 mmol\/L, or need for resuscitation at birth) <em>plus<\/em> clinical or aEEG evidence of encephalopathy. Target rectal temperature is <strong>33–34°C for exactly 72 hours<\/strong>; must start within 6 hours of birth. Seizures are <em>not<\/em> a contraindication. NNT to prevent one death or major neurodisability is approximately 7.',\n imgId: 'neo04-img1'\n },\n\n {\n id: 2,\n tag: 'Apgar Score — Interpretation',\n stem: 'A neonate is born at term by emergency LSCS for fetal bradycardia. At 1 minute: <strong>heart rate 90\/min, gasping respirations, some flexion of limbs, grimace only to stimulation, blue peripheries with pink trunk<\/strong>. At 5 minutes, after positive-pressure ventilation, the baby is crying, heart rate 130\/min, and well flexed. What are the correct 1-minute and 5-minute Apgar scores?',\n correct: '1-minute Apgar 4; 5-minute Apgar 8–9',\n opts: [\n '1-minute Apgar 4; 5-minute Apgar 8–9',\n '1-minute Apgar 2; 5-minute Apgar 10',\n '1-minute Apgar 6; 5-minute Apgar 10',\n '1-minute Apgar 3; 5-minute Apgar 7'\n ],\n exp: '<strong>Apgar scoring<\/strong> at 1 minute: Heart rate 90\/min = <strong>1<\/strong> (slow, <100); gasping = <strong>1<\/strong> (weak effort); some flexion = <strong>1<\/strong> (reduced tone); grimace only = <strong>1<\/strong> (some response); blue peripheries, pink trunk (acrocyanosis) = <strong>1<\/strong> (body pink). Total = <strong>4<\/strong>. At 5 minutes after PPV: crying = <strong>2<\/strong>; HR 130 = <strong>2<\/strong>; well flexed = <strong>2<\/strong>; vigorous cry implies good reflex = <strong>2<\/strong>; colour likely pink body, possibly acrocyanosis = <strong>1<\/strong>. Total <strong>8 or 9<\/strong>. Key point: a <strong>low 1-minute score<\/strong> reflects the need for resuscitation; it is the <strong>5-minute score<\/strong> (and beyond) that correlates with neurological outcome. A neonate who responds rapidly to resuscitation is not at risk for HIE.',\n imgId: null\n },\n\n {\n id: 3,\n tag: 'Neonatal Resuscitation — NRP Algorithm',\n stem: 'A <strong>term neonate<\/strong> is delivered and is <strong>floppy, apnoeic, and pale<\/strong> at birth. Initial steps (warmth, drying, stimulation) fail to establish respirations. Positive-pressure ventilation (PPV) is commenced via a bag-mask. After 30 seconds of effective PPV the heart rate is <strong>55\/min<\/strong>. What is the correct next step according to the NRP algorithm?',\n correct: 'Begin chest compressions at a 3:1 ratio with ventilation and reassess heart rate after 60 seconds',\n opts: [\n 'Begin chest compressions at a 3:1 ratio with ventilation and reassess heart rate after 60 seconds',\n 'Administer IV adrenaline 0.1 mg\/kg immediately without chest compressions',\n 'Switch to CPAP and observe for spontaneous improvement over 2 minutes',\n 'Intubate first, then begin chest compressions at a 15:2 ratio as in adult CPR'\n ],\n exp: 'In the <strong>NRP (Neonatal Resuscitation Program) algorithm<\/strong>, chest compressions are indicated when heart rate remains <strong><60\/min despite 30 seconds of effective positive-pressure ventilation<\/strong>. The neonatal compression:ventilation ratio is <strong>3:1<\/strong> (not 15:2 as in adults) — 90 compressions and 30 breaths per minute — because neonatal arrest is almost always respiratory in origin and ventilation takes priority. Compressions are delivered with two thumbs encircling the chest. Reassess heart rate after 60 seconds of coordinated CPR. <strong>Adrenaline<\/strong> (epinephrine) is indicated only if HR remains <60\/min after 60 seconds of coordinated compressions + ventilation; preferred route is IV (umbilical vein), not endotracheal. Intubation is recommended but should not delay starting compressions.',\n imgId: null\n },\n\n {\n id: 4,\n tag: 'HIE — Seizure Management',\n stem: 'A <strong>term neonate with confirmed moderate HIE<\/strong> on therapeutic hypothermia develops <strong>clinical and electrographic seizures<\/strong> at 8 hours of life. The seizures are confirmed on amplitude-integrated EEG (aEEG). What is the correct first-line anticonvulsant and the key prescribing consideration in this setting?',\n correct: 'Phenobarbitone IV 20 mg\/kg loading dose — first-line for neonatal seizures; dose is the same whether on hypothermia or not, but drug clearance is reduced during cooling',\n opts: [\n 'Phenobarbitone IV 20 mg\/kg loading dose — first-line for neonatal seizures; dose is the same whether on hypothermia or not, but drug clearance is reduced during cooling',\n 'Diazepam IV 0.5 mg\/kg — benzodiazepines are first-line for all neonatal seizures and are safe during hypothermia',\n 'Phenytoin IV 20 mg\/kg — preferred over phenobarbitone during hypothermia as it is not renally cleared',\n 'Levetiracetam IV 50 mg\/kg — now first-line in all neonatal units; phenobarbitone is obsolete'\n ],\n exp: '<strong>Phenobarbitone<\/strong> remains the <strong>first-line anticonvulsant for neonatal seizures<\/strong> at a loading dose of <strong>20 mg\/kg IV<\/strong>; a further 10 mg\/kg may be given if seizures persist, up to 40 mg\/kg total. During therapeutic hypothermia, drug metabolism is slowed — phenobarbitone clearance falls by approximately 20–30% — increasing the risk of toxicity (respiratory depression, sedation). The loading dose is <em>not<\/em> reduced, but maintenance dosing and drug levels require close monitoring. <strong>Levetiracetam<\/strong> is increasingly used as second-line or even first-line at some centres (NEOLEV2 and PHENOBARB trials), but phenobarbitone remains the global standard. Benzodiazepines (midazolam, clonazepam) are second- or third-line; diazepam is generally avoided in neonates.',\n imgId: null\n },\n\n {\n id: 5,\n tag: 'HIE — Prognostication & MRI Timing',\n stem: 'A <strong>term neonate with severe HIE (Sarnat Grade III)<\/strong> completes 72 hours of therapeutic hypothermia. Rewarming is performed over 6 hours. The parents ask about prognosis and when imaging will be most informative. Which statement about MRI brain in HIE is MOST CORRECT?',\n correct: 'MRI at 5–7 days post-injury (after rewarming) gives the most accurate prognostic information; diffusion-weighted imaging is most sensitive in the first week',\n opts: [\n 'MRI at 5–7 days post-injury (after rewarming) gives the most accurate prognostic information; diffusion-weighted imaging is most sensitive in the first week',\n 'MRI should be performed within the first 6 hours of life to guide the decision to start therapeutic hypothermia',\n 'MRI at 3 months of age is the only reliable prognostic tool; early imaging is uninformative in HIE',\n 'CT scan is preferred over MRI in the first week as MRI cannot detect haemorrhage in the neonatal brain'\n ],\n exp: 'MRI brain is the gold-standard prognostic tool in HIE, but <strong>timing is critical<\/strong>. <strong>Diffusion-weighted imaging (DWI)<\/strong> is most sensitive for ischaemic injury in the <strong>first 7 days<\/strong> (peaks at 3–5 days); it reflects cytotoxic oedema and can show restricted diffusion in basal ganglia, thalami, and cortex. <strong>Conventional T1\/T2<\/strong> imaging is most informative at <strong>7–14 days<\/strong> when signal changes in the posterior limb of the internal capsule (PLIC) become reliable predictors of motor outcome. MRI is <em>not<\/em> used to make the initial decision to cool — that decision is clinical. CT is generally avoided in neonates (radiation, inferior soft-tissue resolution). Injury to the <strong>basal ganglia and thalami<\/strong> on MRI predicts dyskinetic cerebral palsy; <strong>watershed cortical injury<\/strong> predicts spastic quadriplegia and cognitive impairment.',\n imgId: null\n }\n\n ];\n\n\n var answers = {};\n var answered = 0;\n var shuffled = {};\n var done = false;\n\n function byId(id) { return document.getElementById(id); }\n function gid(suffix) { return byId(NS + '-' + suffix); }\n\n function shuffleArr(arr) {\n var a = arr.slice(), i, j, tmp;\n for (i = a.length - 1; i > 0; i--) {\n j = Math.floor(Math.random() * (i + 1));\n tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n }\n return a;\n }\n\n function countVal(val) {\n var k, n = 0;\n for (k in answers) {\n if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n }\n return n;\n }\n\n function buildPips() {\n var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n cont.innerHTML = '';\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n if (i > 0) {\n wLine = document.createElement('div');\n wLine.className = 'mr-pip-wrap';\n line = document.createElement('div');\n line.className = 'mr-pip-line';\n line.id = NS + '-pl' + q.id;\n wLine.appendChild(line);\n cont.appendChild(wLine);\n }\n wPip = document.createElement('div');\n wPip.className = 'mr-pip-wrap';\n pip = document.createElement('div');\n pip.className = 'mr-pip';\n pip.id = NS + '-pip' + q.id;\n pip.textContent = String(q.id);\n wPip.appendChild(pip);\n cont.appendChild(wPip);\n }\n }\n\n function build() {\n var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n optEl, ltrSpan, txtSpan;\n\n cont = gid('cases');\n cont.innerHTML = '';\n answers = {}; answered = 0; shuffled = {}; done = false;\n gid('score').style.display = 'none';\n buildPips();\n\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n opts = shuffleArr(q.opts);\n shuffled[q.id] = opts;\n\n card = document.createElement('div');\n card.className = 'mr-case';\n\n top = document.createElement('div');\n top.className = 'mr-case-top';\n\n numDiv = document.createElement('div');\n numDiv.className = 'mr-num';\n numDiv.textContent = q.id < 10 ? 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