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Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
Neonatal Emergencies
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Neonatal Emergencies

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  • 1. NEONATAL EMERGENCIES Rebecca Starr, D.O. Pediatric Emergency Medicine Fellow March 20, 2014
  • 2. OBJECTIVES  Define the neonatal period and a helpful mnemonic for neonatal emergencies  Review case-based emergencies associated with the neonate  Discuss common infections in the neonate  Differentiate between infectious, cardiac, GI, metabolic, and endocrine emergencies  Gain confidence in dealing with neonatal patients
  • 3. CASE PRESENTATION  7 day old M presents to the ED with a 1 day history of poor feeding, lethargy, and increased work of breathing.  Pre and postnatal history are unremarkable  What is your next step?
  • 4. FREAK OUT!!!!
  • 5. SO REALLY…. WHAT’S SHOULD I BE THINKING? “THE MISFITTS”  Trauma/Abuse (NAT)  Heart and Lung  Endocrine  Metabolic disturbances  Inborn errors of metabolism  Sepsis  Formula issues  Intestinal  Toxins  Trisomies  Seizures
  • 6. CASE PRESENTATION #1  7 day old M presents to the ED with a 1 day history of poor feeding, lethargy, and increased work of breathing. At PMD today, a temperature of 101.5 noted rectally.  Pre and postnatal history are unremarkable  What is your next step?
  • 7. RULE OUT SEPSIS WORK UP?  What do you want to order?
  • 8. RULE OUT SEPSIS WORK UP  Blood culture  CBC  CMP  Urinalysis  Urine culture  CSF studies  CSF culture  HSV PCR  CXR (+/-)  RVP (+/-)  NS bolus (+/-)  Antibiotics- Ampicillin and Gentamicin or 3rd generation cephalosporin (0-28 days)
  • 9. FEVER IN THE NEONATE  Neonate: 0-28 days  Fever: 38 C or 100.4 F  Also consider hypothermia  Difficult to evaluate clinically  Increased susceptibility to infection  >10% of infants with fever will have a serious bacterial infection  UTI- 30%  Meningitis- 20%  Bacteremia/septicemia- 15%
  • 10. NEONATAL FEVER  Peripheral WBC alone not an accurate screen for SBI  Consider concomitant viral illness with SBI  All febrile neonates should have a full sepsis evaluation and be admitted for IV antibiotics
  • 11. STUDY ON NEONATAL FEVER IN THE PEDS ED  2253 neonates ( 0-28 days old)  16% discharged, 84% admitted Jain et al, Pediatrics, 2014
  • 12. INFECTIONS IN THE NEONATE  Group B Streptococcus  E. coli  Listeria  S. aureus  H. influenza  S. pneumonia  N. meningitis  Viral  RSV  HSV  Enterovirus
  • 13. GROUP B STREPTOCOCCUS  Gram positive cocci  Most common infection of the newborn  Cause of neonatal pneumonia, bacteremia, and meningitis  Up to 1/3 of women are colonized  Early and late-onset infections  Tx: Ampicillin  Fatality rates 2-15%
  • 14. EARLY AND LATE ONSET  Early onset:  1 hour to 7 days  Bacteremia 45%  Pneumonia 40%  Meningitis <10%  Higher fatality rate  Late onset:  7 days to 3 months (27 day median)  Bacteremia 45%  Meningitis 40%
  • 15. ESCHERICHIA COLI  Gram negative rod  Most frequent cause of infection in the first 7 days of life  Most common cause of meningitis in neonates  Significant cause of UTI’s and urosepsis  Tx: Gentamicin or 3rd generation cephalosporin
  • 16. LISTERIA MONOCYTOGENES  Gram positive rod  Can mimic diphtheroids on gm stain  Highest incidence in patients < 1 month old  Infected from colonized mothers  Meconium staining, PROM, transplacentally  Tx: Ampicillin  Resistant to cephalosporins  Fatality rate 15%
  • 17. CASE PRESENTATION #2  7 day old M presents to the ED with a 1 day history of poor feeding, lethargy, increased work of breathing and poor color. No history of fever and afebrile on presentation. Cap refill 4 seconds on exam and no palpable femoral pulses.  Pre and postnatal history are unremarkable  What diagnosis is concerning for this patient?
  • 18. CONGENITAL HEART DISEASE  1/125 births  Usually ductal dependent  Closes by 72 hours  Symptoms include:  Tachypnea  Cyanosis  Pallor  Lethargy  FTT  Sweating with feeds  Hypoxia and cyanosis usually unresponsive to oxygen  Left and right sided heart lesions
  • 19. CONGENITAL HEART DISEASE  Left sided: systemic blood flow is dependent on ductal patency  Coarctation of the aorta  Hypoplastic left heart  Right sided: pulmonary blood flow is dependent on ductal patency (Cyanotic Lesions)  Truncus Arteriosus  Transposition of the great vessels  Tricuspid atresia  Tetralogy of Fallot  TAPVR
  • 20. CLINICAL  Shock  Poor/absent distal pulses  Poor perfusion/color  Cap refill >3 sec  Tachypnea  Cardiac Failure  Hepatomegaly  Large heart  Gallop  Harsh murmur
  • 21. CASE PRESENTATION #2  7 day old M presents to the ED with a 1 day history of poor feeding, lethargy, increased work of breathing and poor color. No history of fever and afebrile on presentation. Poor perfusion on exam.  Pre and postnatal history are unremarkable  What medication do you want to give?
  • 22. WHAT TO DO?  Prostaglandin E1!!!!!  0.05mcg/kg/min  Response within 15 minutes  Watch for:  Hypotension, flushing, APNEA!  Pressure support  Fluids  Echo  Cardiology consult
  • 23. NAME THAT CARDIAC ABNORMALITY
  • 24. TETRALOGY OF FALLOT  Boot-shaped heart
  • 25. TETRALOGY OF FALLOT  Four criteria 1. Pulmonary atresia/stenosis 2. RV hypertrophy 3. VSD 4. Over-riding aorta
  • 26. NAME THAT CARDIAC ABNORMALITY
  • 27. TRANSPOSITION OF THE GREAT ARTERIES  Egg on a string
  • 28. TRANSPOSITION OF THE GREAT ARTERIES  Most common cyanotic lesion presenting in the first week of life  To be compatible with life, mixing must occur via an ASD, VSD, or PDA
  • 29. NAME THAT CARDIAC ABNORMALITY
  • 30. TOTAL ANOMALOUS PULMONARY VENOUS RETURN  Snowman sign
  • 31. TOTAL ANOMALOUS PULMONARY VENOUS RETURN  All four pulmonary veins fail to make their normal connection to the left atrium
  • 32. CASE PRESENTATION #3  7 day old M presents to the ED with a 1 day history of poor feeding, irritability, very jittery, and mild respiratory distress. No fevers but clammy/ wet skin. PE reveals a tachycardic infant with microcephaly and triangular faces.  What do you want to know about Mom?
  • 33.  Maternal History of Grave’s Disease!
  • 34. GRAVES DISEASE AND THE NEONATE  1-5% of infants from moms with Graves  Results from the transplacental passage of maternal stimulatory TSHR-Ab  Can be seen in mom’s with active Graves or ones previously treated with thyroidectomy or radioactive iodine
  • 35. GRAVES DISEASE AND THE NEONATE  At birth, infants can be  Hypothyroid with a goiter  Euthyroid due to maternal PTU  Hyperthyroid due to maternal TSHR-Ab  Neonatal screening  Self- limiting  Resolution by 12 weeks
  • 36. NEONATAL THYROTOXICOSIS  Essentially “thyroid storm” picture  Irritability  Respiratory distress  Tachycardic  Hyperthermic  Shock  Cardiac Failure
  • 37. NEONATAL THYROTOXICOSIS  Treatment includes:  Beta-blockade  Propanolol 0.1mg/kg IV  Blocking thyroxine production  PTU 5-10mg/kg PO  Blocking thyroxine release  Potassium-iodide 1-4 drop PO  Decreasing T4  T3 conversion  Dexamethasone 0.1mg/kg IV
  • 38. CASE PRESENTATION #4  7 day old F presents to the ED with a 1 day history of poor feeding, vomiting, poor tone, and lethargy. No history of fever.  BP 50/32 with a cap refill of 4 seconds  It was a home birth and neonatal screening wasn’t performed
  • 39. CASE PRESENTATION #4  Physical exams reveals  What is the diagnosis?
  • 40. CONGENITAL ADRENAL HYPERPLASIA  Autosomal recessive, variable penetrance  Involve a defect in the adrenal production of cortisol, mineralocorticoid, or both  Salt-wasting or non-salt-wasting  21-hydroxylase deficiency: >90% of all cases  Functioning 21-hydroxylase  Converts 17-hydroxyprogesterone into cortisol  Converts progesterone to aldosterone
  • 41. CONGENITAL ADRENAL HYPERPLASIA  Lack of 21-hydroxylase causes:  Build-up of 17-hydroxyprogesterone  Converted into androgens
  • 42. CAH PRESENTATION  Cortisol deficiency  hypoglycemia, hypotension, and shock  Aldosterone deficiency  hyponatremia, hyperkalemia, and dehydration  Androgen excess  virilization of female genitalia, less common in males  Males will have normal genitalia at birth and will present in salt-losing adrenal crisis
  • 43. WORK UP  Blood work:  CMP  Accucheck  17-hydroxyprogesterone levels  Cortisol levels  Aldosterone and renin levels
  • 44. CAH TREATMENT  NS bolus  Treat any electrolyte abnormalities  If hypoglycemia given dextrose  Na+  K+  Stress dose hydrocortisone 50-100mg/m2 IV  Glucocorticoid and mineralocorticoid activity
  • 45. CASE PRESENTATION #5  7 day old F presents to the ED with a 1 day history of poor feeding, vomiting green material, poor tone, and lethargy. No history of fever.  BP 57/42 with a cap refill of 4 seconds  What intestinal emergency are you concerned for?
  • 46. MALROTATION AND VOLVULUS  Congenital anomaly during intestinal development  Small bowel predominantly on the right side  Cecum is displaced into the epigastrium  Ladd’s bands course over the horizontal part of the duodenum  Small intestine mesentery has an unusually narrow base  Midgut is prone to volvulus
  • 47. MALROTATION AND VOLVULUS
  • 48. DIAGNOSIS  Abd xray  May show duodenal obstruction  “Double bubble sign”  Upper GI- gold standard  Concern for malrotation if the duodenal C- loop doesn’t cross midline and the duodenojejunal junction isn’t the left of the spine
  • 49. MALROTATION ON UPPER GI  “Whirlpool sign” indicates volvulus
  • 50. TREATMENT  ABC’s  Fluid resuscitation  NPO  NG tube to suction  Pediatric Surgery consult!
  • 51. PUTTING IT ALL TOGETHER  History is key! (prenatal, birth, maternal)  ABC’s  IV access with appropriate blood work  Fluids  Antibiotics  Imaging?  Remember the differential  THE MISFITTS  RESPECT THE NEONATE
  • 52. THE MISFITTS  Trauma/Abuse (NAT)  Heart and Lung  Endocrine  Metabolic disturbances  Inborn errors of metabolism  Sepsis  Formula issues  Intestinal  Toxins  Trisomies  Seizures
  • 53. REFERENCES  Jain S, Cheng J, Alpern E, et al. Management of febrile neonates in US pediatric emergency departments. Pediatrics. 2014;133:187-195.  Menrke DP, Nieman LK, Martin KA, et al. Diagnosis of classic congential adrenal hyperplasia due to 21-hydroxylase deficiency. In: UpToDate. March 2014.  Menrke DP, Nieman LK, Martin KA, et al. Genetics and clinical presentation of classic congenital adrenal hyperplasia due to 21- hydroxylase deficiency. In: UpToDate. April 2013.  Batra CM. Fetal and neonatal thyrotoxicosis. Indian Journal of Endocrinology and Metabolism.2013.17:50-54.
  • 54. Questions?

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