Neonatal Emergencies
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Neonatal Emergencies Presentation Transcript

  • 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?