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NEONATAL EMERGENCIES
Rebecca Starr, D.O.
Pediatric Emergency Medicine Fellow
March 20, 2014
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
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?
FREAK OUT!!!!
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
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?
RULE OUT SEPSIS WORK UP?
 What do you want to order?
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)
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%
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
STUDY ON NEONATAL FEVER IN THE PEDS ED
 2253 neonates ( 0-28 days old)
 16% discharged, 84% admitted
Jain et al, Pediatrics, 2014
INFECTIONS IN THE NEONATE
 Group B Streptococcus
 E. coli
 Listeria
 S. aureus
 H. influenza
 S. pneumonia
 N. meningitis
 Viral
 RSV
 HSV
 Enterovirus
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%
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%
Neonatal Emergencies
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
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%
Neonatal Emergencies
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?
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
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
CLINICAL
 Shock
 Poor/absent distal pulses
 Poor perfusion/color
 Cap refill >3 sec
 Tachypnea
 Cardiac Failure
 Hepatomegaly
 Large heart
 Gallop
 Harsh murmur
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?
WHAT TO DO?
 Prostaglandin E1!!!!!
 0.05mcg/kg/min
 Response within 15 minutes
 Watch for:
 Hypotension, flushing, APNEA!
 Pressure support
 Fluids
 Echo
 Cardiology consult
NAME THAT CARDIAC ABNORMALITY
TETRALOGY OF FALLOT
 Boot-shaped heart
TETRALOGY OF FALLOT
 Four criteria
1. Pulmonary atresia/stenosis
2. RV hypertrophy
3. VSD
4. Over-riding aorta
NAME THAT CARDIAC ABNORMALITY
TRANSPOSITION OF THE GREAT ARTERIES
 Egg on a string
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
NAME THAT CARDIAC ABNORMALITY
TOTAL ANOMALOUS PULMONARY VENOUS RETURN
 Snowman sign
TOTAL ANOMALOUS PULMONARY VENOUS RETURN
 All four pulmonary veins fail to make their
normal connection to the left atrium
Neonatal Emergencies
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?
 Maternal History of Grave’s Disease!
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
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
NEONATAL THYROTOXICOSIS
 Essentially “thyroid storm” picture
 Irritability
 Respiratory distress
 Tachycardic
 Hyperthermic
 Shock
 Cardiac Failure
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
Neonatal Emergencies
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
CASE PRESENTATION #4
 Physical exams reveals
 What is the diagnosis?
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
CONGENITAL ADRENAL HYPERPLASIA
 Lack of 21-hydroxylase causes:
 Build-up of 17-hydroxyprogesterone
 Converted into androgens
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
WORK UP
 Blood work:
 CMP
 Accucheck
 17-hydroxyprogesterone levels
 Cortisol levels
 Aldosterone and renin levels
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
Neonatal Emergencies
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?
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
MALROTATION AND VOLVULUS
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
MALROTATION ON UPPER GI
 “Whirlpool sign” indicates volvulus
TREATMENT
 ABC’s
 Fluid resuscitation
 NPO
 NG tube to suction
 Pediatric Surgery consult!
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
THE MISFITTS
 Trauma/Abuse (NAT)
 Heart and Lung
 Endocrine
 Metabolic disturbances
 Inborn errors of metabolism
 Sepsis
 Formula issues
 Intestinal
 Toxins
 Trisomies
 Seizures
Neonatal Emergencies
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.
Questions?

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Neonatal Emergencies

  • 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?
  • 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%
  • 16. 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
  • 17. 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%
  • 19. 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?
  • 20. 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
  • 21. 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
  • 22. CLINICAL  Shock  Poor/absent distal pulses  Poor perfusion/color  Cap refill >3 sec  Tachypnea  Cardiac Failure  Hepatomegaly  Large heart  Gallop  Harsh murmur
  • 23. 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?
  • 24. WHAT TO DO?  Prostaglandin E1!!!!!  0.05mcg/kg/min  Response within 15 minutes  Watch for:  Hypotension, flushing, APNEA!  Pressure support  Fluids  Echo  Cardiology consult
  • 25. NAME THAT CARDIAC ABNORMALITY
  • 26. TETRALOGY OF FALLOT  Boot-shaped heart
  • 27. TETRALOGY OF FALLOT  Four criteria 1. Pulmonary atresia/stenosis 2. RV hypertrophy 3. VSD 4. Over-riding aorta
  • 28. NAME THAT CARDIAC ABNORMALITY
  • 29. TRANSPOSITION OF THE GREAT ARTERIES  Egg on a string
  • 30. 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
  • 31. NAME THAT CARDIAC ABNORMALITY
  • 32. TOTAL ANOMALOUS PULMONARY VENOUS RETURN  Snowman sign
  • 33. TOTAL ANOMALOUS PULMONARY VENOUS RETURN  All four pulmonary veins fail to make their normal connection to the left atrium
  • 35. 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?
  • 36.  Maternal History of Grave’s Disease!
  • 37. 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
  • 38. 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
  • 39. NEONATAL THYROTOXICOSIS  Essentially “thyroid storm” picture  Irritability  Respiratory distress  Tachycardic  Hyperthermic  Shock  Cardiac Failure
  • 40. 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
  • 42. 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
  • 43. CASE PRESENTATION #4  Physical exams reveals  What is the diagnosis?
  • 44. 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
  • 45. CONGENITAL ADRENAL HYPERPLASIA  Lack of 21-hydroxylase causes:  Build-up of 17-hydroxyprogesterone  Converted into androgens
  • 46. 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
  • 47. WORK UP  Blood work:  CMP  Accucheck  17-hydroxyprogesterone levels  Cortisol levels  Aldosterone and renin levels
  • 48. 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
  • 50. 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?
  • 51. 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
  • 53. 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
  • 54. MALROTATION ON UPPER GI  “Whirlpool sign” indicates volvulus
  • 55. TREATMENT  ABC’s  Fluid resuscitation  NPO  NG tube to suction  Pediatric Surgery consult!
  • 56. 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
  • 57. THE MISFITTS  Trauma/Abuse (NAT)  Heart and Lung  Endocrine  Metabolic disturbances  Inborn errors of metabolism  Sepsis  Formula issues  Intestinal  Toxins  Trisomies  Seizures
  • 59. 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.