Ill appearing neonates

The Ill-Appearing Neonates
Atima Delaney, MD
Division of Emergency Medicine
Children’s Hospital Boston

Case
10-day-old infant presents with poor feeding for 3 days, today noted to be lethargic
PE: Limp, cyanotic, mottled V/S T 37, HR 80, RR 12, BP 52/38, O2 Sat 80% RA HEENT: open, soft AF, pupils 3->2 mm Heart: RRR, no murmur Lungs: no retractions, clear BS Abdomen: soft, nontender, no HSM Ext: cap refills > 5 seconds Neuro: decreased tone throughout

Case
What is initial management?
What history should be taken?
What are the differential diagnoses?

Unique Features of the Neonates

Ill-appearing Infants
Clinical Features Depressed or altered mental status Lethargy Grunting respiration Head bobbing Increased work of breathing Bradypnea, apnea Poor muscle tone or floppy Skin changes: pallor, cyanosis, poor cap refills,

Differential Diagnoses
Most common causes for catastrophic illness in the neonates ID: GBS, Gram-neg bacilli, HSV, enterovirus, RSV Ductal-Dependent CHD: Left-sided lesions: Coarctation of the aorta, Interrupted aortic arch, aortic stenosis, Hypoplastic left heart syndrome Right-sided lesions: Pulmonary atresia or stenosis Tetralogy of Fallot Tricuspid atresia Metabolic Disorder: Inborn error of metabolism, CAH GI: volvulus, NEC, Hirschprung’s disease, incarcerated hernia Neurologic: Seizure, CNS hemorrhage Respiratory: bronchiolitis, pneumonia

Differential Diagnoses
“ NEO SECRETS” i N born error of metabolism E lectrolyte abnormality O verdose S eizures E nteric emergencies C ardiac abnormality R ecipe (formula, additives) E ndocrine crisis T rauma S epsis

Inborn Error of Metabolism
Presentation 2-7 days of age
Several categories of IEM (amino acid disorders, organic acidemias, urea cycle disorders, disorders of carbohydrate metabolism, fatty acid oxidation defects, and mitochondrial disorders)
GI: Poor feeding, poor suck, vomiting, FTT, hepatosplenomegaly, jaundice
CNS: Irritability, lethargy, coma, death
Hyperammonemia, profound acidosis
Consult metabolism

Electrolytes Abnormality
Hyponatremia: Water intoxication, SIADH, CAH
Hypernatremia: Breastfeeding difficulty (dehydration), DI
Hypoglycemia
Hypocalcemia

Overdose/Toxic Exposure
Methhemoglobinemia -Newborns are at risk -Reports of association with Prilocaine and occasionally EMLA use
Carbon monoxide poisoning

Seizures
May not present as tonic-clonic activity
Hypoxic-ischemia injury Intracranial hemorrhage CNS infections Electrolyte abnormalities Inborn error of metabolism Congenital abnormality of brain Drug withdrawal

Seizures
Lorazepam
Phenobarbital or phynetoin/fosphynetoin
Consider giving 10% Calcium gluconate if seizure persists after standard therapy
Consider giving MgSO4
Pyridoxine (Vit B6) if seizure persists after above

Enteric Emergencies
True surgical emergency
Volvulus - twisting around mesenteric artery
Bilious emesis (>90%), maybe well-appearing
Shock if bowel is ischemic or necrotic
Malrotation with or without volvulus emedicine

Enteric Emergencies
UGI series -Dilated duodenum -Abnormal duodeno-jejunal junction
Malrotation with or without volvulus uptodate Normal Malrotation “ corkscrew” Volvulus

Enteric Emergencies
Necrotizing enterocolitis -More common in preemies -Term infants with risk factors -Ill-appearing, distended abdomen, bloody stools
pneumatosis intestinalis Portal vein gas uptodate

Cardiac
CHD often presents during first month of life
Presentations 1) cyanosis 2) mottle or gray appearance 3) CHF

Cardiac
DUCTAL DEPENDENT LESIONS
Right-to-Left Shunt Cyanosis, metabolic acidosis, decreased perfusion or CHF on CXR Transposition of great arteries Tetralogy of Fallot Truncus arteriosus Total anomalous venous return
Left-sided Obstructive Lesions Severe systemic hypoperfusion, decreased or absent pulses, metabolic acidosis, cardiomegaly with pulmonary congestion on CXR Hypoplastic left heart, Coarctation of aorta, interrupted aortic arch, AS

Cardiac
Presents with CHF
Left-to-Right Shunt -Large VSD -Complete AV canal defect -Large PDA
SVT

Cardiac
Ill-appearing neonates not responding to initial resuscitation, consider ductal- dependent CHD
Hyperoxia Test 100% O2 for 10 minutes Left-to-right lesions: PO2 > 60-70 mmHg (Sat > 90-95%) Cyanotic lesions: PO2 < 60 mmHg (Sat < 85-90%)

Recipe
Incorrect formula preparation
Home remedies
Botulism - Infant botulism -Peak 2-4 mo. -Hypotonia, constipation, descending flaccid paralysis, autonomic instability, CN deficits

Endocrine
21-hydroxylase deficiency Salt-losing or Non-salt losing forms Girls: ambiguous genitalia Boys: salt-losing adrenal crisis (vomiting, hyptension, hyponatremia, hyperkalemia, metabolic acidosis, hypoglycemia)
uptodate Congenital Adrenal Hyperplasia (CAH)

Trauma
Inflicted head injury -Lethargy -Altered mental status -Seizures -Respiratory distress, apenea
emedicine

Sepsis & Meningitis
All ill-appearing infants should be considered sepsis until proven otherwise
Irritability, lethargy, poor feeding, ± fever, hypothermia, apnea, cyanosis, poor perfusion
Early onset: First few days - 6 days Associated with perinatal risk factors
Late onset: ≥ 7 days
Common organisms: GBS, E.coli, Gram neg rods, Listeria monocytogenes, Strep pneumoniae

HSV
Birth- 1 month (peak 10-17 days)
1. Localized skin, eye, mouth (SEM) 2. CNS ± SEM 3. Disseminated
HSV cultures of vesicles, oropharynx, conjunctiva, urine, blood, stool or rectum, and CSF HSV PCR and LFTs - Mucocutaneous vesicles - Seizure - CSF pleocytosis with negative gram stain - Mother known to have HSV
uptodate

Other Overwhelming Viral Infections
Enterovirus -Myocarditis -Hepatitis
Bronchiolitis with apnea Risk factors: age < 6 weeks, preemie, low O2 Sat

Sepsis
CBC, UA, blood & urine culture, CRP
LP
Start Ampicillin + Gentamicin (early onset) or Ampicillin + Cefotaxime/Ceftazidime
Start Acyclovir IV -CSF pleocytosis & negative gram stain -CSF pleocytosis & vesicular rash, focal neurologic signs, pneumonitis, hepatitis, maternal hx -CSF elevated RBC

History
Maternal Hx: GBS
Birth Hx: delivery, complications, birth weight
Neonatal course
Symptoms
Feeding, UOP and stooling, emesis - bilious?
Inflicted injury: no clear hx or hx inconsistent with findings

Physical Exam
General Appearance
Vital signs, pulse ox BP : neonates - SBP 60 mmHg, infants - SBP 70 mmHg HR: >220/min consider SVT RR: tachypnea, apnea, periodic breathing T: lack of fever does not exclude serious infection
4-Ext BP Diminished pulse and BP -> left-ventricular outflow obstruction

Physical Exam
Head: fontanelle, scalp
HEENT: pupils, neck
Chest: nasal flaring, grunting, retractions, breath sounds, murmur
Abdomen: distention, rigidity, hepatomegaly Normal exam doesn’t exclude abdominal pathology
Skin: cap refills, petechiae
Neuro: mental status, muscle tone, abnormal movement

Management
ABCD
Obtain V/S, pulse oxymetry, glucose
Monitoring
Treat hypovolemia and electrolyte abnormality
Treat hypothermia & maintain body temperature

Airway
Intubation
Preemie: 2.5 mm Full-term: 3 - 4 mm 1 yo- toddler: 4-4.5 mm
Broselow tape
Cuffed or uncuffed tubes Cuffed tube: high inspiratory pressure
RSI: atropine recommended

Circulation
IV, umbilical vein, IO
IO access early if failed IV attempts
Give 20 ml/kg NSS bolus (unless CHF)
Septic shock: - Requires several fluid boluses - Children who received > 40 ml/kg in the first hour do better than those receiving < 20 ml/kg (Carcillo, JAMA 1991)
Maintenance fluid D5 1/4NSS @ 4 ml/kg/hr

Circulation
Anemia or trauma: 10 ml/kg PRBC
If no improvement in BP, mental status, skin perfusion after 60-80 ml/kg of NSS -> Dopamine starting 6-10 mcg/kg/min -> Consider central line

Hypoglycemia
Presumed hypoglycemia in all critically ill infants until proven otherwise
Treat if blood glucose < 50 mg/dL
Give D10 W 5-10 ml/kg

Antibiotics & Acyclovir
Presumed septic until proven otherwise
Early antibiotic (within 30-40 min) in most ill-appearing infants
≤ 28 days: Ampicillin + gentamicin or Ampicillin + Cefotaxime
Older infants: Ceftriaxone
Acyclovir: infants ≤ 28 days Mucocutaneous vesicles Seizure CSF pleocytosis with negative gram stain CSF RBC from atraumatic LP

Other Specific Treatment
Prostaglandin E1 - Cyanotic or obstructive heart disease with hemodynamic instability - Temporarily restore pulmonary and systemic blood flow - Consult cardiologist & neonatologist - 0.05 mcg/kg IV infusion, titrate to lowest dose Side effects: apnea, tachycardia, hypotension
Hydrocortisone -Usually male patient with adrenal crisis -Draw blood work before if possible

Diagnostic studies
Bedside: glucose, urine dipstick, EKG
Labs CBC, blood culture Electrolytes, Ca, Mg, Phos Blood gas Ammonia, lactate, pyruvate, blood & urine ketone UA, urine culture LP for CSF, CSF culture (if stable) CSF HSV PCR or enterovirus (if indicated) Bilirubin level

Radiology Tests
CXR
Abdominal plain film
Head CT
Upper GI series

Summary
Treat sepsis in all ill-appearing neonates
Check bedside glucose in all ill-appearing neonates
DDx: NEO SECRETS
Neonates with bilious emesis needs work-up to rule out volvulus which is true surgical emergency
Monitor glucose and temperature throughout ED stay

Ill appearing neonates

by Narenthorn EMS Center on Aug 12, 2010

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Ill appearing neonates — Presentation Transcript