Mary McCaskill: Neonatal Nightmares

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Step into the shoes of Mary McCaskill as she walks us through some not to be missed neonatal presentations.

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Mary McCaskill: Neonatal Nightmares

  1. 1. Neonatal NightmaresDr Mary McCaskillPaediatric EmergencyPhysician
  2. 2. Neonates•Major adjustments in physiology•First signs of congenital problems•At risk of serious bacterial infection•No baseline for normal state•Inexperience of parent –infantinteraction
  3. 3. Signs and symptoms•Less specific– Changes to feeding, vomiting– Behaviour, tone– Urine and stool output– Colour, perfusion– Breathing, apnoea
  4. 4. Potential deterioration•Rapid•Apnoea•Bradycardia•Arrest
  5. 5. Catherine•10 days old, born at term, normaldelivery, first child, breast fed, hadregained birth weight•2 days ‘off colour’, shorter feeds•24 hours vomiting small amounts at endof feed•Fever to 38.3oC overnight
  6. 6. Examination•Airway patent•No respiratory distress, chest clear•Pale, tachycardic 180, perfusionreduced•Poorly responsive to mother, floppy•Apnoea noted responding to stimulation•Bedside blood sugar 4.3
  7. 7. Sepsis•Why?– Temperature – hypothermic presentation– Deterioration in condition•Source?– Urinary tract infection –most likely– Meningitis possible– Group B Strep infection
  8. 8. Treatment•IV cannula•Fluids -resuscitate– then glucose containing fluids•IV antibiotics– Gentamicin– Ampicillin– Cefotaxime
  9. 9. Next steps•Consider Acyclovir –if seizures,vesicles, maternal herpes•Inotropes if minimal improvement•Source investigations– Urine specimen– Lumbar puncture– Chest radiograph
  10. 10. James•9 days old, born at term, normaldelivery, second child, breast fed, hadregained birth weight•2 days ‘off colour’, shorter feeds•24 hours vomiting small amounts at endof feed•No fever
  11. 11. Examination•Airway patent•No respiratory distress, chest clear•Pink, bradycardic 80, perfusion reduced•Quiet, reduced response, normal tone•Apnoea noted responding to stimulation•Sepsis treatment started
  12. 12. Electrolytes•Na 123, K 10.33•Glucose 2.8•Lactate 3.4•ECG –runs of ventricular tachycardia•Lab results –Creatinine 133
  13. 13. Hyperkalaemia•Salbutamol•Calcium gluconate•Dextrose 2ml/kg of 10%•Bicarbonate•Resonium rectally•Pads on chest, amiodarone prepared
  14. 14. Hypoglycaemia•Blood and urine for– hormonal levels– amino acids– long chain fatty acid deficiency•Treat with 10% Dextrose as before
  15. 15. Diagnosis•Congenital Adrenal Hypoplasia– hyperkalaemia, hyponatraemia– Hypoglycaemia– Treat with hydrocortisone•Renal disease -Posterior urethral valves– hyperkalaemia, hyponatraemia– raised creatinine
  16. 16. Sam•7 days old, born at term, normaldelivery, second child, bottle fed, stillbelow birth weight•Fussy feeder, breaks off during feed•24 hours vomiting small amounts at endof feed•No fever
  17. 17. Examination•Airway patent•Grunting, tachypnoeic, chest clear•Pale, tachycardic 188, perfusionreduced, skin mottled and grey legs•Poorly responsive to mother, floppy•Apnoea noted responding to stimulation•Bedside blood sugar 4.6
  18. 18. Cardiac examination•Femoral pulses impalpable•BP normal in both arms and unable torecord in legs•No murmurs heard•Diagnosis of Coarctation of the aorta•Shock following closure of ductusarteriosus
  19. 19. Treatment•Treat for sepsis•Fluid to support preload•Prostaglandin infusion to open duct•Intubation to avoid apnoea•Consider fentanyl for sedation
  20. 20. Jasmine•9 days old, born at term, normaldelivery, second child, bottle fed, stillbelow birth weight•Difficulty feeding•48 hours green vomits after each feed•No fever
  21. 21. Examination•Airway patent•Grunting, chest clear•Pale, tachycardic 190, perfusionreduced, eyes sunken•Poorly responsive to mother, floppy•Distended abdomen, soft non tender•Bedside blood sugar 3.2
  22. 22. Treatment•Sepsis treated•Rehydration•Surgical cause likely– Duodenal web, hernia or other obstruction– Necrotising enterocolitis– Volvulus
  23. 23. Nightmares•Consider– Sepsis– Cardiac cause– Endocrine or metabolic– Surgical cause•Treat neonates with great caution
  24. 24. Questions?

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