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Neonatal Emergencies

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Neonatal Emergencies

  1. 1. Neonatal Emergencies (After Discharge) Robert Englert, M.D. Dept Neonatology Bethesda Naval Hospital
  2. 2. Most Interesting ED Chief Complaints <ul><li>Drank the dog’s milk - from the dog’s nipple </li></ul><ul><li>Needs a circumcision because his tonsils are so big </li></ul><ul><li>Can’t find baby’s birthmark </li></ul><ul><li>Piece of bologna string hanging from anus </li></ul><ul><li>Baby is afraid of his hands </li></ul>
  3. 3. Case Presentation 10 day old male presents to ED with 1 day history poor feeding, lethargy and, over last 1-2 hours, increasing work of breathing. Pre- and postnatal history are unremarkable.
  4. 4. ABC’s of Neonatal Resuscitation <ul><li>Airway </li></ul><ul><li>Airway </li></ul><ul><li>Airway </li></ul>
  5. 5. Initial Management <ul><li>IV access </li></ul><ul><li>monitor </li></ul><ul><li>oxygen </li></ul>
  6. 6. Initial Management - Therapy <ul><li>Respiratory Support </li></ul><ul><li>Volume </li></ul><ul><li>Antibiotics </li></ul>
  7. 7. Diagnostic Tests <ul><li>ABG </li></ul><ul><li>CBC </li></ul><ul><li>Lytes </li></ul><ul><li>Cultures </li></ul><ul><li>Radiography </li></ul>
  8. 8. Categories <ul><li>Infectious </li></ul><ul><li>Cardiac </li></ul><ul><li>Endocrine </li></ul>
  9. 9. Late-Onset Infections <ul><li>Group B Streptococcus </li></ul><ul><li>E. coli </li></ul><ul><li>Listeria </li></ul><ul><li>H. influenza, S. Pneumonia, N. meningitis </li></ul><ul><li>Viral </li></ul><ul><ul><li>RSV, HSV, Enterovirus </li></ul></ul>
  10. 10. Group B Streptococcus <ul><li>1-3/1000 live births </li></ul><ul><li>Up to 1/3 women colonized </li></ul><ul><li>Early and late onset disease </li></ul><ul><li>Antibiotics around delivery affect early onset not late onset </li></ul><ul><li>Late onset highly associated with meningitis </li></ul>
  11. 11. Listeria monocytogenes <ul><li>Early and late onset disease </li></ul><ul><li>Early onset often associated with meconium staining even in preterms </li></ul><ul><li>Late onset disease is primarily meningitic </li></ul>
  12. 12. Escherichia coli <ul><li>K1 capsular antigen uniquely associated with neonatal meningitis </li></ul><ul><li>K1 related not only to invasive disease, but to more severe outcomes </li></ul><ul><li>Significant association with galactosemia likely due to depressed PMN function caused by elevated serum galactose levels </li></ul><ul><li>Urosepsis/posterior urethral valves </li></ul>
  13. 13. Case Presentation <ul><li>4 day old infant African American male presents to ER because of decreased feeding, lethargy, poor color, increased work of breathing, prenatal history unremarkable, spent 2 days in hospital, no reported problems, discharged 48 hours ago </li></ul>
  14. 14. Ductal Dependent Cardiac Lesions <ul><li>Left sided heart lesions </li></ul><ul><ul><li>Systemic blood flow is dependent upon ductal patency </li></ul></ul><ul><ul><ul><li>coarctation of the aorta </li></ul></ul></ul><ul><ul><ul><li>interrupted aortic arch </li></ul></ul></ul><ul><ul><ul><li>hypoplastic left heart </li></ul></ul></ul>
  15. 15. Ductal Dependent Cardiac Lesions Left Sided <ul><li>shock </li></ul><ul><li>cardiac failure - hepatosplenomegaly, large heart, gallop </li></ul><ul><li>Pressor support </li></ul><ul><li>prostaglandin E1 </li></ul><ul><ul><li>side effects: </li></ul></ul><ul><ul><ul><li>Flushing, Hypotension, Pyrexia (fever) </li></ul></ul></ul><ul><ul><ul><li>idiosyncratic apnea </li></ul></ul></ul>
  16. 17. Case Presentation <ul><li>3d old caucasian male presents to ER because of poor feeding, lethargy, comfortable tachypnea, “color not right”, harsh murmur </li></ul><ul><li>Pre-natal Hx unremarkable, no U/S done during pregnancy </li></ul><ul><li>D/C to home at 26hol </li></ul>
  17. 18. Ductal Dependent Cardiac Lesions <ul><li>Right sided heart lesions </li></ul><ul><ul><li>pulmonary blood flow is dependent on ductal patency </li></ul></ul><ul><ul><ul><li>tetralogy of Fallot </li></ul></ul></ul><ul><ul><ul><li>transposition of great vessels </li></ul></ul></ul><ul><ul><ul><li>tricuspid atresia </li></ul></ul></ul><ul><ul><ul><li>pulmonary stenosis/atresia </li></ul></ul></ul>
  18. 19. Congenital Heart Lesions
  19. 21. Case Presentation Infant is tachycardic, 200-220/min, mottled with poor perfusion. Poor feeding, Respirations are labored with rate of 80/min.
  20. 22. Neonatal Rhythm Disturbances <ul><li>Fast </li></ul><ul><li>Slow </li></ul><ul><li>In between </li></ul>
  21. 24. Supraventricular Tachycardia <ul><li>persistent ventricular rate of > 200/min </li></ul><ul><li>fixed RR interval </li></ul><ul><li>abnormal P wave shape or axis, abnormal P-R interval, or absence of P waves </li></ul><ul><li>little change in rate with activity, crying, etc. </li></ul>
  22. 25. Supraventricular Tachycardia <ul><li>most common symptomatic arrhythmia in children </li></ul><ul><li>may be associated with WPW syndrome or Ebstein’s anomaly </li></ul><ul><li>CHF rare in first 24 hrs; 50% after 48 hrs </li></ul>
  23. 26. Supraventricular Tachycardia <ul><li>unstable vs stable </li></ul><ul><li>synchronized cardioversion in unstable patient </li></ul><ul><li>vagal stimulation (ice to face) </li></ul><ul><li>adenosine </li></ul><ul><li>side effect of all cardioversion methods: </li></ul><ul><ul><li>asystole </li></ul></ul><ul><ul><li>death </li></ul></ul>
  24. 28. Case Presentation <ul><li>29yo Black female G4P0 presents at 35 +2 weeks with swollen ankles </li></ul><ul><li>No Ctx, normal cervical exam, labs pending </li></ul><ul><li>FHR noted to be 280, U/S otherwise normal </li></ul><ul><li>BPP 4/10, Delivered via LTCS </li></ul>
  25. 30. EKG pre/post Adenosine
  26. 32. Neonatal Hyperthyroidism <ul><li>Maternal Graves disease - 1/2000 pregnancies </li></ul><ul><li>Thyroid-stimulating immunoglobulins cross the placenta </li></ul><ul><li>Mothers with symptomatic disease may be treated with PTU </li></ul>
  27. 33. Neonatal Hyperthyroidism <ul><li>Infants of mothers with Graves disease may be: </li></ul><ul><ul><li>goitrous and hypothyroid </li></ul></ul><ul><ul><li>euthyroid due to maternal PTU which crosses the placenta </li></ul></ul><ul><ul><li>hyperthyroid due to maternal thyroid-stimulating Ig </li></ul></ul>
  28. 34. Neonatal Hyperthyroidism <ul><li>Transplacentally acquired thyroid-stimulating Ig may exert effects for up to 12 weeks postnatally </li></ul><ul><li>Thyroid storm </li></ul><ul><ul><li>Irritibility </li></ul></ul><ul><ul><li>Respiratory distress </li></ul></ul><ul><ul><li>Severe tachycardia </li></ul></ul><ul><ul><li>Cardiac failure </li></ul></ul>
  29. 35. Neonatal Thyrotoxicosis <ul><li>Treatment </li></ul><ul><li>Suppress excess secretion of hormone and conversion of T4 >>T3 </li></ul><ul><ul><li>PTU and/or Potassium Iodide (Lugol’s) </li></ul></ul><ul><li>Adrenergic Blockade </li></ul><ul><ul><li>Propranolol </li></ul></ul>
  30. 36. Case Presentation <ul><li>A 7lb male newborn has bilateral cryptorchidism and hypospadius. At 7 days of age infant presents to the ER with a history of vomiting. The baby is pale, tachycardic, hypotensive. </li></ul><ul><li>Believe it or not it happens….. </li></ul>
  31. 37. Congenital Adrenal Hyperplasia <ul><li>group of enzyme defects which impair steroid hormone production </li></ul><ul><li>21-hydroxylase - 90% of cases </li></ul><ul><li>two forms </li></ul><ul><ul><li>partial: simple virilizing </li></ul></ul><ul><ul><li>more complete deficiency: salt losing </li></ul></ul>
  32. 38. Congenital Adrenal Hyperplasia <ul><li>females are virilized; males usually appear normal </li></ul><ul><li>salt losing - adrenal insufficiency occurs under basal conditions </li></ul><ul><ul><li>significant impairment of cortisol and aldosterone synthesis </li></ul></ul><ul><ul><li>most have onset of symptoms at 6-14 days </li></ul></ul><ul><ul><li>shock with hypoglycemia, hyponatremia, hyperkalemia, acidemia </li></ul></ul>
  33. 39. Congenital Adrenal Hyperplasia Treatment <ul><li>treat hypovolemia </li></ul><ul><li>correct sodium and potassium if necessary </li></ul><ul><li>hydrocortisone is steroid of choice </li></ul><ul><li>mineralocorticoid replacement may be necessary </li></ul>
  34. 40. Inborn Errors of Metabolism <ul><li>Alteration in mental status </li></ul><ul><li>acidosis </li></ul><ul><li>hypoglycemia </li></ul><ul><li>electrolyte abnormalities </li></ul><ul><li>ketosis </li></ul><ul><li>hyperbilirubinemia </li></ul>
  35. 41. Inborn Errors of Metabolism <ul><li>Hepatomegaly </li></ul><ul><li>Seizures </li></ul><ul><li>Hyperammonemia </li></ul><ul><li>Reducing substances in urine </li></ul>
  36. 42. Inborn Errors of Metabolism The Smell Test <ul><li>Maple Syrup Urine Dz maple syrup </li></ul><ul><li>Isovaleric acidemia sweaty feet </li></ul><ul><li>Tyrosinemia rancid butter </li></ul><ul><li>Beta-methylcrotonyl- coenzyme A def. tomcat’s urine </li></ul><ul><li>phenylketonuria mousy/musty </li></ul><ul><li>methionine malabsorption cabbage </li></ul><ul><li>trimethylaminuria rotting fish </li></ul>
  37. 43. Conclusions <ul><li>ABC’s </li></ul><ul><li>Monitor, IV, Oxygen, Antibiotics </li></ul><ul><li>Diagnostic tests </li></ul><ul><li>Know the differential </li></ul>

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