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NEONATAL EMERGENCIES ASHRAF ALAWADI, MD Associated professor of Pediatric Head of Pediatric DepT. -UDH
NEONATAL EMERGENCIES ASHRAF ALAWADI, MD Associated professor of Pediatric Head of Pediatric DepT. -UDH
Neonatal Emergencies <ul><li>Neonates often present with non-specific or a history of symptoms that may or may not be beni...
RESPIRATORY SYSTEM <ul><li>Signs and Symptoms </li></ul><ul><ul><ul><li>Tachypenia (RR 60/min. or more) </li></ul></ul></u...
Retractions
RESPIRATORY SYSTEM <ul><li>Evaluation </li></ul><ul><ul><ul><li>CXR </li></ul></ul></ul><ul><ul><ul><li>ABG </li></ul></ul...
REPSPIRATORY SYTEM <ul><li>Conditions – Anatomic approach </li></ul><ul><ul><ul><li>Alveolar </li></ul></ul></ul><ul><ul><...
RESPIRATORY SYSTEM <ul><ul><ul><li>Space-occupying </li></ul></ul></ul><ul><ul><ul><ul><li>Air Leak </li></ul></ul></ul></...
RESPIRATORY SYSTEM <ul><ul><ul><li>Extra-pulmonary </li></ul></ul></ul><ul><ul><ul><ul><li>Sepsis/meningitis </li></ul></u...
Hyaline Membrane Disease
Meconium Aspiration Syndrome
Pneumonia
Transient Tachypnea of the Newborn
Cystic Adenomatoid Malformation
Pneumothorax
Pneumomediastinum
Pneumopericardium
Chylothorax
Congenital Diaphragmatic Hernia
  ALTE <ul><li>poorly defined term used to describe any event that is “frightening to the observer and is characterized by...
  ALTE <ul><li>Hospitalization for observation and monitoring </li></ul><ul><li>Common differential diagnosis: </li></ul><...
ALTE <ul><ul><li>Intracranial hemorrhage, Meningitis/encephalitis </li></ul></ul><ul><ul><li>Pertussis, Hypoglycemia </li>...
CARDIOVASCULAR SYSTEM <ul><li>Signs and Symptoms </li></ul><ul><ul><ul><li>cyanosis – central vs acrocyanosis </li></ul></...
CARDIOVASCULAR SYSTEM <ul><li>Evaluation </li></ul><ul><ul><ul><li>CXR </li></ul></ul></ul><ul><ul><ul><li>EKG </li></ul><...
Heart Disease and Hypoxia   Cyanotic Heart Disease <ul><li>Terrible T’s: </li></ul><ul><ul><li>Transposition of the great ...
Acyanotic Heart Disease Congestive Heart Failure <ul><li>Typically presents with symptoms of CHF </li></ul><ul><ul><li>Tac...
Acyanotic Heart Disease  Congestive Heart Failure <ul><li>Causes of CHF in Neonates: </li></ul><ul><ul><li>Acyanotic heart...
Acyanotic Heart Disease Supraventricular Tachycardia <ul><li>SVT is the most common neonatal dysrhythmia  (1/25,000 births...
Acyanotic Heart Disease   Supraventricular Tachycardia
Coarctation of the Aorta
CHF – Coarctation with VSD
GASTRO-INTESTINAL SYSTEM <ul><li>Consider pathologic process if vomiting in newborn period </li></ul><ul><li>Difficult to ...
GASTRO-INTESTINAL SYSTEM <ul><li>Signs and Symptoms </li></ul><ul><ul><ul><li>polyhydramnios </li></ul></ul></ul><ul><ul><...
GASTRO-INTESTINAL SYSTEM <ul><li>Conditions </li></ul><ul><ul><li>Congenital malformations </li></ul></ul><ul><ul><ul><li>...
Tracheoesophageal-fistula
Duodenal Atresia
Intestinal Atresia
Gastroschisis Omphalocele
NECROTIZING ENTEROCOLITIS
NECROTIZING ENTEROCOLITIS
NEC - perforation
Malrotation with Midgut Volvulus
CENTRAL NERVOUS SYSTEM <ul><li>Signs and Symptoms </li></ul><ul><ul><ul><li>seizures </li></ul></ul></ul><ul><ul><ul><li>l...
CENTRAL NERVOUS SYSTEM <ul><li>Conditions </li></ul><ul><ul><ul><li>Hypoxic-Ischemic Encephalopathy (HIE) </li></ul></ul><...
CENTRAL NERVOUS SYSTEM <ul><li>Evaluation </li></ul><ul><ul><li>LP </li></ul></ul><ul><ul><li>EEG </li></ul></ul><ul><ul><...
Intra-cranial Hemorrhage
HEMATOLOGIC <ul><li>Signs and Symptoms </li></ul><ul><ul><ul><li>Pallor </li></ul></ul></ul><ul><ul><ul><li>Shock </li></u...
HEMATOLOGIC <ul><li>Conditions </li></ul><ul><ul><li>Acute Blood loss </li></ul></ul><ul><ul><ul><li>Placenta previa </li>...
HEMATOLOGIC <ul><li>Conditions </li></ul><ul><ul><li>Chronic Blood loss </li></ul></ul><ul><ul><ul><li>Maternal-fetal  </l...
HEMATOLOGIC <ul><li>Conditions </li></ul><ul><ul><li>Thrombocytopenia </li></ul></ul><ul><ul><li>Polycythemia </li></ul></...
Endocrine Emergencies <ul><li>Congenital Adrenal Hyperplasia </li></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Hyp...
Inborn Errors of Metabolism Metabolic Emergencies <ul><li>Often have a delayed diagnosis </li></ul><ul><li>Symptoms may be...
Inborn Errors of Metabolism   Metabolic Emergencies <ul><li>Nonspecific symptoms </li></ul><ul><ul><li>Poor feeding </li><...
Inborn Errors of Metabolism   Metabolic Emergencies <ul><li>More apparent symptoms </li></ul><ul><ul><li>Seizures </li></u...
Inborn Errors of Metabolism   Metabolic Emergencies <ul><li>Labs </li></ul><ul><ul><li>Bedside glucose </li></ul></ul><ul>...
Inborn Errors of Metabolism
Inborn Errors of Metabolism   Metabolic Emergencies <ul><li>Management </li></ul><ul><ul><li>Fluid resuscitation </li></ul...
The Misfits Movie
Neonatal Emergencies <ul><li>“ THE MISFITS” </li></ul><ul><ul><li>T-  Trauma   (accidental & nonaccidental) </li></ul></ul...
Conclusion <ul><li>The mnemonic  “THE MISFITS”  is a helpful tool that can be readily used to formulate an approach to the...
THANK YOU
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Neonatal emergencies

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Neonatal emergencies

  1. 1. NEONATAL EMERGENCIES ASHRAF ALAWADI, MD Associated professor of Pediatric Head of Pediatric DepT. -UDH
  2. 2. NEONATAL EMERGENCIES ASHRAF ALAWADI, MD Associated professor of Pediatric Head of Pediatric DepT. -UDH
  3. 3. Neonatal Emergencies <ul><li>Neonates often present with non-specific or a history of symptoms that may or may not be benign </li></ul><ul><li>In order to recognize which neonates will require life-saving interventions, clinicians need to remain current on these life-threatening illnesses and their management </li></ul>
  4. 4. RESPIRATORY SYSTEM <ul><li>Signs and Symptoms </li></ul><ul><ul><ul><li>Tachypenia (RR 60/min. or more) </li></ul></ul></ul><ul><ul><ul><li>nasal flaring </li></ul></ul></ul><ul><ul><ul><li>grunting </li></ul></ul></ul><ul><ul><ul><li>retractions </li></ul></ul></ul><ul><ul><ul><li>Apnea </li></ul></ul></ul><ul><ul><ul><li>Cyanosis </li></ul></ul></ul>
  5. 5. Retractions
  6. 6. RESPIRATORY SYSTEM <ul><li>Evaluation </li></ul><ul><ul><ul><li>CXR </li></ul></ul></ul><ul><ul><ul><li>ABG </li></ul></ul></ul><ul><ul><ul><li>Pulse oximetry </li></ul></ul></ul><ul><ul><ul><li>Ct chest </li></ul></ul></ul><ul><ul><ul><li>Bronchoscope/ Laryngoscope </li></ul></ul></ul>
  7. 7. REPSPIRATORY SYTEM <ul><li>Conditions – Anatomic approach </li></ul><ul><ul><ul><li>Alveolar </li></ul></ul></ul><ul><ul><ul><ul><li>Hyaline Membrane Disease (HMD) or Respiratory Distress Syndrome (RDS) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pneumonia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Meconium Aspiration Syndrome (MAS) </li></ul></ul></ul></ul><ul><ul><ul><li>Parenchymal </li></ul></ul></ul><ul><ul><ul><ul><li>Transient Tachypnea of the Newborn (TTN) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cystic Adenomatoid Malformation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Congenital Lobar Emphysema </li></ul></ul></ul></ul>
  8. 8. RESPIRATORY SYSTEM <ul><ul><ul><li>Space-occupying </li></ul></ul></ul><ul><ul><ul><ul><li>Air Leak </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Effusion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Congenital Diaphragmatic Hernia </li></ul></ul></ul></ul><ul><ul><ul><li>Airway </li></ul></ul></ul><ul><ul><ul><ul><li>Laryngomalacia/tracheomalacia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tracheal web </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vocal cord paralysis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Choanal atresia </li></ul></ul></ul></ul>
  9. 9. RESPIRATORY SYSTEM <ul><ul><ul><li>Extra-pulmonary </li></ul></ul></ul><ul><ul><ul><ul><li>Sepsis/meningitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Congenital Heart Disease </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypothermia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Metabolic error </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Abdominal distention </li></ul></ul></ul></ul>
  10. 10. Hyaline Membrane Disease
  11. 11. Meconium Aspiration Syndrome
  12. 12. Pneumonia
  13. 13. Transient Tachypnea of the Newborn
  14. 14. Cystic Adenomatoid Malformation
  15. 15. Pneumothorax
  16. 16. Pneumomediastinum
  17. 17. Pneumopericardium
  18. 18. Chylothorax
  19. 19. Congenital Diaphragmatic Hernia
  20. 20. ALTE <ul><li>poorly defined term used to describe any event that is “frightening to the observer and is characterized by some combination of apnea, color change, marked change in muscle tone, choking or gagging” </li></ul>
  21. 21. ALTE <ul><li>Hospitalization for observation and monitoring </li></ul><ul><li>Common differential diagnosis: </li></ul><ul><ul><li>Sepsis, Pneumonia, RSV </li></ul></ul><ul><ul><li>Hypothermia, Anemia </li></ul></ul><ul><ul><li>Dysrhythmias </li></ul></ul><ul><ul><li>Acid/base disturbances </li></ul></ul>
  22. 22. ALTE <ul><ul><li>Intracranial hemorrhage, Meningitis/encephalitis </li></ul></ul><ul><ul><li>Pertussis, Hypoglycemia </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>GER </li></ul></ul><ul><ul><li>Child abuse </li></ul></ul><ul><ul><li>Inborn errors of metabolism </li></ul></ul><ul><ul><li>Electrolyte abnormalities </li></ul></ul>
  23. 23. CARDIOVASCULAR SYSTEM <ul><li>Signs and Symptoms </li></ul><ul><ul><ul><li>cyanosis – central vs acrocyanosis </li></ul></ul></ul><ul><ul><ul><li>tachycardia </li></ul></ul></ul><ul><ul><ul><li>tachypnea </li></ul></ul></ul><ul><ul><ul><li>murmur </li></ul></ul></ul><ul><ul><ul><li>gallop </li></ul></ul></ul>
  24. 24. CARDIOVASCULAR SYSTEM <ul><li>Evaluation </li></ul><ul><ul><ul><li>CXR </li></ul></ul></ul><ul><ul><ul><li>EKG </li></ul></ul></ul><ul><ul><ul><li>ABG – hyperoxia test </li></ul></ul></ul><ul><ul><ul><li>Echocardiography </li></ul></ul></ul><ul><ul><ul><li>Cardiac Cath. </li></ul></ul></ul>
  25. 25. Heart Disease and Hypoxia Cyanotic Heart Disease <ul><li>Terrible T’s: </li></ul><ul><ul><li>Transposition of the great arteries (TGA) </li></ul></ul><ul><ul><li>Tetralogy of Fallot (TOF) </li></ul></ul><ul><ul><li>Tricuspid atresia (TA) </li></ul></ul><ul><ul><li>Total anomalous pulmonary venous return (TAPVR) </li></ul></ul><ul><ul><li>Truncus arteriosus (TA) </li></ul></ul>
  26. 26. Acyanotic Heart Disease Congestive Heart Failure <ul><li>Typically presents with symptoms of CHF </li></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Hepatomegaly </li></ul></ul><ul><ul><li>History of poor or slow feeding </li></ul></ul><ul><ul><li>Sweating or color change with feeding </li></ul></ul><ul><ul><li>Poor weight gain </li></ul></ul><ul><li>More gradual clinical decompensation </li></ul><ul><li>May not present until after the first 2-3 weeks of age </li></ul>
  27. 27. Acyanotic Heart Disease Congestive Heart Failure <ul><li>Causes of CHF in Neonates: </li></ul><ul><ul><li>Acyanotic heart disease (VSD, ASD, PDA, CoA) </li></ul></ul><ul><ul><li>Severe anemia </li></ul></ul><ul><ul><li>Trauma,Sepsis </li></ul></ul><ul><ul><li>SVT </li></ul></ul><ul><ul><li>Metabolic abnormalities </li></ul></ul><ul><ul><li>SLE, Thyrotoxicosis </li></ul></ul>
  28. 28. Acyanotic Heart Disease Supraventricular Tachycardia <ul><li>SVT is the most common neonatal dysrhythmia (1/25,000 births) </li></ul><ul><li>Signs/symptoms: </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Poor feeding </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Heart Failure </li></ul></ul><ul><ul><li>Shock </li></ul></ul><ul><li>Heart rate sustained at >220 bpm with a QRS < 0.08 seconds </li></ul>
  29. 29. Acyanotic Heart Disease Supraventricular Tachycardia
  30. 30. Coarctation of the Aorta
  31. 31. CHF – Coarctation with VSD
  32. 32. GASTRO-INTESTINAL SYSTEM <ul><li>Consider pathologic process if vomiting in newborn period </li></ul><ul><li>Difficult to differentiate between a life-threatening cause from a mild viral gastroenteritis or even severe gatroesophageal reflux </li></ul><ul><li>Initial symptoms may be nonspecific </li></ul><ul><li>Bilious emesis is almost always an ominous sign </li></ul>
  33. 33. GASTRO-INTESTINAL SYSTEM <ul><li>Signs and Symptoms </li></ul><ul><ul><ul><li>polyhydramnios </li></ul></ul></ul><ul><ul><ul><li>distention </li></ul></ul></ul><ul><ul><ul><li>failure to pass meconium or stool </li></ul></ul></ul><ul><ul><ul><li>Vomiting </li></ul></ul></ul><ul><li>Evaluation </li></ul><ul><ul><ul><li>Abdominal films </li></ul></ul></ul><ul><ul><ul><li>Contrast studies </li></ul></ul></ul><ul><ul><ul><li>US </li></ul></ul></ul>
  34. 34. GASTRO-INTESTINAL SYSTEM <ul><li>Conditions </li></ul><ul><ul><li>Congenital malformations </li></ul></ul><ul><ul><ul><li>Tracheal-Esophageal Fistula (TEF) </li></ul></ul></ul><ul><ul><ul><li>Duodenal atresia </li></ul></ul></ul><ul><ul><ul><li>Intestinal atresias </li></ul></ul></ul><ul><ul><ul><li>Omphalocele, Gastroschisis </li></ul></ul></ul><ul><ul><li>Malrotation with Midgut Volvulus </li></ul></ul><ul><ul><li>Necrotizing Enterocolitis (NEC) </li></ul></ul><ul><ul><li>Toxic Megacolon </li></ul></ul><ul><ul><li>Hypertrophic Pyloric Stenosis </li></ul></ul>
  35. 35. Tracheoesophageal-fistula
  36. 36. Duodenal Atresia
  37. 37. Intestinal Atresia
  38. 38. Gastroschisis Omphalocele
  39. 39. NECROTIZING ENTEROCOLITIS
  40. 40. NECROTIZING ENTEROCOLITIS
  41. 41. NEC - perforation
  42. 42. Malrotation with Midgut Volvulus
  43. 43. CENTRAL NERVOUS SYSTEM <ul><li>Signs and Symptoms </li></ul><ul><ul><ul><li>seizures </li></ul></ul></ul><ul><ul><ul><li>lethargy </li></ul></ul></ul><ul><ul><ul><li>irritability/tremors </li></ul></ul></ul><ul><ul><ul><li>Hypotonia </li></ul></ul></ul><ul><ul><ul><li>coma </li></ul></ul></ul>
  44. 44. CENTRAL NERVOUS SYSTEM <ul><li>Conditions </li></ul><ul><ul><ul><li>Hypoxic-Ischemic Encephalopathy (HIE) </li></ul></ul></ul><ul><ul><ul><li>Intra-cranial Hemorrhage </li></ul></ul></ul><ul><ul><ul><li>Drug withdrawal </li></ul></ul></ul><ul><ul><ul><li>Malformations </li></ul></ul></ul><ul><ul><ul><li>Meningitis </li></ul></ul></ul><ul><ul><ul><li>IEM </li></ul></ul></ul>
  45. 45. CENTRAL NERVOUS SYSTEM <ul><li>Evaluation </li></ul><ul><ul><li>LP </li></ul></ul><ul><ul><li>EEG </li></ul></ul><ul><ul><li>US </li></ul></ul><ul><ul><li>CT/MRI </li></ul></ul><ul><ul><li>Metabolic screen </li></ul></ul>
  46. 46. Intra-cranial Hemorrhage
  47. 47. HEMATOLOGIC <ul><li>Signs and Symptoms </li></ul><ul><ul><ul><li>Pallor </li></ul></ul></ul><ul><ul><ul><li>Shock </li></ul></ul></ul><ul><ul><ul><li>Early Jaundice </li></ul></ul></ul><ul><ul><ul><li>Petechiae </li></ul></ul></ul><ul><ul><ul><li>bleeding </li></ul></ul></ul>
  48. 48. HEMATOLOGIC <ul><li>Conditions </li></ul><ul><ul><li>Acute Blood loss </li></ul></ul><ul><ul><ul><li>Placenta previa </li></ul></ul></ul><ul><ul><ul><li>Abrutio placentae </li></ul></ul></ul><ul><ul><ul><li>Velamentous cord insertion </li></ul></ul></ul><ul><ul><ul><li>Cord accident </li></ul></ul></ul><ul><ul><ul><li>Organ rupture </li></ul></ul></ul>
  49. 49. HEMATOLOGIC <ul><li>Conditions </li></ul><ul><ul><li>Chronic Blood loss </li></ul></ul><ul><ul><ul><li>Maternal-fetal </li></ul></ul></ul><ul><ul><ul><li>Twin-twin transfusion </li></ul></ul></ul><ul><ul><ul><li>Hemolytic anemias – immune, non-immune </li></ul></ul></ul>
  50. 50. HEMATOLOGIC <ul><li>Conditions </li></ul><ul><ul><li>Thrombocytopenia </li></ul></ul><ul><ul><li>Polycythemia </li></ul></ul><ul><ul><li>Hemorrhagic Disease of the Newborn </li></ul></ul><ul><ul><li>DIC </li></ul></ul>
  51. 51. Endocrine Emergencies <ul><li>Congenital Adrenal Hyperplasia </li></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>Dehydration or even shock </li></ul></ul><ul><li>Neonatal thyrotoxicosis </li></ul><ul><ul><li>poor feeding, failure to thrive, tachycardia, </li></ul></ul><ul><ul><li>irritability, hyperthermia, vomiting, diarrhea, </li></ul></ul><ul><ul><li>thrombocytopenia, respiratory distress, </li></ul></ul><ul><ul><li>heart failure and shock </li></ul></ul>
  52. 52. Inborn Errors of Metabolism Metabolic Emergencies <ul><li>Often have a delayed diagnosis </li></ul><ul><li>Symptoms may be unrecognized because they are uncommon </li></ul><ul><li>Require a high level of suspicion for diagnosis </li></ul><ul><li>Diagnosis should be considered in any infant who does not have any other obvious cause for symptoms </li></ul>
  53. 53. Inborn Errors of Metabolism Metabolic Emergencies <ul><li>Nonspecific symptoms </li></ul><ul><ul><li>Poor feeding </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>FTT </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Irritability </li></ul></ul>
  54. 54. Inborn Errors of Metabolism Metabolic Emergencies <ul><li>More apparent symptoms </li></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Lethargy </li></ul></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Temperature instability </li></ul></ul><ul><ul><li>Acidosis </li></ul></ul>
  55. 55. Inborn Errors of Metabolism Metabolic Emergencies <ul><li>Labs </li></ul><ul><ul><li>Bedside glucose </li></ul></ul><ul><ul><li>CBC </li></ul></ul><ul><ul><li>Blood Ammonia </li></ul></ul><ul><ul><li>ABG </li></ul></ul><ul><ul><li>Lactate and Pyrovate levels </li></ul></ul><ul><ul><li>LFT’s </li></ul></ul><ul><ul><li>Urine for reducing substances and ketones </li></ul></ul><ul><ul><li>Blood and urine for organic and amino acids </li></ul></ul>
  56. 56. Inborn Errors of Metabolism
  57. 57. Inborn Errors of Metabolism Metabolic Emergencies <ul><li>Management </li></ul><ul><ul><li>Fluid resuscitation </li></ul></ul><ul><ul><li>IV dextrose to prevent further catabolism </li></ul></ul><ul><ul><li>Admission to hospital </li></ul></ul><ul><ul><li>Genetics consultation </li></ul></ul>
  58. 58. The Misfits Movie
  59. 59. Neonatal Emergencies <ul><li>“ THE MISFITS” </li></ul><ul><ul><li>T- Trauma (accidental & nonaccidental) </li></ul></ul><ul><ul><li>H- Heart Disease/Hypovolemia/Hypoxia </li></ul></ul><ul><ul><li>E - Endocrine (congenital adrenal hyperplasia, thyrotoxicosis) </li></ul></ul><ul><ul><li>M - Metabolic (electrolyte imbalance) </li></ul></ul><ul><ul><li>I - Inborn Errors of Metabolism : m etabolic emergencies </li></ul></ul><ul><ul><li>S - Sepsis (meningitis, pneumonia, UTI) </li></ul></ul><ul><ul><li>F - Formula mishaps (under or overdilution) </li></ul></ul><ul><ul><li>I - Intestinal catastrophes (volvulus, intususception, NEC) </li></ul></ul><ul><ul><li>T - Toxins/poisons </li></ul></ul><ul><ul><li>S - Seizures </li></ul></ul>
  60. 60. Conclusion <ul><li>The mnemonic “THE MISFITS” is a helpful tool that can be readily used to formulate an approach to the most common neonatal emergencies that may present to general pediatricians in their hospital or private offices as well as ED clinicians in the ED department </li></ul>
  61. 61. THANK YOU

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