1. Neonatal presentations to emergency departments are rising, partly due to shorter postpartum stays. Common non-emergency presentations include jaundice, feeding issues, breathing difficulties, and excessive crying.
2. Factors associated with increased ED attendance among neonates include parental anxiety, perceived convenience of EDs, lack of continuity with primary care, and neonates exhibiting non-specific symptoms.
3. The most common neonatal emergencies can be summarized by the acronym "THE MISFITS" and include conditions like trauma, heart disease, endocrine emergencies, and sepsis. Timely diagnosis and treatment of these conditions in the ED is important for neonatal health outcomes.
Neonatal Emergency and Common Problems in Emergency Departmentnawan_junior
A 5-day-old boy presented with poor feeding and lethargy. On examination, he was difficult to arouse and slightly jaundiced with mottled skin. His vital signs showed hypothermia, tachycardia, and prolonged capillary refill time. Intravenous access was obtained and fluids, antibiotics, and tests were initiated to evaluate for possible sepsis given his concerning symptoms. Further history revealed worsening feeding over the past day.
This document summarizes a presentation on follow-up care for high-risk newborns. It discusses the medical home framework and components of health and developmental follow-up. Key points include:
- High-risk infants requiring ongoing care include preterms and those with special health care needs or technology dependence.
- Follow-up includes primary care, specialty care, developmental surveillance, and addressing family concerns from infancy through adulthood.
- Transition points for parents include concerns in the first 3 months after discharge and needs changing from ages 3 months to 1 year, 1-3 years, preschool, and beyond.
- Barriers to care include limited provider familiarity with complex conditions, insufficient reimbursement, and
Growth charts in Neonates- Preterm and termSujit Shrestha
Growth charts in Newborn, Preterm and term neonates. All historically used charts in NICU are discussed here.
Presented by Dr Sujit, in Sir Ganga Ram Hospital
1. Excessive crying in infants is a common reason for pediatric visits. It can be caused by various medical issues or may be due to colic in some cases.
2. A thorough history and physical examination are important to rule out any serious underlying conditions and make a diagnosis. Common causes found include colic, ear infections, and constipation.
3. While crying is normal infant behavior, it is important for pediatricians to determine if there is an underlying treatable cause to avoid missing potential serious issues and to advise parents on next steps.
Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathyMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
1. Dr. Arif Hossain and Dr. Chit Narayan Sah presented on neonatal anemia at a department seminar.
2. Case scenario 1 involved a 26 day old preterm infant with poor weight gain despite being clinically stable. The possible cause of poor weight gain was anemia.
3. Case scenario 2 was about a 2 hour old term infant with Rh-isoimmunization who was pale with a hemoglobin of 10.6 g/dl and positive Coombs test, indicating the problem was hemolytic anemia.
This document provides an overview and table of contents for the book "Key Topics in Paediatrics". The book covers a wide range of pediatric medical topics in concise chapters intended to provide essential information and high-level summaries. It is the second edition of the text, revised and updated by three pediatric specialists from hospitals in the UK. The table of contents lists over 80 common pediatric conditions and issues that will be covered in the book in an accessible format for healthcare professionals.
Neonatal Emergency and Common Problems in Emergency Departmentnawan_junior
A 5-day-old boy presented with poor feeding and lethargy. On examination, he was difficult to arouse and slightly jaundiced with mottled skin. His vital signs showed hypothermia, tachycardia, and prolonged capillary refill time. Intravenous access was obtained and fluids, antibiotics, and tests were initiated to evaluate for possible sepsis given his concerning symptoms. Further history revealed worsening feeding over the past day.
This document summarizes a presentation on follow-up care for high-risk newborns. It discusses the medical home framework and components of health and developmental follow-up. Key points include:
- High-risk infants requiring ongoing care include preterms and those with special health care needs or technology dependence.
- Follow-up includes primary care, specialty care, developmental surveillance, and addressing family concerns from infancy through adulthood.
- Transition points for parents include concerns in the first 3 months after discharge and needs changing from ages 3 months to 1 year, 1-3 years, preschool, and beyond.
- Barriers to care include limited provider familiarity with complex conditions, insufficient reimbursement, and
Growth charts in Neonates- Preterm and termSujit Shrestha
Growth charts in Newborn, Preterm and term neonates. All historically used charts in NICU are discussed here.
Presented by Dr Sujit, in Sir Ganga Ram Hospital
1. Excessive crying in infants is a common reason for pediatric visits. It can be caused by various medical issues or may be due to colic in some cases.
2. A thorough history and physical examination are important to rule out any serious underlying conditions and make a diagnosis. Common causes found include colic, ear infections, and constipation.
3. While crying is normal infant behavior, it is important for pediatricians to determine if there is an underlying treatable cause to avoid missing potential serious issues and to advise parents on next steps.
Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathyMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
1. Dr. Arif Hossain and Dr. Chit Narayan Sah presented on neonatal anemia at a department seminar.
2. Case scenario 1 involved a 26 day old preterm infant with poor weight gain despite being clinically stable. The possible cause of poor weight gain was anemia.
3. Case scenario 2 was about a 2 hour old term infant with Rh-isoimmunization who was pale with a hemoglobin of 10.6 g/dl and positive Coombs test, indicating the problem was hemolytic anemia.
This document provides an overview and table of contents for the book "Key Topics in Paediatrics". The book covers a wide range of pediatric medical topics in concise chapters intended to provide essential information and high-level summaries. It is the second edition of the text, revised and updated by three pediatric specialists from hospitals in the UK. The table of contents lists over 80 common pediatric conditions and issues that will be covered in the book in an accessible format for healthcare professionals.
Neonatal fluid requirements and specials conditionsRakesh Verma
This document provides an overview of neonatal fluid and electrolyte requirements, including physiological changes affecting balance in fetuses and neonates. It discusses developmental changes in total body water, extracellular and intracellular fluid during gestation and after birth. Maturation of organs like the cardiovascular system and kidneys that regulate fluid compartments is also covered. Guidelines are provided for calculating total fluid needs as well as maintenance, deficit and ongoing loss replacement in both term and preterm infants of different weights. Electrolyte supplementation amounts and choices of IV fluids are also summarized.
This document discusses shock in neonates and neonatal vasoregulation. It begins by defining blood pressure and its components. It then discusses factors that affect blood pressure and the unique features of the neonatal myocardium. It describes the roles of catecholamines and their receptors in relation to blood pressure. The document clarifies terminology around hypotension and shock. It concludes by discussing clinical methods for monitoring systemic hemodynamics in critically ill newborns such as capillary refill time, central-peripheral temperature difference, and blood pressure measurements.
Assessment And Managment Of Critically Ill Child 1Dang Thanh Tuan
This document discusses the paramedic's role in pediatric emergency care. It describes assessing and managing critically ill children using the Pediatric Assessment Triangle to evaluate appearance, work of breathing, and circulation. Case studies demonstrate applying this technique to identify respiratory distress, failure, shock, or brain dysfunction. The document also outlines general pediatric patient management including airway control, fluids, electrical therapy and transport considerations.
This document discusses fluid and electrolyte requirements in newborns. It notes that total body water is divided between intracellular and extracellular spaces, with sodium being the main extracellular ion and potassium the main intracellular ion. Fluid volumes are regulated by sodium and potassium salts in each compartment. Principles of fluid management include maintaining appropriate extracellular fluid volume and osmolality. Factors like gestational age, postnatal age, and weight loss influence fluid needs. Guidelines are provided for initial daily fluid requirements based on birth weight and monitoring fluid status through weight, clinical exam, serum and urine tests.
This document discusses fluid and electrolyte physiology in neonates. It covers developmental changes from intrauterine life through childhood and how this affects total body water, extracellular fluid, and intracellular fluid levels at different ages. It also discusses fluid shifts that occur during labor, delivery, and the postnatal period. Guidelines are provided for estimating insensible water loss and determining intravenous fluid and electrolyte requirements for term and preterm neonates of different gestational ages and weights.
This document provides guidelines for the management of common neonatal emergencies encountered in the emergency department. It outlines the assessment steps, diagnostic workup and initial stabilization measures for respiratory distress, cardiac issues like cyanotic heart disease and supraventricular tachycardia, shock, decreased consciousness, apnea, and various endocrine emergencies including congenital adrenal hyperplasia and thyrotoxicosis. History taking, physical exam focusing on ABCDE, appropriate diagnostic tests and consultation with pediatric specialists are emphasized.
Persistent pulmonary hypertension of the newborn (PPHN) is a major problem in neonatal intensive care units that can lead to death or neurological injury in newborns. It occurs when the pulmonary circulation fails to transition from the high resistance fetal state. Causes include meconium aspiration syndrome, idiopathic PPHN, and pulmonary hypoplasia from conditions like congenital diaphragmatic hernia. Treatment involves optimizing oxygenation and cardiac function along with pulmonary vasodilators like inhaled nitric oxide. Future therapies may include phosphodiesterase inhibitors and prostacyclin analogs to further reduce pulmonary hypertension in newborns.
This document provides guidance on managing a neonate with respiratory distress, including defining the severity, identifying the etiology, initial management with oxygen therapy and supportive care, and the various modes of respiratory support including CPAP, NIV, HHHFNC, IMV, and HFOV. The goal of respiratory support is to optimize oxygenation and ventilation while avoiding lung injury through use of the lowest effective pressures and tidal volumes. Clinical assessment and arterial blood gases are important to monitor the adequacy of respiratory support and make adjustments as needed.
Postnatal growth failure and its preventionMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
Persistent pulmonary hypertension of newborn PPHNChandan Gowda
Persistent pulmonary hypertension of the newborn (PPHN) results from failure of the normal decrease in pulmonary vascular resistance after birth, causing right-to-left shunting of blood and hypoxemia. It can be caused by underdevelopment, maldevelopment, or maladaptation of the pulmonary vasculature. Clinical features include cyanosis and respiratory distress within the first 24 hours of life. Diagnosis involves echocardiography demonstrating elevated pulmonary pressures and responding poorly to oxygen challenges. Treatment aims to reduce PVR through ventilation strategies, medications, and potentially extracorporeal membrane oxygenation.
This document discusses enteral nutrition in preterm neonates. It notes that providing adequate nutrition to preterm infants is challenging due to immaturity of bowel function and inability to suck and swallow. While parenteral nutrition can provide nutrients, lack of enteral intake can impair gut development and function. The document reviews evidence from several Cochrane reviews on different approaches to enteral feeding in preterm infants, finding insufficient evidence to recommend one approach over others and calling for additional large randomized controlled trials to evaluate effects on important outcomes.
This document discusses fluid and electrolyte management in neonates. It outlines the physiological changes in neonates that impact fluid needs, including higher total body water and immature kidney function. It provides guidelines for calculating daily fluid requirements based on gestational age and weight. It describes the use of IV fluids for initial resuscitation and maintenance, adjusting for enteral feedings and weight changes. Conditions requiring IV fluids and formulas for replacing various fluid losses are also summarized.
Surfactant is a natural compound in the lungs that reduces surface tension and prevents alveolar collapse. Surfactant deficiency leads to respiratory distress syndrome (RDS) in premature infants. The document describes Curosurf, a surfactant replacement therapy used to treat RDS via endotracheal instillation, outlining its composition, administration procedures, dosing guidelines, and potential complications.
HIE-Pathophysiology & recent advances in managementViraj Satenahalli
This document discusses hypoxic ischemic encephalopathy (HIE), including its pathophysiology and recent advances in management. It provides details on the brain physiology of newborns, terminology, definition, etiology, pathogenesis through 4 phases, management including hypothermia, and neuroprotective strategies such as maintaining energy stores and growth factors. Hypothermia is highlighted as the most viable neuroprotective strategy, with studies showing it reduces mortality and neurodevelopmental disability in infants with HIE.
Definition of neonatal sepsis,type of neonatal sepsis ,early onset neonatal sepsis,late onset neonatal sepsis,Pathophysiology of neonatal sepsis,,sign and symptoms of neonatal sepsis, diagnosis of neonatal sepsis,management of neonatal sepsis, antibiotic used for neonatal sepsis,prevention of neonatal sepsis, prognosis of neonatal sepsis ,and A summary
Fluid and electrolyte management in neonates. By Dr Rabab Hashemmohamed osama hussein
Fluid and electrolyte management is important in neonates as their kidneys are not well equipped to handle imbalances. Proper assessment of an infant's fluid status and ongoing losses is needed to determine the appropriate amount and composition of intravenous fluids. Neonates have high total body water at birth that decreases rapidly. They also have relatively large surface areas and high insensible water losses. Careful monitoring of weight, clinical signs, lab values, and fluid intake/output is necessary to avoid issues like hyponatremia and hypernatremia. Electrolyte requirements vary based on gestational age and postnatal age. Conditions like prematurity, respiratory distress, or renal impairment require special consideration in fluid and electrolyte
This document discusses thyroid disorders in newborns. It covers thyroid physiology in the fetus and newborn, causes of congenital hypothyroidism including thyroid dysgenesis and dyshormonogenesis, clinical features of hypothyroidism, and methods for screening and diagnosis of congenital hypothyroidism in newborns. It also addresses transient hypothyroidism, sick euthyroid syndrome, and the importance of newborn screening to detect congenital hypothyroidism.
This document describes the case of a 10-day-old infant presenting with signs of shock including tachycardia, poor perfusion, and decreased urine output. Examinations revealed hepatomegaly and other signs suggestive of shock. Investigations showed metabolic acidosis and low blood sugar. The infant did not respond to initial fluid resuscitation and inotropic support. Echocardiogram revealed hypoplastic left heart syndrome. Prostaglandin E1 was started and the infant responded, confirming duct-dependent systemic circulation. The case highlights the importance of early recognition and management of neonatal shock.
A preterm newborn developed respiratory distress soon after birth, with signs including grunting and cyanosis. Evaluation found respiratory distress syndrome (RDS). The baby was treated with nasal CPAP, surfactant, and mechanical ventilation. RDS is caused by surfactant deficiency in premature infants, resulting in alveolar collapse and impaired gas exchange. Management includes respiratory support, surfactant replacement therapy, and care to prevent complications.
This baby needs prostaglandin infusion urgently.
The chest X-ray shows oligemic lung fields suggesting decreased pulmonary blood flow. The clinical features of cyanosis, tachycardia, weak pulses and metabolic acidosis point towards ductal dependant circulation.
Prostaglandin infusion will help open the ductus arteriosus and improve pulmonary blood flow which is critical for survival in this neonate. Ventilator support, inotropes and antibiotics/antifungals may also be needed. An urgent echocardiogram will help identify the underlying cardiac lesion.
The key is to recognize this is not pneumonia but a ductal dependant cardiac lesion and start prostaglandin without delay.
1) Apparent life-threatening events (ALTEs) are acute changes in infant breathing, color, muscle tone, or responsiveness that are frightening to caregivers but usually resolve spontaneously.
2) Risk factors for ALTEs include prematurity, underlying medical conditions, age under 60 days, suspected child abuse, possible seizures, and recurrent events. Common causes are gastroesophageal reflux, seizures, lung infections, and pertussis.
3) Evaluation of infants presenting with ALTEs aims to identify those at risk of serious underlying conditions or recurrent events requiring intervention. History, physical exam, and targeted testing can identify a diagnosis in many cases to guide management.
Neonatal fluid requirements and specials conditionsRakesh Verma
This document provides an overview of neonatal fluid and electrolyte requirements, including physiological changes affecting balance in fetuses and neonates. It discusses developmental changes in total body water, extracellular and intracellular fluid during gestation and after birth. Maturation of organs like the cardiovascular system and kidneys that regulate fluid compartments is also covered. Guidelines are provided for calculating total fluid needs as well as maintenance, deficit and ongoing loss replacement in both term and preterm infants of different weights. Electrolyte supplementation amounts and choices of IV fluids are also summarized.
This document discusses shock in neonates and neonatal vasoregulation. It begins by defining blood pressure and its components. It then discusses factors that affect blood pressure and the unique features of the neonatal myocardium. It describes the roles of catecholamines and their receptors in relation to blood pressure. The document clarifies terminology around hypotension and shock. It concludes by discussing clinical methods for monitoring systemic hemodynamics in critically ill newborns such as capillary refill time, central-peripheral temperature difference, and blood pressure measurements.
Assessment And Managment Of Critically Ill Child 1Dang Thanh Tuan
This document discusses the paramedic's role in pediatric emergency care. It describes assessing and managing critically ill children using the Pediatric Assessment Triangle to evaluate appearance, work of breathing, and circulation. Case studies demonstrate applying this technique to identify respiratory distress, failure, shock, or brain dysfunction. The document also outlines general pediatric patient management including airway control, fluids, electrical therapy and transport considerations.
This document discusses fluid and electrolyte requirements in newborns. It notes that total body water is divided between intracellular and extracellular spaces, with sodium being the main extracellular ion and potassium the main intracellular ion. Fluid volumes are regulated by sodium and potassium salts in each compartment. Principles of fluid management include maintaining appropriate extracellular fluid volume and osmolality. Factors like gestational age, postnatal age, and weight loss influence fluid needs. Guidelines are provided for initial daily fluid requirements based on birth weight and monitoring fluid status through weight, clinical exam, serum and urine tests.
This document discusses fluid and electrolyte physiology in neonates. It covers developmental changes from intrauterine life through childhood and how this affects total body water, extracellular fluid, and intracellular fluid levels at different ages. It also discusses fluid shifts that occur during labor, delivery, and the postnatal period. Guidelines are provided for estimating insensible water loss and determining intravenous fluid and electrolyte requirements for term and preterm neonates of different gestational ages and weights.
This document provides guidelines for the management of common neonatal emergencies encountered in the emergency department. It outlines the assessment steps, diagnostic workup and initial stabilization measures for respiratory distress, cardiac issues like cyanotic heart disease and supraventricular tachycardia, shock, decreased consciousness, apnea, and various endocrine emergencies including congenital adrenal hyperplasia and thyrotoxicosis. History taking, physical exam focusing on ABCDE, appropriate diagnostic tests and consultation with pediatric specialists are emphasized.
Persistent pulmonary hypertension of the newborn (PPHN) is a major problem in neonatal intensive care units that can lead to death or neurological injury in newborns. It occurs when the pulmonary circulation fails to transition from the high resistance fetal state. Causes include meconium aspiration syndrome, idiopathic PPHN, and pulmonary hypoplasia from conditions like congenital diaphragmatic hernia. Treatment involves optimizing oxygenation and cardiac function along with pulmonary vasodilators like inhaled nitric oxide. Future therapies may include phosphodiesterase inhibitors and prostacyclin analogs to further reduce pulmonary hypertension in newborns.
This document provides guidance on managing a neonate with respiratory distress, including defining the severity, identifying the etiology, initial management with oxygen therapy and supportive care, and the various modes of respiratory support including CPAP, NIV, HHHFNC, IMV, and HFOV. The goal of respiratory support is to optimize oxygenation and ventilation while avoiding lung injury through use of the lowest effective pressures and tidal volumes. Clinical assessment and arterial blood gases are important to monitor the adequacy of respiratory support and make adjustments as needed.
Postnatal growth failure and its preventionMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
Persistent pulmonary hypertension of newborn PPHNChandan Gowda
Persistent pulmonary hypertension of the newborn (PPHN) results from failure of the normal decrease in pulmonary vascular resistance after birth, causing right-to-left shunting of blood and hypoxemia. It can be caused by underdevelopment, maldevelopment, or maladaptation of the pulmonary vasculature. Clinical features include cyanosis and respiratory distress within the first 24 hours of life. Diagnosis involves echocardiography demonstrating elevated pulmonary pressures and responding poorly to oxygen challenges. Treatment aims to reduce PVR through ventilation strategies, medications, and potentially extracorporeal membrane oxygenation.
This document discusses enteral nutrition in preterm neonates. It notes that providing adequate nutrition to preterm infants is challenging due to immaturity of bowel function and inability to suck and swallow. While parenteral nutrition can provide nutrients, lack of enteral intake can impair gut development and function. The document reviews evidence from several Cochrane reviews on different approaches to enteral feeding in preterm infants, finding insufficient evidence to recommend one approach over others and calling for additional large randomized controlled trials to evaluate effects on important outcomes.
This document discusses fluid and electrolyte management in neonates. It outlines the physiological changes in neonates that impact fluid needs, including higher total body water and immature kidney function. It provides guidelines for calculating daily fluid requirements based on gestational age and weight. It describes the use of IV fluids for initial resuscitation and maintenance, adjusting for enteral feedings and weight changes. Conditions requiring IV fluids and formulas for replacing various fluid losses are also summarized.
Surfactant is a natural compound in the lungs that reduces surface tension and prevents alveolar collapse. Surfactant deficiency leads to respiratory distress syndrome (RDS) in premature infants. The document describes Curosurf, a surfactant replacement therapy used to treat RDS via endotracheal instillation, outlining its composition, administration procedures, dosing guidelines, and potential complications.
HIE-Pathophysiology & recent advances in managementViraj Satenahalli
This document discusses hypoxic ischemic encephalopathy (HIE), including its pathophysiology and recent advances in management. It provides details on the brain physiology of newborns, terminology, definition, etiology, pathogenesis through 4 phases, management including hypothermia, and neuroprotective strategies such as maintaining energy stores and growth factors. Hypothermia is highlighted as the most viable neuroprotective strategy, with studies showing it reduces mortality and neurodevelopmental disability in infants with HIE.
Definition of neonatal sepsis,type of neonatal sepsis ,early onset neonatal sepsis,late onset neonatal sepsis,Pathophysiology of neonatal sepsis,,sign and symptoms of neonatal sepsis, diagnosis of neonatal sepsis,management of neonatal sepsis, antibiotic used for neonatal sepsis,prevention of neonatal sepsis, prognosis of neonatal sepsis ,and A summary
Fluid and electrolyte management in neonates. By Dr Rabab Hashemmohamed osama hussein
Fluid and electrolyte management is important in neonates as their kidneys are not well equipped to handle imbalances. Proper assessment of an infant's fluid status and ongoing losses is needed to determine the appropriate amount and composition of intravenous fluids. Neonates have high total body water at birth that decreases rapidly. They also have relatively large surface areas and high insensible water losses. Careful monitoring of weight, clinical signs, lab values, and fluid intake/output is necessary to avoid issues like hyponatremia and hypernatremia. Electrolyte requirements vary based on gestational age and postnatal age. Conditions like prematurity, respiratory distress, or renal impairment require special consideration in fluid and electrolyte
This document discusses thyroid disorders in newborns. It covers thyroid physiology in the fetus and newborn, causes of congenital hypothyroidism including thyroid dysgenesis and dyshormonogenesis, clinical features of hypothyroidism, and methods for screening and diagnosis of congenital hypothyroidism in newborns. It also addresses transient hypothyroidism, sick euthyroid syndrome, and the importance of newborn screening to detect congenital hypothyroidism.
This document describes the case of a 10-day-old infant presenting with signs of shock including tachycardia, poor perfusion, and decreased urine output. Examinations revealed hepatomegaly and other signs suggestive of shock. Investigations showed metabolic acidosis and low blood sugar. The infant did not respond to initial fluid resuscitation and inotropic support. Echocardiogram revealed hypoplastic left heart syndrome. Prostaglandin E1 was started and the infant responded, confirming duct-dependent systemic circulation. The case highlights the importance of early recognition and management of neonatal shock.
A preterm newborn developed respiratory distress soon after birth, with signs including grunting and cyanosis. Evaluation found respiratory distress syndrome (RDS). The baby was treated with nasal CPAP, surfactant, and mechanical ventilation. RDS is caused by surfactant deficiency in premature infants, resulting in alveolar collapse and impaired gas exchange. Management includes respiratory support, surfactant replacement therapy, and care to prevent complications.
This baby needs prostaglandin infusion urgently.
The chest X-ray shows oligemic lung fields suggesting decreased pulmonary blood flow. The clinical features of cyanosis, tachycardia, weak pulses and metabolic acidosis point towards ductal dependant circulation.
Prostaglandin infusion will help open the ductus arteriosus and improve pulmonary blood flow which is critical for survival in this neonate. Ventilator support, inotropes and antibiotics/antifungals may also be needed. An urgent echocardiogram will help identify the underlying cardiac lesion.
The key is to recognize this is not pneumonia but a ductal dependant cardiac lesion and start prostaglandin without delay.
1) Apparent life-threatening events (ALTEs) are acute changes in infant breathing, color, muscle tone, or responsiveness that are frightening to caregivers but usually resolve spontaneously.
2) Risk factors for ALTEs include prematurity, underlying medical conditions, age under 60 days, suspected child abuse, possible seizures, and recurrent events. Common causes are gastroesophageal reflux, seizures, lung infections, and pertussis.
3) Evaluation of infants presenting with ALTEs aims to identify those at risk of serious underlying conditions or recurrent events requiring intervention. History, physical exam, and targeted testing can identify a diagnosis in many cases to guide management.
- A neonate presenting as unwell requires prompt assessment and consideration of serious illnesses like sepsis, congenital heart disease, and metabolic disturbances.
- A structured evaluation of vital signs, history, and physical exam can help identify concerning symptoms suggesting an underlying illness and guide appropriate management and investigations.
- Initial management should include empiric antibiotics, fluid resuscitation if needed, and treatment targeted to the suspected condition while consulting pediatric specialists. Ongoing monitoring is needed until the neonate's condition is stabilized.
This document discusses guidelines for evaluating and managing brief resolved unexplained events (BRUEs), formerly known as apparent life-threatening events (ALTEs), in infants. It outlines criteria for classifying infants as low or high risk based on the characteristics and duration of the event. Low risk BRUEs can often be sent home after education and follow up, while high risk cases may warrant further testing and observation to identify potential underlying causes and ensure safety before discharge. The goal is to prevent over-testing and reduce parental anxiety by distinguishing self-limited from concerning episodes.
1. Pulse oximetry screening involves measuring oxygen saturation levels in newborns to detect critical congenital heart defects.
2. Seven heart defects can be detected including hypoplastic left heart syndrome and transposition of the great arteries.
3. Screening involves measuring pre-ductal and post-ductal saturations, with differences or low levels indicating need for further testing.
Pediatrics History Taking and Physical Examination.pptxAJAY MANDAL
This document outlines the components and steps for taking a pediatric history and conducting a physical examination for newborns, infants, children, and adolescents. It discusses obtaining a thorough history, including chief complaint, history of present illness, review of systems, past medical history, family history, and social history. The document also provides guidance on performing a complete physical exam for newborns, assessing vital signs, appearance, and examining each body system.
The ed as gatekeeper in transitions of care james hoekstra md 1jgillmd
This document discusses the role of the emergency department (ED) as a gatekeeper in transitions of care. It covers several key points:
1) The ED plays an important role in determining whether patients are observed, admitted, or discharged. Risk stratification tools help guide these decisions for conditions like chest pain.
2) The ED communicates patient acuity levels and makes recommendations about observation, medical-surgical floors, intensive care, etc. Information on condition, interventions, and risk scores are important to transmit.
3) Protocol-driven care that begins in the ED can continue on hospital floors, improving outcomes. Guidelines help with conditions like heart attacks and pneumonia.
4) The ED can help
This document discusses prematurity, which is defined as a baby born before 37 weeks of pregnancy. Slightly less than 12% of babies are premature. Prematurity can be caused by maternal health factors, issues with the pregnancy, or fetal factors. Premature babies may experience problems like temperature instability, respiratory issues, and neurological impairments. Treatment for premature babies focuses on stabilizing vital functions, providing nutrition, and addressing any complications until the baby is fully developed. The goals before hospital discharge include resolving illnesses, maintaining stable function, and parental ability to care for the baby. Prenatal care and identifying at-risk mothers can help prevent prematurity.
HIE has been one of the problems facing newborns due to birth asphyxia caused by variety of conditions during child birth or after childbirth, i hope the readers will learn something from the slides
The document discusses the long term effects of bacterial meningitis and sepsis in children. It finds that 50% of children develop new psychopathology like depressive and anxiety disorders following meningococcal disease, with 25% still experiencing issues after a year. Children with more severe illness are at higher risk. It also notes long term physical effects in survivors like scarring, neurological impairments, and reduced cognitive function and academic performance, with meningitis and sepsis having particularly detrimental impacts. Survivors are also at risk for hearing loss, motor deficits, and mental health disorders into adolescence and adulthood.
Dr. Anand Gangadharan discusses the management of neonatal hypoxic ischemic encephalopathy (HIE). Initial management focuses on oxygenation, ventilation, circulation, and correcting metabolic derangements. Hypothermia therapy is the only proven neuroprotective treatment for HIE. Applying whole-body hypothermia at 33.5°C for 72 hours in infants with moderate to severe HIE improves outcomes. Several adjunctive neuroprotective treatments are being studied along with hypothermia but require further clinical trials to establish efficacy and safety.
Dr. Dilraj Singh Sokhi gave a presentation on epilepsy to trainees. He discussed causes like infections, head trauma, and neurocysticercosis. Seizures are classified as focal or generalized. Diagnosis involves a detailed history and physical exam. Treatment involves lifestyle management, medication like phenobarbital or phenytoin, and gradual dose adjustments. The goal is complete seizure control with as few side effects as possible.
Patent Ductus Arteriosus - management in preterm infantsStefan Johansson
15 minute lecture about the What, Why and How questions on PDA management of preterm infants in the NICU.
Held at the Berzelius Symposium "The Cardiac Patient from Birth to Adulthood", 22 February 2019, Stockholm, Sweden.
Clinical profile of paediatric patients with rheumatic heart disease at moi t...Alexander Decker
This document summarizes a study on the clinical profile of pediatric patients with rheumatic heart disease at Moi Teaching and Referral Hospital in Eldoret, Kenya. The study found that the most common symptoms in new patients were dyspnea, easy fatigability, palpitations, cough and orthopnea. The most common signs were systolic murmurs, thrills and tachycardia. Most new patients presented with severe disease in NYHA class 3 or 4. Mitral regurgitation alone or combined with aortic regurgitation were the most common valve lesions. The results suggest that most new patients have advanced valvular disease and complications due to late presentation, highlighting the need for early detection
Clinical profile of paediatric patients with rheumatic heart disease at moi t...Alexander Decker
This document summarizes a study on the clinical profile of pediatric patients with rheumatic heart disease at Moi Teaching and Referral Hospital in Eldoret, Kenya. The study found that 84 pediatric patients had rheumatic heart disease, with more female patients than male. New patients most commonly presented with dyspnea, easy fatigability, and palpitations. Signs like systolic murmurs and tachycardia were also common in new patients. Most new patients were in NYHA classes 3 and 4, indicating severe valvular disease and late presentation. The study recommends emphasis on early detection and prevention of rheumatic heart disease.
This document provides guidance on evaluating and managing critically ill pediatric patients in the emergency department. It discusses:
1) Using the Pediatric Assessment Triangle (PAT) model to rapidly assess patients, focusing on appearance, work of breathing, and circulation.
2) Age-specific vital sign ranges that are important to consider.
3) Common causes of respiratory failure, shock, and cardiopulmonary arrest in pediatric patients.
4) The importance of anticipating deterioration and having rapid vascular access for fluid resuscitation or medications when needed.
This case discusses the management of a 2-year-old boy presenting with new onset seizures and a fever of 104F. After examination, the most likely diagnosis is simple febrile seizure given his age, normal development, family history of seizures, and generalized tonic-clonic seizure in the setting of fever. The management involves identifying the cause of fever, no long-term anticonvulsant therapy is needed, and parental counseling on the generally good prognosis despite risk of recurrence during future fevers.
Similar to Neonatal presentations to Emergency department.pptx (20)
This document provides guidance on approaches to pediatric emergencies and assessments. It emphasizes gaining the child's trust and cooperation through gentle, honest communication. Exams should involve the parent and avoid causing pain until the child is comfortable. Injuries are often due to accidents, but abuse requires a careful exam and history that is inconsistent with the reported events.
Examination in paediatric Medicine for medical students.pptxVarsha Shah
This document provides guidance on examining pediatric patients. It emphasizes establishing rapport, keeping exams non-threatening, and tailoring the approach based on a child's age and development. Key points include observing the child first before interacting, explaining procedures, using distraction, and examining painful areas last. Practice is emphasized to improve skills in communication, examination techniques, and handling different age groups in a developmentally-appropriate manner. The goal is to make exams as comfortable as possible for children.
Approach to thalassemia with abdominal distension in childrenVarsha Shah
1. Siti, a 7-year-old girl from Indonesia, has been diagnosed with beta-thalassemia major requiring regular blood transfusions over the past 4 years.
2. During a recent clinic visit, her hemoglobin level was 10 g/dL but her serum iron level was elevated at 150 microg/L, indicating potential iron toxicity from chronic transfusions.
3. Common complications of beta-thalassemia major and lifelong transfusions include organ damage from iron overload, as well as infectious risks from transfused blood. Treatment focuses on maintaining hemoglobin levels while preventing iron toxicity.
This document discusses jaundice in infants and neonatal cholestasis. Neonatal cholestasis is defined as conjugated hyperbilirubinemia occurring in newborns due to diminished bile flow. Clinical presentations include prolonged jaundice, acholic stool, dark urine, hepatomegaly, and bronze discoloration of the body after phototherapy. Treatment involves continuing breastfeeding with MCT supplement if needed, vitamin supplements, surgical procedures like Kasai surgery or liver transplantation depending on the severity and cause of cholestasis. The key points are to promptly refer newborns with prolonged jaundice and dark urine for investigation and to perform surgery for conditions like biliary atresia before
Approach to Cafe au lait spots in childrenVarsha Shah
This document provides guidance on evaluating and monitoring children with neurocutaneous syndromes and café au lait spots. It discusses several neurocutaneous disorders including neurofibromatosis types 1 and 2, tuberous sclerosis, ataxia telangiectasia, and others. For children presenting with café au lait spots, the provider should consider neurofibromatosis type 1 and monitor for diagnostic criteria such as additional café au lait spots, skinfold freckling, neurofibromas, Lisch nodules, and skeletal or ocular abnormalities. Regular examinations are recommended to monitor for signs of NF1 and potential complications.
Mcq in neonatology for medical studentsVarsha Shah
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1. True
2. True
3. False
4. True
5. False
6. e. Tonsillitis
7. e. Infertility
8. c. Higher cost to feed a lactating mother
9. f. No free sponsorship from pharma, samples of formula and less earnings for hospital
10. d. Mother can do house works, can take care of sibling and save money
11. c. Causes high incidence of jaundice
12. e. All of the above
13. a. Exclusive breast feeding till 6 month
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2. Neonatal presentations to
Emergency Department
Summary of presentation:
1. Background
2. Factors associated with Ed attendance among
children included
3. Commonest neonatal presentations to ED
4. Singapore data
5. THE MISFITS-Acronym
6. Conclusions
7. CME-MCQ quiz
3. Background:
ED attendances by neonates (≤28 days old) are rising
disproportionately quicker than older infants
With shorter postpartum hospital stays, most of babies are
discharges after 24 hours in normal vaginal delivery of 72 hours in
LSCS
Many medical concerns, which traditionally have been managed in
newborn nurseries, are presenting to the emergency department
(ED)
Emergency Departments (ED) are under increasing pressure, with
rising attendances and admission rates
Neonates present a challenge due to their non-specific
presentations
Parents may preferentially bring their children to the ED, even for
non-urgent problems
The reasons are parental anxiety, perceived advantages of Eds
(resources and expertise), and convenience
4. You are on call MO in
SGH Emergency on
busy day on Sunday
Newborn well baby born to
LSCS mother,
was discharged on D3 of life
on Saturday, with TCB of 192,
was given routine NNJ advice
to visit ED for repeat TCB next
day.
Presented to ED on busy
Sunday afternoon for routine
TCB check
5. Questions are:
1. Mother with LSCS,
was waiting in
crowded ED next
day, for routine
check of TCB in
crowded ED?
2. Is its appropriate
use of resources?
3. Can they be better
managed at 24 hours
GP clinic?
4. Any other options?
6. Case 2: Another
extreme:
2 months old
Exprem, who was
discharged 3 days
ago, was found
lifeless with vomited
blood in bed,
sleeping with
mother, was brought
to ED by ambulance
7. Questions is
1. Will ED will have enough time to attend
to actual real emergency cases?
2. Is adult ED equipped
and trained with managing such neonates?
2.Is it better to bring them to nearest
Children’s Emergency dept?
8.
9. Daily attendance figures include all patients
who are presented at the EMD regardless of
urgency of medical conditions
10. Singaporean
context
Unfortunately the most relevant SG
paper on Neonatal presentations to ED is
not specific to Neonates (classified as <
3 years)
+ the paper focusses on reattendances,
not attendances
“The patient’s age was found to be
inversely proportional to the
reattendance rate at our ED, consistent
with preceding studies”
Unplanned reattendances at the paediatric
emergency department within 72 hours: a
one-year experience in KKH
- Goh G.L et al, SMJ 2016
11. CGH ED study
-Odds of emergency
attendance in children and
is inversely proportional to
the age of the attendees
Odds were 13 times more
for <10 years than even >
70 years old
12. Some factors that were reported to be
associated with Ed attendance among
children included
Societal/Community:
1. The lack of a continuous relationship with PCPs
2. Caregivers overestimating the severity of their
children’s illness
3. Caregivers having had prior experience of being
taken to the ED as children
4. Being a single parent with no other adults living
in the household
5. Availability of after-hour care offered by the ED
6. Mistrust of the PCP’s ability to manage
paediatric conditions
13. Factors associated with Ed attendance
among children included
Parental
Parental anxiety
Perception of convenience, perceived resources
and expertise
Believing the problem was more appropriate for
or might require tests in the emergency
department
Feeling that the care provider would refer the
baby to emergency department anyway
14. Some factors that were reported to be
associated with Ed attendance among
children included
Neonates
Neonates exhibit non-specific symptoms with serious
conditions
Parental anxiety, lack of confidence, education,
experience
Following discharge advice from nurses/doctors
Most are born at term, never separated from their mother
and discharged within 48 hours of birth
Assessment of neonates is challenging
A vulnerable and high-risk cohort
15. 1st
problem:
UK: ED attendances by neonates
are rising disproportionately
quicker than older infants
In Europe and North America up to
one-third of neonates attending
EDs have no medical issue, and a
high proportion have low acuity
problems requiring no medical
investigation or treatment
16. Why act?
EDs are suboptimal environments for assessing
well neonates
Potential over-investigation & treatment
Potentially modifiable group of patients whose
problems can be managed away from the ED
Reducing ED attendances for neonates with benign
conditions may benefit patients, families, and
healthcare systems
21. Most common Diagnoses
More than half “No significant medical problem”
Bronchiolitis
?Sepsis
22. Common Neonatal Emergencies
Acronym- The Misfits
THE MISFITS
T- Trauma (accidental nonaccidental)
H- Heart Disease/Hypovolemia/Hypoxia
E- Endocrine (congenital adrenal hyperplasia,
thyrotoxicosis)
M- Metabolic (electrolyte imbalance)
I- Inborn Errors of Metabolism metabolic
emergencies
S- Sepsis (meningitis, pneumonia, UTI)
F- Formula mishaps (under or over dilution)
I- Intestinal catastrophes (volvulus,
intussusception, NEC
T- Toxins/poisons
S- Seizures
23. Trauma (accidental non-accidental)
May be a difficult process
Non-accidental? subtle historical findings and no
physical exam findings
Presenting symptoms may be nonspecific
Early diagnosis of an occult head injury may
prevent significant long-term morbidity
An ALTE is often an unrecognized presenting
symptom of abusive head injuries
24. Trauma (accidental non-
accidental)
Infants with ALTE w/o an immediate obvious cause
should be evaluated for head trauma with
neuroimaging
CT scan, HUS or MRI
Skull x-rays may not be helpful- significant head
injury w/o skull fracture
Consider neuroimaging in any non-accidental
injury for other skeletal injuries regardless of
physical examination of the head
25. Trauma(accidental non-
accidental)
37 of abused children lt 2 y/o had an occult traumatic injury
In addition, the ophthalmologic evaluation did not demonstrate retinal
hemorrhages in most of the patients
26. Trauma(accidental non-accidental)
Management
Evaluation and stabilization of the ABCs
Bedside glucose evaluation
Appropriate temperature regulation
If bruising or known intracranial bleed
CBC
Platelet count
PT/PTT
Neuroimaging after stabilization
29. Heart Disease and Hypoxia
Cyanotic Heart Disease
Terrible Ts
Transposition of the great arteries (TGA)
Tetralogy of Fallot (TOF)
Tricuspid atresia (TA)
Total anomalous pulmonary venous return (TAPVR)
Truncus arteriosus (TA)
30. Heart Disease and Hypoxia
Cyanotic Heart Disease
• May not be detected at birth
• Adequately oxygenated blood ? PDA ? systemic
circulation
• PDA functionally closes in the first 10-14 hrs of
life
• Several factors can delay its closure
• Prematurity
• Respiratory distress
• Acidosis
• Hypoxia
31. Heart Disease and Hypoxia
Cyanotic Heart Disease
PDA is anatomically closed by 2 weeks of age,
contributing to a delayed detection of cyanotic
heart disease
100 FiO2
Non-cardiac disease
At least 10 increase in O2 saturation
Cyanotic heart disease
Minimal change in O2 saturation
32. Heart Disease and Hypoxia
Cyanotic Heart Disease
• PDA is anatomically closed by 2 weeks of age,
Hyperoxia test
• Initial ABG on R/A
• Repeat ABG after 10-20 minutes of 100 O2
• Cyanotic heart disease? PaO2 will not increase
significantly
• If PaO2 rises above 150 mm Hg, cardiac disease
can generally be excluded
• Failure of PaO2 to rise above 150 mm Hg suggests
a cyanotic cardiac malformation
33. Heart Disease and Hypoxia
Cyanotic Heart Disease
During stabilization, the physical exam should
include 4 limb BP and careful
cardiac exam
A murmur may be audible
Absence of a murmur does not exclude a cardiac
defect
CXR EKG should be included in the evaluation
ECHO is diagnostic
34. Heart Disease and Hypoxia
Cyanotic Heart Disease
Management
PGE1
Bolus of 0.05 mcg/Kg IV
Drip of 0.05-0.1 mcg/Kg/min
Secure airway
Profound apnea is a non-dose dependent
complication of PGE1
35. Hypoplastic Left Heart Syndrome
25 of cardiac deaths during first week of life
Occurs in both cyanotic and acyanotic forms
In 15 of cases the FO is intact preventing
mixing at the atrial level
Infants with mixing at the atrial level are
acyanotic
37. Hypoplastic Left Heart Syndrome
EKG
Small or absent (L) ventricular forces
CXR
Moderate cardiomegaly
Large PA shadow
ECHO
Small or slit-like (L) ventricle
Hypoplastic ascending aorta
38. Hypoplastic Left Heart Syndrome-
Treatment
PGE1- systemic blood flow is ductal dependent
Surgical correction
Surgical correction
1st stage
Norwood procedure
2nd stage
Fontan procedure
Neonatal cardiac transplantation
Compassionate care may be appropriate in some
instances
39. Acyanotic Heart Disease-
Congestive Heart Failure
Typically presents with symptoms of CHF
Tachypnea
Tachycardia
Hepatomegaly
History of poor or slow feeding
Sweating or color change with feeding
Poor weight gain
More gradual clinical decompensation
May not present until after the first 2-3 weeks
of age
41. Acyanotic Heart Disease
Congestive Heart Failure
Initial management
Stabilization of the ABCs
CXR
EKG
Labs
FBC
BMP
ABG
ECHO- diagnostic of heart defect
Furosemide-1 mg/Kg IV
42. Acyanotic Heart Disease
Congestive Heart Failure
Pressors
Dopamine
5-15 mcg/Kg/min IV
Dobutamine
2.5-15 mcg/Kg/min IV
Careful with fluid overloading
Peds. Cardiology consult
43. Acyanotic Heart Disease-
Supraventricular Tachycardia
Acyanotic Heart Disease
SVT is the most common neonatal dysrhythmia
(1/25,000 births)
Signs/symptoms
Tachycardia
Poor feeding
Irritability
Heart Failure
Shock
Heart rate sustained at gt220 bpm with a QRS lt 0.08
seconds
44. Acyanotic Heart Disease-
Supraventricular Tachycardia
Management
Stable patient
Vagal manoeuvres
Ice to face avoiding the nares
If unsuccessful
Adenosine
50 mcg/Kg rapid IVP (1-2 secs.), increase dose in
50mcg/Kg increments Q2 mins. until return of
sinus rhythm, maximum dose 250 mcg/Kg
45. Acyanotic Heart Disease-
Supraventricular Tachycardia
Management
Unstable patient w/o IV access
Synchronized cardioversion- 0.5-1 J/Kg
Initial cardioversion should be attempted
pharmacologically if IV access is established and
adenosine is readily available
If unresponsive to adenosine cardioversion
Amiodorone- 5mg/Kg IV over 30-60 mins.
46. Acyanotic Heart Disease-
Supraventricular Tachycardia
Procainamide- alternative to amiodorone- 15 mg/Kg IV over 30-60
mins.
The administration of procainamide and amiodorone
together can lead to hypotension and widening of
the QRS complex
Lidocaine- 1mg/Kg IV
Final option for a wide QRS and should only be
used in consultation with a pediatric cardiologist
47. Acyanotic Heart Disease-
Supraventricular Tachycardia
12-lead EKG prior to and after conversion from
SVT to NSR
Useful diagnostic tool for the cardiologists to
help determine further management
Consult pediatric cardiologist for further
evaluation
48. Heart Disease and Hypoxia
Bronchiolitis- Viral
lower-airway disease caused by RSV 80 of
the time
Other etiologies include adenovirus,
influenza,
or parainfluenza
RSV is responsible for 50-90 of bronchiolitis
hospital admissions
More common in winter and spring seasons,
may
present at any time
49. Heart Disease and Hypoxia
Bronchiolitis- Viral
Signs/Symptoms
Rhinorrhea
Cough
Congestion
Wheezing
Significant respiratory distress
Apnea may be the only initial symptom
50. Heart Disease and Hypoxia
Bronchiolitis- Viral
Management
Infants with severe, prolonged apnea with
bradycardia unresponsive to O2 therapy may need
intubation
Nebulized racemic epinephrine
or
Beta-agonist
The adjunct use of corticosteroids has not been
shown to improve symptoms
A fever or sepsis evaluation may be part of the
management
51. Heart Disease and Hypoxia
Bronchiolitis- Viral
Management
Controversy over the incidence of severe
bacterial infections in infants who have RSV
The presence of a viral infection doesnt exclude
the possibility of a concomitant UTI
Consider hospitalization for all RSV() neonates,
especially preemies or all neonates with other
comorbidities
52. Heart Disease and Hypoxia
Apnea/ALTE
Apnea
cessation of respiration for 20 secs. or more, associated
with color change (cyanosis or pallor) or bradycardia
ALTE
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
53. Heart Disease and Hypoxia
Apnea/ALTE
Management depends on history provided by
observers and PE
Hospitalization for observation and monitoring
Common differential diagnosis
Sepsis
Pneumonia
RSV
Hypothermia
Anemia
55. Endocrine Emergencies
Congenital Adrenal Hyperplasia
Most patients diagnosed by newborn screening
Occasionally diagnosis is missed because of
inadequate blood sample, laboratory error, or
inability to contact the family
56. Endocrine Emergencies
Congenital Adrenal Hyperplasia
Autosomal recessive
Most common is 21-hydroxylase deficiency- 95 of
affected patients
Inadequate cortisol levels
Excessive ACTH stimulation
Adrenal hyperplasia
Excessive production of adrenal androgens and
testosterone
? virilization
57. Endocrine Emergencies
Congenital Adrenal Hyperplasia
Two forms
• Virilizing form
• Relative aldosterone deficiency
• Mild salt loss
• Adrenal insufficiency tends not to occur unless
under stressful situations
• Salt-losing form
• Absolute aldosterone deficiency
• Adrenal insufficiency under basal conditions
• Manifests in the neonatal period or soon after as
an adrenal crisis
58. Endocrine Emergencies
Congenital Adrenal Hyperplasia
11- hydroxylase deficiency
Less common- 5-8 of cases
Salt retention
Volume expansion
Hypertension
62. Endocrine Emergencies
Thyrotoxicosis
Hypermetabolic state resulting from excessive
thyroid hormone activity in the newborn
Usually results from transplacental passage of
thyroid-stimulating immunoglobulin from a mother
with Graves disease
Rare disorder
Occurs in 1/70 thyrotoxic pregnancies
Incidence of maternal thyrotoxicosis in pregnancy
is 1-2/1000 pregnancies
63. Endocrine Emergencies
Thyrotoxicosis
Clinical presentation
Fetal tachycardia in the 3rd trimester may be the
first manifestation
Signs usually apparent within hours from birth
If mother is on antithyroid medications
presentation may be delayed 2-10 days
Thyrotoxic signs
Irritability
Tachycardia
Flushing
Tremor
Poor weight gain
Trombocytopenia
Arrhythmias
64. Endocrine Emergencies
Thyrotoxicosis
Initial diagnosis difficult w/o clear history of
Graves disease from mother
Goiter usually present ? tracheal compression
Labs
Increased T4, FT4 T3
Suppressed levels of TSH
Treatment
Mild
Close observation
65. Endocrine Emergencies
Thyrotoxicosis
Moderate
Lugols solution (iodine)- 1 drop PO Q8H
Propylthiouracil- 5-10mg/Kg/day in 3 divided doses
Methimazole- 0.5-1mg/Kg/day in 3 divided doses
Severe
In addition to above meds
Prednisone- 2mg/Kg/day
Propranolol for tachycardia- 1-2mg/Kg/day in 2-4 divided doses
Digitalis may be used to prevent cardiovascular collapse
69. Inborn Errors of Metabolism
Carbohydrate metabolism defects
Galactosemia
Fructose-1,6-biphosphatase deficiency
Glycogen storage diseases (types IA. IB, II, III
and IV)
Hereditary fructose intolerance
70. Inborn Errors of Metabolism
Fatty acid oxidation defects
Short chain acyl-CoA dehydrogenase deficiency
(SCAD)
Medium chain acyl-CoA dehydrogenase deficiency
(MCAD)
Most common (incidence of 1/6,000-10,000)
Long chain acyl-CoA dehydrogenase deficiency
(LCAD)
Acyl-CoA deficiency
71. Inborn Errors of Metabolism-
Metabolic Emergencies
Often have a delayed diagnosis
Symptoms may be unrecognized because they are
uncommon
Require a high level of suspicion for diagnosis
Diagnosis should be considered in any infant who
does not have any other obvious cause for symptoms
73. Inborn Errors of Metabolism-
Metabolic Emergencies
More apparent symptoms
Seizures
Lethargy
Hypoglycemia
Apnea
Temperature instability
Acidosis
74. Inborn Errors of Metabolism-
Metabolic Emergencies
Labs
Bedside glucose
FBC
Basic metabolic panel (BMP)-UECr, Blood sugar, CaPo4
pH
Lactate and ammonia levels
LFTs
Urine for reducing substances and ketones
Blood and urine for organic and amino acids
75. Inborn Errors of Metabolism-
Metabolic Emergencies
Management
Fluid resuscitation
IV dextrose to prevent further catabolism
Admission to hospital
Genetics consultation
76. Sepsis
• It is standard of care to complete a full sepsis
workup (FBC, blood culture, urinalysis, urine
culture, CSF culture and analysis, CXR) in a
neonate with a rectal temperature of 38 C
77. Sepsis
The use of peripheral WBC count is not
helpful to differentiate febrile neonates with a
more serious bacterial infection from those
w/o
serious bacterial infection
One study demonstrated that a low peripheral
WBC count increased the odds of bacterial
meningitis
78. Sepsis
• The urinalysis may be unremarkable in infants
with a culture () UTI
• Approximately 14 of febrile neonates will be
diagnosed with a UTI
• Pediatrics 2000
• McKay Memorial Hospital in Taiwan
• CRP, ESR and U/A imperfect tools in
discriminating for UTI
79. Sepsis
Broad spectrum antibiotics
Ampicillin
50-100mg/Kg IV
Gentamicin
2mg/Kg IV
or
Cefotaxime
50-100mg/Kg IV
Acyclovir
20mg/Kg IV
80. Sepsis
Neonatal herpes
• Symptoms may be subtle
• No maternal history in 60-80 of women with
unrecognized infection
• Early recognition and treatment with acyclovir
may decrease mortality from 90 ? 31
• Initiate treatment in any infant with
• High fever
• CSF lymphocytosis
• Numerous RBCs in an atraumatic spinal tap
• Seizures
• Known maternal history of HSV infection
82. Formula Mishaps
Inappropriate mixing of water and powder formula
Overdilution of concentrated liquid or premixed formula
Life-threatening electrolyte disturbances or FTT
Hyponatremia
Seizures
83. Intestinal Catastrophes
Consider pathologic process if vomiting in
newborn period
Difficult to differentiate between a
life-threatening cause from a mild viral
gastroenteritis or even severe gatroesophageal
reflux
Initial symptoms may be nonspecific
Bilious emesis is almost always an ominous sign
Initiate pediatric surgery consultation
84. Intestinal Catastrophes-
Malrotation with Midgut Volvulus
• Abnormal rotation of bowel in utero resulting in
an unfixed portion of bowel that may later twist
on itself ? bowel ischemia ? death
• Incidence of 1/5,000 live births
• Usually diagnosed in the first month of life
86. Intestinal Catastrophes- Malrotation
with Midgut Volvulus
• KUBs-Normal
• Signs of small bowel obstruction
• Upper GI series is the gold standard for
diagnosis
• Transverse portion of the duodenum leading to a
fixed ligament of Treitz
87. Intestinal Catastrophes-
Toxic Megacolon
Life-threatening presentation of a patient with
Hirschsprung's disease
Hirschsprung's disease occurs in 1/5,000 live
births
May be unrecognized because constipation is
common and usually benign
History of constipation with failure to pass
meconium in the first 24 hours of life is highly
suspicious of Hirschprungs
89. Intestinal Catastrophes-
Toxic Megacolon
Management
• Stabilization of ABCs
• Fluid resuscitation
• Broad-spectrum antibiotics
• KUB
• Enlarged or dilated section of colon
• Surgical consultation
• Pediatric critical care management in the
presence of enterocolitis
90. Intestinal Catastrophes-
Necrotizing Enterocolitis
Classically a disease of premature infants
May occasionally occur in term neonates after
discharge from WBN
Symptoms like those of Hirschsprung's
enterocolitis
92. Intestinal Catastrophes-
Hypertrophic Pyloric Stenosis
• Common, incidence of 1/250 live births
• Male/female ratio 4/1
• More common in firstborn male
• Classic metabolic abnormality of hypochloremic,
hypokalemic metabolic alkalosis- now uncommon
• History of nonbilious projectile emesis
immediately after feeding
93. Intestinal Catastrophes-
Hypertrophic Pyloric Stenosis
Increased incidence in infants with an early
exposure to oral erythromycin
PE
Palpable olive structure in the RUQ
Visible peristaltic waves
Diagnosis
USG
Thickened and lengthened pylorus
Upper GI
String sign
94. Intestinal Catastrophes-
Hypertrophic Pyloric Stenosis
Management
Surgical is standard
IV atropine followed by oral atropine shows
satisfactory results
Stabilization and IV access to replace fluids and
electrolytes
Osaka, Japan
Archives of Disease in Childhood 2002
89 resolution of projectile vomiting with
reduced pyloric muscle thickness
95. Toxins
Toxic ingestions are uncommon
Occasionally the result of a maternal ingestion
in a breastfeeding mother, homeopathic remedies,
or overuse of accepted medications
Teething gels may be used for the relief of colic
Benzocaine
Methemoglobinemia with overuse
96. Toxins
Star anise tea
Relief of infantile colic
Neurotoxicity
Unexplained irritability
Vomiting
Seizures
Baking soda
Used for intestinal gas
Serious toxicity
Hospitalization for monitoring and observation
97. Seizures
May be difficult to diagnose
Not acting right
More somnolent than usual
Immature cortical development
May not be tonic-clonic
Commonly
Lip-smacking
Abnormal eye or tongue movements
Pedaling
Apnea
98. Seizures
Common causes of neonatal seizures
1st day of life
Anoxia/hypoxia
Trauma
Intracranial haemorrhage
Drugs
Infection
Hypoglycaemia/hyperglycaemia
Pyridoxine deficiency
99. Seizures
2nd day of life
Sepsis
Trauma
Inborn errors of metabolism
Hypoglycaemia
Hypocalcaemia
Hyponatremia/hypernatremia
Hyperphosphatemia
Drug withdrawal
Congenital anomalies or developmental brain
disorders
Benign familial neonatal seizures
100. Seizures
Day 4 to 6 months of age
Hypocalcaemia
Infection
Hyponatremia/hypernatremia
Drug withdrawal
Inborn errors of metabolism
Hyperphosphatemia
Congenital anomalies or developmental brain
disorders
Hypertension
Benign idiopathic neonatal seizures
101. Seizures
Management
Stabilization of ABCs
Labs
Bedside glucose level
Immediate correction of hypoglycemia (lt40mg/dL)
with 2-4mL/Kg D10W may be necessary
Serum electrolytes
CBC
Blood CS
LFTs
102. Seizures
Because 5-10 of neonatal seizures are of
infectious etiology, full sepsis work-up
should be performed when patient is
stable
103. Seizures
Management
• Phenobarbital
• Loading dose 20mg/Kg slow IV push over 10-15
mins, additional 5mg/Kg doses up to 40mg/Kg
• Maintenance of 3-4mg/Kg/day, 12-24 hours after
loading dose
104. Seizures
Phenytoin
• Loading dose of 15-20mg/Kg IV over 30 minutes
• Maintenance dose of 4-8mg/Kg IV slow push or PO
• Highly unstable in IV solutions
• Avoid using in central lines because of risk of
precipitation
• IM not an option- crystallizes in muscle
Lorazepam - 0.05-0.1mg/Kg slow IV
• Repeat doses (2-3 times) based on clinical
response-
105. Seizures
Correct serum electrolyte abnormalities
More common
Hyponatremia (lt125mg/Kg)
5-10mL/Kg IV 3 saline solution
Hypocalcaemia (lt7mg/dL)
100-300mg/Kg IV of calcium gluconate
106. Seizures
Immediately start broad-spectrum
antibiotics and acyclovir
Neuroimaging once patient is
stabilized
Admit to hospital for completion of
evaluation and monitoring
107. Conclusion
The mnemonic THE MISFITS
Is a helpful tool
Can be readily used to
formulate an approach to
the most common neonatal
emergencies
108. Interventions & Outcomes in
ED
Most needed only reassurance and advice,
no medication
Of those Discharged from ED, only 1/3
needed investigations
More than half get discharged from ED
109. Alternatives/solutions
24-hour clinics
Walk-in clinic with paediatric specialist
Teleconsultation
24-hour telephone advice from pediatric nurse/Doctor
Easier access to paediatricians
Training GPs for community paediatrics
Postnatal home visit by nurse or doctor
Reading material provided during the birth hospital stay
Information on the Internet
information in newspapers/ magazines or on television/radio
115. Past Medical History
Antenatal and Obstetric history: fetal ultrasound
scans, Hx of miscarriage/NND
Perinatal history: Term, PPROM/pyrexia, GBS status,
Liquor, Delivery
Post natal course: Screening bloods, Blood groups,
G6PDD, medications, interventions, weight on
discharge
116. Clinical Presentation of septic neonates
Temperature Hyperthermia (more common in full
term infant)
Irregularity Hypothermia (more common than fever
in Pret
Skin Poor peripheral perfusion, cyanosis,
pallor, petechial, rashes
Gastrointestinal problems Feeding intolerance, vomiting,
diarrhea, or abdominal distention with
or without visible bowel loops
Cardiopulmonary Tachypnea, respiratory distress, apnea,
tachycardia and hypotension
Metabolic Hypoglycaemia, hyperglycaemia, or
metabolic acidosis
Focal infections Cellulitis, omphalitis, conjunctivitis,
otitis media or osteomyelitis
117. The patient
“The norm”:
Age — Young neonates (< 10 days old) who
present to the ED have a particularly high
incidence of serious illness, with 10% to 33%
requiring hospital admission.
Feeds: type, quality and quantity
Diaper output
Weight
118. Feeding history
Frequency and quality of breastfeeding
How often and how much formula the bottle-fed infants
are receiving
Frequency of stool and urination
Check the weight of the neonate, a normal 10%
of weight loss in the first week is normal
Regain birth weight at day 10-14
Newborn gains 20-30 g per d
119. Presenting complaint: The
many faces of Sepsis
Mostly subtle!
Lethargy, irritability, and decreased oral intake
Vomiting, diarrhea, temperature instability,
abdominal distention or ileus, apnea, tachypnea,
cyanosis, pallor, petechial and poor perfusion
Look for the sources of infection
Omphalitis
120. A two-day-old infant presents to the
emergency department with fever, poor
feeding, and irritability. She was born at
home at 38 weeks gestation. Which of
the following is the most likely pathogen
associated with early neonatal sepsis?
A) Enterococcus
B) Group B Streptococcus
C) Listeria monocytogenes
D) Staphylococcus aureus
MCQ time!
121. Physical exam
Evaluation of neonatal size, weight
Vital signs as heart rate, respiratory rate, oxygen
saturation level and temperature
Pediatric Assessment triangle (PAT) provides an
accurate method for rapid assessment of any child
or infant with an emergency condition, through
visual and auditory evaluation of the infant’s
appearance, work of breathing and circulation to
skin
122.
123. The Pediatric
Assessment
Triangle
Rapid
Global assessment tool
Use visual and auditory clues
Three key domains:
-appearance
-work of breathing
-circulation to the skin.
The combination of
abnormalities determines the
category of pathophysiology
Respiratory distress,
respiratory failure, CNS or
metabolic problem, shock, or
cardiopulmonary failure
124. The Pediatric Assessment
Triangle – Appearance- ‘TICLS’
Tone – the newborn should have a normal flexed tone; the 6-
month-old baby who sits up and controls her head; the toddler
cruises around the room.
Interactiveness – Does the 2-month-old have a social smile? Is the
toddler interested in what is going on in the room?
Consolability – A child who cannot be consoled at some point by
his mother is experiencing a medical emergency until proven
otherwise.
Look/gaze – Does the child track or fix his gaze on you, or is
there the “1000-yard stare”?
Speech/cry – A vigorously crying baby can be a good sign, when
consolable – when the cry is high-pitched, blood-curling, or even
a soft whimper, something is wrong.
125. The Pediatric Assessment
Triangle- Work of Breathing
Symptom of breathlessness
Look for nasal flaring, retractions, abnormal positioning, like
tripodding, or head bobbing
Listen – even without a stethoscope – for abnormal airway sounds
like grunting or stridor.
Grunting is the child’s last-ditch effort to produce auto-PEEP.
Stridor is a sign of critical upper airway narrowing.
126. The Pediatric Assessment
Triangle -Circulation to the skin
Infants and children are vasospastic
they can change their vascular tone quickly (depend on
volume status or environment)
Without even having to touch the child, you can see signs of:
-pallor,
-cyanosis,
-mottling.
If any of these is present, this is an abnormal circulation to
the skin.
127. Assessment of ABC- Airway,
Breathing, Circulation
Assessing the work of breathing and the respiratory rate
A minute of observation or auscultation: assess the
respiratory rate and perceive the clinical signs of
difficulty in breathing.
Presence of congenital heart disease: tachypnoea,
tachycardia, acrocyanosis, poor to absent peripheral
pulses and breathing difficulties, cardiac murmer
Circulation and hydration: Capillary refill time is helpful
and should be less than 2-3 seconds.
Hypotension is a late finding of shock; therefore
Tachycardia must be taken seriously in the ill child
129. A limited neurological
examination in Neonates
Evaluation of cry, tone, activity, cranial nerves, sensation
Primitive reflexes
-Common primitive reflexes as rooting reflex, walking reflex, tonic
neck reflex, Moro reflex, palmar reflex and plantar reflex
Seizures can present with apnea or changes in the tone alone
-Seizures may be due to glucose and electrolytes levels, central
nervous system infections, and metabolic disease or child abuse
Muscular tone: healthy infants prefer to maintain his arms and
legs flexed.
-Hypotonic can be present in any critical ill infant,
-Hypertonia should be a concern for seizures or metabolic disease.
Cry of the infant should be strong and vigorous.
-Neurological problems produce weak or shrill, high-pitched cry
130. Abdominal exam
Newborn liver edge is palpable, but not spleen, palpable
spleen suspect hemolyzing states.
Umbilical cord: signs of infection and bleeding.
Constipation or bloody stool, fissure, NEC
Genitals: hypospadias or other urethral anomalies,
inguinal hernias, varicoceles, hydroceles and
undescended testis.
An incarcerated inguinal hernia can be seen as a hard
mass overlying the inguinal canal may be erythematous,
and it is usually tender to palpation
131. Skin conditions
Most common benign rashes:
-Erythema toxicum whitish-yellow papules and pustules.
Jaundice: Direct bilirubin levels must be measured,
Late onset jaundice
–Breastfeeding jaundice
-Ecoli UTI, Sepsis
-Metabolic disease
-Extrahepatic biliary atresia
132. Approach to the critically ill
neonate to ED
Assessment of vital signs
Placement of a cardiac monitor, pulse oximeter
Bedside testing of blood glucose
Temperature
Delivery of oxygen (high flow mask)
Difficult peripheral intravenous lines:
-Intra-osseous line, umbilical catheter must be placed.
Blood glucose below 35-40 mg/dl is consider abnormal in
a neonate and should mandate an intervention
Saline boluses are required10 ml per kg saline
133. Investigations
FBC with IT ratio: >0.2 is 60 - 90% sensitive & 70%-
80% specific
CRP: needs 8-10h
Urea Electrolyte
Ionized calcium
Serum glucose
Blood c/s
ABG
LP with CSF c/s
In out urine
134. Action and disposition
Commence IV antibiotics early!
Control temperature
Correct electrolytes
All septic infants should be admitted to the hospital
135. WET FLAG
Weight (Age + 4 ) x 2 kg
Energy 4 J x Weight Joules
Tube
Internal Diameter = Age / 4 + 4 cm
Length (oral) = Age / 2 + 12 cm
Length (nasal) = Age /2 + 15 cm
Fluids
Medical = 20 ml x Weight
Trauma /bolus = 10 ml x Weight
Lorazepam
0.1mg x Weight nmg
Adrenaline
0.1ml x Weight of 1:10,000 Adrenaline mls
Glucose
2ml x Weight of 10% Dextrose mls
137. Unique paediatric differences
in trauma management
Spine: SCIWORA
Airway: relatively large tongue, large occiput, anterior
larynx, short trachea, needle cricothyroidotomy?
Breathing: rib # less common, pulmonary injury without
#, Pneumothoraces, hypoxia is a more common cause of
arrest!, TV 6-8ml/kg
Circulation: shock presents with tachycardia first (up to
35% loss of blood volume!), abdominal exsanguination,
insensible fluid losses, consider IO early
Temperature management: more prone to hypothermia
138. Drowning
In Singapore, death by drowning is the second
commonest cause of death due to unintentional injury in
children after road traffic injuries.
139. Unique things to consider in paediatrics
The following factors increase the risk of drowning:
Epilepsy
Cardiac dysrhythmias - congenital long QT syndrome,
catecholaminergic polymorphic ventricular
tachycardia and Brugada syndrome may be triggered
by swimming
Hypoglycemia
hyperventilation – can lead to syncope underwater
Hypothermia resulting in body temperature less than
35°C – can cause poor muscle coordination and
weakness
Trauma prior to drowning?
Alcohol and illicit drugs – should be considered in
adolescents
140. Unique things to consider in
paediatrics
Ventilation with lung protective measures reduces barotrauma and
should aim for normocapnia or mild hypocapnia. FiO2 should be
reduced to less than 0.5 as soon as possible to avoid pulmonary
oxygen toxicity.
A study in Southern California found a poor outcome was likely for
a child with any of the following: • CPR in ED • apnoea and coma in
the ED • pH less than 7.0
A RCT found targeted hypothermia (33°C) did not improve survival
or functional outcomes at 12 months when compared to
normothermia (36.8°C)
Prophylactic antibiotics not recommended unless grossly
contaminated water
all children who present with drowning, even if asymptomatic
should be observed for 4-8h for progression of pulmonary oedema
143. Powerful
statistics
In a study of 173 abused children with
head injuries, 54 were not recognized
as having been abused on initial
presentation. Fifteen of these
children were re-injured after the
missed diagnosis and four of these
children died
Mortality was significantly increased
in patients with recurrent NAT
compared with a single episode
(24.5% vs. 9.9%)
144. Risk factors for NAI
Parents perception that there is little community support and when families feel a lack
of connection to the community
decreased self-esteem, depression, history of suicide attempts, life stressors,
parent in foster care or abandoned as a child
unplanned or unwanted pregnancy
engagement in criminal activity
less prenatal care
a history of relationship problems with other adults
history of corporal punishment as a child
shorter birth intervals
increased number of separations from the child in the first year
History of NAI in siblings
145. History taking in the ED
Who comes with the child?
Delays in seeking treatment … or an injury that looks
older than they say
Inconsistent stories between historians
Caregivers who have an inappropriate affect
A pattern of injury that does not match what caregivers
say happened
A child with a history of injuries
146. When to scan?
A skeletal survey should be obtained in the following
groups: any child less than 2 years of age with any
evidence of abuse, any child less than 5 years of age with a
suspicious fracture, or any older child who is unable to
communicate areas of pain or trauma (e.g., intellectually
disabled).
CT/ MRI brain should there be suspicion of intracranial
injury
CT without intravenous contrast remains the imaging
modality of choice for evaluating a child with acute
neurologic findings or RH on physical examination.
147.
148. Differentials of NAI?
Ask for family history of bleeding disorders
Infections
Accidental trauma
149. Shaken baby syndrome
diagnosis is often missed since no history of head trauma
is provided
non-specific presentation such as vomiting, poor
feeding, irritability or lethargy
Classical injuries:
Cranial: SDH
Ocular manifestations of NAT: Retinal haemorrhage
Long bone fractures
150. – Maguire et al
Clinical features of: apnea; retinal hemorrhage;
rib, skull and long-bone fractures; seizures and
head and/or neck bruising
If >3 of the clinical features were present, the
odds ratio was 100 and the positive predictive
value for abuse was above 85%
151.
152.
153.
154. Subdural Haemangioma (SDH)
Differentials?
Benign enlargement of the subdural space (BESS): rapid
increase in head circumference at 2-3 months of age
head circumference > the 95th percentile at 3 years of age
can still be diagnosed as SDH on CT or MRI brain
Glutaric aciduria type I: rare autosomal recessive
neurometabolic disorder caused by a deficiency in glutarylCoA
dehydrogenase, which affects the degradation of lysine,
hydroxylysine, and tryptophan
results in hypotonia, acute striatal necrosis, frontotemporal
atrophy and neurological deterioration
present with macrocephaly and bilateral SDH
155. Neonatal Presentations to the Children’s Emergency Department
Sarah Blakey, Mark D Lyttle, Dan Magnus
medRxiv 2020.09.07.20190140; doi: https://doi.org/10.1101/2020.09.07.20
190140
Parental characteristics and perspectives pertaining to neonatal visits to
the emergency department: a multicentre survey.
Harrold J, Langevin M, Barrowman N, Sprague AE, Fell DB, Moreau KA,
Lacaze-Masmonteil T, Schuh S, Joubert G, Moore A, Solano T, Zemek RL;
Pediatric Emergency Research Canada Network. CMAJ Open. 2018 Sep
28;6(3):E423-E429. doi: 10.9778/cmajo.20180015. PMID: 30266780;
PMCID: PMC6182114.
156. Conclusion
All emergency departments should be prepared to care for a critically
ill neonates, infant, having the appropriately sized equipment
Nonemergency neonatal conditions should be managed in GP clinics
The most common diagnosis in admitted neonates include
respiratory infections, sepsis, congenital heart disease, bowel
obstruction, hypoglycemia and seizures.
Febrile neonates are at high risk for sepsis and therefore need
blood, urine and CSF testing, should receive empiric antibiotic
therapy in hospital
Emergency physician must be trained to assess the neonate,
stabilize, narrow the differential diagnosis to the most likely and
begin life-sustaining treatment
Many life-threatening conditions absent at birth, can present later in
Neonatal period with different clinical presentation, outcome can be
benign to catastrophic e.g. Congenital heart disease, metabolic,
sepsis
Neonatal seizures may have subtle manifestations and require a
different approach than seizures in older infants and children
157. Q.1 Which of the following
statements is correct regarding this
infant’s fever?
A. The fever is unaffected by the mother’s bundling.
B. The mother should be instructed to alternate
acetaminophen and ibuprofen to better control the
fever.
C. Children with fever are at increased risk of brain
damage.
D. The fact that the fever responded to acetaminophen
indicates that a serious infection is less likely.
158. Q.2: In case of seizures due to
hypoglycemia in a newborn treat with
loading dose of the following:
A.20 mg/Kg of Phenobarbitone
B.2 ml/Kg of 10% Dextrose
C.5 ml/kg of 10% Dextrose
D.5 ml/Kg of 50% dextrose
159. Q.3: In case of shock in newborn
and If bleeding is not the likely
cause, then do the following
EXCEPT
A. Establish IV access
B. Give IV normal saline or ringer
lactate 10 ml/Kg over 10 minutes
C. Give IV normal saline or ringer
lactate 20 ml/Kg over 60 minutes
D. Give 10% Dextrose at
maintenance rate
160. Q.4:Which of the following
statements is TRUE concerning
Inborn Errors of Metabolism?
A. They are easy to diagnose
B. Symptoms always appear within
hours of birth
C. Initial symptoms are typically vague
and non-specific
D. They cannot be inherited
E. All of the statements are true
161. Q.5. A 2-day previously thought to be well and
was just discharged from the nursery in
morning, is presented as acutely pale,
cyanotic, with weak femoral and brachial
pulses. The congenital heart disease most
likely to present in this manner is
A. Tetralogy of Fallot
B. Hypoplastic Left Heart Syndrome
C. Tricuspid Atresia
D. Total Anomalous Pulmonary
Venous Return
E. Co-arctation of aorta
162. Q 6: A 10-day old male presents
with bilious emesis. What is the
most likely diagnosis?
A.Appendicitis
B.Pyloric stenosis
C.Malrotation with midgut
volvulus
D.Feeding intolerance
E.Necrotizing enterocolitis
163. Q.7: A 1-week-old male presents with some
mild erythema around his umbilicus extending
onto the abdominal wall. Which of the following
is the correct management for this patient?
A. Reassurance and continue with alcohol wipes of
umbilicus
B. Topical antibiotic ointment and recheck the patient
the next day
C. Discharge on cephalexin and recheck the next day
D. Perform a full septic workup and admit the patient
E. Apply silver nitrate pen to erythema to cauterize it
164. Q.8 : A 5-day old, well-appearing male is brought to
the ED by his mother today because she noted that he
has a cluster of vesicles on his scalp. Which of the
following should be the management approach?
A. Skin biopsy
B. IV acyclovir and a full septic
workup
C. Oral acyclovir
D. Discharge, with next day follow up
E. Refer to Dermatologist
165. Q.9: Which of the following heart rates is
most suggestive of supraventricular
tachycardia in a newborn?
180 BPM
230 BPM
150 BPM
210 BPM
166. Q.10: A 3-week-old male presenting to the emergency
department with vomiting and altered mental status
and acidosis. What additional laboratory test should be
included in your evaluation?
A. Ammonia level
B. Cortisol level
C. Serum acetone
D. Thyroid function test
E. CRP
167. Q.11: A 3-day-old female is
presented with vaginal bleeding
A. Is always indicative of child abuse
B. May be due to withdrawal of
maternal hormones
C. Is suspicious for gonorrhea
D. Is most commonly due to a vaginal
foreign body-such as baby wipes
168. Answer.1 Which of the following
statements is correct regarding this
infant’s fever?
A. The fever is unaffected by the mother’s bundling.
B. The mother should be instructed to alternate
acetaminophen and ibuprofen to better control the
fever.
C. Children with fever are at increased risk of brain
damage.
D. The fact that the fever responded to acetaminophen
indicates that a serious infection is less likely.
169. A.2: In case of seizures due to
hypoglycemia in a newborn treat with
loading dose of the following:
A.20 mg/Kg of Phenobarbitone
B.2 ml/Kg of 10% Dextrose
C.5 ml/kg of 10% Dextrose
D.5 ml/Kg of 50% dextrose
170. A.3: In case of shock in newborn and
If bleeding is not the likely cause,
then do the following immediately
EXCEPT
A. Establish IV access
B. Give IV normal saline or ringer
lactate 10 ml/Kg over 10 minutes
C. Give IV normal saline or ringer
lactate 20 ml/Kg over 60 minutes
D. Give 10% Dextrose at
maintenance rate
171. A.4:Which of the following
statements is TRUE concerning
Inborn Errors of Metabolism?
A. They are easy to diagnose
B. Symptoms always appear within hours
of birth
C. Initial symptoms are typically vague
and non-specific
D. They cannot be inherited
E. All of the statements are true
172. A.5. A 2-day previously thought to be well and
was just discharged from the nursery in morning,
is presented as acutely pale, cyanotic, with
weak femoral pulses. The congenital heart
disease most likely to present in this manner is
A. Tetralogy of Fallot
B. Hypoplastic Left Heart Syndrome
C. Tricuspid Atresia
D. Co-artctation of aorta
173. A 6: A 10-day old male presents
with bilious emesis. What is the
most likely diagnosis?
A. Appendicitis
B. Pyloric stenosis
C. Malrotation with midgut volvulus
D. Feeding intolerance
E. Necrotizing enterocolitis
174. A.7: A 1-week-old male presents with some mild
erythema around his umbilicus extending onto
the abdominal wall. Which of the following is the
correct management for this patient?
A. Reassurance and continue with alcohol wipes of
umbilicus
B. Topical antibiotic ointment and recheck the patient
the next day
C. Discharge on cephalexin and recheck the next day
D. Perform a full septic workup and admit the patient
E. Apply silver nitrate pen to erythema to cauterize it
175. A.8 : A 5-day old, well-appearing male is brought to
the ED by his mother today because she noted that he
has a cluster of vesicles on his scalp. Which of the
following should be the management approach?
A. Skin biopsy
B. IV acyclovir and a full septic
workup
C. Oral acyclovir
D. Discharge, with next day follow up
E. Refer to Dermatologist
176. A.9: Which of the following heart rates is
most suggestive of supraventricular
tachycardia in a newborn?
A. 180 BPM
B. 230 BPM
C. 150 BPM
D. 210 BPM
177. A.10: A 3-week-old male presenting to the emergency
department with vomiting and altered mental status
and acidosis. What additional laboratory test should be
included in your evaluation?
A. Ammonia level
B. Cortisol level
C. Serum acetone
D. Thyroid function test
E. CRP
178. A.11: A 3-day-old female is
presented with vaginal bleeding
A. Is always indicative of child abuse
B. Likely due to withdrawal of
maternal hormones
C. Is suspicious for gonorrhea
D. Is most commonly due to a vaginal
foreign body-such as baby wipes
E. Due to Vit K deficiency
Editor's Notes
anyone can comment some issues with the scenario itself?
Tyebally A, Ang S Y 2010 - SMJ
as such the history taking should be targeted around this
Queensland paediatric guide in management of drowning in children
bolded are risk factors that we can already identify in the neonatal period
Paul AR, Adamo MA. Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment. Transl Pediatr. 2014;3(3):195-207. doi:10.3978/j.issn.2224-4336.2014.06.01
Accidental bruises are commonly over bony prominences
Also not if baby is not cruising
A high percentage of childhood burns are due to abuse (2% to 35% overall; up to 45% for genital and perineal burns). The two kinds of burns most often seen in abused children
are scald burns (from contact with hot liquids) and thermalburns (contact with hot objects).
Spiral fractures, indicative of a twist injury, of the humeral shaft are significantly more common in abused children
Children’s sutures may not have closed, hematoma able to expand into space
Morechildren in the accidental trauma group presented with skull fracture (57%) whereas patients in the NAT group were more likely to present with SDH (52%),
periorbital hematoma, eyelid laceration, subconjunctival hemorrhage, subluxed or dislocated lens, cataracts, glaucoma, anterior chamber angle regression, iridiodialysis, retinal dialysis or detachment, intraocular hemorrhage, optic atrophy or papilledema
The sensitivity of RH was estimated to be 75% and the specificity at 93.2% for the
diagnosis of child abuse; the predictive positive and negative values were 89.4% and 82.9%, respectively
Arch Dis Child Educ Pract Ed
. 2010 Dec;95(6):170-7. doi: 10.1136/adc.2009.170431. Epub 2010 Oct 6.
healed framers over R ribs
newer fractures over L ribs
Radiographic findings commonly seen in non-accidental trauma (NAT). (A) A left frontoparietal epidural hematoma in a 9-monthold male after being dropped; (B) an acute left frontoparietal subdural hematoma in a 14-year-old male following an assault; (C) a small
amount of traumatic subarachnoid hemorrhage in the right sylvian fissure in a 12-year-old male following assault; (D) a small left frontal contusion in a 31-day-old female who was dropped; (E) restricted diffusion in the left thalamus, splenium of the corpus callosum and
bilateral occipital poles in a 14-year-old female; (F) right frontal epidural hemorrhage as well as bifrontal and right posteromedial parietal/ occipital lobe hypodensity representing infarction in a 3-year-old male following abuse