Neonatal presentations to Emergency department.pptx

Neonatal presentations
to Emergency
Department
Dr Julia Jaffar, Medical Officer
Supervised by Dr Varsha Atul Shah

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

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

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

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?

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

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?

Daily attendance figures include all patients
who are presented at the EMD regardless of
urgency of medical conditions

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

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

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

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

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

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

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

Problem Community/Society
Hospital/Doctors/Nurse
s
Babies/Patient
s
Parents

Commonest neonatal
presentations
Nonemergency
 Neonatal Jaundice
 Feeding problems,
vomiting/regurgitation
 Difficulty breathing,
 Noisy breathing
 Excessive crying/Colic
 Irritability
 ?Fever
 Emergency
• Respiratory
• Cardiac
• Shock
• CNS

Most common Diagnoses
 More than half “No significant medical problem”
 Bronchiolitis
 ?Sepsis

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

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

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


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

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

Trauma(accidental non-accidental)
 Admit the patient
 Report injury to appropriate state department for
abuse
 Skeletal survey
 Ophthalmologic exam

Heart Disease and Hypoxia
Cyanotic Heart Disease
Cyanosis requires immediate attention and evaluation
Differential diagnosis
 Respiratory causes
 Infectious causes
 CNS abnormalities
 Toxins
 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)

• 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


 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

• 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


 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

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

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

 Pulmonary Edema
 Pallor
 Tachypnea
 Poor perfusion
 Poor to absent peripheral pulses
 Loud single S2
 Gallop rhythm w/o murmur
 Hepatomegaly
 Metabolic acidosis

 EKG
 Small or absent (L) ventricular forces
 CXR
 Moderate cardiomegaly
 Large PA shadow
 ECHO
 Small or slit-like (L) ventricle
 Hypoplastic ascending aorta

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


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

Acyanotic Heart Disease
Causes of CHF in Neonates
1. Acyanotic heart disease (VSD, ASD, PDA, CoA)
2. Severe anemia
3. Trauma
4. Sepsis
5. SVT
6. Metabolic abnormalities
7. SLE
8. Thyrotoxicosis

Initial management
Stabilization of the ABCs
CXR
EKG
Labs
FBC
BMP
ABG
ECHO- diagnostic of heart defect
Furosemide-1 mg/Kg IV

Pressors
Dopamine
5-15 mcg/Kg/min IV
Dobutamine
2.5-15 mcg/Kg/min IV
Careful with fluid overloading
Peds. Cardiology consult

Supraventricular Tachycardia
 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

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

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.

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


 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

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

Signs/Symptoms
 Rhinorrhea
 Cough
 Congestion
 Wheezing
 Significant respiratory distress
 Apnea may be the only initial symptom

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

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

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

Apnea/ALTE
Management depends on history provided by
observers and PE
 Hospitalization for observation and monitoring
 Common differential diagnosis
 Sepsis
 Pneumonia
 RSV
 Hypothermia
 Anemia

Apnea/ALTE
 Botulism
 Dysrhythmias
 Acid/base disturbances
 Intracranial haemorrhage
 Meningitis/encephalitis
 Pertussis
 Hypoglycaemia
 Seizures
 GER
 Child abuse
 Inborn errors of metabolism
 Electrolyte abnormalities

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

 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


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


 11- hydroxylase deficiency
 Less common- 5-8 of cases
 Salt retention
 Volume expansion
 Hypertension


Management
Labs
 Blood glucose
 Hypoglycaemia
 Serum electrolytes
 Hyponatremia
 Hyperkalaemia
 Hypotension unresponsive to fluids or inotropes
heightens suspicion of CAH


Management
 Hydrocortisone
 25-50mg/m2 IV
 Treat hypoglycemia
 Hyperkalemia usually responds to fluid therapy
 If patient is symptomatic or with EKG changes
 Calcium chloride
 NaHCO3
 Insulin and glucose
 Polystyrene sulfonate (Kayexalate)

Management
 Pediatric critical care management
 Endocrinology consultation

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


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

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


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

Inborn Errors of Metabolism
Urea cycle defects
 Ornithine-transcarbamylase deficiency
 Carbamyl phosphate synthetase deficiency
 Transient hyperammonemia of the neonate (unclear
cause)
 Argininosuccinate synthetase deficiency
(citrulinemia)
 Argininosuccinate lyase deficiency
 Arginase deficiency
 N-acetylglutamate synthetase deficiency


Amino acid metabolism defects
 MSUD
 Nonketotic hyperglycinaemia
 Hereditary tyrosinemia
 Pyroglutamic academia (5-oxoprolinuria)
 Hyperornithinemia-hyperammonemia-homocitrulinemia
syndrome
 Lysinuric protein intolerance
 Methylene tetrahydrofolate reductase deficiency
 Sulphite oxidase deficiency

Organic Acidemias
 Methylmalonic acidemia
 Propionic acidemia
 Isovaleric acidemia
 Multiple carboxylase deficiency
 Glutaric acidemia type II
 HMG-CoA lyase deficiency
 3-Memethylcrotonoyl-CoA carboxylase deficiency
 3-Hydroxyisobutyric acidemia

Carbohydrate metabolism defects
 Galactosemia
 Fructose-1,6-biphosphatase deficiency
 Glycogen storage diseases (types IA. IB, II, III
and IV)
 Hereditary fructose intolerance


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


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

 Nonspecific symptoms
 Poor feeding
 Vomiting
 FTT
 Tachycardia
 Tachypnoea
 Irritability


 More apparent symptoms
 Seizures
 Lethargy
 Hypoglycemia
 Apnea
 Temperature instability
 Acidosis


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

Management
 Fluid resuscitation
 IV dextrose to prevent further catabolism
 Admission to hospital
 Genetics consultation


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


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

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


Sepsis
Broad spectrum antibiotics
 Ampicillin
 50-100mg/Kg IV
 Gentamicin
 2mg/Kg IV
or
 Cefotaxime
 50-100mg/Kg IV
 Acyclovir
 20mg/Kg IV


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


Sepsis
 CSF analysis
 Herpes PCR
 Herpes culture
 Elevated LFTs
 Chest x-rays
 Pneumonitis

Formula Mishaps
 Inappropriate mixing of water and powder formula
 Overdilution of concentrated liquid or premixed formula
 Life-threatening electrolyte disturbances or FTT
 Hyponatremia
 Seizures

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


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


Intestinal Catastrophes- Malrotation
with Midgut Volvulus
Symptoms
• Bilious emesis
• Poor feeding
• Lethargy
• Shock in more advanced presentations
• Management
• Fluid resuscitation
• NGT placement
• Pediatric surgical consultation


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


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


Intestinal Catastrophes- Toxic
Megacolon
Symptoms
• Poor feeding
• Vomiting
• Irritability
• Abdominal distention
• Hematochezia
• Shock as it progresses to enterocolitis


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


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


Necrotizing Enterocolitis
Management
 Stabilization of ABCs
 Fluid resuscitation
 NGT placement
 Broad-spectrum antibiotics
 Pediatric surgical consultation
 Critical care management


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


 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

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

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

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


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

Seizures
Common causes of neonatal seizures
1st day of life
 Anoxia/hypoxia
 Trauma
 Intracranial haemorrhage
 Drugs
 Infection
 Hypoglycaemia/hyperglycaemia
 Pyridoxine deficiency

Seizures
2nd day of life
 Sepsis
 Trauma
 Hypoglycaemia
 Hypocalcaemia
 Hyponatremia/hypernatremia
 Hyperphosphatemia
 Drug withdrawal
 Congenital anomalies or developmental brain
disorders
 Benign familial neonatal seizures

Seizures
Day 4 to 6 months of age
 Hypocalcaemia
 Infection
 Hyponatremia/hypernatremia
 Drug withdrawal
 Hyperphosphatemia
 Congenital anomalies or developmental brain
disorders
 Hypertension
 Benign idiopathic neonatal seizures


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


Seizures
Because 5-10 of neonatal seizures are of
infectious etiology, full sepsis work-up
should be performed when patient is
stable

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


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-

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


Seizures
 Immediately start broad-spectrum
antibiotics and acyclovir
 Neuroimaging once patient is
stabilized
 Admit to hospital for completion of
evaluation and monitoring

Conclusion
The mnemonic THE MISFITS
 Is a helpful tool
 Can be readily used to
formulate an approach to
 the most common neonatal
emergencies

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

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

Triage
Singapore Paediatric Triage Scale

Approaches to Neonates in ED
Past Medical History
History
Examination
Investigations

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

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

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

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

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

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!

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

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

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.

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.

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.

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

Physical exam
 VITAL SIGNS + blood sugar
 Cardio: Murmurs, perfusion (CRT, peripheral
colour), pulses, AFNT
 Resp: resp distress, cyanosis, percussion, BS & AE
 GI: distension, bowel loops, liver edge,
vomitus/feces, bowel sounds, umbilicus, Inguinal
region
 Neuro: primitive reflexes, equal movement, tone
 Skin

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

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

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

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

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

Action and disposition
 Commence IV antibiotics early!
 Control temperature
 Correct electrolytes
 All septic infants should be admitted to the hospital

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

Special attention
Trauma- mostly
Trauma code
the leading cause of death and
disability in children

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

Drowning
 In Singapore, death by drowning is the second
commonest cause of death due to unintentional injury in
children after road traffic injuries.

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

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

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%)

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

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

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.

Differentials of NAI?
 Ask for family history of bleeding disorders
 Infections
 Accidental trauma

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

– 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%

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

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.

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

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.

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

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
D. Give 10% Dextrose at
maintenance rate

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

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

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

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

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

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

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

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

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.

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

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
C. Give IV normal saline or ringer
D. Give 10% Dextrose at
maintenance rate

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

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

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

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

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

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

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

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

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