Download NIGHTMARE NEONATE ©

Educational Session: Newborn
Emergencies
Maureen D. McCollough, MD, MPH, FACEP
3/24/2010
11:00 AM - 12:00 PM
Maureen McCollough MD, FACEP, FAAEM
Associate Professor of Pediatrics and Emergency Medicine
Keck USC School of Medicine
Medical Director, Department of Emergency Medicine
Los Angeles County+USC Medical Center
NIGHTMARE NEONATE
Term infant, usually good APGAR score, discharged home from the hospital, who returns back to the ED in extremis :
S - SEPSIS
S - SEIZURES
I - INBORN ERRORS OF METABOLISM
C - CARDIAC - Ductal dependent lesions and Left-to-Right shunts
C - CONGENITAL ADRENAL HYPERPLASIA
C - CNS DISASTERS - AVM’s, Child abuse, Vitamin K deficiency
F - FORMULA MIXUPS
I- INTESTINAL DISASTERS - volvulus, hernias, necrotizing enterocolitis
T - TOXINS
FEVER or SEPSIS
Age at which fever means automatic admission has dropped; Admit infant less than 4 weeks old with a fever (temp > 38.0 rectally)
Late onset (>1 week old) more likely to have meningitis so tap all neonates
Sepsis can present subtly - abdominal distention, tachypnea, “not doing well”
May not be febrile; may be hypothermic
Viral infections are most common - enteroviruses; Bacterial includes E. coli, Strep Group B, Listeria
Sepsis workup includes CBC, blood culture, urinalysis and culture (may have neg urinalysis but positive culture), and lumbar puncture
CBC may show neutropenia or low platelets as signs of sepsis
Urine - catheterize girls
Suprapubic or catheterize boys
Chest Xray necessary if infant has signs of lower respiratory tract disease (tachypnea, cough, retractions, grunting, nasal flaring or
hypoxia)
Lumbar puncture - dangerous for ill neonate to be curled up; place on a pulse ox; reportedly less dangerous sitting up; don’t cover
the infant during the LP; 22 gauge with a stylet to avoid epitheliomas
Up to one month - WBC - 7-22 / hp;
Protein - up to 150
Antibiotics are Ampicillin and Gentamicin or
Cefotaxime and Ampicillin
If suspicious for herpes (vesicles, CSF shows WBC’s or high protein but negative gram stain, seizures, maternal history of herpes, or
any “ill” appearing neonate), then add Acyclovir 10 mg/kg per dose q 8hrs IV
SEIZURES
Present more subtly than in older infants or adults:
tonic seizure or migratory slow clonic movements or subtleties like lip smacking, eye deviation, bicycling or apnea
Generalized tonic/clonic rare due to neurons not interacting well yet
Differential diagnosis includes:
CNS - child abuse, Vitamin K deficiency, hypoxic encephalopathy
Infection - meningitis (bacterial or herpes)
Metabolic - hypoglycemia, hypocalcemia, hypo or hypernatremia, Inborn Errors, pyridoxine deficiency
Drug withdrawal from maternal opiate abuse
Toxins like bilirubin
Family seizures - Benign familial and 5th day fits
Jitteriness is all limbs, short rapid movements, can be induced, stops with restraint of limb, gaze is normal, rarely has autonomic signs
History - ask about birth trauma, infection, drug abuse, family history of neonatal seizures, formulas and home remedies
Physical exam - bruising, cranial bruit for AVM, cafe-au-lait spots, jaundice, herpes vesicles
Neuro exam for cranial nerves, motor exam, neonatal reflexes
Treat like regular seizures with benzodiazepines, phenobarbitol, Dilantin - don’t wait for the seizure to stop on its own
Be ready with airway equipment !!
Check glucose and calcium right away even if seizures are stopped
Glucose D10 5-10cc/kg IV (0.5-1.0 g/kg)
Calcium gluconate 10% 100-300mg/kg IV (1-3ml/kg at 1ml/min) - weak cry, sounds like a bleating lamb, and extreme
jitteriness are signs of hypocalcemia
Consider Pyridoxine 50-100 mg IV if unresponsive to traditional therapy
Workup will be dictated by the history and physical exam; admit for further workup and observation
INBORN ERRORS
Hereditary biochemical disorder that results in the accumulation of a metabolite that is toxic at high levels
Typical metabolites are ammonia, lactic acid and ketones and usual target organ is the central nervous system
Categories include urea cycle defect, organic acidemias, aminoacidopathies or galactosemia
Family may have a history of previous child dying in infancy
Presents usually in the neonatal period with altered mental status, lethargy, vomiting, dehydration, hypoglycemia, seizures
Physical exam could reveal hepatomegaly or odor
Labs show elevated levels of metabolite; may not be acidotic
Ammonia - best if drawn arterially, green top tube, place on ice
Lactic acid level - if acidotic
Urine may show spindle shaped orotic acid crystals if urea cycle defect exists
Attempt to get red and green top tubes drawn before hydration and glucose; BUT RESUSCITATION ALWAYS COMES FIRST !!
Treatment includes rehydration and glucose for hypoglycemia and to decrease production and enhance elimination of the toxic
metabolite
HCO3 may increase ammonia passage into the CNS
Continue with D 10 1/4NS at 1.5-2 times maintenance rate
CARDIAC
Two categories - Ductal dependent lesions and Left-to-right shunts
Ductal dependent congenital heart disease:
Ductus arteriosus connects pulmonary artery to aorta; shunts fetal blood away from lungs; closes first few days after birth
Ductus needed to remain open to supply blood to either the lungs or to the systemic circulation
Ductus closes usually in the first day of life but can be delayed several days
Ductal dependent neonate gets into trouble when the ductus closes
Usually presents in the first week of life with sudden change in color or respiratory rate
Lungs dependent Defect is usually a right-to-left intracardiac shunt like:
Tetralogy of Fallot, Tricuspid atresia, Truncus Arteriosus, Pulmonary stenosis
Ductus closes ----> neonate presents cyanotic because of decreased blood flow to lungs
Oxygen will not correct the hypoxia
Systemic circulation dependent Defect is usually a severe obstruction to flow to the systemic circulation like:
Coarctation of the aorta, severe Aortic stenosis, Hypoplastic left heart
Ductus closes ----> neonate presents hypotensive or with poor circulation to lower extremities because of decreased
blood flow to the systemic circulation
Exam includes blood pressure and palpation of pulses in all extremities; O2 saturation will be decreased in the lower
extremities
Treatment includes Airway, Breathing, Circulation
Prostaglandin E1 is a potent vasodilator, especially to ductal tissue; start at 0.05-0.1mcg/kg/min IV infusion; side effects
include hypotension, apnea
Dopamine and Dobutamine sometimes needed for better cardiac output
Left-to-right intracardiac shunts present with congestive heart failure
Usually presents at end of first month or during first few months of life
Example is a large ventricular septal defect
Normally, pulmonary vascular pressures drop during first months of life ---> any pre-existing left-to-right shunt, like a VSD,
will worsen as these pulmonary pressures decrease ---> more and more blood flows to the lungs, putting the child into
congestive heart failure
Neonates present with slower onset of symptoms: difficulty feeding, sweating or tiring during feeds, poor weight gain,
tachypnea
Exam will show tachypnea, ?rales, enlarged liver; neonates do not have pitting edema
Treatment includes admission and diuresis
CONGENITAL ADRENAL HYPERPLASIA
Adrenal insufficiency resulting from deficient enzyme needed to produce cortisol
Results in deficiency of cortisol and aldosterone, and accumulation of androgens
Clinically results in adrenal hyperplasia, salt wasting, dehydration, hyponatremia, hyperkalemia, azotemia, acidosis, and sometimes
cardiovascular collapse
Females have enlarged clitoris and fused labia; males have hyperpigmented scrotums
Attempt to get red and green top tubes drawn before Hydrocortisone given; BUT RESUSCITATION ALWAYS COMES FIRST !!
Treatment includes hydration and Hydrocortisone 25mg IV and admission
Hyperkalemia is usually well tolerated, but treat if arrhythmias are present
CNS DISASTERS
Child Abuse
Vitamin K deficiency – Vit K not given at birth; CNS, skin, GI bleeding
Cerebral AVM
INTESTINAL DISASTERS:
Volvulus, Incarcerated Hernia, Diaphragmatic Hernia, Necrotizing Enterocolitis
VOLVULUS
Congenital malrotation of the midgut portion of the intestine - during the 5 - 8th week of embryonic life, the intestine projects out of
the abdominal cavity, rotates 270 degrees and returns into the abdomen; if the rotation is not right, the intestine will not be “fixed
down” correctly at the mesentery ------> at risk for volvulus
Volvulus is the twisting of a loop of bowel about its mesenteric base attachment
True medical emergency because necrotic bowel can occur within hours of onset of the twisting
Presents one of three ways:
- sudden onset of bilious vomiting and abdominal pain
- history of “feeding problems” with bilious vomiting that now appears like a bowel obstruction
- failure to thrive with severe feeding intolerance (least common)
BILIOUS (green) VOMITING IN NEONATES IS ALWAYS WORRISOME AND IS A TRUE EMERGENCY !!
abdomen may or may not be distended depending upon location of the volvulus; if obstruction is high, abdomen may not be
distended; abdomen may be “blue” if bowel is already ischemic / necrotic
Pain is a constant pain, not intermittent; neonate may be jaundiced
Hematochezia is a late, BAD sign !
Labs - nothing classic except dehydration and acidosis
Abdominal plain film
- classic “double bubble sign” - paucity of gas (airless abdomen) with two air bubbles - one in the stomach and one in the
duodenum
- plain film can also be entirely normal
Upper GI - considered the gold standard
- small intestine is rotated to right side of the abdomen; contrast narrows at site of obstruction “cork-screwing”; spiraling of
small bowel about the superior mesenteric artery
Need to diagnose this life threatening process EMERGENTLY !!!
Re-hydrate the infant aggressively; place an NG tube
Antibiotics: Ampicillin, Clindamycin and Gentamicin
When the diagnosis is being considered, contact the Pediatric Surgeon on-call immediately; the sooner the child gets to the OR, the
lower the morbidity and mortality
- some peds surgeons will take an ill appearing neonate with BILIOUS vomiting to the OR directly without any additional
diagnostic tests
FORMULA MIXUPS and TOXINS
Mixing formula incorrectly
Any other liquids, powders or herbs given for a variety of reasons – colic, spitting up, vomiting, constipation, diarrhea