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