Transcript Neonatal Emergencies

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
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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
