Neonatal Emergencies

1
Neonatal Emergencies

• Lazaro Lezcano, MD
• Director, Division of Neonatology
• August 31, 2010

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Neonatal Emergencies

• Neonates are a group of patients that often
  present anxiety-provoking diagnostic challenges
• They often present with non-specific or a history
  of symptoms that may or may not be benign
• In order to recognize which neonates will require
  life-saving interventions, clinicians need to
  remain current on these life-threatening
  illnesses and their management

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The Misfits Movie
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Neonatal Emergencies

• 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 overdilution)
• I- Intestinal catastrophes (volvulus,
  intususception, NEC)
• T- Toxins/poisons
• S- Seizures

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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

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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

7
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
• Pediatrics 6/2003
• CHOP
• 74 ? No retinal hemorrhages

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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

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Trauma(accidental non-accidental)

• Admit the patient
• Report injury to appropriate state department for
  abuse
• Skeletal survey
• Ophthalmologic exam

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Heart Disease and HypoxiaCyanotic Heart Disease

• Cyanosis requires immediate attention and
  evaluation
• Differential diagnosis
• Respiratory causes
• Infectious causes
• CNS abnormalities
• Toxins
• Cyanotic heart disease

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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)

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Heart Disease and Hypoxia Cyanotic Heart Disease

• May not be detected in the WBN
• 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

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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

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Heart Disease and Hypoxia Cyanotic Heart Disease

• 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

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Heart Disease and Hypoxia Cyanotic Heart Disease

• During stabilization the physical exam should
  include B/Ps in all 4 extremities 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

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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

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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

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Hypoplastic Left Heart Syndrome

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

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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

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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

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Acyanotic Heart DiseaseCongestive 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 when
  compared with CCHD
• May not present until after the first 2-3 weeks
  of age

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Acyanotic Heart Disease Congestive Heart Failure

• Causes of CHF in Neonates
• Acyanotic heart disease (VSD, ASD, PDA, CoA)
• Severe anemia
• Trauma
• Sepsis
• SVT
• Metabolic abnormalities
• SLE
• Thyrotoxicosis

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Acyanotic Heart Disease Congestive Heart Failure

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

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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

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Acyanotic Heart DiseaseSupraventricular
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

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Acyanotic Heart Disease Supraventricular
Tachycardia
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Acyanotic Heart Disease Supraventricular
Tachycardia

• Management
• Stable patient
• Vagal maneuvers
• 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

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Acyanotic Heart Disease Supraventricular
Tachycardia

• 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.

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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
• Final option for a wide QRS and should only be
  used in consultation with a pediatric
  cardiologist
• 1mg/Kg IV

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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

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HypoxiaBronchiolitis

• 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
• In NY from October-April

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Hypoxia Bronchiolitis

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

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Hypoxia Bronchiolitis

• 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

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Hypoxia Bronchiolitis

• 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

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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

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HypoxiaApnea/ALTE

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

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Hypoxia Apnea/ALTE

• Botulism
• Dysrhythmias
• Acid/base disturbances
• Intracranial hemorrhage
• Meningitis/encephalitis
• Pertussis
• Hypoglycemia
• Seizures
• GER
• Child abuse
• Inborn errors of metabolism
• Electrolyte abnormalities

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Endocrine EmergenciesCongenital 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

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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

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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

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Endocrine Emergencies Congenital Adrenal
Hyperplasia

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

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Endocrine Emergencies Congenital Adrenal
Hyperplasia

• Management
• Labs
• Blood glucose
• Hypoglycemia
• Serum electrolytes
• Hyponatremia
• Hyperkalemia
• Hypotension unresponsive to fluids or inotropes
  heightens suspicion of CAH

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Endocrine Emergencies Congenital Adrenal
Hyperplasia

• 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)

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Endocrine Emergencies Congenital Adrenal
Hyperplasia

• Pediatric critical care management
• Endocrinology consultation

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Endocrine EmergenciesThyrotoxicosis

• 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

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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

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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

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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
• Propanolol for tachycardia
• 1-2mg/Kg/day in 2-4 divided doses
• Digitalis may be used to prevent cardiovascular
  collapse

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Inborn Errors of Metabolism
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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
• HYPERAMMONEMMIA
• (-) ACIDOSIS

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Inborn Errors of Metabolism

• Amino acid metabolism defects
• MSUD
• Nonketotic hyperglycinemia
• Hereditary tyrosinemia
• Pyroglutamic acidemia (5-oxoprolinuria)
• Hyperornithinemia-hyperammonemia-homocitrulinemia
  syndrome
• Lysinuric protein intolerance
• Methylene tetrahydrofolate reductase deficiency
• Sulfite oxidase deficiency
• (-) HYPERAMMONEMIA
• (-) ACIDOSIS

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Inborn Errors of Metabolism

• 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
• HYPERAMMONEMMIA
• ACIDOSIS
• INCREASED URINE KETONES

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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
• HYPERAMMONEMIA
• ACIDOSIS
• INCREASED URINE KETONES

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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
• HYPERAMMONEMIA
• ACIDOSIS
• DECREASED URINE KETONES

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Inborn Errors of MetabolismMetabolic 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

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Inborn Errors of Metabolism Metabolic Emergencies

• Nonspecific symptoms
• Poor feeding
• Vomiting
• FTT
• Tachycardia
• Tachypnea
• Irritability

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Inborn Errors of Metabolism Metabolic Emergencies

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

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Inborn Errors of Metabolism Metabolic Emergencies

• Labs
• Bedside glucose
• CBC
• BMP
• pH
• Lactate and ammonia levels
• LFTs
• Urine for reducing substances and ketones
• Blood and urine for organic and amino acids

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Inborn Errors of Metabolism Metabolic Emergencies

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

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Sepsis

• It is standard of care to complete a full sepsis
  evaluation (CBC, blood culture, urinalysis, urine
  culture, CSF culture and analysis, CXR) in a
  neonate with a rectal temperature of gt100.4 F (38
  C)

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Sepsis

• Symptoms that should prompt the consideration of
  a full sepsis evaluation
• Poor feeding
• Irritability
• Apnea
• Hypothermia
• Jaundice
• Rashes
• Increased sleeping
• Vomiting

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Sepsis

• Thorough maternal history and physical
  examination
• One study evaluating the heart rate
  characteristics of neonates found that reduced
  heart rate variability was present before
  clinical signs of sepsis
• Initial laboratory screening is not always
  helpful
• Pediatrics 2005
• University of Virginia

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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
• Emergency Medicine Journal 2005
• Loma Linda University Medical Center
  Childrens Hospital
• Academic Emergency Medicine 6/08
• Childrens Hospital of Columbus, OH

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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

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Sepsis

• Treatment
• Broad spectrum antibiotics
• Ampicillin
• 50-100mg/Kg IV
• Gentamicin
• 2mg/Kg IV
• or
• Cefotaxime
• 50-100mg/Kg IV
• Acyclovir
• 20mg/Kg IV

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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

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Sepsis

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

68
Formula Mishaps

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

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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

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Intestinal CatastrophesMalrotation 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

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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

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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

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Intestinal CatastrophesToxic Megacolon

• Life-threatening presentation of a patient with
  Hirschprungs disease
• Hirschprungs 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

74
Intestinal Catastrophes Toxic Megacolon

• Symptoms
• Poor feeding
• Vomiting
• Irritability
• Abdominal distention
• Hematochezia
• Shock as it progresses to enterocolitis

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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

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Intestinal CatastrophesNecrotizing Enterocolitis

• Clasically a disease of premature infants
• May occasionally occur in term neonates after
  discharge from WBN
• Symptoms similar to those of Hirschprungs
  enterocolitis

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Intestinal Catastrophes Necrotizing Enterocolitis

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

78
Intestinal CatastrophesHypertrophic Pyloric
Stenosis

• Common, incidence of 1/250 live births
• Malefemale ratio 41
• More common in firstborn male
• Classic metabolic abnormality of hypochloremic,
  hypokalemic metabolic alkalosis- now uncommon
• History of nonbilious projectile emesis
  immediately after feeding

79
Intestinal CatastrophesHypertrophic Pyloric
Stenosis

• Increased incidence in infants with an early
  exposure to oral erythromycin
• PE
• Palpable olive structure in the RUQ
• Visible peristaltic waves
• Diagnosis
• US
• Thickened and lengthened pylorus
• Upper GI
• String sign

80
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

81
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

82
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

83
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

84
Seizures

• Common causes of neonatal seizures
• 1st day of life
• Anoxia/hypoxia
• Trauma
• Intracranial hemorrhage
• Drugs
• Infection
• Hypoglycemia/hyperglycemia
• Pyridoxine deficiency

85
Seizures

• 2nd day of life
• Sepsis
• Trauma
• Inborn errors of metabolism
• Hypoglycemia
• Hypocalcemia
• Hyponatremia/hypernatremia
• Hyperphosphatemia
• Drug withdrawal
• Congenital anomalies or developmental brain
  disorders
• Benign familial neonatal seizures

86
Seizures

• Day 4 6 months of age
• Hypocalcemia
• Infection
• Hyponatremia/hypernatremia
• Drug withdrawal
• Inborn errors of metabolism
• Hyperphosphatemia
• Congenital anomalies or developmental brain
  disorders
• Hypertension
• Benign idiopathic neonatal seizures

87
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

88
Seizures

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

89
Seizures

• Management
• Lorazepam
• 0.05-0.1mg/Kg slow IV
• Repeat doses (2-3 times) based on clinical
  response
• 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

90
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

91
Seizures

• Correct serum electrolyte abnormalities
• More common
• Hyponatremia (lt125mg/Kg)
• 5-10mL/Kg IV 3 saline solution
• Hypocalcemia (lt7mg/dL)
• 100-300mg/Kg IV of calcium gluconate

92
Seizures

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

93
Conclusion

• The mnemonic THE MISFITS is a helpful tool that
  can be readily used to formulate an approach to
  the most common neonatal emergencies that may
  present to general pediatricians in their
  hospital or private offices as well as ED
  clinicians in the ED department