neonatal emergencies-3 dr. miada mahmoud rady ems 481 final lecture

Neonatal emergencies-3

Dr. Miada Mahmoud Rady

EMS 481

Final lecture

Previously ………

• We discussed at the end of the lecture the proper prehospital

signs of vomiting and diarrhea???

• What dangerous signs and symptoms you should look for..?

• And significance of each of these finding …..

Fever .. Guarding Absent Tears …. Rigidity

Dry Mucous Membrane……

Management

1. Address the ABCs :

Maintain a patent airway.

Keep face turned to one side to prevent aspiration.

Suction or clear vomitus from airway with a suction catheter

or suction bulb.

Provide either free-flow supplemental oxygen or bag-mask

ventilation as necessary.

Management

2. Consider a nasogastric or orogastric tube to decompress the

stomach.

3. Do not administer antiemetic in the field.

4. The newborn may need fluid resuscitation ( normal saline ) if

there is dehydration

Neonatal jaundice

Jaundice : yellowish discoloration of the skin and mucous

membrane.

• Jaundice can be physiological in neonates and it is due to

failure of immature liver to conjugate bilirubin.

Characteristics of physiological jaundice

1. First appears between 24-72 hours of age

2. Maximum intensity seen on 4-5th day in term and 7th day in

preterm neonates

3. Does not exceed 15 mg/ dl

4. Clinically undetectable after 14 days.

5. No treatment is required but baby should be observed closely

for signs of worsening jaundice.

Pathological jaundice

1. Clinically visible in first 24 hours after birth

2. Total serum bilirubin increases by more than 5 mg/dL/d.

3. Total bilirubin exceeds 12 mg/dL in full-term infants.

4. Conjugated bilirubin exceeds 15 to 20 mg/dl.

5. Persists for more than 1 week in full-term infants and for

more than 2 weeks in preterm infants

Risk factors of jaundice

Simple pneumonic for risk factors is JAUNDICE

1. J - Jaundice within first 24 hrs of life

2. A - A sibling who was jaundiced as neonate

3. U - Unrecognized hemolysis

4. N – Non-optimal sucking/nursing

5. D - Deficiency of G6PD

6. I - infection

7. C – Cephalhematoma /bruising

Assessment and management

1. Address the ABCs .

2. Start on IV fluids if the neonate shows significant clinical

jaundice.

3. Communicate with medical control about any newborn with

jaundice.

4. Transport is essential for bilirubin measurement at the

hospital.

Birth trauma

• Definition : Birth trauma are injuries resulting from

mechanical forces that occur during the delivery process.

• Mostly are self-limiting .

Risk Factors for Birth Injury

1. Prematurity.

2. Post maturity.

3. Prolonged labor.

4. Breech presentation.

5. Cephalopelvic disproportion.

6. Diabetic mother ( large baby ).

7. Explosive delivery.

Head

1. Excessive molding of the head

2. Caput succedaneum : Swelling of soft tissue of the

scalp from pressing against the dilating cervix

3. Cephalhematoma : Area of bleeding between the

parietal bone and the covering periosteum , May take 2

weeks to 3 months to resolve , Do not try to drain

because it may worsen or prolong bleeding.

4. Linear skull fractures.

Nerves

1. Brachial plexus injuries

2. Facial nerve palsy

3. Diaphragmatic paralysis

4. Laryngeal nerve injury

5. Spinal cord injury

Congenital heart disease (CHD)

CHD is commonest birth defects .

Based on the presence of cyanosis , it is divided into two

groups:

1. Congenital cyanotic heart disease.

2. Congenital acyanotic heart disease.

Congenital cyanotic heart diseases

Most famous examples include :

1. Tetralogy of Fallot .

2. Truncus arteriosus.

3. Transposition of great vessels.

4. Tricuspid atresia.

Acyanotic heart diseases

Divided into two groups based on the main pathology :

1. Right to left shunt :

Ventricular septal defect.

Atrial septal defect .

Patent ductus arteriosus.

1. Outflow obstruction :

Pulmonary stenosis .

Aortic stenosis.

Coarctation of the aorta.

Left to right shunt anomalies

All share the same complication and presentation

Clinical presentation :

1. Easy fatigability .

2. Heart murmur .

3. Repeated chest infections.

4. Tachycardia .

5. Tachypnea .

Complication :

1. Heart failure .

2. Growth retardation .

3. Increased risk of

endocarditis.

Right to left shunt anomalies

It include :

1. Atrial septal defect (ASD):

Defect exists in the atrial septum .

Usually due to failure of closure of foramen ovale .

It allows blood to pass from the left atrium to right atrium

causing mixing of oxygenated and deoxygenated blood.

Most commonly asymptomatic .

Ventricular septal defect

A defect exists in the wall between the two ventricles.

Allows blood to pass from left ventricle to right ventricle .

It has same clinical manifestation and complication as left to

right shunt in addition to :

1. Pulmonary hypertension , which causes reversal of the

shunt , blood flows from right ventricle to left ventricle

leading to cyanosis.

Management

1. Address ABCs .

2. High flow oxygen if indicated .

3. Careful monitoring of vital signs .

4. Watch for signs of heart failure.

5. Definitive treatment :

Small defect : careful follow up and assurance as

defect will eventually close.

Large defect : surgical correction.

Patent Ductus Arteriosus

Patent Ductus Arteriosus

• Pathophysiology :

1. Ductus arteriosus exists between pulmonary artery and aorta

before birth

2. It Normally closes within few hours of birth

3. Failure of closure allows blood to mix between pulmonary

4. artery and aorta blood that should flow through aorta to

nourish body returns to lungs

5. Common in premature infants and rare in full‐term babies.

Patent Ductus Arteriosus

• It has the same clinical presentation and complication of left to

right shunt .

• Definitive treatment : usually surgery , to close defect and

restore circulation .

Remember

Hall mark of shunt disorders is heart murmur which becomes louder as

shunt increases.

Tetralogy of Fallot

Definition : Combination of four congenital heart defect :

1. A large ventricular septal defect (VSD).

2. An overriding aorta.

3. Pulmonary stenosis.

4. Right ventricular hypertrophy.• All result in poor oxygenation and cyanosis.

Clinical presentation

1. Cyanosis

2. Shortness of breath and Tachypnea.

3. Fainting attacks

4. Clubbing of fingers and toes

5. Poor weight gain

6. Easy fatigability and irritability

7. A heart murmur.

8. Tet spells

Tet spells

Typically cyanotic spells occur early in the morning.

The possible triggers are anxiety, fever, anemia, sepsis or even

spontaneously.

1. A typical infant with cyanotic spell would appear fussy,

irritable which then progresses to increasing cyanosis,

hyperpnoea.

Management : squatting position (children) , knee to chest

position (infant)

TOF management

• Surgical correction

Any questions

Thank you