neonatal emergencies
TRANSCRIPT
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Neonatal EmergenciesNeonatal Emergencies(After Discharge)(After Discharge)
Robert Englert, M.D.Dept Neonatology
Bethesda Naval Hospital
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Most Interesting ED Chief Most Interesting ED Chief ComplaintsComplaints 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
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Case PresentationCase 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.
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ABC’s of Neonatal ABC’s of Neonatal ResuscitationResuscitation Airway Airway Airway
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Initial ManagementInitial Management
IV access
monitor
oxygen
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Initial Management - Initial Management - TherapyTherapy Respiratory Support
Volume
Antibiotics
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Diagnostic TestsDiagnostic Tests
ABG CBC Lytes Cultures Radiography
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CategoriesCategories
Infectious
Cardiac
Endocrine
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Late-Onset InfectionsLate-Onset Infections
Group B Streptococcus E. coli Listeria H. influenza, S. Pneumonia, N.
meningitis Viral
– RSV, HSV, Enterovirus
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Group B StreptococcusGroup 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
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Listeria monocytogenesListeria monocytogenes
Early and late onset disease Early onset often associated with
meconium staining even in preterms
Late onset disease is primarily meningitic
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Escherichia coliEscherichia 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
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Case PresentationCase 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
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Ductal Dependent Cardiac Ductal Dependent Cardiac LesionsLesions Left sided heart lesions
– Systemic blood flow is dependent upon ductal patency»coarctation of the aorta» interrupted aortic arch»hypoplastic left heart
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Ductal Dependent Cardiac Ductal Dependent Cardiac LesionsLesions Left Sided Left Sided shock cardiac failure - hepatosplenomegaly,
large heart, gallop Pressor support prostaglandin E1
– side effects:»Flushing, Hypotension, Pyrexia (fever)» idiosyncratic apnea
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Case PresentationCase 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
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Ductal Dependent Cardiac Ductal Dependent Cardiac LesionsLesions Right sided heart lesions
– pulmonary blood flow is dependent on ductal patency»tetralogy of Fallot» transposition of great vessels » tricuspid atresia»pulmonary stenosis/atresia
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Congenital Heart Congenital Heart LesionsLesions
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Case PresentationCase Presentation
Infant is tachycardic, 200-220/min, mottled with poor perfusion. Poor feeding, Respirations are labored with rate of 80/min.
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Neonatal Rhythm Neonatal Rhythm DisturbancesDisturbances Fast
Slow
In between
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Supraventricular Supraventricular TachycardiaTachycardia 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.
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Supraventricular Supraventricular TachycardiaTachycardia 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
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Supraventricular Supraventricular TachycardiaTachycardia unstable vs stable synchronized cardioversion in
unstable patient vagal stimulation (ice to face) adenosine side effect of all cardioversion
methods:– asystole– death
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Case PresentationCase 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
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EKG pre/post EKG pre/post AdenosineAdenosine
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Neonatal HyperthyroidismNeonatal Hyperthyroidism
Maternal Graves disease - 1/2000 pregnancies
Thyroid-stimulating immunoglobulins cross the placenta
Mothers with symptomatic disease may be treated with PTU
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Neonatal HyperthyroidismNeonatal 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 thyroid-
stimulating Ig
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Neonatal HyperthyroidismNeonatal Hyperthyroidism
Transplacentally acquired thyroid-stimulating Ig may exert effects for up to 12 weeks postnatally
Thyroid storm– Irritibility– Respiratory distress– Severe tachycardia– Cardiac failure
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Neonatal Neonatal ThyrotoxicosisThyrotoxicosis Treatment Suppress excess secretion of
hormone and conversion of T4 >>T3– PTU and/or Potassium Iodide (Lugol’s)
Adrenergic Blockade– Propranolol
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Case PresentationCase 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…..
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Congenital Adrenal Congenital Adrenal HyperplasiaHyperplasia group of enzyme defects which
impair steroid hormone production 21-hydroxylase - 90% of cases two forms
– partial: simple virilizing– more complete deficiency: salt losing
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Congenital Adrenal Congenital Adrenal HyperplasiaHyperplasia 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
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Congenital Adrenal Congenital Adrenal HyperplasiaHyperplasia
Treatment Treatment treat hypovolemia correct sodium and potassium if
necessary hydrocortisone is steroid of choice mineralocorticoid replacement
may be necessary
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Inborn Errors of Inborn Errors of MetabolismMetabolism Alteration in mental status acidosis hypoglycemia electrolyte abnormalities ketosis hyperbilirubinemia
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Inborn Errors of Inborn Errors of MetabolismMetabolism Hepatomegaly Seizures Hyperammonemia Reducing substances in urine
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Inborn Errors of Inborn Errors of MetabolismMetabolism
The Smell Test The Smell Test Maple Syrup Urine Dz maple syrup Isovaleric acidemia sweaty feet Tyrosinemia rancid butter Beta-methylcrotonyl-
coenzyme A def. tomcat’s urine phenylketonuria mousy/musty methionine malabsorption cabbage trimethylaminuria rotting fish
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ConclusionsConclusions
ABC’s Monitor, IV, Oxygen, Antibiotics Diagnostic tests Know the differential