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trekk.ca

Oh SCH… It’s a neonatal emergency

Emma Burns, MD, FRCPC IWK Health Centre

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Objectives

Critically ill neonate approach and tips

Stay on time!

Thanks to:  Shannon MacPhee, Mike Young, Jon Cherry, Katrina Hurley

Neonate

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Approach

What is the Differential Diagnosis?

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Case

10 day old – fussy and not feeding well

You are ALERT at triage ….

The history from parents is important

Make sure you look at the baby in car seat while taking history

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Step One

Triage Tips

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Step Two

Sick or not sick?

Keep them warm (pink and sweet!) Full set of vitals (rectal temp and SpO2) Naked weight Auscultate heart sounds Bedside Glucose

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Sick

Keep them warm: overbed warmer, blankets, warm packs Airway: Suction if needed (5F), saline is your

friend Apply O2 and provide CPAP with flow inflating

bag if needed Circulation: Secure 1-2 IVs and get blood work Get a bedside Glucose

IV Access

Instead of big blue rubber tourniquets - cut them in 1/2 long way or use a 4x4 gauze open fully and fold on diagonal

If using AC put facecloth or roll under upper arm Call on your friends experts early - neonatal

team/labour & delivery/NICU nurses. Scalp IV is a good option Can always give antibiotics IM IO access an option in the sick infant

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Sucrose as Analgesia

Sucrose for procedural pain management:• With only a few exceptions, sucrose, glucose,

or other sweet solutions reduced pain responses during commonly performed painful procedures in diverse populations of infants up to 12 months of age. (Pediatrics. 2012;130;918)

• only small volumes are required, such as 0.1 to 1 mL or ∼0.2 to 0.5 mL/kg.

For LP, catheter, IV

Same approach

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SCHITIE

Is it the Sepsis? Is it the CNS? Is it the Heart? Is this an Intraabdominal catastrophe? Is it in the Thorax/lungs? Is it Inborn error of metabolism/Endocrine?

Is this Sepsis?

It is always sepsis!

Cultures and antibiotics• Ampicillin and gentamicin• Ampicillin and cefotaxime if meningitis

Don’t delay for cultures or access

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Fever without sourcein the young infant

10% of febrile infants less than 3 months old without source will have SBI (majority UTI)

Clinical evaluation inadequate to rule out serious bacterial infections in neonate

Risk stratification is less reliable under 28 days of age:  FSWU and treat pending cultures both well and unwell

Is it CNS?

Neurologically abnormal• Apnea• Change in tone• Irritable/Sleepy

Clinical distinction• Seizures• No seizures

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Neonatal Seizures

Facial movements, lip smacking, eye deviation

Subtle tonic clonic movements

Bradycardia, increased tone

Apneas Floppy tone

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Neonatal seizure

Concern for • Meningitis• HSV Encephalitis• Trauma• Metabolic derangements• Structural brain abnormality

Neonatal HSV

20‐40% of neonatal HSV cases never manifest skin lesions

Typically HSV type 2 acquired during delivery

HSV Encephalitis: Weeks 2‐3 

In septic‐appearing neonate, especially if lethargy, seizures, unexplained acute hepatitis, HSV risk factors consider acyclovir 

Treatment: Acyclovir 60 mg/kg/day IV divided TID

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Is it CNS?

Neurologically abnormal• Support ABCs• CT head

Seizure• Add acyclovir• Consider metabolic causes• CT head

Is it the Heart?

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Neonatal Heart Disease

Prenatal Diagnosis:  Sensitivity up to 80%• More easily missed: Coarctation of the aorta VSD/ASD

Pulse oximetry screening• Done at IWK in Halifax since 2013• More complicated question without ECHO but there is a protocol in place for other centres

ED Presentation CHD

Those missed in screening and newborn exam• Presentation will depend on the lesion Cyanosis Cardiogenic Shock Cardiac Failure

CCHD can be difficult to differentiate from neonatal sepsis

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Oh SCH…

Major presentations:

SVT• Fixed HR > 220• No p waves

Duct dependent lesion• Sats < 92% despite O2• Differential spO2 >3%

Is it the Heart?

SVT• Vagal maneuvers• PALS

Duct dependent lesion• Prostaglandin infusion 0.05-0.1 mcg/kg/min Aim for sats 85%

• Judicious IV fluids R/A for CHF (RR, crackles, liver edge)

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Is it Intraabdominal?

Abdominal X-rays

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Which is the most likely diagnosis?

A. pyloric stenosis B.  Viral gastroenteritis C. Malrotation with volvulus

Answer:

A. pyloric stenosis B.  Viral gastroenteritis C. Malrotation with volvulus

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Bilious vomit in the neonate = surgical

emergency Bilious vomiting in the neonate should be considered due to mechanical obstruction until proven otherwise

40% of bilious vomiting in the neonate will require surgical intervention

The implications of missing malrotation and volvulus are substantial

Oh Schi…

Sick neonate: ABCs, warm, monitor, glucose Is it sepsis:

• yes – line and culture, antibiotics, IVF Is it CNS:

• acyclovir, +/- CT Is it the Heart:

• do pre and post ductal sats• Treat SVT • consider protaglandin

Is it Intrabdominal:• NG to LIS, call surgery

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Is it the thorax?

Is it the thorax?

Lower respiratory infection:• Suction• Oxygen• CPAP/BVM• Intubate

Pneumothorax• Needle decompress if needed

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Clinical Pearl

Low sats with no increased work of breathing

THINK CARDIAC

Is it IEM or Endocrine?

AHHHHHHHHH….

Vomiting, lethargy Alkalosis Acidosis Hypoglycemia

Ambiguous genitalia (Glucose,Na,K+ )

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Is it IEM or Endocrine?

IEM;• NPO• D10W at 6mL/kg/hr

CAH:• Hydrocortisone 25mg IV push

Question

Is it Sepsis? Is it the CNS? Is it the Heart? Is it an Intraabdominal catastrophe? Is it in the Thorax/lungs? Is it Inborn error of metabolism Is it Endocrine?

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Sick neonate: ABCs, warm, monitor, glucose Is it Sepsis:

• yes – line and culture, antibiotics, IVF Is it CNS:

• acyclovir, +/- CT Is it the Heart: do pre and post ductal sats Treat SVT • consider protaglandin

Is it Intrabdominal:• NG to LIS, call surgery

Is it Thoracic:• Suction, O2, support airway

Is it IEM/Endocrine:• NPO, D10W @ 6mL/kg/hr• Hydrocortisone 25mg IV

Summary

Approach all sick neonates in the same way Pay attention to vitals, feeding, exam, how they

handle

Fever is important (Rectal ≥38) Pre and post ductal sats are important Bilious vomit is important

Don’t forget Acyclovir Don’t forget steroids

Mix prostaglandin early

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Questions / Comments?

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