Neonatal EmergenciesNeonatal Emergencies(After Discharge)(After Discharge)

Robert Englert, M.D.Dept Neonatology

Bethesda Naval Hospital

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

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.

ABC’s of Neonatal ABC’s of Neonatal ResuscitationResuscitation Airway Airway Airway

Initial ManagementInitial Management

IV access

monitor

oxygen

Initial Management - Initial Management - TherapyTherapy Respiratory Support

Volume

Antibiotics

Diagnostic TestsDiagnostic Tests

ABG CBC Lytes Cultures Radiography

CategoriesCategories

Infectious

Cardiac

Endocrine

Late-Onset InfectionsLate-Onset Infections

Group B Streptococcus E. coli Listeria H. influenza, S. Pneumonia, N.

meningitis Viral

– RSV, HSV, Enterovirus

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

Listeria monocytogenesListeria monocytogenes

Early and late onset disease Early onset often associated with

meconium staining even in preterms

Late onset disease is primarily meningitic

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

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

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

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

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

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

Congenital Heart Congenital Heart LesionsLesions

Case PresentationCase Presentation

Infant is tachycardic, 200-220/min, mottled with poor perfusion. Poor feeding, Respirations are labored with rate of 80/min.

Neonatal Rhythm Neonatal Rhythm DisturbancesDisturbances Fast

Slow

In between

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.

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

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

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

EKG pre/post EKG pre/post AdenosineAdenosine

Neonatal HyperthyroidismNeonatal Hyperthyroidism

Maternal Graves disease - 1/2000 pregnancies

Thyroid-stimulating immunoglobulins cross the placenta

Mothers with symptomatic disease may be treated with PTU

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

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

Neonatal Neonatal ThyrotoxicosisThyrotoxicosis Treatment Suppress excess secretion of

hormone and conversion of T4 >>T3– PTU and/or Potassium Iodide (Lugol’s)

Adrenergic Blockade– Propranolol

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…..

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

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

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

Inborn Errors of Inborn Errors of MetabolismMetabolism Alteration in mental status acidosis hypoglycemia electrolyte abnormalities ketosis hyperbilirubinemia

Inborn Errors of Inborn Errors of MetabolismMetabolism Hepatomegaly Seizures Hyperammonemia Reducing substances in urine

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

ConclusionsConclusions

ABC’s Monitor, IV, Oxygen, Antibiotics Diagnostic tests Know the differential