Oh SCH… It’s a neonatal emergency · unexplained acute hepatitis, HSV risk factors consider ......
Transcript of Oh SCH… It’s a neonatal emergency · unexplained acute hepatitis, HSV risk factors consider ......
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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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