Neonatal%20Emergencies

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Neonatal Emergencies
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Objectives

• Relate the history of resuscitation.
• Outline the sequence of care in the resuscitation
  of a newborn.
• Describe the difference between the newly born
  and newborn, and the common reasons they may
  require or seek emergency care.

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Introduction

• Neonate 0-28 days
• Newly born Immediately at birth when fetus is
  physiologically converting to newborn life

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Case Study 1Abdominal Pain

• A 16-year-old girl arrives in your ED with
  abdominal pain.
• She states she is pregnant and is having
  abdominal pain about every 1 to 2 minutes.
• Her appearance is anxious but alert she breathes
  rapidly with pain but then slows her rate between
  episodes of pain.
• There are no retractions, and her skin color is
  normal.

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Initial Assessment

• PAT
• Normal appearance, normal breathing, normal
  circulation
• Vital signs
• HR 120, RR 22, BP 100/70, T 38C

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Questions

• What three questions should the patient be asked
  to predict the need for resuscitation of the
  newborn?
• What priorities of care should be initiated to
  resuscitate the newborn?

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Brief Resuscitation-Oriented History
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Case Progression (1 of 2)

• The patient states that
• She does not think she has twins.
• Her due date is in 3 weeks.
• The color of the fluid has been clear.

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Case Progression (2 of 2)

• Exam shows babys head crowning.
• What priorities of care should be initiated to
  resuscitate the newly born?

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Preparation for Delivery

• Assume that the infant will be depressed.
• Locate all necessary equipment in advance.

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Equipment for Neonatal Resuscitation

• Manual resuscitator (infant)
• Masks (2 sizes, term and premature)
• Dry towels/blankets
• Suction equipment
• ET tubes (sizes 2.5, 3.0, 3.5)
• Laryngoscope and blades (sizes 0, 1)

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Newborn Resuscitation Priorities (1 of 11)

• Clear meconium as needed when head delivers.

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Newborn Resuscitation Priorities (2 of 11)

• Deliver baby.
• Place your hand around neck posteriorly and one
  underneath head to control delivery.

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Newborn Resuscitation Priorities (3 of 11)

• Deliver baby.
• If babys anterior shoulder does not deliver,
  gently pull downward on head to allow shoulder to
  clear.

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Newborn Resuscitation Priorities (4 of 11)

• Deliver baby.
• Tie or clamp cord in two places and cut between
  ties/clamps.

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Newborn Resuscitation Priorities (5 of 11)
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Newborn Resuscitation Priorities (6 of 11)
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Newborn Resuscitation Priorities (7 of 11)
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Newborn Resuscitation Priorities (8 of 11)

• Assess breathing, tone, and color.
• If not normal, then warm, dry, position,
  stimulate, and give oxygen.

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Newborn Resuscitation Priorities (9 of 11)

• Begin bag-mask ventilation if apneic or heart
  rate is less than 100 bpm.

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Newborn Resuscitation Priorities (10 of 11)

• Assess heart rate.
• If less than 60 bpm after 30 sec of bag-mask
  ventilation, begin chest compressions and prepare
  medications.

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Newborn Resuscitation Priorities (11 of 11)

• Epinephrine is indicated when HR is lt60 bpm after
  30 sec of assisted ventilation plus 30 sec of
  chest compressions.
• Access may be difficult
• Tracheal
• Umbilical vein

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Challenging Resuscitation Conditions

• Technical problems
• Esophageal or mainstem intubation, hypoxia,
  hypoventilation
• Unrecognized pulmonary problems
• Pneumothorax, meconium aspiration, diaphragmatic
  hernia
• Severe metabolic problems
• Acidosis, hypoglycemia, hypothermia
• Other
• Congenital anomalies, severe anemia

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Case Progression/Outcome

• 16-year-old delivered a near-term infant.
• Baby had poor tone and color initially, but with
  suctioning, drying, warming, and stimulation
  became vigorous with good cry, tone, and color.

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Case Study 2 Fever

• Mother brings 3-week-old boy to private
  physicians office with decreased feeding today
  and fever.
• Infant is sleeping, has normal tone, no
  retractions, and color is normal.

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Initial Assessment (1 of 2)

• PAT
• Normal appearance, normal breathing, normal
  circulation
• Vital signs
• HR 120, RR 40, T 38.7C, Wt 3.5 kg

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Initial Assessment (2 of 2)

• A Open, no stridor
• B Normal rate and depth
• C Normal pulse quality and rate
• D Good tone, nonfocal
• E No trauma, no rash

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Focused History/Detailed Physical Examination

• SAMPLE Fever, mild irritability, normal birth
  history, taking formula but less than previous
• Physical exam No meningismus, no rash, infant
  taking a bottle

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Question

• What is your general impression of this patient?
• How would you transport this infant to the ED?

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General Impression

• Stable infant with fever
• Transport may be by private car or BLS transport.
• Good communication must exist with parents and ED
  staff.

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ED Management Priorities

• Thorough history, physical exam, and full sepsis
  evaluation to determine source of infection.
• Bacteremia rates in neonates with fever are much
  higher (7-12) than in older infants with fever.

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Case Discussion Fever

• Infections occurring after 5 days of life are
  termed late onset.
• Causes include
• Gram-negative organisms (e.g., E coli,
  Klebsiella, Enterobacter)
• Gram-positive organisms (e.g., Staphylococcus
  aureus, group B strep, Streptococcus pneumoniae)
• Other infections Salmonella (infectious
  gastroenteritis), Listeria monocytogenes
  (meningitis), herpes simplex virus (meningitis,
  skin vesicles)

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Case Progression/Outcome

• CBC, blood culture, urinalysis, urine culture,
  lumbar puncture, CSF culture, and chest
  radiograph were performed.
• All were negative except the urine, which showed
  20 WBCs.
• Infant was admitted and treated with intravenous
  antibiotics.

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Case Study 3 Not Acting Right

• 12-day-old girl is brought to the ED by her
  mother with a complaint of not acting right.
• Mom states that the infant has been listless for
  the past day and now will not take a bottle.
• Baby appears to be asleep and does not arouse
  with removal of her clothes. She has no
  retractions, and her color is pale.

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Initial Assessment

• PAT
• Abnormal appearance, normal breathing, abnormal
  circulation
• Vital signs
• HR 170, RR 40, BP 70/50, T 37C, Wt 3 kg
• ABCDEs
• Normal except for tachycardia, pale skin, and
  poor tone

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Focused History/Detailed Physical Examination

• Head Fontanel flat
• Neck Without meningismus
• Lungs Clear
• Cardiac No murmur
• Abdomen Nondistended, nontender
• Neurologic Poor tone and poorly arousable
• Extremities No rash

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Question

• What is your general impression of this patient?

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General Impression

• Shock or primary CNS/metabolic abnormality
• What are your initial management priorities?

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Management Priorities

• Monitor cardiorespiratory function.
• Place infant on oxygen.
• Establish intravenous access.
• Obtain rapid glucose test and draw samples for
  tests and cultures.
• Obtain head CT.
• Begin empiric antibiotic therapy for possible
  sepsis.

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Case Discussion Lethargy

• Lethargy in a neonate suggests life-threatening
  disease.
• Main causes may include
• Infection
• Metabolic disease
• Sepsis
• Anemia (severe)
• Trauma

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Case Outcome

• Rapid bedside glucose was 30 mg/dL, and serum
  ammonia was 400 µmoles.
• D10W was administered.
• Patient was admitted to PICU for care and
  hemodialysis for urea cycle defect.

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Case Study 4 Jaundice

• 5-day-old boy is brought to the ED by his parents
  with the complaint of appears yellow.
• Baby had vacuum delivery but otherwise is well.
• Baby is alert, with good tone, no retractions,
  and color of skin is yellow.

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Initial Assessment

• PAT
• Normal appearance, normal breathing, normal
  circulation
• Vital signs
• HR 120, RR 36, T 37.8C, Wt 3.3 kg
• ABCDEs
• Normal

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Focused History/Detailed Physical Examination

• Baby is breastfed and has good suck.
• Birth weight was 3.3 kg.
• Babys sleeping patterns have not changed since
  birth.
• Physical exam reveals a jaundiced baby with a
  cephalohematoma.

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Question

• What is your general impression of this patient?

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General Impression

• Stable patient with jaundice
• What are your initial management priorities?

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ED Management Priorities

• Obtain blood for serum bilirubin measurement.
• Determine total and direct bilirubin.
• Consider ordering other laboratory tests,
  including blood typing and Coombs test, CBC, and
  reticulocyte count.

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Background Jaundice

• Bilirubin can exist in one of two forms
• Unconjugated (indirect-reacting)
• Conjugated (direct-reacting)
• Three fundamental causes of hyperbilirubinemia
• Increased heme degradation (indirect)
• Delay in maturation or inhibition of conjugation
  mechanism (indirect)
• Obstruction of excretion from the liver (direct)

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Common Causes of Jaundice

• Physiologic jaundice
• Peaks at about 3 days of age
• Multifactorial may be due to immature
  conjugation mechanism in liver
• Breast milk jaundice
• Peaks after 4 days of age
• Results from breast milk inhibitors of conjugation

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Causes of Nonphysiologic Jaundice

• Indirect hyperbilirubinemia
• Hemolysis
• Extravasation of blood (cephalohematoma)
• ABO incompatibility, Rh disease
• Sepsis
• Drugs
• Direct hemolysis

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Hemolysis

• Intrinsic
• Congenital defects of RBC membrane (hereditary
  spherocytosis), or RBC hemoglobin (thalassemia,
  sickle cell disease), or RBC enzyme deficiency
  (G6PD, pyruvate kinase)
• Extrinsic
• Isoimmunization (ABO incompatibility, Rh
  disease), bacterial sepsis, or drugs

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Extravasation of Blood

• Common causes include
• Cephalohematoma
• Vacuum extractor hematoma
• Bruising with breech presentation
• Traumatic or premature delivery
• Intraventricular hemorrhage

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Direct Hyperbilirubinemia

• Occurs when gt20 of total bilirubin is conjugated
  (direct-acting).
• Always abnormal
• Results from interference of excretion of
  bilirubin from liver
• Intrahepatic Hepatitis (infections), metabolic
  disease (galactosemia)
• Extrahepatic Biliary atresia, choledochal cyst

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Case Progression

• Total bilirubin level is 20 mg/dL 19 mg/dL is
  indirect.
• Cause is probably multifactorial
• Breast milk jaundice
• Extravasation of blood with resolving
  cephalohematoma
• What are your management priorities now?

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Further Management
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Case Outcome

• Baby was admitted for phototherapy.
• Discharged 2 days later with a bilirubin of 14
  mg/dL.

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Case Study 5 Swollen Belly Button

• 6-day-old girl is brought in by father with 2-day
  history of increasing redness and swelling of the
  belly button.
• Baby is irritable with increased respiratory rate
  without retractions skin is normal in color.

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Initial Assessment

• PAT
• Abnormal appearance, normal breathing, normal
  circulation
• Vital signs
• HR 170, RR 48, T 39C, Wt 3.5 kg

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Question

• What are your management priorities?

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ED Management Priorities

• The concern is omphalitis, which is a
  life-threatening infection of the umbilicus.
• Place on cardiorespiratory monitor.
• Obtain IV access and send blood samples for CBC
  and culture.
• Begin fluid resuscitation with normal saline at
  20 mL/kg.
• Administer empiric antibiotics.

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Umbilical Problems

• Delayed separation gt3 weeks may be normal or due
  to immune deficiency or sepsis.
• Bleeding due to irritation
• Granulation tissue
• Umbilical hernia
• Discharge Omphalomesenteric duct or patent
  urachus
• Infection Omphalitis

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Case Outcome

• The baby was admitted.
• Vancomycin and cefotaxime were administered.
• Baby required three surgical debridements of
  necrotic tissue but survived.

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The Bottom Line

• Resuscitation of the newly born requires
  preparation and skill.
• Many life-threatening conditions in the newborn
  period may present with few signs or symptoms.

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