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Neonatal Emergencies Beyond the A,B,C’s of Resuscitation in the DR and NICU Case # 1 Summoned to the LDR STAT term infant no prenatal complications cyanotic severe respiratory distress cyanosis, grunting, retractions, HR 140, good tone Case # 1 Attempt PPV unsuccessful Attempt intubation can’t see past the base of the tongue very small mandible What is the name and etiology of this infant’s anatomical condition? Pierre Robin Sequence Case # 1 Approach to this airway place infant prone nasal trumpet or 2.5 ETT insert via nasal passage tip at level of the posterior pharynx call Peds ENT stat if you can’t secure an airway Case # 1 Pierre-Robin triad macroglossia + cleft palate glossoptosis micrognathia respiratory obstruction tongue held against posterior pharyngeal wall secondary to marked neg pressure during insp effort Case # 1 Treatment support airway Positioning Nasal Airway Tracheostomy Nutrition Prognosis the more prolonged the resuscitation the worse the neurologic outcome Case # 2 You are called to attend a delivery secondary to fetal distress A, B, C’s of resuscitation initiated Person managing the airway increased epinephrine tachycardia and tremors excessive PPV Case # 2 What complication would you anticipate? What clinical signs are indicative of a pneumothorax? cyanosis bradycardia decreased BS on affected side Emergency intervention? Needle Thoracostomy What equipment will you gather? Case # 3 Summoned to the LDR STAT Corpsman meets you at the door and says “doc the babies intestines are all over the place” How will you manage this? Delivery Room Management: Gastroschisis ABC’s of resuscitation Warm, saline-soaked lap sponges, plastic wrap or bowel bag to cover the intestines Decompression of the bowel ASAP Avoid volvulus of the mesenteric vessels Avoid tearing bowel mesentery or causing unnecessary damage to bowel Remember importance of thermoregulation and controlling fluid losses Gastroschisis E m Intestines herniate through the abdominal b wall r Area weakened by involution of the right y umbilical vein (theoretical) o Sequence occurs relatively early in l gestation o Differs from omphalocele g y Omphalocele Gastroschisis Incidence 1:6,000-10,000 1:20,000-30,000 Covering Present (may be Absent Sac ruptured) Fascial Small to large Small (vascular Defect compromise) Cord Attach. Umbilical the sac Abd wall Omphalocele Gastroschisis Herniated Protected Edematous and Bowel matted Other organs Liver often in sac Remain in abd. IUGR Less common Common NEC If sac is ruptured 18 % Assoc.. Anomalies Omphalocele Gastroschisis Overall 55% to 80% 10% to 15% 37 % (Midgut 18 % (stenosis and GI volvulus Meckel’s atresias) Diverticulum, atresia, duplications) Cardiac 20 % 2% Trisomy 30 % No increase Prognosis Gastroschisis: 70% to 90% survival morbidity related to prematurity and bowel compromise Case # 4 Summoned to the LDR for a meconium delivery Light mec is present and the infant cries immediately upon delivery Within 15 seconds respiratory distress ensues Case # 4 You initiate A, B, C’s of resuscitation PPV is ineffective cyanosis is worsening HR begins to decline BS are decreased on the left compared to the right You notice the abdomen looks like this Diagnosis? Diaphragmatic Hernia Case # 4 Resuscitation Intubation to overcome resp distress or failure Bowel decompression to prevent gas from inflating the bowel Physiologic consequences of D-Hernia Pulmonary hypoplasia Pulmonary hypertension Air leak syndrome Non-rotation of the bowel Feeding difficulties Case # 4 1 in 3,000 90% occur on the left side Abdominal content within chest Compresses both lungs Pulmonary hypoplasia Pulmonary hypertension NO and/or ECMO Definitive tx---surgical repair Case # 5 You are called to see a newborn shortly after delivery for “coughing” Mild respiratory distress tachypnea and “gasping” respirations You suction coughing persists oral secretions continue to pool in the back of the throat Case # 5 What are your next steps? Oral suction, pulse ox, OG, IV Evaluation for infection Blood culture, cbc, abx, chest film Case # 5 Abdominal distention continues to increase followed by worsening resp distress and cyanosis Next step? Will intubation help decrease abdominal distention? Case # 5 Causes of increased Resp distress? Secretions TEF leading to increased intestinal gas Anal atresia----no decompression How do you relieve the abdominal distention? What syndrome would you consider?
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