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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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