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Neonatal Emergencies Approach to the sick Infant

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Neonatal Emergencies Approach to the sick Infant Powered By Docstoc
					Approach to the sick Infant

        Arun Abbi MD
Neonatal Physiology/Anatomy
 Infants have different Physiology and anatomy
  than adults

 They are dependant on their primary caregiver
  for hydration and nutrition

 They are also unable to communicate to
  adults and therefore often present later in the
  course of an illness
 They have less cardiorespiratory reserve than
  adults
Airway

   1. Primarily a Nasal Breather
      This is relevant when an infant presents with
      URI Sx and has trouble breathing due to nasal
       congestion
   2. Larger tongue
      Makes intubation harder
      prone to upper airway obstruction when
       bagging and when infant becomes obtunded
Breathing

 Normal Respiratory rate for
   Newborns - 30 - 60 /min
   Infants (1-6 months) - 30 - 50 /min
 Tachypnea, Accessory muscle use and
 Grunting are signs of Respiratory distress

 FEEDING is the most physically demanding
  thing that infants do.
   When they present with diseases causing
   respiratory compromise, they stop feeding - this
   is a sign of a SICK INFANT
 BRADYCARDIA - late sign of hypoxia
Circulation

 Normal
   HR -
       Neonate- 90 - 150
       Infant - 100 -130
   BP - (70 + 2 X age)
       Neonate - 60 - 80 - syst
       Infant - 80 - 100


 Infants can not increase their stroke volume.
  They increase their cardiac output by
  becoming tachycardic (compensatory
  mechanism of shock)
Circulation

The Ductus closes in the first 2 weeks of
 life
Infants with right to left shunts will
 present with cyanosis.
Infants with left to right shunts will
 present with CHF (coarctation of the
 Aorta, VSD, ASD)
Circulation

 Signs of Shock
     1. LETHARGY
     2. POOR FEEDING
     3. DELAYED CAP REFILL
     4. HYPOTHERMIA
     5. TACHYCARDIA
     6. HYPOTENSION (Late Sign)
Metabolic

 The infant has diminished glycogen stores and
  a high metabolic rate.
   Hypoglycemia is a common symptom for a sick
    infant when they are not feeding
   CHECK A CHEMSTRIP in an infant who has not
    been feeding for > 12 hrs and is lethargic
      Hypoglycemia - glucose 4 cc/kg of D10W
 Infants have a high surface area to body
 weight ratio
   This predisposes them to hypothermia due to
    much greater heat loss
Approach to the sick infant

 Perform an initial brief assessment and
  determine LOC and stability
 Get a chemstrip quickly while getting the
  history
   Hx from time of discharge till ED presentation
         Discharge weight/gestational age
         Length of labour
         Rupture of Membranes
         Group B step?
         FEEDING HX (how much and how often)
Assessment

 Overall appearance
     Alert versus lethargic
     Vital signs
     Fontanalle
     Cardiac exam/peripheral pulses
     Abdomen
       Tender
       Palbable liver?
   Genitals
       Any ambiguous genitalia?
Differential Diagnosis

 There are a multitude of different causes for a
  SICK APPEARING INFANT
 1. Infection
 2. Cardiac diseases
 3. Metabolic disorders
 4. Gastrointestinal disorders
 5. Child abuse
PNEUMONIC FOR SICK INFANT

 THE MISFITS
       T rauma
       H eart disease and Hypovolemia
       E ndocrine
       M etabolic (electrolyte disturbance)
       I nborn Errors of Metabolism
       S epsis
       F ormula Mishaps (under/overdilution)
       I ntestinal Catastrophes (volvulus,intussusception,NEC)
       T oxins and poisons
       S eizures
Case 1

6 day old male presents with increased
 lethargy and decreased feeding for 24
 hours
Mother brings in child to ER
Patient born at term NSVD (no
 complications
Exam

Child appears mildly jaundiced
Child is slightly lethargic but not irritable
Vitals
   RR - 46 P - 144 BP 73/35 T - 36.2 Sat
    95% (RA)
Labs

BGL - 4.4
WBC - 13.2
   Neuts 9.5
   Lymphs - 3.6
CH6 - normal
Bili - 404 (normal < 340)
What do you want to do?

1. Phototherapy
2. Send home and encourage more
 breast feeding with formula
 supplementation
3. More tests
Tests

Cath Urine
   Moderate bacteria
   10 - 20 wbc


CXR - nil acute
LP

WBC - 150
RBC - 1
Gram Stain - gram neg rods
Treatment

 Ampiciliin - 50mg/kg/dose Q6h

 Cefotaxime - 50mg/kg/dose Q6h

 Consider acyclovir 10mg/kg if conerned about
  neonatal herpes

 No Dexamethasone for neonates
Infection

 Bacterial
    UTI, pneumonia, Meningitis.
    Group B strept, Listeria, E Coli, Staph



 Viral
    RSV, enterovirus, neonatal herpes
Infections

 Infants will present with lethargy, poor feeding,
  tachycardia and tachypnea
 They may have a fever (>38.0 C) or be
  hypothermic

 Infants do not have the ability to localize
  infections till about 3 months of age.
 Meningitis can’t be ruled out clinically < 3
  months of age
Infections
 UTI is the most common infection
    Get a catheter specimen if an infant is sick


 Respiratory infections present with
  tachypnea, grunting/wheezing (RSV)


 Meningitis will have nonspecific signs and
  will be diagnosed on LP
 Bugs - Group B Strept, E coli, Listeria
Infections

Treat infants if they appear sick
   Drugs -
      Amp/Gent
      Cefotaxime/ampicillin
Case 2

10 day old male who presents to the ER
 with decreased feeding for 24 hours
Mother states the child has only taken 4
 oz in the last 24 hours
Child had one bloody mucousy BM
Born at term and no complications
Case 2 Exam

Child appears lethargic
Pt is tachypneic with some accessory
 muscle use
Case 2 Cont’d

Any Concerns???


What do you want to check?


What else do you want to know?
BGL - 1.1
Treatment of hypoglycemia

Give 4 cc/kg of D10W (10% glucose)
 and reassess BGL Q 30 minutes
CXR

Mild increased perhilar markings
DDX

Query pneumonia versus cardiac


Patient has a palpable liver and has
 diminished pulses peripherally
Case 2
Cardiac Diseases

 The Patent Ductus Arteriosis closes and 7 - 14
  days.

 Infants with Right - Left shunts present with
  cyanosis - not relieved with oxygen

 Infants with Left - Right shunts/ Coarct present
  with signs of CHF
Cardiac Diseases

Other presentations can include SVT -
 causing CHF. The rate is usually around
 240 and there is minimal variation (239 -
 241)

Viral myocarditis can present at any age
 with cardiogenic shock
Cardiac Diseases - CHF
 Infants presenting with CHF will have signs
  of
    1. Respiratory distress
        Tachypnea, indrawing, accessory muscle use, crackles
    2. Hepatomegaly
    3. JVD
    4. Peripheral edema

 CXR will show signs of CHF- usually increased
  perihilar markings with an enlarged heart
 A Cap gas is useful to determine if the infant is in
  shock
Cardiac Diseases- Treatment CHF

 1. Oxygen
 2. If BP is low - initiate inotropes - dopamine or
  epinephrine
 3. Lasix 1mg/kg iv
 4. PGE 1 - 0.05 - 0.1 units/kg
 5. Intubate if infant is in persistent shock
 6. Arrange for echocardiogram
Cardiac Diseases - Right to Left
Shunt
 These infants present with cyanosis that is
  unresponsive to oxygen.
 Oxygen saturations will be low

 Treatment is PGE 1 - 0.05 - 0.1 units/kg/min to
  keep the ductus open
 Transfer to a centre where a permanent shunt
  can be inserted in the heart
Case 3

2 week old child presents with lethargy
 and fatigue
Patient has been vomiting for 16 hours
 and mother is concerned about
 dehydration
Nurse places child on the monitor
Exam

Child is dehydrated
Child is lethargic and had decreased cap
 refill
Chest is clear
Abdomen is soft and nontender
Concerns?

DDX
   Get a stat Cap gas to look at the K+
   Will see low Na+ with a high K+ and a
    normal anion gap
Metabolic Disorders
 1. Dehydration -
   hypernatremia, hyponatremia

 2. Congenital adrenal hyperplasia

 3. Urea cycle defects

 4. Hypothyroidism

 5. Toxins - ASA, ETOH
Metabolic Disorders
1. Dehydration -
   Will see delayed cap refill. Decreased
    skin turgor, lethargy, tachycardia, dry
    mucous membranes
   Tx - fluids - 20 cc/kg of NS - then
    reassess
Metabolic Disorders


 2. Congenital Adrenal Hyperplasia
    Will see ambiguous genitalia
     in females but males may have a hyperpigmented scrotum
        1 - fluids 20 cc/kg- fluids
        2. - Insulin/glucose for K+ (often resolves with fluids)
        3. Dexamethasone 0.2 mg/kg iv
 3. Urea Cycle Defects
    Check the glucose
    - need to draw an “ammonia” level, serum ketones,
     Urine for reducing substances, ketones and pH, serum
     lactate
Case 4

2 day old presents with vomiting after
 feeding
Patient was sent home day of birth and
 presents 36 hours later as he is vomiting
 with feeding for the last 12hours
Case 4

Child is alert and looking around
Chest is clear
Abdomen is mildly distended and
 moderately tender
DDX?
Gastrointestinal disorders

 1. Gastroenteritis
 2. Pyloric Stenosis
 3. Intussusception
 4. Appendicitis
 5. Necrotizing Enterocolitis
 6. Midgut volvulus
 7. Duodenal atresia
Initial Management

 Check BGL
 Start IV D10W NS at 4 cc/kg/hr
 Check Urine
 If abdomen is quite tender - surgical consult
 If not sure - then get Upper GI/US of abdomen
 Start antibiotics (cefotaxime)
 Gastrointestinal

 1. Gastroenteritis -
    presents with vomiting and diarrhea
    Rotavirus is a common cause
       Tx - oral rehydration if possible - otherwise IV


 2. Pyloric stenosis -
    presents with projectile vomiting. Often bilious. 3- 6
     weeks of age
       Diagnosis is made by US
 Gastrointestinal

 3. Intussusception

   Usually 6 months - 18 months of age.
   Sx
      Vomiting, poor feeding, bloody stools
       Abdominal pain that is intermittent
       May see a paucity of gas in the RLQ

   Diagnosis - air contrast enema - also a good
    therapeutic maneuver
Gastrointestinal
 4. Neonatal Appendicitis
    High mortality
    Presents with poor feeding and abdominal
     pain/tenderness.
    Abdominal distension

 5. Necrotizing Entercolitis
    Seen in premature infants who have anoxic insults
     at birth
    Bloody stools
    Distended abdomen
    Pneumatosis intestinalis on X-ray
Gastrointestinal

6. Midgut volvulus
   Presents similar to neonatal appendicitis -
    pain, distension, lethargy and poor feeding
   High mortality as it leads to necrosis of
    most of the small bowel
Case 5

Patient is a 4 week old female who was
 born at 34 weeks (38 weeks corrected)
Child was DC home after 10 days due to
 some feeding difficulties
Exam

Child is lethargic and has poor tone
Chest is clear with no accessory muscle
 use
Abdomen is soft and nontender
CVS - normal heart sounds/pulses and
 no murmers
Labs

Cath urine - clean
CXR - nil acute
CBC
   WBC - 12.7
   HgB - 114 (slightly low)
   Platelets - 240
Concerns?

Further Tests?
LP

WBC - 30
RBC - 12 000
Glucose 5.5
Protein -normal
Child Abuse

 Can present at any age
 In infants - will appear as a septic infant
  without a fever
 Lethargy is usually due to intra-cerebral
  hemorrhages
 Retinal hemorrhages are diagnostic of Shaken
  baby syndrome
 Other signs of abuse are often rare
 Diagnosis often made with LP - bloody
KEY POINTS

 1. Infants have diminished reserve
 2. Feeding is their most physically demanding
  activity.
    Any cardiorespiratory illness will lead to
     diminished feeding
 3. If lethargic - check a CHEMSTRIP
 4. If child is ill and no focus is found, think of
  child abuse

				
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posted:4/14/2011
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