emergencies in the first 30 days of life – fever, …...emergencies in the first 30 days of life...

Emergencies in the First 30 days of Life – Fever, Breathing, Vomiting, RashILENE CLAUDIUS

HARBOR-UCLA MEDICAL CENTER

IACLAUDIUS@GMAIL.COM

DisclosuresI have no disclosures relevant to this talk

Signs of a ProblemAMS (crying or lethargy)

Poor oral intake/ vomiting

Mottling

Hyper- or hypothermia

Abnormal VS◦ Hypoxia◦ RR >60◦ SBP <60◦ HR >160 (or bradycardia)

Prime first week Out of first week

Sepsis

CHD

IEM

NAT

CAH

VolvulusDehydration

Where Do I Start?

Question #1Bilious emesis?

Prime first week Out of first week

Sepsis

CHD

IEM

NAT

CAH

VolvulusDehydration

Bilious Emesis: Malrotation w/ Midgut VolvulusAbn rotation and fixation of intestinesCan volvulize25-40% in first week◦ 50% present by 1 month◦ 75% by 1 year

50% with normal abd exam◦ 32% distended only

2-24% mortality

Malrotation with VolvulusCBC and CRP are normal earlyNormal XR, double bubble, or gaslessUGI is test of choice ◦ Sensitivity high for malrotation◦ 54% volvulus

IVF, NGT, AntibioticsEmergent surgery consult

Hirshsprung’s with Enterocolitis

No stool for first 48hConstipation with infrequent explosive stoolsEmergent when enterocolitis◦Abdominal distension◦ Foul-smelling, watery diarrhea◦ Lethargy and poor feeding

IVF, Abx, surgical consult, rectal irrigationTight sphincter on exam

Question #2

Is there ketoacidosis or elevated ammonia?

Prime first week Out of first week

Sepsis

CHD

IEM

NAT

CAH

VolvulusDehydration

STUFF Energy

Toxic Metabolites=BAD

STUFF

Food◦ Protein (breast milk or

formula)

Catabolic products from body◦ Starvation◦Dehydration◦ Fever/illness

Ammonia

Ketoacids

Neonatal IEM3-5 days of life Symptoms◦ Poor sucking and feeding◦Vomiting◦Altered Mental Status/Coma/Neuro abnormalities◦ Tachypnea/Breathing Problems

Neonatal IEMAmmonia (usually ~300 umol/L)◦ Ill neonate without metabolic disease =80

Ketoacidosis (organic acidemias)Check glucose, CBC, CMP

TreatmentStop potentially toxic substances◦ NPO◦ Stop catabolism◦ 20 mL/kg NS bolus◦ D10 0.45 NS with K at 1.5 maintenance◦ Insulin (0.05 U/kg/hr) & glucose (10mg/kg/min)

Remove ammonia◦ Na benzoate/phenylacetate 0.25 g/kg IV (2h)◦ DialysisConsider cofactors (B12), bicarbonate

Congenital Adrenal HyperplasiaOn neonatal screenPresents at 1-4 weeksSigns adrenal crisisoLethargyoVomitingoDehydrationoPoor feedingVirulization

CAHLabsoLow Na and high KoLow glucoseoAcidosis

Send 17-hydroxyprogesterone, testosterone, dehydroepianderosterone, testosterone, cortisol

Rule of 50Adult: 1 amp of D50

Child: 2 mL/kg of D25Infant: 5 mL/kg of D10

1 X 50 = 50

2 x 25 = 505 x 10 = 50

IVF (NS 20mL/kg)

25mg IV hydrocortisone, followed by drip

Question #3Have you looked at the pulse-oximeter?

◦Oxygen saturation?◦HR >220?◦RUE/LE saturation difference?

Prime first week Out of first week

Sepsis

CHD

IEM

NAT

CAH

VolvulusDehydration

Post-natal Oxygen Saturation Testing

Screen all infants with p-ox 24-36h<90% anywhere is a FAILSensitivity and specificity ◦ Sensitivity ~76.5%◦ Specificity ~99.9%

Prenatal US 50% sensitive

Ductal-dependent Heart DxCyanotic (right sided/ both sided)◦No oxygen cyanosis◦ Can’t get to lungs◦ Can’t get from lungs to systemic circulation

◦ Tetralogy of Fallot, TGA

Obstructive (left sided)◦Abn left ventricle to systemic blood flow shock◦Hypoplastic left heart syndrome, CoA

CCHD: PresentationOvert cyanosis (saturation <80-85%)

+Murmur

Comfortable tachypnea (unless in CHF)Cyanosis worsens with crying

Labs: Moderate acidosis

EKG: VariableCXR: Cardiomegaly, Characteristic pattern

CCHD: DiagnosisHyperoxia test: ◦Give 10-15 minutes of 100% oxygen ◦Repeat ABG◦ PaO2 on oxygen of <150 is indicative of cyanotic

cardiac disease ◦ If you can’t get, look for 10% p-ox improvement◦ TAPVR is exception

Echo

Obstructive Heart DiseaseLook for shockHLHS◦Deep acidosis◦ Signs of ischemia on EKG

CoA◦Upper and lower difference in pulse, BP and

oxygen saturation (3%)

Ductal-dependent HD: TxPGE1 (alprostadil, Prostin VR)◦ Start at 0.1 mcg/kg/min decrease by half◦ Lower doses (0.02 mcg/kg) ◦Administration: Any line◦ SE◦ Apnea◦ Hypotension◦ Hyperpyrexia

10 mL/kg NS, bicarbonate, furosemide, DA

PGE1 GoalsImprovement◦ Left sided lesion◦ Palpable pulses◦ Improving lactate/ acidosis

◦ Cyanotic lesions◦ Oxygen saturation 75-85%

Transfer without airway◦ > 1hour◦Down to 0.02 mcg/kg/min

SVTPresentation◦ Initially: irritability, poor feeding and pallor◦After ~24h: Heart failure cardiovascular collapse◦HR 200-350 and very regular◦No p waves

Etiology◦ Frequently Wolfe-Parkinson-White in infants◦ 20-25% with structural heart disease

SVT: Treatment

Infants: Ice bag to face (33-62% effective)Adenosine◦ 0.1 mg/kg IV◦ 0.2 mg/kg IV

No verapamilElectricity 0.5 J/kg

Question #4Is the baby eating OK (breast mild in, 2 oz every 2 hours)?

Does he urinate ~ 8 times per day?

Did the infant drop more than 7-10% of birth weight or not regain birth weight by 7-10 days?

Prime first week Out of first week

Sepsis

CHD

IEM

NAT

CAH

VolvulusDehydration

Neonatal DehydrationCheck electrolytesoHypernatermiaoCan poor developmentoCan seizuresoHypoglycemia

10-20 mL/kg NS bolus only for shock

Otherwise even correction of hypernatremia over 48 hours with correction goal <0.5 mmol/hr

Question #5

Sketchy story from parents?Bulging fontanel?

Prime first week Out of first week

Sepsis

CHD

IEM

NAT

CAH

VolvulusDehydration

Non-accidental TraumaConsider CT for head injuryAlways do skeletal survey if suspiciousConsider LFTs (abdominal CT if AST or ALT >80)Consider poisoning/ intoxication- generally narcotics, benzodiazepines, alcohol

Question #6Hyper or hypothermia OR just everyone else?

Prime first week Out of first week

Sepsis

CHD

IEM

NAT

CAH

VolvulusDehydration

Serious Bacterial InfectionSBI rate ~20% till 21 daysIn infants < 28 days meeting low risk criteria (well, normal WBC, UA, LP):◦ 6.2% have SBI

Ampicillin and gentamycin or cefotaximeComplications◦Hypoglycemia: 22-38%◦Apnea: 18-22%

SummaryBilious emesis VolvulusKetoacidosis, ammonia IEMLow Na/ High K CADCyanosis or poor pulses/ shock CHDSketchy scenario NATLoss of >10% birth weight DehydrationHypo or hyperthermia Sepsis

Summary PearlsDon’t know Check istat and p-ox, give abx, hydrocortisone, IVF, and transfer!Can have 2 at onceTreatments are benign; failure to treat is not