emergencies in the first 30 days of life – fever, …...emergencies in the first 30 days of life...
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Emergencies in the First 30 days of Life – Fever, Breathing, Vomiting, RashILENE CLAUDIUS
HARBOR-UCLA MEDICAL CENTER
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