NEONATAL EMERGENCIESASHRAF ALAWADI, MDAssociated professor of

PediatricHead of Pediatric DepT. -

UDH

NEONATAL EMERGENCIES

ASHRAF ALAWADI, MDAssociated professor of Pediatric

Head of Pediatric DepT. -UDH

Neonatal EmergenciesNeonatal Emergencies

• Neonates often present with non-specific or a history of symptoms that may or may not be benign

• In order to recognize which neonates will require life-saving interventions, clinicians need to remain current on these life-threatening illnesses and their management

RESPIRATORY SYSTEM

• Signs and Symptoms• Tachypenia (RR 60/min. or more)• nasal flaring• grunting• retractions• Apnea• Cyanosis

Retractions

RESPIRATORY SYSTEM

• Evaluation• CXR• ABG• Pulse oximetry• Ct chest• Bronchoscope/ Laryngoscope

REPSPIRATORY SYTEM

• Conditions – Anatomic approach• Alveolar

– Hyaline Membrane Disease (HMD) or Respiratory Distress Syndrome (RDS)

– Pneumonia– Meconium Aspiration Syndrome (MAS)

• Parenchymal– Transient Tachypnea of the Newborn (TTN)– Cystic Adenomatoid Malformation– Congenital Lobar Emphysema

RESPIRATORY SYSTEM

• Space-occupying– Air Leak– Effusion– Congenital Diaphragmatic Hernia

• Airway– Laryngomalacia/tracheomalacia– Tracheal web– Vocal cord paralysis– Choanal atresia

RESPIRATORY SYSTEM

• Extra-pulmonary– Sepsis/meningitis– Congenital Heart Disease– Hypothermia– Metabolic error– Abdominal distention

Hyaline Membrane Disease

Meconium Aspiration Syndrome

Pneumonia

Transient Tachypnea of the Newborn

Cystic Adenomatoid Malformation

Pneumothorax

Pneumomediastinum

Pneumopericardium

Chylothorax

Congenital Diaphragmatic Hernia

ALTEALTE

• poorly defined term used to describe any

event that is “frightening to the observer

and is characterized by some

combination of apnea, color change,

marked change in muscle tone, choking

or gagging”

ALTEALTE

• Hospitalization for observation and monitoring

• Common differential diagnosis:– Sepsis, Pneumonia, RSV– Hypothermia, Anemia– Dysrhythmias– Acid/base disturbances

ALTEALTE

– Intracranial hemorrhage, Meningitis/encephalitis

– Pertussis, Hypoglycemia

– Seizures

– GER

– Child abuse

– Inborn errors of metabolism

– Electrolyte abnormalities

CARDIOVASCULAR SYSTEM

• Signs and Symptoms• cyanosis – central vs acrocyanosis• tachycardia• tachypnea• murmur• gallop

CARDIOVASCULAR SYSTEM

• Evaluation• CXR• EKG• ABG – hyperoxia test• Echocardiography• Cardiac Cath.

Heart Disease and HypoxiaHeart Disease and Hypoxia Cyanotic Heart DiseaseCyanotic Heart Disease

• Terrible T’s:– Transposition of the great arteries (TGA)– Tetralogy of Fallot (TOF)– Tricuspid atresia (TA)– Total anomalous pulmonary venous return

(TAPVR)– Truncus arteriosus (TA)

Acyanotic Heart DiseaseAcyanotic Heart DiseaseCongestive Heart FailureCongestive Heart Failure

• Typically presents with symptoms of CHF– Tachypnea

– Tachycardia

– Hepatomegaly

– History of poor or slow feeding

– Sweating or color change with feeding

– Poor weight gain

• More gradual clinical decompensation

• May not present until after the first 2-3 weeks of age

Acyanotic Heart Disease Acyanotic Heart Disease Congestive Heart FailureCongestive Heart Failure

• Causes of CHF in Neonates:– Acyanotic heart disease (VSD, ASD, PDA,

CoA)– Severe anemia– Trauma,Sepsis– SVT– Metabolic abnormalities– SLE, Thyrotoxicosis

Acyanotic Heart DiseaseAcyanotic Heart DiseaseSupraventricular TachycardiaSupraventricular Tachycardia

• SVT is the most common neonatal dysrhythmia (1/25,000 births)

• Signs/symptoms:– Tachycardia– Poor feeding– Irritability– Heart Failure– Shock

• Heart rate sustained at >220 bpm with a QRS < 0.08 seconds

Acyanotic Heart DiseaseAcyanotic Heart Disease Supraventricular TachycardiaSupraventricular Tachycardia

Coarctation of the Aorta

CHF – Coarctation with VSD

GASTRO-INTESTINAL SYSTEM

• Consider pathologic process if vomiting in newborn period

• Difficult to differentiate between a life-threatening cause from a mild viral gastroenteritis or even severe gatroesophageal reflux

• Initial symptoms may be nonspecific

• Bilious emesis is almost always an ominous sign

GASTRO-INTESTINAL SYSTEM

• Signs and Symptoms• polyhydramnios• distention• failure to pass meconium or stool• Vomiting

• Evaluation• Abdominal films• Contrast studies• US

GASTRO-INTESTINAL SYSTEM

• Conditions– Congenital malformations

• Tracheal-Esophageal Fistula (TEF)• Duodenal atresia• Intestinal atresias• Omphalocele, Gastroschisis

– Malrotation with Midgut VolvulusMalrotation with Midgut Volvulus– Necrotizing Enterocolitis (NEC)– Toxic MegacolonToxic Megacolon– Hypertrophic Pyloric StenosisHypertrophic Pyloric Stenosis

Tracheoesophageal-fistula

Duodenal Atresia

Intestinal Atresia

Gastroschisis Omphalocele

NECROTIZING ENTEROCOLITIS

NECROTIZING ENTEROCOLITIS

NEC - perforation

Malrotation with Midgut VolvulusMalrotation with Midgut Volvulus

CENTRAL NERVOUS SYSTEM

• Signs and Symptoms• seizures• lethargy• irritability/tremors• Hypotonia• coma

CENTRAL NERVOUS SYSTEM

• Conditions• Hypoxic-Ischemic Encephalopathy (HIE)• Intra-cranial Hemorrhage• Drug withdrawal• Malformations• Meningitis• IEM

CENTRAL NERVOUS SYSTEM

• Evaluation

– LP– EEG– US– CT/MRI– Metabolic screen

Intra-cranial Hemorrhage

HEMATOLOGIC

• Signs and Symptoms• Pallor• Shock• Early Jaundice• Petechiae• bleeding

HEMATOLOGIC

• Conditions– Acute Blood loss

• Placenta previa• Abrutio placentae• Velamentous cord insertion• Cord accident• Organ rupture

HEMATOLOGIC

• Conditions– Chronic Blood loss

• Maternal-fetal • Twin-twin transfusion• Hemolytic anemias – immune, non-

immune

HEMATOLOGIC

• Conditions– Thrombocytopenia– Polycythemia– Hemorrhagic Disease of the Newborn– DIC

Endocrine Emergencies

• Congenital Adrenal Hyperplasia– Vomiting– Hypoglycemia– Dehydration or even shock

• Neonatal thyrotoxicosis– poor feeding, failure to thrive, tachycardia, – irritability, hyperthermia, vomiting, diarrhea, – thrombocytopenia, respiratory distress,– heart failure and shock

Inborn Errors of MetabolismInborn Errors of MetabolismMetabolic EmergenciesMetabolic Emergencies

• Often have a delayed diagnosis

• Symptoms may be unrecognized because they are uncommon

• Require a high level of suspicion for diagnosis

• Diagnosis should be considered in any infant who does not have any other obvious cause for symptoms

Inborn Errors of MetabolismInborn Errors of Metabolism Metabolic EmergenciesMetabolic Emergencies

• Nonspecific symptoms– Poor feeding– Vomiting– FTT– Tachycardia– Tachypnea– Irritability

Inborn Errors of MetabolismInborn Errors of Metabolism Metabolic EmergenciesMetabolic Emergencies

• More apparent symptoms– Seizures– Lethargy– Hypoglycemia– Apnea– Temperature instability– Acidosis

Inborn Errors of MetabolismInborn Errors of Metabolism Metabolic EmergenciesMetabolic Emergencies

• Labs– Bedside glucose– CBC– Blood Ammonia– ABG– Lactate and Pyrovate levels– LFT’s– Urine for reducing substances and ketones– Blood and urine for organic and amino acids

Inborn Errors of MetabolismInborn Errors of Metabolism

Inborn Errors of MetabolismInborn Errors of Metabolism Metabolic EmergenciesMetabolic Emergencies

• Management– Fluid resuscitation– IV dextrose to prevent further catabolism– Admission to hospital– Genetics consultation

The Misfits MovieThe Misfits Movie

Neonatal EmergenciesNeonatal Emergencies

“THE MISFITS”– T- Trauma (accidental & nonaccidental)

– H- Heart Disease/Hypovolemia/Hypoxia

– E- Endocrine (congenital adrenal hyperplasia, thyrotoxicosis)

– M- Metabolic (electrolyte imbalance)

– I- Inborn Errors of Metabolism: metabolic emergencies

– S- Sepsis (meningitis, pneumonia, UTI)

– F- Formula mishaps (under or overdilution)

– I- Intestinal catastrophes (volvulus, intususception, NEC)

– T- Toxins/poisons

– S- Seizures

ConclusionConclusion

• The mnemonic “THE MISFITS” “THE MISFITS” is a helpful tool that can be readily used to formulate an approach to the most common neonatal emergencies that may present to general pediatricians in their hospital or private offices as well as ED clinicians in the ED department

THANK YOUTHANK YOU