Oh SCH It s a neonatal emergency

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1 trekk.ca 1 1 Oh SCH It s a neonatal emergency Emma Burns, MD, FRCPC IWK Health Centre 2 1

2 Objectives Critically ill neonate approach and tips Stay on time! Thanks to: Shannon MacPhee, Mike Young, Jon Cherry, Katrina Hurley 3 Neonate 4 2

3 Approach 5 What is the Differential Diagnosis? 6 3

4 7 8 4

5 9 Case 10 day old fussy and not feeding well You are ALERT at triage. The history from parents is important Make sure you look at the baby in car seat while taking history 10 5

6 Step One 11 Triage Tips 12 6

7 Step Two 13 Sick or not sick? Keep them warm (pink and sweet!) Full set of vitals (rectal temp and SpO2) Naked weight Auscultate heart sounds Bedside Glucose 14 7

8 Sick Keep them warm: overbed warmer, blankets, warm packs Airway: Suction if needed (5F), saline is your friend Apply O2 and provide CPAP with flow inflating bag if needed Circulation: Secure 1-2 IVs and get blood work Get a bedside Glucose 15 IV Access Instead of big blue rubber tourniquets - cut them in 1/2 long way or use a 4x4 gauze open fully and fold on diagonal If using AC put facecloth or roll under upper arm Call on your friends experts early - neonatal team/labour & delivery/nicu nurses. Scalp IV is a good option Can always give antibiotics IM IO access an option in the sick infant 16 8

Sucrose as Analgesia Sucrose for procedural pain management: With only a few exceptions, sucrose, glucose, or other sweet solutions reduced pain responses during commonly performed painful procedures

9 Sucrose as Analgesia Sucrose for procedural pain management: With only a few exceptions, sucrose, glucose, or other sweet solutions reduced pain responses during commonly performed painful procedures in diverse populations of infants up to 12 months of age. (Pediatrics. 2012;130;918) only small volumes are required, such as 0.1 to 1 ml or 0.2 to 0.5 ml/kg. For LP, catheter, IV 17 Same approach 18 9

10 SCHITIE Is it the Sepsis? Is it the CNS? Is it the Heart? Is this an Intraabdominal catastrophe? Is it in the Thorax/lungs? Is it Inborn error of metabolism/endocrine? 19 Is this Sepsis? It is always sepsis! Cultures and antibiotics Ampicillin and gentamicin Ampicillin and cefotaxime if meningitis Don t delay for cultures or access 20 10

11 Fever without source in the young infant 10% of febrile infants less than 3 months old without source will have SBI (majority UTI) Clinical evaluation inadequate to rule out serious bacterial infections in neonate Risk stratification is less reliable under 28 days of age: FSWU and treat pending cultures both well and unwell 21 Is it CNS? Neurologically abnormal Apnea Change in tone Irritable/Sleepy Clinical distinction Seizures No seizures 22 11

12 23 Neonatal Seizures Facial movements, lip smacking, eye deviation Subtle tonic clonic movements Bradycardia, increased tone Apneas Floppy tone 24 12

13 Neonatal seizure Concern for Meningitis HSV Encephalitis Trauma Metabolic derangements Structural brain abnormality 25 Neonatal HSV 20 40% of neonatal HSV cases never manifest skin lesions Typically HSV type 2 acquired during delivery HSV Encephalitis: Weeks 2 3 In septic appearing neonate, especially if lethargy, seizures, unexplained acute hepatitis, HSV risk factors consider acyclovir Treatment: Acyclovir 60 mg/kg/day IV divided TID 26 13

14 Is it CNS? Neurologically abnormal Support ABCs CT head Seizure Add acyclovir Consider metabolic causes CT head 27 Is it the Heart? 28 14

15 Neonatal Heart Disease Prenatal Diagnosis: Sensitivity up to 80% More easily missed: Coarctation of the aorta VSD/ASD Pulse oximetry screening Done at IWK in Halifax since 2013 More complicated question without ECHO but there is a protocol in place for other centres 29 ED Presentation CHD Those missed in screening and newborn exam Presentation will depend on the lesion Cyanosis Cardiogenic Shock Cardiac Failure CCHD can be difficult to differentiate from neonatal sepsis 30 15

16 Major presentations: SVT Fixed HR > 220 No p waves Oh SCH Duct dependent lesion Sats < 92% despite O2 Differential spo2 >3% 31 Is it the Heart? SVT Vagal maneuvers PALS Duct dependent lesion Prostaglandin infusion mcg/kg/min Aim for sats 85% Judicious IV fluids R/A for CHF (RR, crackles, liver edge) 32 16

17 Is it Intraabdominal? 33 Abdominal X-rays 34 17

18 Which is the most likely diagnosis? A. pyloric stenosis B. Viral gastroenteritis C. Malrotation with volvulus 35 Answer: A. pyloric stenosis B. Viral gastroenteritis C. Malrotation with volvulus 36 18

19 Bilious vomit in the neonate = surgical emergency Bilious vomiting in the neonate should be considered due to mechanical obstruction until proven otherwise 40% of bilious vomiting in the neonate will require surgical intervention The implications of missing malrotation and volvulus are substantial 37 Oh Schi Sick neonate: ABCs, warm, monitor, glucose Is it sepsis: yes line and culture, antibiotics, IVF Is it CNS: acyclovir, +/- CT Is it the Heart: do pre and post ductal sats Treat SVT consider protaglandin Is it Intrabdominal: NG to LIS, call surgery 38 19

20 Is it the thorax? 39 Is it the thorax? Lower respiratory infection: Suction Oxygen CPAP/BVM Intubate Pneumothorax Needle decompress if needed 40 20

21 Clinical Pearl Low sats with no increased work of breathing THINK CARDIAC 41 AHHHHHHHHH. Vomiting, lethargy Alkalosis Acidosis Hypoglycemia Is it IEM or Endocrine? Ambiguous genitalia ( Glucose, Na, K+ ) 42 21

22 Is it IEM or Endocrine? IEM; NPO D10W at 6mL/kg/hr CAH: Hydrocortisone 25mg IV push 43 Question Is it Sepsis? Is it the CNS? Is it the Heart? Is it an Intraabdominal catastrophe? Is it in the Thorax/lungs? Is it Inborn error of metabolism Is it Endocrine? 44 22

23 Sick neonate: ABCs, warm, monitor, glucose Is it Sepsis: yes line and culture, antibiotics, IVF Is it CNS: acyclovir, +/- CT Is it the Heart: do pre and post ductal sats Treat SVT consider protaglandin Is it Intrabdominal: NG to LIS, call surgery Is it Thoracic: Suction, O2, support airway Is it IEM/Endocrine: NPO, 6mL/kg/hr Hydrocortisone 25mg IV 45 Summary Approach all sick neonates in the same way Pay attention to vitals, feeding, exam, how they handle Fever is important (Rectal 38) Pre and post ductal sats are important Bilious vomit is important Don t forget Acyclovir Don t forget steroids Mix prostaglandin early 46 23

24 Questions / Comments? 47 24

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