Neonatal Red Flags Workshop

Transcription

1 Neonatal Red Flags Workshop APEM 2017 Dr Lisa Gotley What s so special about neonates Transi;on to life Structural anomalies- cardiac, GIT, renal, neuro, etc Immune system Establishing feeds New parents without an instruc;on manual 1

2 Neonates- General rules Don t panic but don t trust them! Respiratory distress = sepsis ;l proven otherwise Vomi;ng with bile = bowel obstruc;on ;l proven otherwise Jaundice on Day 1 = something serious ;l proven otherwise Respiratory distress in a neonate 2

3 Clinical Assessment PC Collateral System rv Why now? Observa;ons Hx and Ex ADLs Life threats Targeted Exam Bedside Ix Age Who is my pa;ent? Social Gender Allergies PMHx Meds Immunisa;ons DDx How sick is this child? Risk stra;fy M a n a g e m e n t Most likely Severity Exclude diagnoses not to miss Inves;ga;ons Consulta;on Causes of respiratory distress Infec;on: NOT TO MISS! Retained fetal lung fluid = transient tachypnoea of the newborn (TTN) Respiratory Distress Syndrome/ Hyaline Membrane Disease Aspira;on (meconium, blood, liquor) Pneumothorax Congenital: pulmonary hypoplasia, diaphragma;c hernia, airway obstruc;on, congenital cardiac disease Congenital cardiac 3

4 How can I tell- structured approach? Life Threat assessment ABCDEFG History Gesta;on, mode of delivery, ;me of onset of respiratory distress, liquor, infec;on risk factors Examina;on: Severity of respiratory distress, air entry, percussion, transilluminate, cardiac exam Inves;ga;ons: CXR, BGL, Blood gas Differen;al Diagnosis Dangerous diagnoses to exclude- blood culture and an;bio;cs as infec;on un;l proven otherwise Risk StraAficaAon & Severity assessment- what level of respiratory support is needed, which inves;ga;ons for causes How do I work out what the cause is? Clues Gesta;on Method of delivery Liquor Time of onset of respiratory distress CXR Infec;on risk factors 4

5 What are the risk factors for neonatal infection? Premature labour Maternal fever Prolonged rupture of membranes Previous EOGBS infant MANY BABIES WILL HAVE SEPSIS WITHOUT ANY OF THESE RISK FACTORS! Does examination help? It might Severity assessment Equal expansion, air entry Added sounds Transilluminate Murmur pulses Other congenital anomaly 5

6 Management principles ABCDEFG Specific Management Suppor;ve management Complica;ons/ correct diagnosis Consulta;on Disposi;on ABC Oxygen- humidicrib IPPV/ PEEP via Neopuff CPAP/ ven;la;on 6

7 Specific Management Blood culture and an;bio;cs: Don t think, just do! Surfactant for HMD Supportive management IV Fluids: 10% dextrose 60ml/kg/day Monitor vitals, temperature, blood glucose (Sweet, pink, warm) Small trophic feeds EARLY Minimal handling 7

8 Vomiting in a neonate Bile stained vomiting Never ignore bile stained vomit Intes;nal obstruc;on distal to the ampulla of Vater Assume malrota;on with midgut volvulus un;l proven otherwise Could also be: Duodenal atresia Jejunoileal atresia Meconium ileus Necro;zing enterocoli;s A surgical emergency by defini;on 8

9 Clinical Assessment PC Collateral System rv Why now? Observa;ons Hx and Ex ADLs Life threats Targeted Exam Bedside Ix Age Who is my pa;ent? Social Gender Allergies PMHx Meds Immunisa;ons DDx How sick is this child? Risk stra;fy M a n a g e m e n t Most likely Severity Exclude diagnoses not to miss Inves;ga;ons Consulta;on How can I tell- structured approach? Life Threat assessment ABCDEFG History Vomit specifics, feeds, weigh gain, chronicity, hydra;on Examina;on: Is the baby sick? Abdo exam, inguinal/scrotal, hydra;on Inves;ga;ons: AXR, upper GI contrast study Differen;al Diagnosis Dangerous diagnoses to exclude: ObstrucAon- Malrota;on with volvulus un;l proven otherwise Risk StraAficaAon & Severity assessment 9

10 More on neonatal vomiting New vomi;ng: THINK! Large vomi;ng (not posits): THINK No diarrhoea: THINK Other causes of vomi;ng (medical): UTI Sepsis Meningi;s Take home massage: be very careful to diagnose as Gastroenteri;s!! More on neonatal vomiting Targeted examina;on in vomi;ng: CNS Abdo Scrotum, inguinal region ENT Inguinal hernias in babies have a very high rate of strangula;onplease refer immediately even if reducible 10

11 Other causes of vomiting Pyloric stenosis GORD: effortless Cow s milk protein allergy Adrenal insufficiency Metabolic Other intes;nal obstruc;on Neonatal jaundice 11

12 Clinical Assessment PC Collateral System rv Why now? Observa;ons Hx and Ex ADLs Life threats Targeted Exam Bedside Ix Age Who is my pa;ent? Social Gender Allergies PMHx Meds Immunisa;ons DDx How sick is this child? Risk stra;fy M a n a g e m e n t Most likely Severity Exclude diagnoses not to miss Inves;ga;ons Consulta;on How can I tell- structured approach? Life Threat assessment ABCDEFG: Is the baby sick? History How old is the baby? Risk factors? How/ what is baby feeding? When did jaundice start? Examina;on: Is the baby sick? How jaundiced are they? Inves;ga;ons: How high is the bilirubin? Conjugated or unconjugated? ABO incompa;bility Differen;al Diagnosis Dangerous diagnoses to exclude- haemolysis, obstruc;ve jaundice Risk StraAficaAon & Severity assessment- day 1 jaundice, high bilirubin, bilirubin level not decreasing with phototherapy, sick baby 12

13 Jaundice: Red flags High bilirubin Conjugated hyperbilirubinemia Jaundice day 1 Significant risk factors Sick baby Failure to respond to treatment Take home messages Respiratory distress is sepsis un;l proven otherwise Bilious vomi;ng is bowel obstruc;on un;l proven otherwise Think hard about NEW vomi;ng, FORCEFUL vomi;ng Vomi;ng without diarrhoea may not be gastroenteri;s Inguinal and scrotal exam cri;cal in vomi;ng- inguinal/scrotal hernias need urgent repair Jaundice on day 1/ aoer 2 weeks/ high levels = pathological 13