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Chapter 3
Emergency treatment
History and examination Laboratory investigations, if required Diagnoses (main and secondary) Treatment Monitoring and supportive care Reassess Plan discharge
What emergency (danger) and priority (important) signs have you noticed from the history and from the picture?
Triage
Emergency signs (Ref: p2) Obstructed breathing Severe respiratory distress Signs of shock Coma Priority signs (Ref: p.2) Severe wasting Oedema of feet Palmer pallor Young infant
Convulsing
Severe dehydration
Lethargy, drowsiness
Irritable and restless Major burns
Triage
Emergency signs (Ref: p2) Obstructed breathing Severe respiratory distress Signs of shock Coma Priority signs (Ref: p.2) Severe wasting Oedema of feet
Palmer pallor
Young infant Lethargy, drowsiness
Convulsing
Severe dehydration
What emergency measures will you take for this newborn baby?
Progress
After brief resuscitation (about 30 seconds) with bag and mask ventilation, the baby has spontaneous respiration and the heart rate was more than 120/minute. Chest in drawing with grunting respiration observed Birth weight is 1.4 kg (Very Low Birth Weight).
What further measures will you take? What investigations would you like to proceed? Will you start antibiotics in this newborn?
Investigations
Full Blood Examination Haemoglobin: Platelets: WCC: Neutrophils: Lymphocytes: 180 gm/L (145 - 225) 175 x 109/L (84 478) 4.2 x 109/L (5 25.0) 1.2 x 109/L (1.5 10.5) 3.0 x 109/L (2.0 10.0)
Investigations continued
Blood sugar:
Blood culture: Chest X-ray:
Progress
On day 3 baby Sukhmans general condition looks better. His RR is 60/min with mild chest indrawing. His abdomen is soft. He is not grunting but looks slightly jaundiced. So he is commenced on feeding with expressed breast milk (EBM) 3 ml every three hourly by nasogastric tube. The following day he looks lethargic and more jaundiced and has some further apnoeas. His abdomen is distended and there is bile stained nasogastric aspirate.
What may be the cause of his deterioration? What investigations you will perform now?
Investigations
Full Blood Examination Haemoglobin: Platelets: WCC: Neutrophils: Lymphocytes: 135 gm/L 97 x 109/L 3.1 x 109/L 1.1 x 109/L 1.8 x 109/L (145 - 225) (150 400) (5 25) (1.0 8.5) (2.0 10.0)
Investigations continued
Blood glucose Serum Bilirubin Blood group Blood group (mother) Abdominal X-ray 3.2 mmol/l (3.0 8.0) 277 UC / 17 C mol/L B Rh positive A Rh positive
What interpretation can you make from the reports provided? How will you manage the baby?
Progress
A diagnosis of necrotising enterocolitis was made. Sukhmans feeds are withheld. 10% glucose + 0.45% NaCl was given intravenously. Metronidazole was added to penicillin and gentamicin. Oxygen Aminophylline was continued for apnoea He was also commenced on phototherapy for his jaundice.
Summary
Baby Sukhman was delivered prematurely. He needed brief resuscitation after birth. He was admitted management of prematurity, VLBW, respiratory distress and possible sepsis. He was commenced on oxygen, antibiotics and IV fluid. He had some apnoeas early but these resolved with aminophylline. He developed necrotising enterocolitis after commencement of nasogastric feeding on the third day of life. This was treated with a change in his antibiotics and cessation of enteral feeds.
Breast milk feeds were restarted after 4 days and gradually increased. This time they were well tolerated and his feeding volume was gradually increased to 180ml/kg/day. He was discharged when he tolerated breast milk well and had reached a weight of 2kg.
Better outcomes from VLBW means need for better follow-up to prevent morbidity
Malnutrition Low birth weight Difficult feeding Mothers may have limited milk supply Anaemia (iron deficiency common)
Neurological complications
Increased risk of infections Pneumonia and bronchiolitis Diarrhoea (zinc is helpful)