Neonatal Emergencies

(After Discharge)
Robert Englert, M.D.
Dept Neonatology
Bethesda Naval Hospital
Most Interesting ED Chief
Complaints
Drank the dogs milk - from the dogs
nipple
Needs a circumcision because his
tonsils are so big
Cant find babys birthmark
Piece of bologna string hanging from
anus
Baby is afraid of his hands
 Case Presentation

10 day old male presents to ED with 1 day his

poor feeding, lethargy and, over last 1-2 hours
increasing work of breathing.

Pre- and postnatal history are unremarkable.

ABCs of Neonatal
Resuscitation
Airway
Airway
Airway
Initial Management

IV access

monitor

oxygen
Initial Management -
Therapy
Respiratory Support

Volume

Antibiotics
Diagnostic Tests

ABG
CBC
Lytes
Cultures
Radiography
Categories

Infectious

Cardiac

Endocrine
Late-Onset Infections

Group B Streptococcus
E. coli
Listeria
H. influenza, S. Pneumonia, N.
meningitis
Viral
RSV, HSV, Enterovirus
Group B Streptococcus

1-3/1000 live births

Up to 1/3 women colonized
Early and late onset disease
Antibiotics around delivery affect
early onset not late onset
Late onset highly associated with
meningitis
Listeria monocytogenes

Early and late onset disease

Early onset often associated with
meconium staining even in
preterms
Late onset disease is primarily
meningitic
Escherichia coli
K1 capsular antigen uniquely associated
with neonatal meningitis
K1 related not only to invasive disease,
but to more severe outcomes
Significant association with galactosemia
likely due to depressed PMN function
caused by elevated serum galactose
levels
Urosepsis/posterior urethral valves
 Case Presentation

4 day old infant African American

male presents to ER because of
decreased feeding, lethargy, poor
color, increased work of breathing,
prenatal history unremarkable,
spent 2 days in hospital, no
reported problems, discharged 48
hours ago
Ductal Dependent Cardiac
Lesions
Left sided heart lesions
Systemic blood flow is dependent
upon ductal patency
coarctation of the aorta
interrupted aortic arch
hypoplastic left heart
Ductal Dependent Cardiac
Lesions
shock Left Sided
cardiac failure - hepatosplenomegaly,
large heart, gallop
Pressor support
prostaglandin E1
side effects:
Flushing, Hypotension, Pyrexia (fever)
idiosyncratic apnea
 Case Presentation

3d old caucasian male presents to

ER because of poor feeding,
lethargy, comfortable tachypnea,
color not right, harsh murmur
Pre-natal Hx unremarkable, no U/S
done during pregnancy
D/C to home at 26hol
Ductal Dependent Cardiac
Lesions
Right sided heart lesions
pulmonary blood flow is dependent
on ductal patency
tetralogy of Fallot
transposition of great vessels
tricuspid atresia
pulmonary stenosis/atresia
 Congenital Heart
Lesions
 Case Presentation

Infant is tachycardic, 200-220/min, mottled

with poor perfusion. Poor feeding, Respiratio
with rate of 80/min.
Neonatal Rhythm
Disturbances
Fast

Slow

In between
Supraventricular
Tachycardia
persistent ventricular rate of >
200/min
fixed RR interval
abnormal P wave shape or axis,
abnormal P-R interval, or absence of
P waves
little change in rate with activity,
crying, etc.
Supraventricular
Tachycardia
most common symptomatic
arrhythmia in children
may be associated with WPW
syndrome or Ebsteins anomaly
CHF rare in first 24 hrs; 50% after
48 hrs
Supraventricular
Tachycardia
unstable vs stable
synchronized cardioversion in
unstable patient
vagal stimulation (ice to face)
adenosine
side effect of all cardioversion
methods:
asystole
death
 Case Presentation

29yo Black female G4P0 presents

at 35 +2 weeks with swollen ankles
No Ctx, normal cervical exam, labs
pending
FHR noted to be 280, U/S otherwise
normal
BPP 4/10, Delivered via LTCS
 EKG pre/post
Adenosine
Neonatal Hyperthyroidism

Maternal Graves disease - 1/2000

pregnancies
Thyroid-stimulating
immunoglobulins cross the
placenta
Mothers with symptomatic disease
may be treated with PTU
Neonatal Hyperthyroidism

Infants of mothers with Graves

disease may be:
goitrous and hypothyroid
euthyroid due to maternal PTU which
crosses the placenta
hyperthyroid due to maternal thyroid-
stimulating Ig
Neonatal Hyperthyroidism

Transplacentally acquired thyroid-

stimulating Ig may exert effects for
up to 12 weeks postnatally
Thyroid storm
Irritibility
Respiratory distress
Severe tachycardia
Cardiac failure
 Neonatal
Thyrotoxicosis
Treatment
Suppress excess secretion of
hormone and conversion of T4
>>T3
PTU and/or Potassium Iodide (Lugols)
Adrenergic Blockade
Propranolol
 Case Presentation

A 7lb male newborn has bilateral

cryptorchidism and hypospadius.
At 7 days of age infant presents to
the ER with a history of vomiting.
The baby is pale, tachycardic,
hypotensive.
Believe it or not it happens..
Congenital Adrenal
Hyperplasia
group of enzyme defects which
impair steroid hormone production
21-hydroxylase - 90% of cases
two forms
partial: simple virilizing
more complete deficiency: salt losing
Congenital Adrenal
Hyperplasia
females are virilized; males usually
appear normal
salt losing - adrenal insufficiency
occurs under basal conditions
significant impairment of cortisol and
aldosterone synthesis
most have onset of symptoms at 6-14 days
shock with hypoglycemia, hyponatremia,
hyperkalemia, acidemia
Congenital Adrenal
Hyperplasia
Treatment
treat hypovolemia
correct sodium and potassium if
necessary
hydrocortisone is steroid of choice
mineralocorticoid replacement
may be necessary
Inborn Errors of
Metabolism
Alteration in mental status
acidosis
hypoglycemia
electrolyte abnormalities
ketosis
hyperbilirubinemia
Inborn Errors of
Metabolism
Hepatomegaly
Seizures
Hyperammonemia
Reducing substances in urine
Inborn Errors of
Metabolism
The Smell
Maple Syrup Urine Dz
Test
maple syrup
Isovaleric acidemia sweaty
feet
Tyrosinemia rancid butter
Beta-methylcrotonyl- coenzyme A def.
tomcats urine
phenylketonuria mousy/musty
methionine malabsorption cabbage
trimethylaminuria rotting fish
Conclusions

ABCs
Monitor, IV, Oxygen, Antibiotics
Diagnostic tests
Know the differential