Neonatal Emergencies

(After Discharge)
Robert Englert, M.D.
Dept Neonatology
Bethesda Naval Hospital
Most Interesting ED Chief Complaints

 Drank the dog’s milk - from the dog’s

nipple
 Needs a circumcision because his
tonsils are so big
 Can’t find baby’s 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 history

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

Pre- and postnatal history are unremarkable.

ABC’s 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
Left Sided
 shock
 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, Respirations are
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 Ebstein’s 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 (Lugol’s)
 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 Test
 Maple Syrup Urine Dz maple syrup
 Isovaleric acidemia sweaty feet
 Tyrosinemia rancid butter
 Beta-methylcrotonyl-
coenzyme A def. tomcat’s urine
 phenylketonuria mousy/musty
 methionine malabsorption cabbage
 trimethylaminuria rotting fish
Conclusions

 ABC’s
 Monitor, IV, Oxygen, Antibiotics
 Diagnostic tests
 Know the differential