EMERGENCIES

IN NICU
SONALI SHRIVASTAVA

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Objectives:

1. To discuss some common

baby-killers.

2. To discuss some basic

terms.

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Introduction
 For this talk, neonates will refer to infants aged 0-28 days.
 Just think of them as “little children.”
 They can have pathology of virtually any organ system.

Metabolic
Cardiac
Sepsis Toxins

GI
Heme
Endo
SONALI SHRIVASTAVA( MPT- PEDIATRICS)
Classification
 There are many different ways to organize the neonatal
emergencies.
 This talk will focus on “THE MISFITS” approach.

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

“THE

MISFITS”
Trauma/Abuse (NAI)
 Heart and Lung
 Endocrine
 Metabolic disturbances
 Inborn errors of metabolism
 Sepsis
 Formula
 Intestinal
 Toxins
 Seizures

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

TRAUMA
ACCIDENTAL
DELIBERATE

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

HEART AND LUNG
ACYANOTIC CHD CYANOTIC CHD
 VSD PUL STENOSIS
 ASD AORTIC STENOSIS
 PDA ENDOCARDIAL FIBRE
 PRIMARY PUL ELASTOSIS
HYPERTENSION COA
 TOF CONG. VALVULAR DISEASE
 TOGA
 PUL ATRESIA

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

CARDIAC EMERGENCIES -My Ductus is
Closing !
Ductal -dependant PBF:
Tetralogy of Fallot
Transposition of the
Great Arteries
Pulmonary Atresia
Tricuspid Atresia
Ductal-dependant SBF:
Interrupted Aortic Arch
Coarctation of the Aorta
Hypoplastic Left Heart
Syndrome
 Critical Aortic Stenosis

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Ductal-Dependant Lesions

SONALI SHRIVASTAVA( MPT-

PEDIATRICS)
Cardiac Emergencies -Hypercyanotic Spells
Pathophysiology:
 Lowering of SVR or increase in
RVOT resistance increases R->L
shunting.
 Increased shunting stimulates
respiratory center to produce
hyperpnea.
 Hyperpnea results in increased
systemic venous return.
 Increased systemic venous
return increases R->L shunt
creating a vicious cycle.

SONALI SHRIVASTAVA( MPT-

PEDIATRICS)
CARDIAC EMERGENCIES
Pulmonary
Hypertensive Crisis
Patients at risk
 Large VSD
 AVSD
 Truncus arteriosus

 Transposition of the great

arteries
 TAPVR
 Single ventricle without

pulmonary stenosis

SONALI SHRIVASTAVA( MPT-

PEDIATRICS)
HLHS - The Balancing ACT
Normal Circulation
has QP:QS = 1:1
In HLHS, QP:QS
depends on resistances
in the pulmonary and
systemic circuits.
We have to try to keep
the balance!

SONALI SHRIVASTAVA( MPT-

PEDIATRICS)
ENDOCRINE
1. Hypoglycemia
2. Thyrotoxicosis
3. Congenital adrenal hyperplasia (CAH)

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Neonatal Hypoglycemia
 This is most commonly seen in the neonates born to
diabetic mothers.
 During pregnancy, maternal hyperglycemia crosses the
placenta to cause fetal hyperglycemia.
 The fetal pancreas responds by increasing insulin
production.
 Following delivery, the hyperglycemic stimulus is instantly
removed—but insulin production may take longer to slow
down.

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Neonatal Hypoglycemia
 Neonatal hypoglycemia therefore typically arises in the
nursery, but could still be seen in the ED.
 As with any patient, check a chem strip in any neonate
presenting with:
- decreased LOC - weak tone
- seizures - hypotension
- resp distress - cardiac failure

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Neonatal Hypoglycemia
 Glucose < 40(in a symptomatic neonate) or < 30 (in an
asymptomatic neonate) should be treated.
 Can use 2cc/kg of D10W (repeated prn).
 This should be followed by:
1. Searching for an etiology (if not obvious)
2. Repeated glucose monitoring

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Neonatal Thyrotoxicosis
 This is a very uncommon condition—occurring in about
1% of pregnancies of mothers with Graves disease.
 The risk in babies born to euthryoid mothers is negligible.
 Caused by the placental passage of stimulating TSH-
receptor antibodies from the mother to the fetus.

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Neonatal

Thyrotoxicosis
All neonates are screened for thyroid function at birth.
 As such, it would be unusual for neonatal thyrotoxicosis to
present to the ED.
 That being said, potential findings could include:
- goiter - proptosis
- HR > 160 - dysrhythmias
- shock - CHF
- hyperthermia - pallor

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Congenital Adrenal Hyperplasia
 CAH refers to any one of several autosomally-inherited
disorders.
 These disorders involve a defect in the adrenal production
of cortisol, mineralocorticoid, or both.
 These defects are caused by a missing or malfunctioning
enzyme.
 “21-hydroxylase deficiency” accounts for 90-95% of all
cases

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

 21-hydroxylase deficiency
• A highly-simplified schematic is shown here.

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

FEATURES SEEN…..
1.Cortisol deficiency  hypoglycemia, hypotension, and
shock
2. Aldosterone deficiency  hyponatremia,
hyperkalemia, and dehydration

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

“THE MISFITS”
 Trauma/Abuse (NAI)
 Heart and Lung
 Endocrine
 Metabolic disturbances

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Metabolic disturbances
 Remember to ANALYSE the following bloodwork in any
toxic neonate:
1. LFT’s and coagulation parameters
2. Lipase
3. Ammonia
4. Lactate levels
5. pH

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

“THE MISFITS”
 Trauma/Abuse (NAI)
 Heart and Lung
 Endocrine
 Metabolic disturbances
 Inborn errors of
metabolism

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Inborn Errors of Metabolism
 The inborn errors of metabolism are a group of
diverse disorders—usually caused by the lack of a
specific enzyme.
 They include:
1. Urea Cycle Defects
2. Organic Acidurias
3. Galactosemias
 These disorders are rare—affecting only 1 in
100,000-200,000 live births.
 Unfortunately, they typically present during the
neonatal period—and cause irreparable brain
injury if missed.
SONALI SHRIVASTAVA( MPT- PEDIATRICS)
Inborn Errors of Metabolism
Alteration in mental status
acidosis
hypoglycemia
electrolyte abnormalities
ketosis
hyperbilirubinemia

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

“THE

MISFITS”
Trauma/Abuse (NAI)
 Heart and Lung
 Endocrine
 Metabolic disturbances
 Inborn errors of metabolism
 Sepsis
 Formula
 Intestinal
 Toxins
 Seizures

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

SEPSIS
Early intubation
Aggressive fluid resuscitation
Vasopressors/inotropes should be used in septic shock only after
appropriate volume resuscitation
Endpoints to resuscitation:
a) Normal LOC
b) Cap refill < 2 sec
c) Normal pulses
d) Warm extremities
e) Urine output > 1mL/kg/hr
f) Decreased lactate
g) Increased Ph
Steroids

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Formula and Feeding Mishaps
 Neonates are ideally breastfed.
 The neonatal breastfeeding schedule should be “on-
demand.”
 ~10mins/breast, ~q3h, but ++variable.
 The neonate should be allowed ample time to fully drain
each breast.
 The final dregs of breastmilk (or “hind-milk”) are felt to
contain more fat.
 The mother’s breasts should feel “empty” following a full
feed.

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Formula and Feeding Mishaps
 Always ask about potentially dangerous feeding
behaviours:
1. Feeding the neonate inappropriate substances (i.e.
pop, juice, Coffeemate).
2. Feeding the neonate water.
 Neonates should not get any
 supple-mentary water until 6 months (or older)
 Water lacks nutritional content but causes satiety
 decreased food intake.
3. Lack of money to afford proper food.

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

“THE MISFITS”
 Trauma/Abuse (NAI)
 Heart and Lung
 Endocrine
 Metabolic disturbances
 Inborn errors of metabolism
 Sepsis
 Formula
 Intestinal

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Necrotizing Enterocolitis
 Initial symptoms can include:
 feeding intolerance
 abdominal distension
 +/- hematochezia
 This can progress to:
 lethargy
 apnea
 DIC
 shock and cardiovascular collapse
 Lab findings can include:
 abnormal WBC
 thrombocytopenia
 hyponatremia
 elevated PT/PTT
 metabolic acidosis
SONALI SHRIVASTAVA( MPT- PEDIATRICS)
 Pneumatosis intestinalis is the presence of air bubbles
within the bowel wall (caused by extravasation of air
from the lumen.)
 It has a characteristic train-track lucency appearance
on AXR.

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

“THE

MISFITS”
Trauma/Abuse (NAI)
 Heart and Lung
 Endocrine
 Metabolic disturbances
 Inborn errors of metabolism
 Sepsis
 Formula
 Intestinal
 Toxins

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

TOXINS
 consider:
a) Maternal toxins (ie. if breastfeeding).
b) Environmental toxins (eg. cigarette smoke, carbon
monoxide).
c) Abuse (ie. Munchausen by proxy).

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

“THE

MISFITS”
Trauma/Abuse (NAI)
 Heart and Lung
 Endocrine
 Metabolic disturbances
 Inborn errors of metabolism
 Sepsis
 Formula
 Intestinal
 Toxins
 Seizures

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Seizures
 There are several forms of benign neonatal convulsions—
but these are unlikely to be diagnosed.
 Remember that the differential of seizures in a neonate
essentially includes all of the other MISFITS.

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Others…………………..
1. TRISOMIES
2. ABDOMINAL DEFECTS
3. TEF
4. CLEFT PALATE
5. CTEV
6. MAS
7. RDS

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Trisomies
Trisomy 21 (Down’s Syndrome)
Trisomy 18 (Edward’s Synd)
Trisomy 13 (Patau’s Synd)

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

SONALI SHRIVASTAVA( MPT- PEDIATRICS)
SONALI SHRIVASTAVA( MPT- PEDIATRICS)
SONALI SHRIVASTAVA( MPT- PEDIATRICS)
 Tracheoesophageal Fistula

Clinical Presentation
choking on 1st feed
coughing
cyanosis
excessive salivation
aspiration pneumonia

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

 TracheoEsophageal Fistula

5 Types (Gross and Vogt)

7.7% 0.8% 86% 0.7% 4.2%

Gregory GA, ed, Pediatric Anesthesia, 3 rd edition, 1996

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

 Tracheoesophageal Fistula

35-65% have associated anomalies

VATER and VACTERL
V vertebral anomalies or VSD
A anorectal malformation
C cardiac anomalies (common)
T TEF
E esophageal atresia
R renal abnormalities
L limb/radial malformation

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Abdominal Wall Defects
Gastroschisis

Omphalocoele

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

 Gastroschisis

Greek word for “belly cleft”

Evisceration of gut through a 2-3 cm defect in the anterior abdominal wall
lateral to the umbilicus, usually on the right
Absence of covering or sac
chemical peritonitis infection
ECF loss heat loss
Incidence: 1:15,000-30,000 live births

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

 Omphalocoele

External herniation of abdominal viscera into the base of the umbilical

cord through a central defect
Defect: small or large
Umbilical cord is inserted into the apex of the lesion
Presence of covering or sac (amnion and peritoneum)
Incidence: 1-5,000-10,000 live births

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

MAS

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

CLEFT PALATE

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

CTEV

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RESPIRATORY DISTRESS SYNDROME
SIGNS……
1. BRADYPNOEA
2. EXPIRATORY GRUNT
3. CYANOSIS
4. NASAL FLARING
5. HEAD BOBBING
6. RETRACTIONS

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

Putting It All Together
1. Basics.
 IV, O2, monitors, vitals, foley, +/- NG
2. Stat chem strip and ABG/VBG (with the works).
3. Stat EKG and CXR.

SONALI SHRIVASTAVA( MPT- PEDIATRICS)

SONALI SHRIVASTAVA( MPT- PEDIATRICS)