emDocs Podcast – Episode 11: The Sick Neonate

Today on the emDocs cast with Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER) we cover the sick neonate.


EM@3AM: The Sick Neonate

Background: The sick neonate in the ED is uncommon, but can be terrifying. Having an approach for evaluation and management is the most important aspect.

Causes: Two mnemonics include THE MISFITS and NEO SECRETS. The most common causes of severe illness include sepsis, ductal-dependent congenital heart disease, and metabolic disturbance.

  

History:

  • Obtain history concerning pregnancy and delivery, PROM, neonatal course, gestational age, vitamin K.
  • Ask about maternal illness and lab results (GBS, HIV, rubella, HSV, Hep B).
  • Inquire about neonate feeding/sweating, urination, stool, activity, skin changes, and presence of fever.
  • Ask about neonate growth, screening labs, weight.

 

Assessment:

  • Use the Pediatric Assessment Triangle: appearance, work of breathing, and circulation.
  • Obtain vital signs with blood pressure and pulse oximetry in all four extremities.
  • Perform head to toe examination. Use the pediatric triangle repeatedly to assess patients.
  • Assess for cyanosis, murmur, liver size, and femoral pulses.
  • Irritability and hypothermia are concerning for infection.

Evaluation:

  • Start with cardiopulmonary resuscitation first with airway, breathing, and circulation.
  • Normal VS: HR 110-180, RR 40-60, MAP = current gestational age (39 mm Hg if 1 week old born at 38 weeks).
  • Assess serum glucose and obtain access.
  • Obtain ECG, CXR, CBC, venous blood gas, electrolytes, liver function, coagulation function, ammonia, lactate, blood cultures X2, urinalysis, lumbar puncture if able.
  • Head CT for concerns of head trauma.
  • Perform bedside US to evaluate for source of shock and cardiac abnormalities.

 

Management:

  • Based on differential, provide fluid bolus. If concerned for cardiogenic etiology, provide 5 ml/kg bolus. For other patients, provide 10 ml/kg bolus.
  • Warm the patient (warmer to 36.5 C).
  • For hypoglycemia, provide 5 mL/kg of D10 IV.
  • For infection, the most common microbes are Group B streptococcus, E. coli, S. aureus.
    • Provide ampicillin and gentamicin OR cefotaxime.
      • Many consider ampicillin and gentamicin to be the first line regimen, with ampicillin and cefotaxime recommended for those with direct evidence of meningitis (please see reference number 12 for more information).
      • With the current cefotaxime shortage, substituting ceftazidime or cefepime is a valid option.
    • IV fluids 20 mL/kg up to 60 mL/kg is recommended.
    • For cold shock start epinephrine. For warm shock use norepinephrine. Norepinephrine is a safe choice.
    • If unresponsive to fluid and vasopressors, administer hydrocortisone.
    • Concern for HSV (mom with history, vesicles, elevated LFTs) warrants acyclovir.
    • Omphalitis with erythema surrounding the umbilicus is a surgical emergency.
  • Cardiac: Neonates with shock but afebrile more likely have cardiac cause as opposed to infection and sepsis.
    • Three primary obstructions: Shock with obstructed flow to body (aortic coarctation), Blue with obstructed flow to lungs (tricuspid atresia), and Heart failure (AV canal defect).
    • Hyperoxia test to evaluate for cardiac disease. Perform US to evaluate cardiac chambers.
    • Consult PICU and cardiac surgeon.
    • Ductal dependent pulmonary lesion with cyanosis and hypoxia but normal chest x-ray: use phenylephrine (norepinephrine or epinephrine will work as well).
    • Ductal dependent systemic lesion with shock, difference between pre/post-ductal blood pressure and pulse oximetry, congestion on chest x-ray: consider milrinone.
    • Provide prostaglandin starting at 0.05 mcg/kg/min IV. Prepare for hypotension and hypoxia. May increase to 0.1 mcg/kg/min after 10 minutes if there is no effect.
    • Caution with IV fluids recommended; it is reasonable to start with 5 mL/kg bolus and reassess.
    • Consider furosemide 1 mg/kg IV if systemically fluid overloaded.
    • Correct glucose and electrolytes, which will improve cardiac function.
  • For intestinal condition, administer broad-spectrum antibiotics, make NPO, obtain surgical consult. Assess for history/presence of bilious emesis and failure to pass meconium.
    • Malrotation with volvulus peaks in first month; evaluate with upper GI series.
    • Intussusception presents with history of colicky episodes. Diagnosis with US or air/barium enema.
    • Bowel obstruction presents with bilious emesis, history of maternal polyhydramnios, failure to pass meconium, abdominal distension.
    • Pyloric stenosis presents around 3-5 weeks, non-bilious emesis, US versus upper GI series.
    • Necrotizing enterocolitis usually occurs in patients with premature birth, occurs in first 2 weeks, X-ray show pneumatosis intestinalis or portal venous air.
    • Toxic megacolon or Hirschsprung’s disease presents with failure to pass meconium and toxic appearance.
  • Hyperbilirubinemia: Obtain biliary labs, reticulocyte counts, Coombs test.
    • Unconjugated is typically physiologic.
    • Conjugated is abnormal.
  • Respiratory: Muscle fatigue sets in quickly in neonates.
    • Neonates are obligatory nasal breathers, so any congestion may result in respiratory distress.
    • Pneumothoraces are rare at this age. US and X-ray can be used for diagnosis. For pneumothorax causing respiratory distress and hyoxemia, needle aspirate or place pigtail catheter.
  • Seizure: Most commonly due to ischemic injury, but up to 10% due to intracranial infection.
    • Correct glucose; administer lorazepam or phenobarbital, antibiotics, acyclovir for HSV.
    • Obtain CT head and LP.
  • Inborn errors of metabolism: Present within first week after birth
    • In addition to above labs, obtain serum amino acids, pyruvate, urine organic acids.
    • May have elevated ammonia, elevated lactate, low blood glucose, electrolyte abnormalities.
    • Make NPO and replete glucose; provide antibiotics for sepsis.
    • Ammonia > 200 needs dialysis.
  • Endocrine:
    • Consider congenital adrenal hyperplasia in patients with shock unresponsive to fluids and vasopressors, hyponatremia, hyperkalemia, hypoglycemia.
      • Administer hydrocortisone and antibiotics.
    • Consider thyrotoxicosis for failure to thrive, maternal Graves disease.
      • Administer propranolol 0.25 mg/kg, propylthiouracil 1.25 mg/kg, hydrocortisone, antibiotics, Lugol’s solution.
    • Consider congenital hypothyroidism in those with poor feeding and poor tone.
  • Electrolytes:
    • Typically due to underlying process, but avoid correcting too rapidly
    • For seizures due to hyponatremia, provide 4-6 mL/kg of 3% hypertonic saline.
    • For hyperkalemia, administer Ca gluconate 10% 100 mg/kg over 5 minutes, sodium bicarbonate 1-2 mEq/kg IV, insulin 0.1 units/kg
    • For hypocalcemia, provide 100-200 mg/kg 10% Ca gluconate.
  • Trauma: Occurs rarely in this age group.
    • Subgaleal hemorrhage may result in decompensation due to low circulatory volume in neonate (5 kg neonate has 400 mL of circulating volume, 80 mL/kg X 5 kg).
    • Non-accidental trauma/abuse: Head trauma may result in 30% mortality rate. Obtain head CT and X-rays. Always keep NAT on the differential.
  • Toxicologic: Consider diphenhydramine or isopropyl alcohol exposure, homeopathic exposures.

 

Disposition:

  • Consult pediatrics and admit.
  • Further consultation depends on suspected underlying etiology.

 

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