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Crushing Neonate – Diagnostic Algorithm and Treatment

  • Post category:Pediatrics
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General Approach

  • Definition: Full-term newborn, born well and discharged home by pediatrician → returns in first month looking sick, hypotensive and dehydrated.
  • Always begin with ABCs and decide whether or not to emergently intubate.
  • Begin fluid resuscitation if not in overt CHF and check/correct hypoglycemia.
  • Consider and rule-out emergent causes starting with focused H&P, labs and possibly imaging.
  • At minimum, these neonates will get a septic work-up including labs, antibiotics and possibly LP, then admission.
Crushing Neonate Diagnostic Algorithm and Treatment
Crushing Neonate Diagnostic Algorithm and Treatment

ABCs and Resuscitation

Resuscitation

  • Early IV access
    • Scalp vein, IO line, umbilical line
  • Vital signs:
    • 4 extremity Blood Pressure; Pre and post ductal O2 saturation
    • Minimally acceptable SBP = 60 mmHg
  • Initial labs
    • Full sepsis work-up (Accucheck, CBC/CMP/BCx/Lactate/NH4/UA/UCx)

Treat reversible causes

  • Hypoglycemia always present → treat early with D10 (5-10ml/kg IV)
  • Begin fluid resuscitation → NS boluses (10ml/kg IV)
Neonatal resuscitation - Airway and breathing
Neonatal resuscitation – Airway and breathing
Neonatal resuscitation – Circulation and Drugs
Neonatal resuscitation – Circulation and Drugs

Differential Diagnosis : THE MISFITS

– Trauma
– Heart disease/Hypovolemia
– Endocrine (CAH)
– Metabolic (electrolytes)
– Inborn errors metabolism
– Seizures
– Formula mishaps
– Intestinal disaster
– Toxins
– Sepsis
Presentation and causes of serious illness in children
Presentation and causes of serious illness in children

Begin Neonatal Sepsis Work-up

Full septic work-up

  • All ill appearing neonates are septic until proven otherwise
  • CBC, LFTs, BCx
  • Urine Analysis/Urine culture
  • CSF studies-LP
  • CXR
  • Antibiotics
  • Admit

Emergent Differentials

  1. Seizures
  2. Congenital Heart Disease
  3. Intestinal Emergencies
  4. Inborn Errors of Metabolism
  5. CAH (Congenital Adrenal Hyperplasia)
  6. Non-Accidental Trauma

1. Seizures

Presentation of Seizures in Neonate

  • Atypical seizure
    • Presents with atypical movements → usually not tonic-clonic
    • Usually staring spell, lip smacking, bicycling, tonic, migratory clonic

Diagnosis of Seizures in Neonate

  • Differential diagnosis is large: (Emerg Med Clinics North Am 2002;20:27-48)
    • Hypoxic-Ischemic encephalopathy → most common cause(50-65%)
    • Intracranial hemorrhage: IVH/SDH/SAH (15%)
    • Electrolyte abnormalities: Hypercalcemia, Hyper and Hyponatremia, Hyperphophatemia, Hyper and Hypoglycemia
    • Other: Infection, IEM, metabolic, drug withdrawal, toxins, trauma, hypertension, formula mix-up (Hyponatremia)
  • Work-up
    • Labs
      • Check labs even if seizures have stopped
      • Check glucose immediately
      • Check and correct Natriuum, glucose, Calcium
    • CT Head
    • Sepsis work-up

Treatment of Seizures in Neonate

  • Correct hypoglycemia: D10: (5 to 10 ml/kg)
  • Benzodiazepines: Lorazepam 0.1mg/kg initial drug of choice
  • Anticonvulsant
    • Phenobarbital 20mg/kg IV
    • Levetiracetam (Keppra) 20mg/kg IV
    • Fosphenytoin 15-20 mg/kg IV
  • Treat hypocalcemia (≤7mg/dl): Ca gluconate 10% (100–300 mg/kg IV)
  • Treat hyponatremia (<125 mg/dl): 3% saline (4 ml/kg)
  • Pyridoxine (50-100mg)
    • Consider if refractory seizures
  • Sepsis
    • Begin sepsis work-up and broad antibiotics (see peds fever algorithm)
    • Treat for HSV (Lumbar Puncture and begin acyclovir)

2. Congenital Heart Disease (CHD)

General

  • Neonate with congenital heart disease may rely on a patent ductus arterious (PDA) to shunt blood for pulmonary blood flow or systemic blood flow
  • PDA usually closes within 2 weeks → ductus arteriosus no longer able to shunt blood past
  • CHD lesion → rapid clinical deterioration depending on site of lesion
  • May have ductal dependent pulmonary blood flow (Cyanotic CHD) or ductal dependent systemic blood flow (Acyanotic CHD)

Cyanotic CHD (Congenital Heart Disease)

  • General
    • Ductal dependent pulmonary blood flow
    • When duct closes → low pulmonary blood flow → low O2 to body → infant becomes cyanotic/blue
    • Cardiovascular consult immediately → OR?
  • Diagnosisof Cyanotic CHD
    • Physical Exam: Cyanosis (blue baby)
    • Hypoxia
      • Low O2 saturation → likely ductal dependent lesion
      • Hyperoxia test:
        • i. 10-15 min of 100% FiO2
        • ii. If ABG PaO2 <150 → indicative of cyanotic CHD
    • CXR
      • Rule out other causes for hypoxia
  • Treatmentof Cyanotic CHD
    • O2
    • PGE1
    • IV fluids if hypotensive
    • Vasopressors: Dopamine/Dobutamine if needed

Acyanotic CHD

  • General
    • Ductal dependent systemic blood flow
    • When duct closes → low blood flow to body → shock
    • Likely lesion: critical coarctation, aortic stenosis, hypoplastic LV
  • DiagnosisofAcyanotic CHD
    • Shock?
      • Poor perfusion, tachycardia, hypotension
    • 4 extremity Blood Pressure and SaO2
      • Look for gradient between extremities
  • TreatmentofAcyanotic CHD
    • PGE1
    • IV Fluids if not in CHF
    • Vasopressors: Dopamine, Dobutamine, Milrinone

Treatments of Congenital Heart Disease (CHD)

  • PGE1
    • Dose: 0.1 mcg/kg/min
    • Side effects
      • Hypotension
      • Apnea
        • i. Dose-dependent and occurs early
        • ii. May need to intubate before transfer (do not stop PGE1)
    • Check for clinical improvement → Perfusion, pH, BP, SaO2, Urine output
  • Vasopressors
    • Cyanotic CHD:
      • Dopamine/Dobutamine
    • Acyanotic CHD:
      • Dopamine/Dobutamine (5-10 mcg/kg/min), Milrinone
      • Do not use Levophed or Epinephrine → may worsen coarctation
  • Other
    • IV fluids
    • Acidosis? → Consider HCO3 for pH < 7.0
    • Anemia? → Consider transfusion

3. Intestinal Emergencies

VOLVULUS IN NEONATE

  • PresentationofVolvulus
    • Congenital malrotation
    • Irritable, vomiting: gastroenteritis symptoms
    • Unexplained Bilious Vomiting in young infant = malrotation and midgut volvulus until proven otherwise
  • Work-upfor Volvulus
    • Urinary X-Ray: usually normal but can have ”double-bubble” sign with severe duodenal obstruction
    • Upper gastrointestinal X-Ray : corkscrewing of intestine

Vomit Pearl

Bilious vomit = Volvulus

NECROTIZING ENTEROCOLITIS

  • Usually in premature but can be in full term infants
  • Presentation: similar to volvulus → feeding difficulties, irritability, abdominal distention, and hematochezia
  • X-Ray
    • Low sensitivity – usually normal
    • Late: pneumatosis intestinalis (gas in bowel wall) or portal free air
  • Therapy: Bowel rest, antibiotics, surgical consultation

Other Intestinal emergencies in Neonate

  • Incarcerated hernia
  • Diaphragmatic hernia
  • Toxic Megacolon
  • Duodenal atresia
  • Pyloric stenosis

Treatment for all

  • ABCs and resuscitation: Saline and Dextrose as above
  • NPO
  • Antibiotics
  • Upper GI contrast study
  • Surgical Consult

4. Inborn Errors of Metabolism

Pathophysiology of Inborn Errors of Metabolism

  • Biochemical defect that causes accumulation of toxic metabolite (NH4, ketones, lactic acid)

Presentation of Inborn Errors of Metabolism

  • Aleterd Mental Status, vomiting, lethargy, coma, dehydration
  • History of sibling deaths
  • CNS symptoms
  • Hepatomegaly
  • Odor (sweat, musty, fruity, like urine)
  • Family history of siblings with same presentation?

Work-up and treatment of Inborn Errors of Metabolism

  • Labs
    • Hypoglycemia
    • ↑ NH4 (Hyperammonemia)
    • Ketonemia (Ketosis)
    • High Lactate
  • NPO
  • Hypoglycemia: D10 (5-10ml/kg IV)
  • Rehydrate
    • Bolus: 10cc/kg NS boluses
    • Maintenance: D10 ¼ NS 1.5-2x maint rate after fluid boluses
  • HCO3 ? (if pH<7.1 for organic acidemia)

5. CAH (Congenital Adrenal Hyperplasia)

Pathophysiology of CAH

  • 21-hydroxylase deficiency (90%)
    • Deficiency in cortisol and aldosterone → hyponatremia, hyperkalemia
    • Accumulation of androgens → changes in female genitalia

Presentation of CAH

  • Vomiting, dehydration, lethargy, decreased po intake
  • Shock in the first 2 weeks of life
  • Hyponatremia, hyperkalemia and hypoglycemia

Treatment of CAH

  • Hypoglycemia treatment → D10 (5 to 10 ml/kg)
  • Resuscitate: 10cc/kg NS boluses
  • Treat hyperkalemia
    • Ca-gluconate for hyperK and EKG changes
  • Steroids: Hydrocortisone 25mg IV/IM/IO

6. Non-Accidental Trauma

  • Presentation
    • May have no external signs of trauma
    • Scalp hematoma → associated with high risk of intracranial hemorrhage
    • Retinal hemorrhages
  • Work-up
    • CT head
    • Admit
    • Social work/child services

Other Causes of Crashing Neonate

  • NAT (Non accidental Trauma)
  • Arrhythmias
  • Formula-mix ups
  • Omphalitis
  • AVM (Arteriovenous Malformation)
  • Bronchiolitis

References

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