Crushing Neonate – Diagnostic Algorithm and Treatment

  • Post category:Pediatrics

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


  • 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)

Differential Diagnosis : THE MISFITS

Heart disease/Hypovolemia
Endocrine (CAH)
Metabolic (electrolytes)
Inborn errors metabolism
Formula mishaps
Intestinal disaster
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)


  • 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


  • 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


  • 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