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Neonatal Emergencies

Neonatal Emergencies. Beyond the A,B,C’s of Resuscitation in the DR and NICU. Case # 1. Summoned to the LDR STAT term infant no prenatal complications cyanotic severe respiratory distress cyanosis, grunting, retractions, HR 140, good tone. Case # 1. Attempt PPV unsuccessful.

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Neonatal Emergencies

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  1. NeonatalEmergencies Beyond the A,B,C’s of Resuscitation in the DR and NICU

  2. Case # 1 • Summoned to the LDR STAT • term infant • no prenatal complications • cyanotic • severe respiratory distress • cyanosis, grunting, retractions, HR 140, good tone

  3. Case # 1 • Attempt PPV unsuccessful • Attempt intubation • can’t see past the base of the tongue • very small mandible

  4. What is the name and etiology of this infant’s anatomical condition? Pierre Robin Sequence

  5. Case # 1 • Approach to this airway • place infant prone • nasal trumpet or 2.5 ETT • insert via nasal passage • tip at level of the posterior pharynx • call Peds ENT stat if you can’t secure an airway

  6. Case # 1 • Pierre-Robin • triad • macroglossia + cleft palate • glossoptosis • micrognathia • respiratory obstruction • tongue held against posterior pharyngeal wall secondary to marked neg pressure during insp effort

  7. Case # 1 • Treatment • support airway • Positioning • Nasal Airway • Tracheostomy • Nutrition • Prognosis • the more prolonged the resuscitation the worse the neurologic outcome

  8. Case # 2 • You are called to attend a delivery secondary to fetal distress • A, B, C’s of resuscitation initiated • Person managing the airway • increased epinephrine • tachycardia and tremors • excessive PPV

  9. Case # 2 • What complication would you anticipate? • What clinical signs are indicative of a pneumothorax? • cyanosis • bradycardia • decreased BS on affected side • Emergency intervention?

  10. Needle Thoracostomy What equipment will you gather?

  11. Case # 3 Summoned to the LDR STAT Corpsman meets you at the door and says “doc the babies intestines are all over the place”

  12. How will you manage this?

  13. Delivery Room Management:Gastroschisis • ABC’s of resuscitation • Warm, saline-soaked lap sponges, plastic wrap or bowel bag to cover the intestines • Decompression of the bowel ASAP • Avoid volvulus of the mesenteric vessels • Avoid tearing bowel mesentery or causing unnecessary damage to bowel • Remember importance of thermoregulation and controlling fluid losses

  14. Gastroschisis E m b r y o l o g y • Intestines herniate through the abdominal wall • Area weakened by involution of the right umbilical vein (theoretical) • Sequence occurs relatively early in gestation • Differs from omphalocele

  15. Incidence Covering Sac Fascial Defect Cord Attach. 1:6,000-10,000 Present (may be ruptured) Small to large Umbilical the sac 1:20,000-30,000 Absent Small (vascular compromise) Abd wall Omphalocele Gastroschisis

  16. Gastroschisis Omphalocele Protected Liver often in sac Less common If sac is ruptured Herniated Bowel Other organs IUGR NEC Edematous and matted Remain in abd. Common 18 %

  17. Assoc.. Anomalies Omphalocele Gastroschisis Overall 55% to 80% 10% to 15% 18 % (stenosis and atresias) 2 % No increase 37 % (Midgut volvulus Meckel’s Diverticulum, atresia, duplications) 20 % 30 % GI Cardiac Trisomy

  18. Prognosis Gastroschisis: • 70% to 90% survival • morbidity related to prematurity and bowel compromise

  19. Case # 4 • Summoned to the LDR for a meconium delivery • Light mec is present and the infant cries immediately upon delivery • Within 15 seconds respiratory distress ensues

  20. Case # 4 • You initiate A, B, C’s of resuscitation • PPV is ineffective cyanosis is worsening • HR begins to decline • BS are decreased on the left compared to the right • You notice the abdomen looks like this

  21. Diagnosis?

  22. Diaphragmatic Hernia

  23. Case # 4 • Resuscitation • Intubation to overcome resp distress or failure • Bowel decompression to prevent gas from inflating the bowel • Physiologic consequences of D-Hernia • Pulmonary hypoplasia • Pulmonary hypertension • Air leak syndrome • Non-rotation of the bowel • Feeding difficulties

  24. Case # 4 • 1 in 3,000 • 90% occur on the left side • Abdominal content within chest • Compresses both lungs • Pulmonary hypoplasia • Pulmonary hypertension • NO and/or ECMO • Definitive tx---surgical repair

  25. Case # 5 • You are called to see a newborn shortly after delivery for “coughing” • Mild respiratory distress • tachypnea and “gasping” respirations • You suction • coughing persists • oral secretions continue to pool in the back of the throat

  26. Case # 5 • What are your next steps? • Oral suction, pulse ox, OG, IV • Evaluation for infection • Blood culture, cbc, abx, chest film

  27. Case # 5 • Abdominal distention continues to increase followed by worsening resp distress and cyanosis • Next step? • Will intubation help decrease abdominal distention?

  28. Case # 5 • Causes of increased Resp distress? • Secretions • TEF leading to increased intestinal gas • Anal atresia----no decompression • How do you relieve the abdominal distention? • What syndrome would you consider?

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