Neo emergencies_Tate

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NeonatalEmergencies : 

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

Case # 1 : 

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 : 

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

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

Case # 1 : 

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

Case # 1 : 

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

Case # 1 : 

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

Case # 2 : 

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

Case # 2 : 

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

Needle Thoracostomy : 

Needle Thoracostomy What equipment will you gather?

Case # 3 : 

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

Slide 12: 

How will you manage this?

Delivery Room Management:Gastroschisis : 

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

Slide 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

Slide 16: 

Omphalocele Gastroschisis

Slide 17: 

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

Slide 18: 

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

Prognosis : 

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

Case # 4 : 

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

Case # 4 : 

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

Slide 22: 

Diagnosis?

Diaphragmatic Hernia : 

Diaphragmatic Hernia

Case # 4 : 

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

Case # 4 : 

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

Case # 5 : 

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

Case # 5 : 

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

Case # 5 : 

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

Case # 5 : 

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?