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

NeonatalEmergencies

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

Attempt intubationcan’t see past the base of the tonguevery small mandible

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

Pierre Robin Sequence

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

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

Treatment support airway

Positioning Nasal Airway Tracheostomy Nutrition

Prognosis the more prolonged the resuscitation the

worse the neurologic outcome

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

What complication would you anticipate?

What clinical signs are indicative of a pneumothorax?

cyanosisbradycardiadecreased BS on affected side

Emergency intervention?

Needle Thoracostomy

What equipment will you gather?

Case # 3

Summoned to the LDR STAT

Corpsman meets you at the door and says“doc the babies intestines are all over the place”

How will you manage this?

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

GastroschisisEmbryology

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

Omphalocele Gastroschisis

Incidence

Covering Sac

Fascial Defect

Cord Attach.

1:6,000-10,000

Present (may beruptured)

Small to large

Umbilical the sac

1:20,000-30,000

Absent

Small (vascularcompromise)

Abd wall

Omphalocele Gastroschisis

Herniated Bowel

Other organs

IUGR

NEC

Protected

Liver often in sac

Less common

If sac is ruptured

Edematous andmatted

Remain in abd.

Common

18 %

Omphalocele GastroschisisAssoc..

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%

PrognosisGastroschisis:

70% to 90% survival morbidity related to prematurity and

bowel compromise

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 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

Diagnosis?

Diaphragmatic Hernia

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 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 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 What are your next steps? Oral suction, pulse ox, OG, IV Evaluation for infection

Blood culture, cbc, abx, chest film

Case # 5

Abdominal distention continues to increase followed by worsening resp distress and cyanosis

Next step?

Will intubation help decrease abdominal distention?

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?