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?