Neonatal emergencies-3 Dr. Miada Mahmoud Rady EMS 481 Final lecture

Fever .. Guarding Absent Tears …. Rigidity Dry Mucous Membrane…… Previously ……… We discussed at the end of the lecture the proper prehospital signs of vomiting and diarrhea??? What dangerous signs and symptoms you should look for..? And significance of each of these finding ….. Fever .. Guarding Absent Tears …. Rigidity Dry Mucous Membrane…… Please state at least one significance of each word , if you cannot please revise the previous lecture…….

Management Address the ABCs : Maintain a patent airway. Keep face turned to one side to prevent aspiration. Suction or clear vomitus from airway with a suction catheter or suction bulb. Provide either free-flow supplemental oxygen or bag-mask ventilation as necessary.

Management Consider a nasogastric or orogastric tube to decompress the stomach. Do not administer antiemetic in the field. The newborn may need fluid resuscitation ( normal saline ) if there is dehydration

Neonatal jaundice Jaundice : yellowish discoloration of the skin and mucous membrane. Jaundice can be physiological in neonates and it is due to failure of immature liver to conjugate bilirubin.

Characteristics of physiological jaundice First appears between 24-72 hours of age Maximum intensity seen on 4-5th day in term and 7th day in preterm neonates Does not exceed 15 mg/ dl Clinically undetectable after 14 days. No treatment is required but baby should be observed closely for signs of worsening jaundice.

Pathological jaundice Clinically visible in first 24 hours after birth Total serum bilirubin increases by more than 5 mg/dL/d. Total bilirubin exceeds 12 mg/dL in full-term infants. Conjugated bilirubin exceeds 15 to 20 mg/dl. Persists for more than 1 week in full-term infants and for more than 2 weeks in preterm infants

Risk factors of jaundice Simple pneumonic for risk factors is JAUNDICE J - Jaundice within first 24 hrs of life A - A sibling who was jaundiced as neonate U - Unrecognized hemolysis N – Non-optimal sucking/nursing D - Deficiency of G6PD I - infection C – Cephalhematoma /bruising

Assessment and management Address the ABCs . Start on IV fluids if the neonate shows significant clinical jaundice. Communicate with medical control about any newborn with jaundice. Transport is essential for bilirubin measurement at the hospital.

Birth trauma Definition : Birth trauma are injuries resulting from mechanical forces that occur during the delivery process. Mostly are self-limiting .

Risk Factors for Birth Injury Prematurity. Post maturity. Prolonged labor. Breech presentation. Cephalopelvic disproportion. Diabetic mother ( large baby ). Explosive delivery.

Head Excessive molding of the head Caput succedaneum : Swelling of soft tissue of the scalp from pressing against the dilating cervix Cephalhematoma : Area of bleeding between the parietal bone and the covering periosteum , May take 2 weeks to 3 months to resolve , Do not try to drain because it may worsen or prolong bleeding. Linear skull fractures.

Nerves Brachial plexus injuries Facial nerve palsy Diaphragmatic paralysis Laryngeal nerve injury Spinal cord injury

Congenital heart disease (CHD) CHD is commonest birth defects . Based on the presence of cyanosis , it is divided into two groups: Congenital cyanotic heart disease. Congenital acyanotic heart disease.

Congenital cyanotic heart diseases Most famous examples include : Tetralogy of Fallot . Truncus arteriosus. Transposition of great vessels. Tricuspid atresia.

Acyanotic heart diseases Divided into two groups based on the main pathology : Right to left shunt : Ventricular septal defect. Atrial septal defect . Patent ductus arteriosus. Outflow obstruction : Pulmonary stenosis . Aortic stenosis. Coarctation of the aorta.

Left to right shunt anomalies All share the same complication and presentation Clinical presentation : Easy fatigability . Heart murmur . Repeated chest infections. Tachycardia . Tachypnea . Complication : Heart failure . Growth retardation . Increased risk of endocarditis.

Right to left shunt anomalies It include : Atrial septal defect (ASD): Defect exists in the atrial septum . Usually due to failure of closure of foramen ovale . It allows blood to pass from the left atrium to right atrium causing mixing of oxygenated and deoxygenated blood. Most commonly asymptomatic .

Ventricular septal defect A defect exists in the wall between the two ventricles. Allows blood to pass from left ventricle to right ventricle . It has same clinical manifestation and complication as left to right shunt in addition to : Pulmonary hypertension , which causes reversal of the shunt , blood flows from right ventricle to left ventricle leading to cyanosis.

Management Address ABCs . High flow oxygen if indicated . Careful monitoring of vital signs . Watch for signs of heart failure. Definitive treatment : Small defect : careful follow up and assurance as defect will eventually close. Large defect : surgical correction.

Patent Ductus Arteriosus

Patent Ductus Arteriosus Pathophysiology : Ductus arteriosus exists between pulmonary artery and aorta before birth It Normally closes within few hours of birth Failure of closure allows blood to mix between pulmonary artery and aorta blood that should flow through aorta to nourish body returns to lungs Common in premature infants and rare in full‐term babies.

Patent Ductus Arteriosus It has the same clinical presentation and complication of left to right shunt . Definitive treatment : usually surgery , to close defect and restore circulation .

Remember Hall mark of shunt disorders is heart murmur which becomes louder as shunt increases.

Tetralogy of Fallot Definition : Combination of four congenital heart defect : A large ventricular septal defect (VSD). An overriding aorta. Pulmonary stenosis. Right ventricular hypertrophy. All result in poor oxygenation and cyanosis.

Clinical presentation Cyanosis Shortness of breath and Tachypnea. Fainting attacks Clubbing of fingers and toes Poor weight gain Easy fatigability and irritability A heart murmur. Tet spells

Tet spells Typically cyanotic spells occur early in the morning. The possible triggers are anxiety, fever, anemia, sepsis or even spontaneously. A typical infant with cyanotic spell would appear fussy, irritable which then progresses to increasing cyanosis, hyperpnoea. Management : squatting position (children) , knee to chest position (infant)

TOF management Surgical correction

Any questions Thank you