An Evidence-Based Review Of Neonatal Emergencies

Table of Contents

 

1. Abstract
2. Practice Recommendations (key points from the issue)
3. Case Presentations
4. Critical Appraisal Of The Literature
   1. Population-Based Data
   2. Diagnosis, Treatment, And Outcome Data
   3. Literature Search
5. Pathophysiology
6. Epidemiology
7. Prehospital Treatment
8. Emergency Department Evaluation
   1. Important History Questions
   2. Physical Examination
9. Laboratory Testing
   1. Sepsis/SBI
   2. Cardiac Disease
   3. GI Disease
      1. Malrotation
      2. Necrotizing Enterocolitis
   4. Metabolic Disease
   5. Child Abuse
10. Other Diagnostic Studies
    1. Sepsis/SBI
    2. Cardiac Disease
    3. GI Disease
    4. Child Abuse
11. Treatment
    1. Neonatal Advanced Life Support And Resuscitation
    2. Infectious Disease
    3. Cardiac Disease
    4. GI Disease
    5. Metabolic Disease
    6. Child Abuse
12. Transfer Issues
13. Disposition
14. Summary
15. Risk Management Pitfalls To Avoid In The Critically Ill Neonate
16. Cost-Effective Strategies
17. Case Conclusion
18. Clinical Pathway: Management Of The Critically Ill Neonate
19. Tables and Figures
    1. Table 1. Common Signs And Symptoms Of Life-Threatening Neonatal Illnesses
    2. Table 2. Suggested Testing By Suspected Diagnosis
20. References

Abstract

The ill neonate is a frightening entity for most emergency clinicians. Neonates are a rare entity at many nonpediatric emergency departments (EDs), and when they are brought in, it is frequently for minor complaints.² When critically ill infants do present, appropriate newborn resuscitation equipment and consultations are often unavailable.^3,4 Even when a general pediatric consultation is readily available, the experience with ill children may be limited. One study of academic pediatric training programs indicated that only 36% of graduating residents had led a pediatric resuscitation, and a handful had no pediatric advanced life support (PALS) training.⁵ It is easy to understand why the resuscitation of a neonate can be an intimidating and lonely experience for an emergency clinician.

This issue of Pediatric Emergency Medicine Practice will discuss recognition of the causes as well as general and disease-specific means of stabilizing the critically ill neonatal patient. There are many rare diseases that can cause shock in a neonate. This article will concentrate on some of the most common: sepsis/serious bacterial infections (SBIs), including meningitis, bacteremia, and urinary tract infection; malrotation; necrotizing enterocolitis (NEC); ductal-dependant cardiac lesions, including cyanotic congenital heart disease and ductal-dependent obstructive lesions; inborn errors of metabolism (IEMs) that present with significant metabolic derangement in the neonatal period (specifically, urea cycle defects and organic acidemias); salt-wasting types of congenital adrenal hyperplasia (CAH); and nonaccidental trauma (NAT).

Practice Recommendations (key points from the issue)

Click here to download a PDF of the Evidence-Based Practice Recommendations for this issue.

Case Presentations

A 5-day-old boy is brought into the emergency department for poor feeding and lethargy. The patient is the full-term product of a vaginal delivery to a healthy mother who received routine prenatal care. He had been eating well—2 oz of formula every 2 hours—until today, when he began sucking poorly and taking less than half an ounce with each feeding. He has been afebrile, and the review of his systems is otherwise negative. On examination, the baby is notably difficult to arouse. He appears slightly jaundiced and mottled, which the mother believes are new findings. His temperature is low at 35.5ºC (95.9ºF), his heart rate is 190 beats per minute, his respiratory rate is 50 breaths per minute, and his blood pressure reading is 66/38 mm Hg. His anterior fontanel is open and flat, his lungs are clear, the cardiac examination reveals significant tachycardia, the liver is palpable 1 cm below the costal margin, results of the abdominal examination are unremarkable, and the capillary refill time is poor at 5 seconds. It has been some time since you reviewed the differential diagnosis of the ill neonate, but you recall the mnemonic THE MISFITS and generate an extensive list: trauma, heart disease, electrolyte disturbances, metabolic, inborn errors, sepsis, formula mishaps, intestinal catastrophes, toxins, and seizures.¹ You have pediatric colleagues available, but this newborn looks like he needs some intervention before they are likely to return your page. Where should you start with the resuscitation? If little blood is available, what are the high-yield laboratory tests? What if the nurses can't obtain access in this critical patient? And what illnesses are most likely (ie, to help you establish a diagnosis and start disease-specific treatment as quickly as possible)?

Critical Appraisal Of The Literature

Population-Based Data

Neonatal mortality information was derived from the National Vital Statistic System maintained by the Centers for Disease Control and Prevention. This is a national reporting database. Small prospective studies on the incidence and test characteristics of neonatal sepsis were also available.

Diagnosis, Treatment, And Outcome Data

Each of the diseases discussed in this article is an uncommon entity, and the diagnosis and treatment is generally based on extrapolation from pathophysiology, expert opinion, and small retrospective data sets. A large prospective study was available on treatment of IEMs and optimal antibiotic therapy for the infected neonate. A well-researched literature review resulting in national guidelines was available regarding screening for congenital heart disease and treatment of neonatal sepsis. Small prospective studies were done on the association between SBIs and apparent life-threatening events (ALTEs). The remainder of the studies used in this paper consisted of retrospective case series.

Literature Search

PubMed® and Ovid MEDLINE® were searched for literature on neonatal emergencies published from 1950 to the present. Multiple search terms were used because of the variety of conditions discussed. Pertinent abstracts were used for non-English language studies.

Risk Management Pitfalls To Avoid In The Critically Ill Neonate

1. "The child did not appear blue, so I didn't investigate the possibility of a cyanotic cardiac anomaly."Apparent cyanosis requires 5 g/dL of deoxygenated hemoglobin. Early in the neonatal period, most infants are polycythemic and can manifest cyanosis overtly at an oxygen saturation of 85%. However, later in the neonatal period or in the anemic neonate, the oxygen saturation required to produce a blue appearance is much lower.
2. "The neonate had some bilious emesis, but the plain radiographs of the abdomen were normal."A surgical cause of bilious emesis in the neonate is found in 30% to 40% of cases. In malrotation specifically, findings from plain radiographs are often normal. A UGI study should still be considered, but if it is not possible, the patient should be observed or a pediatric surgeon consulted.
3. "The mother reported a temperature at home, but the infant had no fever in the ED."Tactile fevers can be difficult to interpret. Nevertheless, one retrospective study indicated that in infants with a documented rectal temperature at home, 92% had a fever either on presentation to the ED or during a subsequent 48-hour hospitalization for observation.¹⁰⁰ The safe course is always to take a parent's history of fever seriously unless there is a compelling reason not to.
4. "The parents say the child rolled off the bed, which may explain the intracranial hemorrhage."Being responsible for removing an infant from his or her home can be difficult; it is even harder when the diagnosis is unclear. It is important to remember, however, that any suspicion on the part of the emergency clinician requires a DCFS report, and further action is up to the legal system and child abuse teams. Rolling is unlikely in an infant under 4 months of age, making the history suspect. Additionally, although skull fractures and epidural hematomas have been reported in infants after a 3-foot fall, subdural hematomas are highly implausible from that mechanism.
5. "I was waiting for the results of the herpes simplex virus PCR before starting the acyclovir."About 1% of neonates with a fever and CSF pleocytosis have herpes meningitis. It is a high morbidity and mortality disease with improved outcomes when treatment is started early in the disease course. As the side effect profile is minimal for acyclovir, it is reasonable to start the drug in the ED.
6. "I was waiting for the nurses to secure an IV in order to start therapy."It is easy to fall into the trap of waiting for the nurse to obtain an IV, whether the delay involves awaiting the arrival of a NICU nurse or a lack of communication about whether access has been established. In the critically ill neonate, a few attempts should be made before moving on to obtain an intraosseous line. Alternatively, an emergent umbilical line can be attempted in neonates up to 10 days old.
7. "I did everything right with the diagnosis of hypoplastic left heart syndrome. Why did the patient die after transfer?"The gut hypoperfusion associated with hypoplastic left heart syndrome can cause bowel ischemia and resultant sepsis. Although some patients clearly die from the cardiac lesion itself, it is important to have a low threshold for diagnosing and/or empirically treating infections in these infants.
8. "The patient's glucose level was 35 mg/dL. I understood that to be normal in the neonate."Historically, lower values were tolerated. Current recommendations consider values below 45 mg/dL to be hypoglycemic, requiring treatment.¹⁰¹
9. "I've intubated the child, but I'm still having trouble ventilating her."Neonatal intubations can be difficult, but when one does not have the desired result, following the adult algorithm of reconfirming placement, assessing for equipment failure, ruling out pneumothorax, and checking for obstruction is appropriate. Additionally, it is easy to intubate the right mainstem bronchus in an infant; generally, the tube measurement at the lip should be 3 times the size of the ETT (ie, a size 4 tube will be inserted at 12). Finally, gastric distension from bagging can be significant enough to impair ventilation. Placing an NGT or OGT may improve the ability to ventilate the infant.
10. "An infant brought in died in the department, and it sounds like a clear-cut case of SIDS. The parents are strongly against an autopsy."Unfortunately, any unexpected neonatal death does require an autopsy. Sudden infant death syndrome is a diagnosis of exclusion and requires an autopsy to ensure that other potential causes (such as abuse) have been ruled out.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

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