Pediatric Emergency
Aids
Dr.Ammar Rahamn Kadum
Seizure (Fit)
It is a common presentation in pediatrics emergencies , presented as
repetitive limbs movements , upward deviation of eye ball , sometimes
apnea or focal limb movement (focal fit) .
Management :
1-A (airway protection : put the patient in the lateral position , fluid
suction by sucker if there is mouth secretion).
2-B (breathing exam because the fit may cause apnea, so resuscitate and
give O2 as needed ).
3-C (circulation and cannulation to administer medications).
Give the patient I.V diazepam (valium) 0.1 - 0.3 mg/kg diluted with distal
water slowly , if there is no response , the dose may be repeated up to
three times every 2-5 minutes .
If there is no response with diazepam, give luminal (Phenobarbital) bolus
dose 15- 20 mg/kg infused in 30 cc G/W during several minutes or IV
very slow, you can repeat it up to three times but with lower dose (5 –
10 mg/kg) in the two further doses.
If there is no benefit with luminal, give phenytoin bolus dose (the same
as luminal).
If there is no response with all these medications, tracheal intubation
should be done and prepare the patient for general anesthesia.
Note// Diazepam is not recommended under 6 months old, with these
age group start with luminal .
Any case of fit you should find the underlying cause as possible .
DDX :
1-Febrile convulsion (occurs between 6 months – 6 years exclusively).
2-Metabolic causes (hypoglycemia, hypocalcaemia, hypomagnesaemia ,
hypo or hypernatraemia , uremia , hepatic encephalopathy ).
3- Intracranial causes (infection like meningitis or encephalitis ,
hemorrhage , trauma , tumor , kernicterus , brain anomalies and CP ).
4- Idiopathic (epilepsy).
5- Drugs (aminophylline, plasil) and other causes like: pica (lead
poisoning) or after DPT vaccine.
Hypoglycemia
Any lethargy or decrease in consciousness level, you should exclude
hypoglycemia.
In general, emergent hypoglycemia occurs when RBD is :
45mg/dl or less in pediatric age groups.
55mg/dl or less in adult female.
65mg/dl or less in adult male .
but the level of glucose may be higher than this and the patient is
clinically deteriorated, so the clinical picture is more important which
includes:
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Shakiness
Nervousness or anxiety
Sweating, chills and clamminess
Irritability or impatience
Confusion, including delirium
Rapid/fast heartbeat
Lightheadedness or dizziness
Hunger and nausea
Sleepiness
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Blurred/impaired vision
Tingling or numbness in the lips or tongue
Headaches
Weakness or fatigue
Anger, stubbornness, or sadness
Lack of coordination
Nightmares or crying out during sleep
Seizures
Unconsciousness and may be apnea
Possible causes:
1- Diabetic patient:
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Too much medication; for instance, too much insulin or oral diabetes
medication.
Medication mistakes. All families will, at some point, give the wrong
kind of insulin for a meal or at bedtime.
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Inaccurate blood-glucose readings.
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A missed meal.
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A delayed meal.
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Too little food eaten, as compared to the amount of insulin taken.
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More exercise than usual.
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Diarrhea or vomiting.
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Injury, illness, infection, or emotional stress.
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Other medical problems sometimes seen in people with type 1 diabetes,
such as celiac disease or an adrenal problem.
2-In non diabetic patient
The hypoglycemia may be due to (fasting ,stomach surgery , enzyme
deficiency , serious illness like heart , liver or kidney diseases ,
medications like aspirin or quinine, Low levels of certain hormones,
such as cortical, growth hormone, glucagon, or epinephrine, tumors such
as a tumor in the pancreas that makes insulin or a tumor that makes a
similar hormone called IGF-II.
Treatment: give dextrose IV bolus
(0.25 – 0.5 g/kg) if under 6 months old.
(0.5 – 1g/kg) if 6months old and older.
For rapid calculation give IV dextrose 10% (3cc/kg) bolus dose.
Then maintenance dextrose 0.4 g/kg/hr , till the level of glucose
becomes more then 60 mg/dl . The glucose level should be measured
after 15 minutes then hourly, (don’t take the blood sample from the
same side of IV line to avoid error reading) .
Notes:
Dextrose 10 % means there is (10 g of glucose in each 100 cc water).
Dextrose 5 % means there is (5 g of glucose in each 100 cc water).
Dextrose 50 % (hypertonic) means there is (50g of glucose in each 100 cc
water).
When dextrose 10% is not available (this is the usual) , prepare it by
mixture of (88 cc dextrose 5% with 12 cc dextrose 50% ) .
Keep in your mind (in pediatric age group ) hypertonic (50% dextrose) is
diluted with fluid before administered , because direct IV
administration of hypertonic dextrose (50%) may cause cerebral
oedema or rebound hypoglycaemia.
The patient stay in the emergency department for observation.
Example:
Patient W.T is 10 kg with emergent hypoglycemia :
Bolus dose of dextrose is 30 cc
Maintenance: 4 g /hr witch obtained by 40 cc dextrose 10% (dextrose
10% contains 10 g of glucose in each 100 cc water).
Note // when there is no IV access , give the patient glucagon IM in the
deltoid muscle or anteriolateral aspect of thigh (0.5mg for less than 6
years old , 1 mg for more than 6 years old) .
Fever
Normal body Temperature (36.5 – 37.5 ) C .
Significant fever (when the body temp. is 38 C or more )
Body temp. measurement methods : put the thermometer for 2-4
minutes:
1-In the axilla (add half degree to the readings).
2-Rectal (subtract half degree from the reading ).
3-Sublingual (consider the same reading)
Treatment:
1-Paracetol vial 1.5 cc/kg (weight + 1/2 weight = dose in cc).
Note // the dose of paracetol (15 mg /kg/dose) calculate the optimal
dose when there is another formula like paracetol ampoule ,syrup or
suppositories .
2- Cold sponges (not very cold water) apply them in the forehead, axilla,
between thighs and abdomen).
3-Antiobiotics (according to the source of infection).
4- Fluid :(G/S) 1/5 for less than 6 months old children .
(G/S)1/2 for more than 6 months old children .
DDx:
the common ddx (meningitis , encephalitis, meningioencephalitis,
tonsillitis , chest infection , pneumonia , bronchiolitis , gastroenteritis ,
UTI , sepsis , rheumatoid arthritis , haematological disease like leukemia
…ect).
Dyspnea
Dyspnea: is difficulty to take spontaneous breathing,the patient
presentation is variable according to the severity of the case, may be
presented with or without cyanosis (central, peripheral, or both) ,
irritability , jitteriness or fit due to hypoxia , decrease of consciousness
level , coma or apnea in severe cases .
Management:
1-Iniatially in any case of dyspnea check the airway patency and take
quick history (it's very important to ask about documented disease).
2-Check the vital signs specially SPO2 and respiratory rate.
3-Chest examination : (inspection , palpitation , auscultation …ect).
4-Send for investigation according to the expected diagnosis that you
got via history and examination (CBC , chest x-ray , CT chest , renal
function test , serum albumin , liver function test …ect).
5-Treatment: according to the underlying cause. The common causes
are:
1-Asthmatic exacerbation.
2-Chest infection or pneumonia.
3-Bronchioliatis.
4-Croup.
5-Pulmonary oedema: (renal failure, heart failure (e.g. congenital
heart disease), liver failure , fluid overload or inflammatory pulmonary
) congestion e.g. lung cancer or metastases).
6-Pulmonary embolism.
7-Surgical causes : pneumothorax , haemothorax ,
haemopneumothrax , pleural effusion , foreign body inhalation , CO
toxicity (burn) , trauma , lung contusion , tumor ..ect).
Asthmatic exacerbation
Presented with dyspnea , cough and wheezy chest , treated by :
1-O2
2-Ventolin nebulizer (1/2cc diluted with 2cc N/S) , you can repeat it 6
hourly as required or every 20 minutes in severe cases .
3-Hydrocortisone vial (5 – 10 mg/kg) or decadron ampoule (0.5 mg /kg).
4--In case of refractory dyspnea use aminophylline, give bolus dose
5mg/kg (infusion with 30 cc G/W during 30 minutes). Then maintenance
dose (2 – 3 mg/kg) divided 12 hourly (infusion with 30 cc G/W during 30
minutes) and should be given after 8 hours after the bolus dose .
5-Antiobiotics if there is suspicion of infection.
Chest infection or
pneumonia
The patient presented with dyspnea , baronial breath , and fever .
Treated by :
1-O2
2- Hydrocortisone vial (5 – 10 mg/kg) or decadron ampoule (0.5 mg /kg).
3-Antibiotics
4-Ventolin nebulizer : (1/2cc diluted with 2cc N/S) , you can repeat it 6
hourly as required or every 20 minutes in sever cases .
5-In case of refractory dyspnea use aminophylline, give bolus dose
5mg/kg (infusion with 30 cc G/W during 30 minutes) . Then
maintenance dose(2 – 3 mg/kg) divedied 12 hourly (infusion with 30 cc
G/W during 30 minutes) and should be given after 8 hours after bolus
dose .
Bronchiolitis
Its seasonal infection occurs mostly in infants during the winter
(November and December), involves the bronchioles. The patient
presented with dyspnea, fever , cough or sneezing . On examination, the
patient may be presented with hypoxia , wheezy chest and acidic
breathing due to respiratory acidosis. Chest x-ray in severe cases may
show air bronchogram (atelectasis) in severe cases . Treated by :
1-O2
2- Hydrocortisone vial (5 – 10 mg/kg) or decadron ampoule (0.5 mg /kg).
3-Antibiotics.
4-Ventolin nebulizer: (1/2cc diluted with 2cc N/S) , you can repeat it 6
hourly as required or every 20 minutes in sever cases .
5-In case of refractory dyspnea use aminophylline, give bolus dose
5mg/kg (infusion with 30 cc G/W during 30 minutes). Then maintenance
dose (2 – 3 mg/kg) divided 12 hourly (infusion with 30 cc G/W during 30
minutes) and should be given after 8 hours after bolus dose.
6-Sodium bicarbonate in case of acidosis 1 – 3 meq/kg (1 – 3 cc/kg)
infused in 30 cc G/W slowly (during 4 hours).
Croup
(Laryngeotrachiobronchitis)
Its acute condition characterized by croupy cough with may be
associated with inspiratory stridor and voice hoarseness due to varying
degree of laryngeal obstruction. The causes may be mechanical
(laryngeal web , tracheal or laryngeal malacia , laryngeal stenosis ,
foreign body ) or inflammatory (parainfluenza , haemophilus influenza ,
acute diaphragmatic laryngitis .. ect) or other causes like congenital
goiter . Treated by:
1- Adrenaline ampoule (1/2cc ) with cold N/S (2cc) : given as nebulizer.
2-O2
‫ مرات اذا مفاد‬٣ ‫اول شي تبخير ثلجي ينعاد‬٣ ‫و ياها‬
١ ‫واذا مفاد‬
3-Decadron ampoule : (0.6mg/kg) IM or IV , but in suspected sever
laryngeal odeme give decadron (2mg/kg) IV .
4-Antiobitics are given in suspected bacterial involvement (toxic patient ,
fever , elevated WBC , sever dyspnea or cyanosis).
5-In case of sever laryngeal obstruction, the patient may need tracheal
intubation and RCU admission.
Pulmonary oedema
The patient presented with dyspnea , chest crepitation . Ask about
chronic diseases. It's could be heart failure , congenital heart disease ,
renal failure ,nephrotic syndrome , hepatic failure , hypoproteinaemia ,
inflammatory causes like lung CA or metastasis ) . Treated by :
1-Sitting upright position and swing the legs down to reduce the venous
preload .
1-O2
2-Diuretics: lasix (furosemide) ampoule 0.5 – 1 mg/kg IV . Be aware that
the patient has no hypotension, and ask about Sulfa allergy (Sulfa is one
of the contents of laxis) . You may need insert foley catheter to assess
the urine output .
3- Observe the SPO2 , other vital signs and general condition.
Pulmonary embolism
The patient presented with sudden dyspnea , chest pain , cyanosis
(central or peripheral or both) , hypotension , tachypnea , hypoxia ,
congested JVP and shock in severe cases . The patient usually has history
of long bone fracture, bedridden, DVT , thrombophilia , congenital heart
disease , family history of thrombotic disease or thromboembolic
phenomena . Send the patient for ECG (sinus tachycardia), the criteria of
S1Q3T3 may present in ECG. The definitive diagnosis is obtained by CT
pulmonary angiography (filling defect) .
Any suspected pulmonary embolism, don’t wait for full investigations
results , take a rapid action :
1-High flow O2
2-Anticoagulant (heparin or enoxaparin).
3-Call for senior help for definitive treatment (thrombolytic or
thromboectomy).
Surgical causes:
pneumothorax , haemothorax , haemopneumothrax , pleural effusion
, foreign body inhalation , CO toxicity (burn) , trauma , lung contusion ,
tumor ..ect).
Any one of these cases needs surgical intervention and treated
according to the underlying cause but initially do the supportive
measures:
1-High flow O2.
2-Sterodis.
3-Antiobiotics.
4- Surgical intervention.
DKA
It's precipitated by stress (infection , psychological , insulin dose
error , trauma or vomiting) . Clinical presentation (vomiting,
abdominal or legs pain , dehydration , acidic breathe, fever,
irritability.. ect)
Lab investigations :RBS (elevated) , GUE (ketones and glucose
in urine), S.electrolytes (K , Na , HCO3 ) and CBC.
Management :
Fluid replacement : give the patient bolus dose of fluid (shoot),
(N/S) 20cc/kg during one hour for any suspected DKA (don’t wait
for lab investigations results). Then calculate the fluid that the
patient needs per hour via this equation:
85cc/Kg = the deficit
M= the maintenance which is calculated as following :
1st 10 kg: 100 cc/kg
2nd 10 kg: 1000 cc + 50 cc for each kg after 10 kg
3rd 10 kg: 1500 cc + 20 cc for each kg after 20 kg
The total amount of fluid sometimes given during 36 or 48 hrs
in severe cases when we need slow correction of dehydration
to avoid cerebral edema . The type of fluid initially is N/S but
when the RBS has fallen to 250-300 mg/dl , glucose containing
fluid should be given (either 5% glucose with 0.9% saline or 5%
glucose with 0.45% saline ). If cerebral edema developed,
restrict the fluid replacement to two thirds of the maintenance
and give the deficit during 48 hrs or longer.
Insulin replacement: the insulin should be started after 1 or
2 hours of fluid resuscitation to avoid cerebral oedema. The
fluid of insulin infusion should be subtracted from the amount
of fluid witch infused hourly. Continuous infusion of soluble
insulin (0.1 unit/kg/hr) is effective and safe regime. The
infusion rate can be reduced when the glucose levels fall but
should not be reduced below (0.05 unit/kg/hr) to prevent any
recurrence of ketosis. Blood glucose should not be reduced
more than 90 mg% per hour. When the blood glucose level
falls to 120 mg%, increase the concentration of infused glucose
to prevent hypoglycemia .ketosis clears more quickly if insulin
infusion prolonged for 36 hrs or more.
Potassium replacement: potassium is given after 1 or 2
hours of fluid resuscitation and after make sure that the patient
pass urine (has good urine output), the potassium (kcl) is added
to replacement fluids, and scientifically KCL is given according
to the level of serum K:
S. k (mEq/L)
2.5 – 3.5 mEq/L
3.5 – 5 mEq/L
5 - 6 mEq/L
KCl dose in infusion fluid
40 mEq/L
20 mEq/L
Stop k infusion and repeat S.k level after
2 hours
But roughly and for safety add 1cc of Kcl for each 100cc of fluid
(for example when the fluid requirement is 150cc/hr add 1.5cc
kcl /hr , when the fluid requirement is 50cc/hr add 0.5cc kcl/hr
….ect) . The potassium should be administered slowly to avoid
cardiac standstill, monitor the level of S.K each 2 hours, and
observe the heart beat and patient general condition carefully.
Notes:
Foley cath. may be inserted on need , N/G tube should be inserted in
comatose or semiconscious patients , ECG monitoring in severe cases .
Treat the underlying cause of DKA such as infection.
If cerebral edema is suspected and hypoglycemia is excluded give
osmotic diuretic (mannitol 0.5- 1g/kg infused during 30 minutes and
can be repeated after one hour , admit him/her to an intensive care
unit , followed by CT scan , referral to a neurosurgeon . Intubation,
hyperventilation, and intracranial pressure monitoring improve
outcome.
Other complications may occur (hypoglycemia, hypo or hyperkaliemia,
myocardial infarction or thromboembolic phenomena,
hypocalcaemia).
Gastroenteritis
Clinical presentation: diarrhea, vomiting, fever, dehydration, perhaps
abdominal cramp.
Treatment:
1-Give the patent N/S 20cc/kg/hour (shoot) if there is dehydration, the
shoot may be repeated according to the severity of dehydration status.
2- Flagyl (metronidazole) vial : 7.5 mg/kg (W.T + 1/2 W.T = dose in cc)
8 hourly (three times daily).
3-Amikacin vial: 15 mg/kg divided 12 hourly
4-Antipyretic (if there is fever).
4-Fluid:
Deficit = 5 * 10 * W.T (mild dehydration).
10 * 10 * W.T (moderate dehydration).
15 * 10 * W.T (severe dehydration).
Maintenance = 1st 10 kg: 100 cc/kg
2nd 10 kg: 1000 cc + 50 cc for each kg after 10 kg
3rd 10 kg: 1500 cc + 20 cc for each kg after 20 kg
UTI
Presentation : dysurea , haematuria , vomiting , fever , sometimes crying
during urination (infants) .
Treatment :
1-Antiobiotics : amikacin vial 15 mg/kg divided 12 hourly.
2-Antipyretic: (if there is fever).
3-Fluid .
4-Analgesia .
Tonsillitis
Presentation: Fever, malaise, vomiting, odynophagia, palpable neck
lymph nodes .
Treatment:
1-Antiobiotics.
2-Fluid (if there is repetitive vomiting).
3-Antipyretic (if there is fever).
Snake bite
1-Check the vital signs of the patient (risk of shock).
2-Give hydrocortisone vial (5 – 10 mg/kg) I.V.
3-Give allermine ampoule I.V:
Less than 6 months:0.25 mg/kg (maximum 2.5 mg) .
6 months – 6 years: 2.5 mg .
6 – 12 years: 5 mg .
12 – 18 years: 10 mg .
3-N/S fluid 20cc/kg if the patient shocked.
4-Antivinin (polyvalent snake): give 4 – 6 vials infused in one hour (in 250
cc N/S) , be careful from allergic reaction . Try to give it early as possible
(DON’T DELAY MORE THAN 6 HOURS).
5- Send the patient for CBC (platelets), PT, and PTT (risk of DIC).
6- Anti tetanus and antibiotics.
Note // try to avoid IM injection in case of snake bite because there is
risk of bleeding tendency due to expected DIC .
Scorpion sting
1-Check the vital signs of the patient (risk of shock).
2-Give hydrocortisone vial (5 – 10 mg/kg) I.V.
3-Give allermine ampoule I.V:
Less than 6 months:0.25 mg/kg (maximum 2.5 mg)
6 months – 6 years: 2.5 mg
6 – 12 years: 5 mg
12 – 18 years: 10 mg
3-N/S fluid 20cc/kg if the patient shocked.
4-Antivinin (scorpion): initially give 3 vials infused in 50 cc N/S over 10
minutes. Be careful from allergic reaction.
5-Anti tetanus and antibiotics.
Dog bite
1-Check the vital signs.
2-Wash the area of bite with normal saline.
3-DON’T SUTURE THE BITE WOUND, because this may accelerate the
migration of rabies virus via the nerves to CNS.
3-Give the patient anti rabies immunoglobulin 20 U/kg infiltration in the
site of bite wound or IM in the deltoid muscle or anteriolateral aspect of
thigh (in young children).
4-Give rabies vaccine IM in the deltoid muscle (in another site of anti
rabies IG as following :
Day zero (bite day) : anti rabies IG + rabies vaccine.
Day 3 : rabies vaccine.
Day 7 : rabies vaccine.
Day 14: rabies vaccine.
Day 28 : rabies vaccine.
5- ATS (anti tetanus) + antibiotics (augmentin, doxyclycline,
erythromycin).
6-Follow up and teach the relative to be aware of signs of rabies
infection (behavioral changes, insomnia, mental deterioration, excessive
salivation, and fever …ect).
Common neonatal
presentations
General protocol for admission to neonatal unites:
1-Incubator 32 C˚ (for term neonate) , 35 C˚ (for preterm neonate).
2-Continous O2
3-Double antibiotics: in general its good combination to give
amoxicillin vial +Gentamycin ampoule. (Amoxicillin 50 – 100 mg/kg
divided 12 hourly, Gentamycin 5 mg/kg divided 12 hourly).
Sometimes specific antibiotics are prescribed accordingly.
4-Give Vit. K ampoule 1 mg (in the 1st day of life).
5-Fluid:
1st day: 60 cc/kg/24 hrs (for term neonate), 70 cc/kg/24 hrs (for
preterm neonate).
Type of fluid: G/W 10 % exclusively.
2nd day: 70 cc/kg/24 hrs
Type of fluid: G/W 10 % exclusively.
3rd day: 80 – 90 cc/kg/24 hrs
Type of fluid: G/S (1/5) exclusively.
4th day and above: 100 cc/kg
Type of fluid: G/S (1/5) exclusively.
6-Specific treatment according to the case.
Neonatal Apnea
Apnea: failure to take spontaneous breathing for 10 seconds or long
enough to produce cyanosis and bradycardia .
DDX :
1-Infection : sepsis or meningitis.
2-CNS : immaturity , drugs , kernicterus or haemorrhage.
3-Respiratory : respiratory distress , intrapulmonary pathology .
4-Gastroentistinal : oral feeding , esophageal reflex , intestinal rupture .
5-Cardiovascular : hypo or hypertension , anemia, heart failure .
6-Metabolic : hypoglycemia , hypocalcaemia , hypoxia , fluid and
electrolytes disturbance .
7-Idiopathic : immaturity of respiratory center , deep sleep .
Management:
-Check A B C ..ect
-Check RBS
-Ascultate the heart beat :
If tachycardia + apnea = seizure (treat as seizure) .
If bradycardia + apnea = cardiorespiratory arrest (Start CPR as
following ) :
1-CPR : Central chest compression by the two thumbs (100
compressions /minute ) , then after each 30 chest compressions tilt the
head and lift the chin, and give two effective breaths with ambubag (30
chest compressions/2 breaths) .
2- Give aminophylline ampoule bolus dose (5mg /kg diluted with
G/W) IV , adrenaline ampoule (IV) , after the injection push 20 cc
N/S .
3-Continue on CPR and perform cetaceous respiratory stimulation by
spinal and sterna massage, striking the lateral thigh and the buttock.
4-IF there is no response try to identify the underlying cause, give trial
of sodium bicarbonate (1 – 3 meq/kg).
Respiratory Distress
Syndrome
Also known as hyaline membrane disease occurs almost exclusively in
premature infants, in which hyaline membrane and atelectasis found by
biopsy.
Predisposing factors: (prematurity, diabetic mother, preterm labor,
prenatal anoxia, cesarean section, second borne twin, family history of
RDS and also liability increase with white male infants).
Factors in which the incidence of RDS decreases: (use of
antenatal steroids, pregnancy induced or chronic hypertension, prolonged
rupture of membranes, maternal narcotic addiction).
Physical findings: tachypnea 60 cycle/min or more, grunting, nasal
flaring, subcostal or intercostal retraction, cyanosis, chin tug and frothing.
This stage called (asphyxia livida).
Manifestation of respiratory failure, shock, pallor, irregular breathing,
apnea and may lead to death, this stage called (Asphyxia pallida).
By auscultation the findings are minimal or normal, diminished air entry
or fine crepitating may be found.
X-ray findings: air bronchogram, ground glass appearance in both
lungs.
Lab investigations: shake test and arterial blood gas analysis.
Treatment: such neonate should be admitted to neonatal intensive care
unit and put in the incubator to avoid hypothermia. Gentile handling and
minimal disturbance. The oral feeding is contraindicated for fear of
exacerbation of respiratory distress.
1-Correction of hypoxia: by humidified oxygen, this alone may
be not sufficient so we need CPAP (continuous positive airway
pressure).
2-Correction of the metabolic acidosis: by Na bicarbonate (1-3
meq/kg) slow iv infusion, which may be repeated as needed
3- Antibiotics: penicillin + garamycin combination is one of the
good combinations to be used.
4- Synthetic surfactant.
5-Total blood transfusion: may be needed to replace the fetal Hb
with adult Hb.
Complications of RDS:
1-Septicemia.
2-Bronchopulmonary dysplasia.
3-Patent ducctus arteriosus.
4-Pulmonary hemorrhage.
5-Apnea/bradycardia.
6-Necrotizing enterocolitis.
7-Retinopathy of prematurity.
8-Hypertension.
9-Failure to thrive.
10-Intraventricular Hemorrhage.
Notes:
Secondary surfactant deficiency may occur in:
(Meconium aspiration pneumonia, intrapartum asphyxia,
pulmonary infection, pulmonary hemorrhage, oxygen toxicity
along with barotrauma or volutrauma to the lungs, congenital
diaphragmatic hernia, and pulmonary hypoplasia).
Transient attack of apnea
)Respiratory distress syndrome type 2)
It can occur in term or preterm neonate whatever if delivery is
vaginal or cesarean, it occurs as a result of delay or slow absorption
of fetal lung fluid.
Clinical picture: (Tachypnea, sternal retraction, expiratory
grunting and cyanosis which may be relieved by minimal O2
It's relieved usually within 3 days; chest examination shows neither
crepitating nor wheezes. Chest x-ray shows fluid in the lung fissure
and increase in the pulmonary vasculature but no evidence of air
bronchgram.
Treatment: oxygen therapy, stop oral feeding and replace it by
IV fluids till the tachypnea improves.
Neonatal jaundice
Jaundice means yellow discoloration of sclera and skin , it occurs
when serum bilirubin is 3 mg/dl or more .
Management :
1-History taking : ask about duration , activity , feeding , any
family history of hemolytic diseases , Rh and ABO incompatibility,
fever , Cephalohematoma ,color of urine and stool, any attacks of
irritability , jitteriness or fit , lethargy and family history of
jaundice.
2-Examination : exam the consciousness level of the patient , the
posture (the patient may present with hyperextended neck in case
of kernicterus , sclera and skin color , moro reflex , sucking reflex ,
feeding try , temperature and hydration status .
3-Investigation : RBS , T.S.B (total S.bilirubin with deferential
direct and indirect ) , CBC ,PCV, GUE (general urine
examination), imaging study (abdominal U/S , abdominal CT scan
for suspected obstructive jaundice ).
4-DDX :
#Jaundice in the 1st day of life :
1-Rh incompatibility or ABO incompatibility.
2-Antenatal infection (STORCH-EB).
#Jaundice in the 2nd -3rd day of life :
1-Physiological jaundice .
2-Familial non-haemolytic jaundice (Crigler –Najjar syndrome)
3-Antenatal infection (STORCH-EB).
#Jaundice in after the 3rd day to the 7th day :
1-Neonatal sepsis
2-Absorbtion of hematoma e.g. (cephalohematoma , IC
haemorrhage , subcabsular hematoma in the liver …ect).
3- Hereditary spherocytosis and G6PD deficiency.
4-Antenatal infection (STORCH-EB).
#Jaundice appearing after the first weak :
1-Congenital biliary atresia.
2-Neonatal hepatitis , septicemia and infection .
3-Heridery spherocytosis and elliptocytosis .
4-G6PD deficiency .
5-Breast milk jaundice.
6-Galactocemia.
7-Inspissated bile syndrome.
8-Choleducal cyst.
9-Synthetic Vit.K injection .
#persistent jaundice after the first month of life :
1-Congenital biliary atresia.
2-Hypothyroidism .
3-Neonatal hepatitis .
4-Intestinal obstruction .
5-Congenitla infection .
6-Metabolic (galactocemia ).
7-Inspissated bile syndrome.
8-Crigler –Najjar syndrome.
5-Treatment : if there is no need for phototherapy , your action
should be directed on follow up (T.S.B , PCV , CBC and general
condition of the patient ) .
If there is indication for phototherapy , admit the patient to
neonatal unit (see the protocol in page 20) and apply phototherapy.
The indication of phototherapy is guided by the following :
Indications of total exchange transfusion:
1-Cord bilirubin is more than 5 mg/dl or serum bilirubin
rising more than 1mg/dl/hr in the first 12 hrs.
2-Cord Hb is less than 10 mg/dl.
3-Serum bilirubin exceed or tend to exceed the toxic level of
bilirubin (18-20mg/dl in term neonate and 16-18mg/dl in
preterm neonate).
4-Any sign of Kernicterus.
5-History of previous Kericterus or sever hemolytic disease
in the sibling favors the decision of early exchange.
Note // Kernicterus can occur at any level of S.bilirubin
according to presence of risk factors (sepsis, acidosis,
perinatal hypoxia, prematurity, hypo or hyperglycemia,
hypothermia, hypercabnia or CNS anomalies).
Total blood exchange is performed via this equation :
For term neonate: 85cc × Body W.T × 2 = Volume of
needed blood.
For preterm neonate: 90cc × Body W.T × 2 = volume
of needed blood.
How to deal with infantile irritability (e.g. crying)?
Such presentation always disturbs the resident doctor, you
have to exclude the common causes then you start
examination and treatment which applied according to the
underlying cause .
DDx:
1-Hungry.
2-Trauma.
3- Insect bite.
4-Fever (muscle pain due to prostaglandin release ).
5-Napkin rash (treated by zinc oxide ointment , steroids
ointment and nystatin ointment ).
6-Oral candidiasis (Crying during feeding) : treated by oral
nystatin drops .
7-UTI (crying during urination) : diagnosed by GUE , treated
by antibiotics.
8- Infantile colic (diagnosis of exclude ): treated by oral
antispasmodic drops e.g. colic – ez drops or antispasmin
drops ..ect ) .
‫عمار رحمن كاظم‬.‫د‬
23/4/2018