Neonatal Emergencies
Objectives
• Relate the history of resuscitation.
• Outline the sequence of care in the
resuscitation of a newborn.
• Describe the difference between the
newly born and newborn, and the
common reasons they may require or
seek emergency care.
Introduction
• Neonate: 0-28 days
• Newly born:
Immediately at birth
when fetus is
physiologically
converting to
newborn life
Case Study 1:
“Abdominal Pain”
• A 16-year-old girl arrives in your ED with
abdominal pain.
• She states she is pregnant and is having
abdominal pain about every 1 to 2 minutes.
• Her appearance is anxious but alert; she
breathes rapidly with pain but then slows her
rate between episodes of pain.
• There are no retractions, and her skin color
is normal.
Initial Assessment
PAT:
– Normal appearance, normal breathing,
normal circulation
Vital signs:
– HR 120, RR 22, BP 100/70, T 38°C
Questions
What three questions should the patient
be asked to predict the need for
resuscitation of the newborn?
What priorities of care should be initiated
to resuscitate the newborn?
Brief Resuscitation-Oriented
History
Case Progression (1 of 2)
• The patient states that:
– She does not think she has twins.
– Her due date is in 3 weeks.
– The color of the fluid has been clear.
Case Progression (2 of 2)
• Exam shows baby’s
head crowning.
What priorities of care
should be initiated to
resuscitate the newly
born?
Preparation for Delivery
• Assume that the infant will be
depressed.
• Locate all necessary equipment in
advance.
Equipment for Neonatal
Resuscitation
•
•
•
•
•
•
Manual resuscitator (infant)
Masks (2 sizes, term and premature)
Dry towels/blankets
Suction equipment
ET tubes (sizes 2.5, 3.0, 3.5)
Laryngoscope and blades (sizes 0, 1)
Newborn Resuscitation
Priorities (1 of 11)
• Clear
meconium as
needed when
head delivers.
Newborn Resuscitation
Priorities (2 of 11)
• Deliver baby.
– Place your hand
around neck
posteriorly and
one underneath
head to control
delivery.
Newborn Resuscitation
Priorities (3 of 11)
• Deliver baby.
– If baby’s anterior
shoulder does
not deliver,
gently pull
downward on
head to allow
shoulder to
clear.
Newborn Resuscitation
Priorities (4 of 11)
• Deliver baby.
– Tie or clamp cord
in two places and
cut between
ties/clamps.
Newborn Resuscitation
Priorities (5 of 11)
Newborn Resuscitation
Priorities (6 of 11)
Newborn Resuscitation
Priorities (7 of 11)
Newborn Resuscitation
Priorities (8 of 11)
• Assess breathing, tone, and color.
– If not normal, then warm, dry, position,
stimulate, and give oxygen.
Newborn Resuscitation
Priorities (9 of 11)
• Begin bag-mask ventilation if apneic or
heart rate is less than 100 bpm.
Newborn Resuscitation
Priorities (10 of 11)
• Assess heart rate.
– If less than 60 bpm
after 30 sec of bagmask ventilation,
begin chest
compressions and
prepare
medications.
Newborn Resuscitation
Priorities (11 of 11)
• Epinephrine is indicated when HR is
<60 bpm after 30 sec of assisted
ventilation plus 30 sec of chest
compressions.
• Access may be difficult:
– Tracheal
– Umbilical vein
Challenging Resuscitation
Conditions
• Technical problems:
– Esophageal or mainstem intubation, hypoxia,
hypoventilation
• Unrecognized pulmonary problems:
– Pneumothorax, meconium aspiration,
diaphragmatic hernia
• Severe metabolic problems:
– Acidosis, hypoglycemia, hypothermia
• Other:
– Congenital anomalies, severe anemia
Case Progression/Outcome
• 16-year-old delivered a near-term
infant.
• Baby had poor tone and color initially,
but with suctioning, drying, warming,
and stimulation became vigorous with
good cry, tone, and color.
Case Study 2: “Fever”
• Mother brings 3-week-old boy to
private physician’s office with
decreased feeding today and fever.
• Infant is sleeping, has normal tone, no
retractions, and color is normal.
Initial Assessment (1 of 2)
PAT:
– Normal appearance, normal breathing,
normal circulation
Vital signs:
– HR 120, RR 40, T 38.7°C, Wt 3.5 kg
Initial Assessment (2 of 2)
A:
B:
C:
D:
E:
Open, no stridor
Normal rate and depth
Normal pulse quality and rate
Good tone, nonfocal
No trauma, no rash
Focused History/
Detailed Physical Examination
• SAMPLE: Fever, mild irritability, normal
birth history, taking formula but less
than previous
• Physical exam: No meningismus, no
rash, infant taking a bottle
Question
What is your general impression of this
patient?
How would you transport this infant to
the ED?
General Impression
• Stable infant with fever:
– Transport may be by private car or BLS
transport.
– Good communication must exist with
parents and ED staff.
ED Management Priorities
• Thorough history, physical exam, and
full sepsis evaluation to determine
source of infection.
– Bacteremia rates in neonates with fever
are much higher (7%-12%) than in older
infants with fever.
Case Discussion: Fever
• Infections occurring after 5 days of life are termed
“late onset.”
• Causes include:
– Gram-negative organisms (e.g., E coli, Klebsiella,
Enterobacter)
– Gram-positive organisms (e.g., Staphylococcus
aureus, group B strep, Streptococcus
pneumoniae)
– Other infections: Salmonella (infectious
gastroenteritis), Listeria monocytogenes
(meningitis), herpes simplex virus (meningitis,
skin vesicles)
Case Progression/Outcome
• CBC, blood culture, urinalysis, urine
culture, lumbar puncture, CSF culture,
and chest radiograph were performed.
• All were negative except the urine,
which showed 20 WBCs.
• Infant was admitted and treated with
intravenous antibiotics.
Case Study 3:
“Not Acting Right”
• 12-day-old girl is brought to the ED by her
mother with a complaint of “not acting right.”
• Mom states that the infant has been listless
for the past day and now will not take a
bottle.
• Baby appears to be asleep and does not
arouse with removal of her clothes. She has
no retractions, and her color is pale.
Initial Assessment
PAT:
– Abnormal appearance, normal breathing,
abnormal circulation
Vital signs:
– HR 170, RR 40, BP 70/50, T 37°C, Wt 3 kg
ABCDEs:
– Normal except for tachycardia, pale skin, and
poor tone
Focused History/
Detailed Physical Examination
Head: Fontanel flat
Neck: Without meningismus
Lungs: Clear
Cardiac: No murmur
Abdomen: Nondistended, nontender
Neurologic: Poor tone and poorly arousable
Extremities: No rash
Question
What is your general impression of this
patient?
General Impression
• Shock or primary CNS/metabolic
abnormality
What are your initial management
priorities?
Management Priorities
•
•
•
•
Monitor cardiorespiratory function.
Place infant on oxygen.
Establish intravenous access.
Obtain rapid glucose test and draw samples
for tests and cultures.
• Obtain head CT.
• Begin empiric antibiotic therapy for possible
sepsis.
Case Discussion: Lethargy
• Lethargy in a neonate suggests
life-threatening disease.
• Main causes may include:
– Infection
– Metabolic disease
– Sepsis
– Anemia (severe)
– Trauma
Case Outcome
• Rapid bedside glucose was 30 mg/dL,
and serum ammonia was 400 µmoles.
• D10W was administered.
• Patient was admitted to PICU for care
and hemodialysis for urea cycle defect.
Case Study 4: “Jaundice”
• 5-day-old boy is brought to the ED by
his parents with the complaint of
“appears yellow.”
• Baby had vacuum delivery but
otherwise is well.
• Baby is alert, with good tone, no
retractions, and color of skin is yellow.
Initial Assessment
PAT:
– Normal appearance, normal breathing,
normal circulation
Vital signs:
– HR 120, RR 36, T 37.8°C, Wt 3.3 kg
ABCDEs:
– Normal
Focused History/
Detailed Physical Examination
• Baby is breastfed and has good suck.
• Birth weight was 3.3 kg.
• Baby’s sleeping patterns have not
changed since birth.
• Physical exam reveals a jaundiced
baby with a cephalohematoma.
Question
What is your general impression of this
patient?
General Impression
• Stable patient with jaundice
What are your initial management
priorities?
ED Management Priorities
• Obtain blood for serum bilirubin
measurement.
– Determine total and direct bilirubin.
• Consider ordering other laboratory
tests, including blood typing and
Coombs test, CBC, and reticulocyte
count.
Background: Jaundice
• Bilirubin can exist in one of two forms:
– Unconjugated (indirect-reacting)
– Conjugated (direct-reacting)
• Three fundamental causes of
hyperbilirubinemia:
– Increased heme degradation (indirect)
– Delay in maturation or inhibition of conjugation
mechanism (indirect)
– Obstruction of excretion from the liver (direct)
Common Causes of Jaundice
• “Physiologic jaundice”:
– Peaks at about 3 days of age
– Multifactorial – may be due to immature
conjugation mechanism in liver
• “Breast milk jaundice”:
– Peaks after 4 days of age
– Results from breast milk inhibitors of
conjugation
Causes of Nonphysiologic
Jaundice
• Indirect hyperbilirubinemia:
– Hemolysis
– Extravasation of blood
(cephalohematoma)
– ABO incompatibility, Rh disease
– Sepsis
– Drugs
• Direct hemolysis
Hemolysis
• Intrinsic:
– Congenital defects of RBC membrane
(hereditary spherocytosis), or RBC
hemoglobin (thalassemia, sickle cell
disease), or RBC enzyme deficiency
(G6PD, pyruvate kinase)
• Extrinsic:
– Isoimmunization (ABO incompatibility, Rh
disease), bacterial sepsis, or drugs
Extravasation of Blood
• Common causes include:
– Cephalohematoma
– Vacuum extractor hematoma
– Bruising with breech presentation
– Traumatic or premature delivery
– Intraventricular hemorrhage
Direct Hyperbilirubinemia
• Occurs when >20% of total bilirubin is
conjugated (direct-acting).
• Always abnormal
• Results from interference of excretion of
bilirubin from liver:
– Intrahepatic: Hepatitis (infections), metabolic
disease (galactosemia)
– Extrahepatic: Biliary atresia, choledochal cyst
Case Progression
• Total bilirubin level is 20 mg/dL;
19 mg/dL is indirect.
• Cause is probably multifactorial:
– Breast milk jaundice
– Extravasation of blood with resolving
cephalohematoma
What are your management priorities now?
Further Management
Case Outcome
• Baby was admitted for phototherapy.
• Discharged 2 days later with a bilirubin
of 14 mg/dL.
Case Study 5:
“Swollen Belly Button”
• 6-day-old girl is brought in by father
with 2-day history of increasing
redness and swelling of the belly
button.
• Baby is irritable with increased
respiratory rate without retractions; skin
is normal in color.
Initial Assessment
PAT:
– Abnormal appearance, normal breathing,
normal circulation
Vital signs:
– HR 170, RR 48, T 39°C, Wt 3.5 kg
Question
What are your management priorities?
ED Management Priorities
• The concern is omphalitis, which is a lifethreatening infection of the umbilicus.
• Place on cardiorespiratory monitor.
• Obtain IV access and send blood samples
for CBC and culture.
• Begin fluid resuscitation with normal saline
at 20 mL/kg.
• Administer empiric antibiotics.
Umbilical Problems
• Delayed separation >3 weeks may be
normal or due to immune deficiency or
sepsis.
• Bleeding due to irritation
• Granulation tissue
• Umbilical hernia
• Discharge: Omphalomesenteric duct or
patent urachus
• Infection: Omphalitis
Case Outcome
• The baby was admitted.
• Vancomycin and cefotaxime were
administered.
• Baby required three surgical
debridements of necrotic tissue but
survived.
The Bottom Line
• Resuscitation of the newly born
requires preparation and skill.
• Many life-threatening conditions in the
newborn period may present with few
signs or symptoms.