Neonate Flashcards
what does the APGAR score tell you?
resuscitation need/effectiveness:
1 minute: evaluates conditions during L/D
5 minutes: response to resuscitation efforts
does NOT imply mortality
APGAR
Appearance: blue-extremities-normal Pulse: less than 60, 60-100, 100+ Grimace: no response, +grimace/weak cry, sneeze/cough Activity: none-some flexion-active mvmnt Respirations: absent-weak/irreg-strong
neonatal conjuctivitis timeline most likely cause day 1 day 2-7 >7 days >3 wks
day 1: chemical (from silver nitrate)
day 2-7: Gonorrhea (ppx: ointments, tx: ceftriaxone)
>7 days: Chlamydia (PO erythromycin)
>3 wks: HSV (acyclovir and topical vidarabine)
what given immediately after birth
erythromycin or tetracycline ointment (prevent Gonorrhea NOT Chlamydia conjunctivitis) silver nitrate? give vitamin K IM dose Hep B vaccine (+HBIG if Hep B+ mom)
screening tests prior to d/c neonate
PKU (low phenylalanine diet) CAH biotinidase B-thalassemia galactosemia (no lactose) hypothyroidism (cretinism) homocysteinuria cystic fibrosis (initial test: sweat chloride, best: CFTR gene) hearing test
normal newborn derangements
transient polycythemia splenomegaly transient tachypnea (wet lungs, C-section, give PPV; if +4hrs consider sepsis) trainsient hyperbilirubinemia subconjunctival hemorrhage
newborn skull fxs
basilar: most fatal
depressed: needs sx
linear: most common
caput succedaneum vs cephalohematoma
caput saccedaneum: soft tissue swelling that DOES cross suture lines
cephalohematoma: subperiosteal hemorrhage that DOES NOT cross suture lines (below periosteum so follows compartments)
(should self-resolve)
“waiter’s tip”
Duchenne-Erb Paralysis (C5-6)
“claw hand” (lack of grasp reflex)
Klumpke Paralysis (C7-8 +/- T1) paralyzed hand with Horner syndrome
causes of polyhydramnios
neurological: Werdnig-Hoffman: fetus not swallowing
GI: instestinal atresia
causes of oligohydramnios
prune belly: lack of abd. muscles so cannot bear down and urinate
renal agenesis: Potter syndrome
fetus may have flat facies due to lack of fluid
diaphragmatic hernia types
Bochdalek: most common, posterolateral defect
Morgagni: retro or parasternal defect
associations:
Omphalocele
Umbilical hernia
Gastroschisis
Omphalocele: Edwards (trisomy 18) +sac, midline
Umbilical hernia: congenital hypothyroidism
Gastroschisis: intestnal atresias, no sac, lateral
most common abdominal mass in children?
presents how?
best imaging?
tx?
Wilms tumor
aniridia, palpable renal mass, n/v, constipation, GU malformations, MR (WAGR syndrome, chrom. 11 deletion)
initial: abdominal U/S, CT with contrast is most accurate
tx: total nephrectomy +/- chemo/radiation, if b/l do partial nephrectomy
most common cancer in infancy, also most common extracranial solid malignancy?
presents how?
dx?
Neuroblastoma: adrenal medulla tumor
hypsarrhythmia (EEG) and opsomyoclonus (“dancing eyes, dancing feet”)
dx: ^VMA and metanephrines in urine
orchipexy of cryptorchid testicle prevents ?
sterility, but does not decrease risk of malignancy
hypospadias vs epispadias
hypo: ventral (lower) side, associated with cryptorchidism and inguinal hernias
epi: on dorsal (top) surface, associated with urinary incontinence and bladder exstrophy
both: DO NOT CIRCUMCISE, need surgical correction
developmental reflexes
Sucking Grasping Babinski Rooting Moro Stepping Superman
1st minute of life:
what to suction first?
SpO2?
HR?
mouth than nose
focus on airway
spO2: 60-65%
HR should be +100, if not: PPV
min 1-5
want APGAR 7-10
SpO2: 80-85%, if less FiO2, PPV
HR: 60-100: PPV, if less than 60: cardiac problem (do CPR (3:1) and give EPI in umb. vein)
min 5-10
2nd APGAR
SpO2: 90-95%, if less FiO2, PPV
HR: same as min 1-5
continue to do APGAR scores after if still low
RDS
lack of surfactant, atelectasis
premature infant
hypoextended lungs
may need intubation and surfactant
jittery, tremors, lethargy, seizures in neonate, think?
hypoglycemia (but may be sepsis)
tx: IV bolus 2mL/kg D50, if refractory D5 or D10 constant infusion
bronchopulmonary dysplasia
decreased surfactant (RDS) leading to alveolar de-recruitment leading to scarring
premature infant with ^ respiratory demand
dx: ground-glass opacities, ^FiO2 req. for 28ds+
tx: steroids (in utero)
f/u: to assess for DPLD
ROP (retinopathy of prematurity)
neoangiogenesis worsened by ^FiO2
premie, see BVs on asymptomatic screen
tx: laser ablation
f/u: still may get early glaucoma
IVH
caused by highly vascular lining of ventricles, sensitive to changes in BP
asymptomatic screen
see ^ICP (bulging fontanelles, coma seizure)
dx: cranial doppler
tx: VP shunt/drain
f/u: MR, seizure
NEC
dead gut, premie in ICU who has bloody BM
dx: XR showing air in wall of intestine (pneumatosis intestinalis)
tx: NPO, IV abx (G-), TPN
f/u: surgery
both gastroschisis and omphalocele have ? and are tx with ?
^AFP
tx: silo
worsening jaundice at about 7-14 days (direct hyperbili) think ?
what to do next?
biliary atresia
dx: U/S showing absent ducts
HIDA scan after 5-7 days phenobarbital (stim. biliary tree to secrete bile)
tx: resect
NTD is found how?
^AFP, see on U/S
spina bifida occulta
only breakdown of caudal spine
+/- tuft of hair
meningocele
breakdown of caudal spine + out pouching of sac with CSF
meningomyelocele
breakdown of caudal spine + out pouching of sac with CSF and nerves
NTDs may lead to?
Arnold Chiari malformation, hydrocephalus, developmental delay, focal neuro deficit below lesion
ToF: 4 things
associated with ?
presentation?
pulmonary stenosis, overriding aorta, RVH, VSD
chromosome 22 deletion, Downs (endocardial cushion defect)
acrocyanosis, holosystolic murmur at LLSB, boot-shaped heart and decreased vasculature on CXR
VSDs seen in ?
Downs, Edwards, Pataus, infants of DM moms
most common cardiac defect in Downs
endocardial cushion defect of AV canal
3 holosystolic murmurs
MR, TR, VSD
transposition of great vessels needs ?
see what on CXR?
tx?
needs PDA, ASD, or VSD to oxygenate blood
CXR: “egg on a string”
tx: PGEs, 2 surgeries
pulses? pulsus alternans pulsus bigeminus pulsus bisferiens pulsus tardus et parvus pulsus paradoxus
pulsus alternans: LV systolic dysfunction
pulsus bigeminus: HOCM
pulsus bisferiens: aortic regurg
pulsus tardus et parvus: aortic stenosis
pulsus paradoxus: cardiac tamponade and tension PTX
absent pulses + single S2, ^RV impulse, gray cyanosis, globular-shaped heart + pulmonary edema on CXR, think ?
hypoplastic left heart
tx: 3 surgeries or transplant
severe dyspnea, early/frequent resp. infections, single S2, bounding peripheral pulses
truncus arteriosis
tx: sx to prevent pulmonary HTN (within 4 mos)
where does oxygenated blood from the pulmonary veins return to in TAPVR?
to the SVC instead of left atrium
if obstructed presents earlier and shows pulmonary edema on CXR
if not obstructed presents at age 1-2 with RHF and SOB, CXR shows “snowman” or “figure 8” sign
both dx with echo and need sx
EKG findings in VSDs
RVH from L–>R shunt, could later lead to Eisenmenger syndrome (R–>L)
cyanotic heart defects
R–>L shunts
ToF, TGV, TA, TAPVR, hypoplastic left heart
VSD
loud pulmonic S2, holosystolic murmur of LLSB, increased markings on CXR
dx: echo, cardiac cath definitive
tx: diuretics, digoxin, may need sugary
f/u: CHF, endocarditis, pulmonary HTN
fixed wide splitting of S2
dx?
tx?
ASD
dx: echo, most definitive is cardiac cath; ^vascular markings and cardiomegaly on CXR
tx: most spontaneous, tx of transcath closure
f/u: dysrhythmias and paradoxical emboli from DVTs
machinery-like (multi phasic) murmur after day 1, wide pulse pressure, bounding pulses?
when is it pathologic?
PDA
after 24 hrs of life, normal in 1st 12 hrs
dx: echo, cardiac cath most accurate, LVH on EKG
tx: indomethacin unless need it
f/u: resp. infections, infective endocarditis
CXR findings: pear-shaped heart: boot: jug handle: "3":
pear-shaped heart: pericardial effusion
boot: ToF
jug handle: primary pulmonary artery HTN
“3”: coarctation of aorta (also rib notching)
hearing loss, syncope, normal vitals and exam, fam hx of sudden cardiac death, think ?
long QT syndrome
tx for coarctation
surgical resection of narrow segment and then balloon dilation if recurrent stenosis
transposition of the great vessels associated with ?
mom was DM before pregnancy (failure to twist wk 8)
RA->RV->aorta->VC (unO2)
LA->LV->pulm. a.->pulm v. (O2)
when is hyperbili pathologic in newborn?
- it appears on 1st day of life (normal rise after 72 hrs)
- rises +5mg/dL/day
- rises +19.5 mg/dL in term baby
- D. bili rises +2 mg/dL at any time
- persists after 2nd week of life
hypotonia, seizures, choreoathetosis, hearing loss, consider?
kernicterus: bilirubin in basal ganglia
consider exchange transfusion if bilirubin rises to ?
20-25 mg/dL
if lower use phototherapy
common complication of TE fistula
aspiration pneumonia
signs seen with upper GI series in pyloric stenosis
string sign: thin column of barium leaking through tightened muscle
shoulder sign: filling defect in antrum due to prolapse of muscle inward
mushroom sign: hypertrophic pylorus against duodenum
railroad track sign: excess mucosa in pyloric lumen causing 2 columns of barium
doughnut sign seen in intussusception (and in pyloric stenosis?)
double bubble with duodenal atresia, malrotation
associations:
choanal atresia:
duodenal atresia:
Hirschsprung:
choanal atresia: CHARGE syndrome
duodenal atresia: trisomy 21 (Downs), annular pancreas, polyhydramnios
Hirschsprung: trisomy 21 (Downs)
Imperforate anus: trisomy 21 (Downs)
CHARGE syndrome
Coloboma of eye Heart defects Atresia of choanae (blue with feeding, pink with crying) Retardation of growth/development GU defects Ear anomalies/deafness
failure to pass meconium for over 48 hrs, LBO, tight sphincter, inability to pass gas, think?
dx, tx?
Hirschsprung: lack of innervation of distal bowel by Auerbach plexus (constant contracture) (failure of migration) failure in distal colon, failure to pass meconium at 48 hrs, explosive with DRE
dx: XR: distended loops of bowel, good colon: dilated, contrast enema, high pressure on manometry
full thickness biopsy: lack of ganglionic cells in submucosa
sx: 3 stages
VACTERL syndrome
Vertebral anomalies Anal atresia (imperforate) CV anomalies TEF Esophageal atresia Renal anomalies Limb anomalies
duodenal atresia is due to ?
lack/absence of apoptosis leading to improper canalization of duodenal lumen
vomiting and colicky abdominal pain with air-fluid levels and “bird beak” appearance think?
volvulus
tx: untwisting surgically or endoscopically (+decompression)
Intussusception imaging and tx
associations
U/S: doughnut/target sign
tx: barium enema (dx and tx) but CONTRAINDICATED if pt has signs of peritonitis, shock, perforation, fluid resuscitation, NGT decompression
associated with rotavirus vaccine, HSP
painless BRBPR in kid under 2, think ?
dx/tx?
Meckel’s diverticulum, technetium-99m (99mTc) pertechnetate scan
true diverticula with all layers +/- ectopic gastric tissue
tx: surgery
bilious vomiting 1st day vs 1st yr of life
1st day: duodenal atresia
1st year: volvulus, intussusception
w/u for diarrhea/GE
stool studies: blood and leukocyte count
stool cultures with O/P
D. diff toxin
+/- sigmoidoscopy to look for pseudomembranes (C.diff)
viral infectious diarrhea
winter vs year-round
winter: rotavirus, year round: adenovirus (endemic)
both have viral prodrome, fever, emesis, NO blood, and last less than 7 days
epidemic (cruise-ship): norwalk
-explosive, crampy, 1-2 days
next step if see air in the bowel wall on abdominal XR
+vomiting, fever, abdominal distension in premie
+/- frank/occult blood in stool
(NEC) FIRST start abx: vanc, gentamicin, metronidazole
exclude perf via XR (pneumoperitoneum on CT)
start IVF, bowel rest, NGT for decompression
if refractory, sx to remove affected bowel
30% mortality
findings in infants of diabetic moms (IDM)
macrosomia, polycythemia
small left colon syndrome
asymmetric septal hypertrophy (obliteration of LV lumen) leads to decreased CO (dx: EKG/echo, tx: BB/IVF)
renal vein thrombosis (hematuria, low plts)
metabolic findings in IDM
hypoglycemia, hypocalcemia, hypomag, hyperbili (icterus/kernicterus)
3 different deficiencies in CAH
21-hydroxylase: low aldo, ^testosterone, low cortisol
17-hydroxylase: ^aldo, low testosterone, low cortisol
11-B-hydroxylase: ^deoxycorticosterone (acts like aldo which is low), ^testosterone, low cortisol
how to dx CAH
at birth: serum electrolytes and ^17-OHP levels (in 21-OH def, most common), virilization
hypotensive, hyponatremia, hypochloremia, hypoglycemia, hyperK, acidosis
3 causes of rickets
Vit D deficient
Vit D dependent: can’t convert 25-OH to 1,25(OH)2
X-linked hypophosphatemic rickets: kidneys cannot retain phos resulting in inadequate mineralization
rickets tx
replace Ca2+, phos, vit D (1,25-OH), cacitrol and annual blood vit D monitoring
ppx: give vit D supplements beginning at 2 mos to exclusively breast fed infants
if febrile seizure what next steps to take
sepsis w/u: CBC with diff, blood culture, U/A with urine culture, CXR, LP
neonatal sepsis most commonly due to what conditions, what orgs?
dx/tx
pneumonia, meningitis
GBS, E. coli, S. aureus, Listeria
dx: bld/ur cx, CXR
tx: amp and gent +/- cefotaxime, IVF
pentad of scarlet fever
dx/tx?
fever pharyngitis sand-paper rash strawberry tongue cervical LAD
dx: clinical, ^ASO titers, ESR, CRP
tx: PCN, azithromycin, cephs
HSV presentation based on weeks
wk 1: shock and DIC
wk 2: vesicular rash
wk 3: encephalitis
croup dx/tx
dx: clinical, do not need CXR
tx: steroids if mild, mod-sec give racemic EPI
1st step if suspect epiglottitis
intubate (preferrably in the OR)
next: ceftriaxone 7-10 ds, rifampin for close contacts
stages in Pertussis
Catarrhal: 14 ds congestion/rhinorrhea
Paroxysmal: 14-30 ds severe cough/whoop/vomit
Convalescent: 14 ds decrease cough
Pertussis dx/tx
dx: “butterfly pattern” on CXR, PCR of nasal secretions, B. pertussis toxin ELISA
tx: erythromycin/azithromycin in catarrhal (1st) stage
isolate, macrolides for close contacts
Diptheria dx/tx
gray pseudomembrane (do not scrape!), get culture of membrane tx: antitoxin (abx not effective)
congenital hip dysplasia tx
Pavlik harness
LCP disease ages, dx, tx
2-8
XR show jt effusions and widening
tx: rest and NSAIDs, then sx to BOTH hips
SCFE age, dx, tx
adolescent
XR shows joint space widening
tx: internal fixation with pinning
tricky vitamin derangement tricks
vitamin A low/high
vit B2
vit B5
vitamin A low/high: low: hypoPTH, high: hyperPTH, pseudotumor cerebri vit B2 (riboflavin): think "flavor": angular chelosis, stomatitis, glossitis (mouth stuff) vit B5 (panthothenic acid): burning feet syndrome (run from the panther)
failure to pass meconium in CF newborn
dx/tx
meconium ileus
dx: XR will show “transition point” and gas-filled plug
tx/dx: water enema, (w/u CF) sweat Cl-
malrotation vs duodenal atresia on XR
both have double-bubble, malrotation will have normal gas pattern, duodenal atresia will have NO gas
(annular pancreas presents same as duodenal atresia)
intestinal atresia
vascular accidents in utero (mom does cocaine)
+/- polyhydramnios
XR: double-bubble and multiple air-fluid levels
tx: sx, worry about short-gut syndrome
find pyloric stenosis, what to do next?
give IVF and correct e-lyte derangements, THEN myomectomy
w/u for physiologic jaundice (^I. bili)
- Coombs: if +: isoimmunization
- Hgb: if low: hemorrhage (cephalohematoma)
if ^: transfusion (twin/twin, delayed clamping) - if Hgb normal, get Retic count:
if ^: hemolysis: G6PD def, pyruvate kinase def, Hgb SS
if not ^: reabsorption problem: breast feeding (quantity) vs breast milk (quality) jaundice
meningitis abx in infants less than 30 ds
vanc
cefotaxime (ceftriaxone causes hyperbili in kids)
ampicillin
+/- steroids
if want to know if baby less than 18 mos is HIV+
DNA PCR, cannot use ELISA
most common cause osteomyelitis
dx/tx
S. aureus if see salmonella, think SCD if toxic: give abx then biopsy if nontoxic: XR, if + biopsy, if - MRI, if + biopsy abx 4-6 wks
septic joint
Gonorrhea, *S.aureus
dx: arthrocentesis, +50,000 WBC
treatment:
scabies
lice
pinworm
scabies: permethrin, lindane
lice: permetrhin
pinworm: albendazole
pneumonia less than 5yo
typically viral, still treat with ceftriaxone and azithromycin (CAP)
TB testing
less than 5: PPD
older than 5: IGRA
