Neonatology/Critical Care Flashcards
When is neonatal mortality the highest?
In 1st 24 hours after birth
Leading cause of infant death in the post-neonatal period?
SIDS
What is nonstress test
FHR and reactivity
Positive = good
What is a stress test?
FHR response to contractions
Positive = late decelerations = bad
What is a biophysical profile
NST Movements Breathing Tone Amniotic fluid index
0 or 2 points each
>8/10 reassuring
Oligohydramnios is associated with…
Renal anomalies
Pulmonary hypoplasia
Limb contractures
Cord compression
Polyhydramnios is associated with…
Intestinal obstruction
Neurologic disorders
Maternal diabetes
When does twin-twin transfusion happen
Monochorionic/diamniotic twins, placental AV anastomoses
Findings in donor twin in twin-twin transfusion
Anemia
Hypovolemia
Oligohydramnios
LBW
Findings in recipient twin in twin-twin transfusion
Polycythemia
Polyhydramnios
CHF
Hydrops
What are complications of hypothermia in the DR?
Metabolic acidosis
Hypoxemia
Hypoglycemia
Renal loss of water & salt
Considerations for LGA infants
May be normal
IDM
Obesity/insulin resistance
Beckwith-Wiedemann
Increased risk of:
- Hypoglycemia
- Birth trauma
Small for Gestational Age
May be normal
Consider chromosomal abnormalities or infection
If IUGR, increased risk for:
- Perinatal asphyxia
- Hypothermia
- Hypoglycemia
- MAS
- Polycythemia
Perinatal period
28wks ega to 7 days of life
Neonatal period
Birth to 28 days
Infant period
Birth through 1 year
Preterm
<37wks
Term
37 -41+6
Postterm
> 42wks ega
LBW
<2500g
VLBW
<1500g
ELBW
<1000g
What maternal medications decrease Vitamin K levels?
Anticonvulsants
Warfarin
AntiTB meds
What is eye ointment given for?
To prevent gonococcal opthalmia – NO EFFECT ON CHLAMYDIAL CONJUNCTIVITIS
1% silver nitrate aqueous solution
0.5% erythromycin ointment
1% tetracycline ophthalmic ointment
Silver nitrate can cause chemical conjunctivitis
Coag findings in vitamin K deficiency
Low PT, normal fibrinogen, normal platelets
Whey:Casein in human milk
80: 20 in colostrum
55: 45 in mature milk (>1 month)
Expected growth in the first2 weeks
20 mg/kg/day
110-120 kcal/kg/day
50% of kcals from fat
How does preterm human milk compare to term milk?
Increased protein " sodium " lactoferrin " lysozyme " LC PUFAs " IgA
BUT, inadequate protein, calcium, phosphorus, vitamin D, iron
Causes of false negative NBS
- Insufficient feeding
- Blood transfusion - galactosemia, hemoglobinopathies
- TPN or ABX
- Dialysis
Causes of false positive NBS
- TPN or ABX
- Hemoglobinopathies
When is the peak hematocrit
2hrs of life
What is a normal hct?
45-55%, need venous sample
Capillary samples artificially high due to sludging
What newborns ar at risk for congenital syphillis if maternal nontreponemal and treponemal serology is positive?
- Treatment is inadequate, unkn or undocumented
- Treatment was <30 days before delivery
- Mother was not treated with PCN
- Maternal nontreponeal titers not decreased 4-fold or more
If maternal treatment is adequate, infant positive nontreponemal test = passively acquired antibody
Vomiting, musty/mousy odor, seizures, hypertonicity, MR
Phenylketonuria
Defect in tyrosine pathway (phenylalanine hydroxylase or cofactor tetrahydrobiopterin) –> accumulation of phenylalanine in CNS
Rx: low phenylalanine diet
Most common cause of genetic hearing loss
Non-syndromic
Hearing testing in first 6mos
ABR
Delayed cord release
> 2 weeks
- urachal abnormalities - US
- LAD
- infection
Causes of delayed stooling
GI obstruction
- no emesis –> lower
- meconium disease - plug or ileus (CF)
- congenital aganglionosis/Hirschsprung disease
- small left colon (IDM, drug abuse)
- MgSO4
- hypothyroidism
What percentage of infants void within 24 hours?
95%
Physiologic jaundice
Increased RBC load
“ enterohepatic circulation
Decreased glucuronyl transferase
Term peak 3-5days, PT later and higher
Concerning rate of bilirubin rise
> 0.5mg/dL/hr
Caput succadeneum
Fluid/bruising under skin
Cephalohematoma
Beneath periosteum - does not cross suture lines
Subgaleal hematoma
Between aponeurosis and periosteum - crosses suture lines
Can lose entire blood volume in area
Inspiratory stridor, worse with agitation, better with prone positioning
Laryngomalasia
Expiratory stridor
Tracheomalasia, usually in preterm babies after long duration of ET tube
Causes of EO Sepsis
GBS, E.coli, Listeria, H.flu, enterococcus
Causes of LO Sepsis
CNS, S aureus, pseudomonas, GBS
10% symptomatic, sensorineural hearing loss (progressive, can initially pass)
CMV, gancyclovir (to prevent hearing loss)
Cats, meats, intracranial calcifications, blindness, MR
Toxo
Pyrimethamine, sulfonamides, folinic acid
Primary infection, intrapartum exposure, periventricular calcifications, can be isolated/disseminated or SEM
HSV
Acyclovir
Cataracts, blindness, deafness, microcephaly, MR, CHD
Rubella
VACTERL Findings
V ertebral A norectal C ardiac TE F R enal, radial L imb
Gastroschisis
Not covered
Usually to right side of cord
Malrotation always associated, otherwise no associated anomalies
Omphalocele
Bowel in covering sac
Umbilical cord part of sack
80% with associated anomalies
Mortality due to other anomalies
Chronic HTN
Incr perinatal mortality
IUGR
Incr risk of pre-E
Incr risk of abruption
Risks of htn to fetus/neonate
IUGR PT delivery Thrombocytopenia Neutropenia Exposure to meds Death
Pre-existing DM
Incr fetal loss Congenital anomalies - Caudal dysplasia/sacral agenesis - NT defects - CHD - Small left colon IUGR
Gestational Diabetes
LGA 2/2 hyperinsulinemia Incr perinatal mortality -RDS -Preterm delivery -Asphyxia Birth injury Hypoglycemia Polycythemia/thromboses IV septal hypertrophy Impaired glucose tolerance later in life
Maternal hyperthyroidism
IUGR
Preterm birth
Tachycardia
SLE
Antibodies destroy fetal cardiac conduction pathway
Effects independent of maternal disease severity
Maternal myasthenia gravic
Abs to acetylcholine receptors
Effects correlate with severity of illness in mother
Weakenss w/in 12-72hrs of birth
Resolves in 6 weeks
Rx with antiholinesterase and give supportive care
AMA
Spont abortion, chromosomal abnormalities, congenital malformations, premature delivery, PIH, gestational diabetes
Incr incidence of nondisjunction during meiosis
Trisomies 21, 18, 13; Klinefelter syndrome
Low MSAFP
Incorrect fetal age
Trisomies 13, 18, 21
IUGR
Fetal demise
High MSAFP
Incorrect fetal age Multiple gestation NT defects Turner syndrome Gastroschisis Omphaloceles GI obstruction Sacrococcygeal teratoma
What’s included in triple screen
AFP hCG uE3
NTD I - -
T21 D I D
T18 D D D
Fetal Alcohol Exposure
Most common teratogenic exposure Microcephaly Neurosensory hearing loss CHD: VSD Growth deficiency MR
Magnesium
respiratory depression, hypotonia
Opiates
Respiratory depression, withdrawal
Indomethacin
Intestinal perforation, oliguria
Phenobarbital
Bleeding (vit K déficience)
Propranolol
Hypoglycemia, bradycardia, apnea
Cigarettes
Growth restriction
Cocaine
Abruption
Blood pressure maintained, tachycardia, vasoconstriction
Compensated Shock
Hypotension (<5th percentile)
Decompensated Shock
Progressive end organ dysfunction leading to irreversible organ damage and death
Irreversible Shock
7m/o with diarrhea, vomiting, decreased urine output
Hypovolemic shock
- decreased preload, osmotic diuresis, hemorrhage
- tachycardia, poor perfusion
8d/o with poor feeding, tachypnea, mottled
Cardiogenic Shock
- cardiomyopathies, arrhythmias, obstructive disorders (coarctation, tamponade)
- large heart, gallop, murmur, HSM, JVD (think tamponade)
14d/o with fever, lethargy, extreme tachycardia
Septic Shock
- different etiologies
- tachypnea, grunting, tachycardia, warm extremities, bounding pulses
4y/o with peanut allergy who went to the circus
Distributive Shock
- anaphylaxis, neurogenic (spinal cord injury)
- tachycardia, warm extremities, stridor/wheezing with anaphylaxis
Rx Shock
ABCs
Vascular access - IO early
Fluid administration 20mL/kg crystalloid, repeat as necessary (60-200mL/kg)
Recognize no or poor response to fluid with cardiogenic shock
Vasoactive medications
- Dopamine
- Cold shock –> epi
- Warm shock –> norepi
- Cardiogenic shock –> milrinone
- Refractory shock in pts at risk for adrenal insufficiency –> steroids
Complications of near drowning
Hypoxemia 2/2 aspiration or reflex laryngospasm
Complications of hypoxemia:
- Pulm (ARDS, pulm edema)
- Neuro (edema, increased ICP)
- CV (arrhythmia, asystole)
- Renal (renal failure, ATN)
- Metabolic (acidosis, hypernatremia in the Dead Sea)
Poor prognostic indicators in near drowning:
- 10 min
- resuscitation >25 min
- resuscitation in ER
- water temp >10C
Survival 75%
Most common fatal foreign body aspiration
Balloons
First degree burn
superficial/sunburn
2nd degree burn
Partial thickness
- superficial - pain/blisters
- deep - white, leathery
3rd degree burn
full thickness
- well-demarcated, painless, no blistering
- requires skin grafting
4th degree burn
full thickness plus adjacent structures
- requires reconstructive surgery
Treatment of burns in 1st 24 hrs
1st 24hrs:
- 4mL/kg x %BSA + maintenance OR
- 2000mL/m2 BSA + 5000mL/m2 TBSA
- 1/2 over 1st 8 hours, rest over 16 hours
- crystalloid x 24 hours, then colloid later
- target UOP >1mL/kg/hr
Half life of CO
- 300min room air
- 90min with HF non-rebreather mask
- hyperbaric oxygen for COHb >25% (half-life decreases to 30 min)
Dog bite rx
- isolate dog if possible (r/o rabies)
- wound care/cleaning
- ABX NOT INDICATED
- pasteurella canis most common
Rx cat bites
- wound care essential
- wounds SHOULD NOT be sutured unless on face
- ABX!! pasteurella multocida –> Augmentin or Clindamycin
What has the highest case fatality rate of any infectious diseae?
Rabies
Most common carriers of rabies
Bats, skunks, foxes, raccoons
Domestic Animal Bite and Rabies
- PPX immediately if animal rabid or bite is to the head/neck region
- If animal is healthy, observe animal x 10 days, PPX pen
- If animal unavailable, consider PPX if rabies is common in region
Bat, raccoon, skunk, fox bites
- Consider rabid
- Begin PPX immediately - rabies Ig and vaccine
Indications for giving Crotalid anti venom for snake bites
- any systemic symptoms
- bite to face or neck
- for all rattlesnake and water moccasin bites
- small snakes release more toxin
Rx of brown recluse spider bites
Debridement and ABX for necrosis >2cm in 48hrs
Leading cause of death from spider bites
Black widow
Systemic symptoms of black widow bite
muscle spasms, autonomic stimulation, coma
Antivenom for suspected black widow bite
Lactrodectus antivenom
Core body temp >40C with CNS dysfunction
Heat stroke
AVPU
- Alert
- Responds to Voice
- Responds to Pain
- Unresponsive
Glasgow Coma Scale
- Eye opening (4 pts)
- Verbal (5 pts)
- Motor (6 pts)
Coma = GCS <8, intubation indicated
Middle meningeal artery, initial loss of consciousness with lucid interval
Epidural hematoma
Bridging veins, slow deterioration
Subdural hematoma
Severe brain injury, blood in CSF
SAH
Pain RLQ on palpation of L side
Rovsing’s sign
Pain on internal rotation of right hip
Obturator sign (appendix in pelvis)
Pain on extension of right hip
Iliopsoas sign (retrocecal appendix)
Most common abdominal emergency in children <2yrs
Intussusception
Potential lead points for intussusception
Sm bowel lymphoma, Meckel diverticulum, HSP, CF
Sausage shaped mass on right side
Intussusception
Most common presenting sign of midgut volvulus
Emesis
Gasless abdomen, double bubble sign
Midgut volvulus
Misplaced duodenum, corkscrew sign on UGI
Midgut volvulus
Upper abd pain after blunt and pain
= pancreatitis
lipase more specific than amylase level
Painless rectal bleeding
MECKELS DIVERTICULUM
- incomplete obliteration of omphalomesenteric duct
- rule of 2’s
- 2% population
- 2:1 male:female
- 2 feet from the ileocecal valve
- 2 inches long
Best imaging study for ovarian torsion
Transvaginal US
