Neonatology (NEW) Flashcards
1
Q
Murmur evaluation and management
A
Initial response
- Vitals
- > hypotension
- > pulse ox (pre and post >3%)
- Primary survey
- > cyanosis/differential cyanosis
- > shock with ductal dependent or critical CHD
- > pulmonary oedema
Hx
- PC
- > cyanosis
- > respiratory distress
- > diaphoresis
- > lethargy
- > poor growth + feeding
- > older = exercise intolerance/angina/syncope
- Antenatal
- > antenatal US
- > maternal TORCH infections + serology + immunisation
- > maternal diabetes
- > maternal exposure (drugs/alcohol/smoking/phenytoin)
- Family hx
- > genetic disorder
- > congenital heart disease
Exam
- Growth
- Inspection
- > cyanosis
- > respiratory distress
- > syndromic features
- Vitals
- > bradycardia/tachycardia
- > HTN
- > BP gradient >10mmHg upper/lower
- > pulse ox
- Pulse
- > irregular
- > weak femoral
- Inspect + palpate chest
- > apical impulse = aortic/mitral regurg
- > parasternal impulse = pulmonary/tricuspid regurg/ASD
- > thrill = stenosis or VSD
- Auscultate
- > first and second heart sounds + splitting
- > third or fourth sounds
- > added sounds
- > murmur (SCRIPT)
- Pathological
- > intense + blowing + harsh
- > holosystolic or diastolic
- > added sounds
- Abdo
- > hepatomegaly
Investigations
- ABG
- > hypoxia/hypercapnoea
- > pH
- > lactate
- FBC
- > polycythemia
- > leukocytosis in sepsis
- BNP
- CXR
- > cardiomegaly
- > pulmonary oedema + vascular congestion = left to right
- > absence of pulmonary markings = right to left (TOF)
- ECG
- > WPW
- > LQTS
- > Second or third degree heart block
- > MI
- Echo with doppler
- > abnormal flow
- Consider
- > blood culture
- > MCS
- > LP
Management
- Call for help
- > cyanosis
- > abnormal clinical evaluation
- > abnormal investigations
- Stabilise
- > secure airway + support breathing as needed
- > gain IV access (umbilical vessels)
- > 10mL/kg fluid bolus +- dobutamine if shocked
- > consider gentamycin + amoxicillin if aetiology unknown
- Supportive
- > diuresis
- > beta blockers
- > ACEI
- > promote feeding if delayed surgery
- Cyanotic
- > NETS transfer
- > PGE1 infusion for ductus
- > cardiac catheter + ballooning (palliative or corrective)
2
Q
Developmental delay evaluation and management
A
Hx
- Development
- > explore concerns
- > attainment/regression of milestones
- > global delay or specific impairment
- > hearing and vision
- Antenatal
- > substances and medications
- > complications
- Perinatal
- > prematurity
- > HIE
- > resuss or NICU
- Post natal
- > hospital admissions
- > meningitis/encephalitis
- > TBI
- > growth
- Family hx
- > genetic disorders
- > epilepsy
- > ASD
- > AHDH
- > consanguinity
- Social
- > home stress
- > trouble at school/specific classes
- > interaction with other children
- Red flag
- > sudden change in previously well
- > headache with nausea/vomiting
- > focal neuro signs
- > lapses in attention or speech
Exam
- Growth
- Inspect
- > syndromic features
- > carer attachment
- > response to visual/auditory stimuli
- Palpate
- > muscle tone
- > weakness
- Head to toe
Investigations
- Formal optometry test
- Formal audiology test
- First line
- > FBC
- > EUCs
- > Iron + ferriton
- > Lead
- > TSH
- > CK
- > Karyotyping
- Metabolic
- > lactate
- > amino acids
- > ammonia
- > urine organic acids
- Neuro
- > MRI brain
- > EEG
Management
- MDT
- > paediatrician
- > speech path
- > OT
- > physio
- > psychologist
- Early interventional service
- Social
- > NDIS
- > social worker
- > school involvement
- General health
- > immunisations
- > nutrition
- > parental support
- Comorbidities
- > ASD
- > ADHD
- > anxiety
3
Q
BRUE evaluation and management
A
Hx
- During
- > A = choking/gagging
- > B = respiratory distress/apnoea
- > C = cyanosis/plethora/pallor
- > D = level of consciousness
- > E = floppy/stiff + eye movements
- Before
- > awake or asleep
- > prone/supine/side
- > feeding or vomiting
- > environment (co-sleeping/temperature/bedding)
- > nearby choking hazard objects
- > preceding illness
- End
- > duration
- > self resolved/re-positioned/stimulation/compressions
- > gradual or rapid recovery
- Past
- > previous events
- > previous illnesses
- > reflux
- > medications
- Family
- > childhood illness
- Social
- > sick contacts
- > attachment
Exam
- A
- > obstruction
- B
- > wheeze/crackles
- > distress
- C
- > irregular pulse
- > cyanosis/plethora/pallor
- > murmur
- > HF
- D
- > developmental milestones
- > tone
- E
- > abdo tenderness
- > testicular torsion
- F
- > volume status
- G
- > check
Investigations
- Low risk
- > normal hx + exam
- > born at term
- > over 3 months old
- > first event
- High risk
- > ECG
- > glucose
- > FBC
- > EUC
- > Nasopharyngeal PCR viral + pertussis
Management
- Low risk
- > most admitted for observation
- > parental support and education
- High risk
- > cardiac monitoring
- > pulse ox
- > paediatrician review
4
Q
Baby check
A
When
- within 48 hours
- > always before discharge
Patient centred
- seek parental consent
- consider cultural needs
- discuss
- > purpose
- > process
- > limitations
- ask about concerns
Hx
- Review delivery
- > gestational age
- > mode of delivery
- > complications
- > APGARs
- > need for resuscitation
- Review current pregnancy
- > complications
- > screening tests (imaging and bloods)
- > risk factors for sepsis
- Review past pregnancies
- > congenital anomalies
- > still births and SUDI
- > genetic/syndromic conditions
- Maternal health
- > blood group
- > illnesses prior to and during pregnancy
- > medications, alcohol, drugs
- Family hx
- > genetic and congenital conditions
- > still births and SIDS
- > psychosocial dynamics
- Since birth
- > vitals
- > measurements
- > medications
- > feeding
Exam
-top to toe
Investatigations
- Glucose
- > not routinely measured
- Newborn screening
- > blood spot
- > SWISH
- Jaundice
- > all babies
- > review risk factors
- > visual or transcutaneous (every 8-12 hrs)
Management
- Vitamin K
- > recommended for all shortly after birth
- > prophylaxis for hemorrhagic disease of newborn
- > approx 1mg IM
- Hep B
- > vaccine offered to all within 7 days
- > IgG offered when mum HBVsAg+
- Umbilicus
- > standard infection control only
- > usual hand hygiene
- > clamp 2cm from skin
- > wash with soap and water
- > expose to air (above nappy)
- > detachment usually at 1 week
Patient education
- Complete blue book (my personal health record)
- Normal newborn care
- > sleep
- > feeding
- > urine and stools (frequency, colour, meconium passing)
- > growth
- > umbilical cord care
- > detection of jaundice
- Health promotion
- > injury prevention
- > illness warning signs
- > written information of SUDI
- > breast feeding advocacy
- > immunisation schedule
- Information on support agencies
- arrange follow up
- > one week
5
Q
SWISH
A
What
-audiology screening for all newborns
Why
- incidence of permanent severe bilateral hearing loss
- > 80 births/year in NSW
- intervention before 6 months
- > prevents poor health, social and cognitive impairement
Process
- when
- > ideally first few days of life
- > up to 3 months
- requires consent
- > refusal documented in blue book
- screening test
- > automated auditory brainstem response (AABR)
- > baby asleep or resting
- > electrodes on head
- > sound introduced through earphones
- > waveform detected and compared to template
- results available immediately
- > parents informed of results
- if negative
- > routine surveillance
- if positive
- > second screen conducted to confirm result
- still positive
- > audiology test at john hunter, westmead or SCH
- if diagnosed, referral to australia hearing
- > different commonwealth funded interventions offered
- document screening in blue book
