The Crashing Neonate Flashcards
What should always come to mind with a crashing neonate?
Sepsis
What does grunting signify?
Need for PEEP
What is the first step in assessing a crashing neonate?
The pediatric assessment triangle:
Appearance: tone, interaction, vocalizations
Work of breathing: RR, retractions, nasal flaring, grunting, breath sounds
Circulation: pallor, cyanosis, mottling, warmth, cap refill
Also include the vitals, and probably a POC glucose
What two signs are ominous in this age group?
Hypothermia
Bradycardia
How is irritability defined?
It is paradoxical irritability where the kid gets more irritable when they are touched or handled and are not soothed by the means that usually work
What are the first actions basically every patient gets?
IV, O2, Monitor POC glucose, Hgb, check lytes, VBG All cultures Bolus 10–20 cc.kg of NS First dose of Abx
How rapidly should abnormalities be addressed?
Remember to fix abnormalities as fast as they developed. Slow onset issues should be corrected slowly.
Name 6 rapid lab abnormalities that should be corrected?
Dehydration/shock Low Ca High K Anemia Low Na Low glucose
How is dehydration/hypovolemia treated?
NS bolus of 10–20 cc/kg
How is Hypocalcemia treated? What level is treated?
<7 mg/dL is treated
Ca gluconate 100–200 mg/Kg
How is Hyperkalemia treated?
Treat symptomatic or above 7 mEq/L
Regular insulin 0.1 u/Kg with D10W 2–3mL/Kg
Consider albuterol
Check EKG for peaked T’s, loss of P waves, wide QRS, Sine waves, dysrhythmias, asystole
Give Ca as this acts the fastest
Insulin takes 10–20 minutes to start working and peaks at 30–60 min
Check POC glucose 1 hour later
Bicarb and albuterol tend to be more transient
How is anemia treated?
PRBC 10 mL/Kg
How is hyponatremia treated?
If less than 125, give 3% Saline 5mL/Kg with goal of 125–130
Correct remaining over the next 1–2 days
How is hypoglycemia treated?
if less than 60, give D10W 5mL/Kg
What does an open fontanelle mean for head trauma and intracranial pressure?
Symptoms are less likely to develop and therefore less reliable to indicate an intracranial issue
Where can neonates have bleeding to the point of hypovolemic shock where other patients cannot?
In their heads!
What brain bleed pattern = abuse?
Subdural hematoma
Neonates don’t break bones in trauma and are therefore more likely to have what injuries?
Pulmonary contusion
Liver and spleen injuries
What labs are needed in neonatal trauma?
Type/screen/cross
Coags, LFT’s, Lipase, UA
What imaging is indicated in neonatal trauma assessment?
CXR, Skeletal survey, CT’s (faster than MRI), and FAST exam
What are broad categories to consider when evaluating a crashing neonate?
Trauma Heart/Hypovolemia/Hypoxia Endocrine Metabolic Inborn errors of metabolism Seizures Formula Issues Intestinal catastrophes Toxins/ingestions Sepsis
Also remember: Botulism, Meningitis, Hydrocephalus
What are the CSF findings suggestive of bacterial vs Viral meningitis?
Bacterial: low glucose, high protein, high WBC’s PMN predominant
Viral: normal glucose and protein, smaller increase in WBC’s with lymph predominance
What should be the empiric antibiotic regimen when meningitis is possible?
Ampicillin + Gentamicin + 3rd/4th gen Cephalosporin
Cephalosporin is needed to improve CSF activity against pneumococcus, and to cover for GBS resistant to ampicillin and enteric G (-) resistant to ampicillin and to cover listeria (Cetotaxime, Ceftazidime, Cefepime)
Vanco is substituted for ampicillin if a hospitalized patient unless concern for GBS, Listeria, or Enteric bacteria are suspected based on gram stain, in which case ampicillin and vanco are both given because vanco is not bactericidal in the CSF for these organisms
Acyclovir included if any suspicion for viral infection
Meropenem sub for cephalosporin if concern for MDR G(-) organisms
What are the two ways that cardiac disease can present?
Cyanosis and Shock
Both require prostaglandin
