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Hasbro and PEM > The Crashing Neonate > Flashcards

The Crashing Neonate Flashcards

1
Q

What should always come to mind with a crashing neonate?

A

Sepsis

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2
Q

What does grunting signify?

A

Need for PEEP

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3
Q

What is the first step in assessing a crashing neonate?

A

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

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4
Q

What two signs are ominous in this age group?

A

Hypothermia

Bradycardia

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5
Q

How is irritability defined?

A

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

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6
Q

What are the first actions basically every patient gets?

A 
IV, O2, Monitor
POC glucose, Hgb, check lytes, VBG
All cultures
Bolus 10–20 cc.kg of NS
First dose of Abx
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7
Q

How rapidly should abnormalities be addressed?

A

Remember to fix abnormalities as fast as they developed. Slow onset issues should be corrected slowly.

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8
Q

Name 6 rapid lab abnormalities that should be corrected?

A 
Dehydration/shock
Low Ca
High K
Anemia
Low Na
Low glucose
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9
Q

How is dehydration/hypovolemia treated?

A

NS bolus of 10–20 cc/kg

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10
Q

How is Hypocalcemia treated? What level is treated?

A

<7 mg/dL is treated

Ca gluconate 100–200 mg/Kg

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11
Q

How is Hyperkalemia treated?

A

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

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12
Q

How is anemia treated?

A

PRBC 10 mL/Kg

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13
Q

How is hyponatremia treated?

A

If less than 125, give 3% Saline 5mL/Kg with goal of 125–130

Correct remaining over the next 1–2 days

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14
Q

How is hypoglycemia treated?

A

if less than 60, give D10W 5mL/Kg

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15
Q

What does an open fontanelle mean for head trauma and intracranial pressure?

A

Symptoms are less likely to develop and therefore less reliable to indicate an intracranial issue

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16
Q

Where can neonates have bleeding to the point of hypovolemic shock where other patients cannot?

A

In their heads!

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17
Q

What brain bleed pattern = abuse?

A

Subdural hematoma

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18
Q

Neonates don’t break bones in trauma and are therefore more likely to have what injuries?

A

Pulmonary contusion

Liver and spleen injuries

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19
Q

What labs are needed in neonatal trauma?

A

Type/screen/cross

Coags, LFT’s, Lipase, UA

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20
Q

What imaging is indicated in neonatal trauma assessment?

A

CXR, Skeletal survey, CT’s (faster than MRI), and FAST exam

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21
Q

What are broad categories to consider when evaluating a crashing neonate?

A 
Trauma
Heart/Hypovolemia/Hypoxia
Endocrine
Metabolic
Inborn errors of metabolism
Seizures
Formula Issues
Intestinal catastrophes
Toxins/ingestions
Sepsis

Also remember: Botulism, Meningitis, Hydrocephalus

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22
Q

What are the CSF findings suggestive of bacterial vs Viral meningitis?

A

Bacterial: low glucose, high protein, high WBC’s PMN predominant
Viral: normal glucose and protein, smaller increase in WBC’s with lymph predominance

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23
Q

What should be the empiric antibiotic regimen when meningitis is possible?

A

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

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24
Q

What are the two ways that cardiac disease can present?

A

Cyanosis and Shock

Both require prostaglandin

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25
When should empiric prostaglandin be given to a suspected cardiac issue?
When cyanosis/hypoxia doesn't respond to 100% O2 or | Shock does not respond to fluid bolus
26
What is a side effect of prostaglandin that should be remembered?
Causes apnea and the child should probably be intubated
27
What are the two potential causes of central cyanosis that you should consider and how to differentiate the two?
Think primary respiratory vs cardiac Give 100% O2 and if not >85% saturations after ten minutes then it is likely a shunt and cardiac in origin and PGE1 should be given
28
In broad terms, what are the two types of congenital cardiac issues and how do they present?
Left and right sided obstructive lesions Left: Present in shock Right: Present with hypoxia and cyanosis
29
What are the left sided obstructive CHD's?
Coarctation, hypoplastic LV, aortic stenosis | PDA is needed for systemic flow
30
What are the right sided obstructive CHD's?
These are the cyanotic lesions, the five T's Truncus arteriosis, Transposition of the great vessels, Tricuspid atresia, Tetrology of fallot, Total anomalous venous return PDA is needed for pulmonary flow
31
What is the dosing of PGE1?
0.05–0.1 mcg/kg/min
32
What presenting symptom equals heart disease until proven otherwise?
Diaphoresis with feeding
33
An infant presents with hypotension. It is unclear if it is sepsis or heart disease. How should fluids be managed?
Give 10cc/Kg and reassess. Sepsis should get better but heart disease will not. Give the sepsis patients more fluid and the heart disease patient start with pressors (Epinephrine)
34
What is the dosing for epinephrine as a pressor for infants?
0.01–0.1 mcg/kg/min
35
A crashing neonate has hypotension and is not responding to fluids or pressors. What exam finding will be helpful and what intervention is needed?
Consider congenital adrenal hyperplasia Check the genitalia for ambiguity or hyperpigmentation Give hydrocortisone 25mg IV Check labs: low glucose, high K, low Na
36
Explain 21-alpha hydroxylase deficiency
Most common cause of congenital adrenal hyperplasia Inhibits progression to aldosterone and cortisol pushing everything to sex hormones leading to excessive androgens Lack of aldosterone leads to Na wasting and hyper K Lack of cortisol leads to hypoglycemia and steroid deficient shock
37
Explain 17-beta hydroxylase deficiency
Stops formation of sex steroids and cortisol | Causes lack of androgens and cortisol but high mineralcorticoid activity
38
Explain 11-alpha hydroxylase deficiency
One step down from 21-alpha hydr. deficiency preventing cortisol production and increasing androgen production but paradoxically increasing mineralcorticoid function
39
What endocrine issues should be considered?
Congenital adrenal hyperplasia Thyroid Glucose Calcium
40
What should always come to mind when a baby is found to be hypoglycemic?
Sepsis | And probably other things
41
Patient comes in with jerks, seizures, tetany. | What lab abnormality should be suspected?
Low calcium
42
What are the symptoms of low calcium? What disease causes this and what can be seen on imaging?
Seizures, jitteriness, tetany, apnea, dysrhythmias DiGeorge syndrome No thymus
43
When hypocalcemia is found what other studies should be ordered?
ECG to check QTc | PTH levels, Vit D, Mg, Phos
44
What is the treatment for hypocalcemia?
Ca gluconate 100mg/kg (1mL/Kg of 10%) IV over 5–10 minutes | Also find and correct other electrolyte abnormalities such as Mg (25–50mg/Kg IV)
45
What are the labs that are helpful for inborn errors of metabolism? What can all these kids get empirically?
Ammonia, Lactate, Ketones, Glucose Also include LFT's These all affect some form of the 3 energy sources: fat, protein, sugar Give empiric glucose D10W in 0.5NS @ 1.5X maintenance
46
What infectious bug should be suspected if a patient is septic and with seizures?
Remember to consider Herpes among others
47
What history do you need from mom when working up sepsis?
PROM?, vaginal vs c-section, maternal infections?
48
What do all kids less than 30 days old get when they present with a fever?
Septic workup, admission, +/- Abx Labs: CBC, UA, all cultures, Lactate, CRP, Procal CSF gram stain, cultures, protein, glucose, cell count and CSF for herpes RPP, LFT's, Coags Fluid bolus Epi if hypotensive despite fluids Abx: ampicillin 50–100mg/kg Gentamicin 4mg/Kg Consider Vancomycin 15mg/kg Consider Acyclovir 20mg/kg if CSF suggestive or other reasons to suspect herpes Include 3rd gen cephalosporin if meningitis
49
Describe omphalitis
Erythema, purulent drainage from stump with fever Progresses rapidly! High mortality Necrotizing infection Needs surgical consultation, Abx, and septic workup A clinical diagnosis
50
What should you remember about localized infections in neonates?
There is no such thing as a "localized infection" in neonates
51
When considering formula mishaps, what is a serious presenting symptom and the underlying cause?
Can present with seizures from hyponatremia from over dilution or too much free water Kids under 3 months should not be given free water Treat with hypertonic saline
52
What is the treatment for seizure from low Na?
3% NaCl 3–5mL/Kg IV over 30–60 minutes Goal Na 125–130 Correct remaining levels gradually over 24–48 hours
53
Patient presents with seizures that are not responding to usual therapy. What causes should be considered?
Hyponatremia and Pyridoxime requiring seizures
54
What are the symptoms of hypo and hyper natremia?
Hypo: seizures, lethargy, hypothermia, resp. insufficiency Hyper: dehydration, lethargy, not fed enough, from concentrated formula
55
What is the MI of pediatric surgery?
Malrotation with midgut volvulus
56
Describe features of malrotation and midgut volvulus
``` 50% present <1 month of age Time is bowel ANY TIME there is bilious vomiting Belly can be benign or peritoneal Workup with abd X-Ray flat and upright Ultimately need an upper GI study looking for a corkscrew shape in the duodenum ```
57
Describe features of necrotizing enterocolitis
Usually only in premies but can happen in shock states Can mimic sepsis +/- hematochezia Can perf bowel Exam: distended abdomen, red abdomen, palpable bowel loops Abd X-Ray: pneumatosis intestinalis, portal venous gas
58
What is the workup and treatment for Hirschsprungs?
X-Ray, call GI for definitive Dx Watch out for perforation NPO, NGT, Abx, need surgery
59
What are the features of infantile spasms?
Epileptic spasms in infancy or early childhood Hypsarrhythmia on EEG Developmental regression Often develop seizures later in childhood Poor neurodevelopmental prognosis Often subtle findings and hard to recognize Consider brain imaging and LP
60
How are seizures managed?
Secure airway and give O2 Benzos first: Midazolam 0.2mg/kg IN Phenobarb or keppra second line Febrile seizures most common cause in kids Low Na is the second most common cause and need to ask about formula and feeding Give pyridoxine 100mg IV push to any kid not responding to benzos
61
What are the doses and routes of administration for banzos in a seizing patient?
Lorazepam: 0.1mg/kg IV Midazolam: 0.1mg/kg IV or 0.2mg/kg IN or IM Diazepam: 0.2mg/kg IV Repeat doses after 4 minutes

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