WEEK 6 - NEUROLOGY & CARDIOLOGY Flashcards
9 Key Points
- SCRIPT mnemonic?
- 4 cardinal features of cardiogenic syncope?
- How may congenital cadiac disease present?
- Most common seizure syndrome in children?
Differentials for:
- Cyanosis? (3)
- Seizure? (4)
- Collapse? (5)
- Murmur(infants)? (2)
- Murmur(older child/adolescent)? (2)
- Lethargy/ Irritability (encephalopathy)? (4)
CAHS Guidelines - Cardiac: Neonatal Circulation Changes / Unbalanced Circulation
- What are 3 Basic differences between the foetal circulation compared with the postnatal circulation?
CAHS Guidelines - Cardiac: Neonatal Circulation Changes / Unbalanced Circulation
- Describe the blood flow in the fetus?
CAHS Guidelines - Cardiac: Neonatal Circulation Changes / Unbalanced Circulation
- What changes occur in circulation at birth?
- What is the Ductus Arteriosus?
- What is the Foramen Ovale?
- What is the Ductus Venosus?
- What is the Umbilical Vein?
Changes in the Circulation at Birth
- As the umbilical cord is clamped, the SVR increases due to increased blood volume in the placenta. As the infant takes its first breath, the lungs expand and the PVR drops, increasing the blood flow to the lungs which increases the oxygenation of the blood.
- The PVR continues to fall over the following weeks and ultimately takes about a month to fall to a mean level of 1/3 of mean systolic pressure.
CAHS Guidelines - Cardiac: Neonatal Circulation Changes / Unbalanced Circulation
CAHS Guidelines - Cardiac: Neonatal Circulation Changes / Unbalanced Circulation
- What is the Unbalanced Circulation ratio?
- What does too little blood flow to the lungs result in? 5 Examples?
- What does too much blood flow to the lungs result in? 5 Examples?
Too little blood flow to the lungs results in hypoxia.
1. PPHN.
2. Severe Tetralogy of Fallot.
3. Pulmonary stenosis/atresia.
4. Single ventricle anatomy/DORV (some).
5. BT shunt too small/blocked.
Too much blood flow to the lungs results in shock, lactic acidosis, pulmonary oedema, multiorgan failure.
1. HLHS.
2. Truncus arteriosus.
3. Large PDA.
4. Single ventricle anatomy/ DORV (some).
5. BT shunt too large.
CAHS Guidelines - Cardiac: Neonatal Circulation Changes / Unbalanced Circulation
- 6 Respiratory Ways to Influence the Circulation when it is unbalanced?
- 7 Cardiovascular Ways to Influence the Circulation when it is unbalanced?
- 4 Other?
Other
1. Ensure no electrolyte abnormalities.
2. Maintain haematocrit 0.4-0.5 for maximum O2 carrying capacity.
3. Minimal handling.
4. Sedation +/- paralysis.
CAHS Guidelines - Cardiac: Neonatal Circulation Changes / Unbalanced Circulation
- Management of Qp < Qs? (9)
Management of Qp < Qs
1. Give supplemental O2.
2. Low normal pCO2/high normal pH.
3. NO if PHT.
4. Alprostadil.
5. MgSO4.
6. Ensure adequately filled.
7. Inotropic support - Dobutamine +/- Noradrenaline or Milrinone only if good BP.
8. If PS, normal cardiac function - Noradrenaline or Phenylephrine (intense peripheral vasoconstrictor, forces blood to lungs).
9. Sedation/paralysis + minimal handling.
CAHS Guidelines - Cardiac: Neonatal Circulation Changes / Unbalanced Circulation
- Management of Qp > Qs? (10)
Management of Qp > Qs
1. Be watchful in any lesion prone to developing this problem - SaO2 ‘too good’, regular gases and beware of metabolic acidosis/rising lactate.
2. Early ventilation in air, if needs hand bagging use air or low FiO2 e.g. 30%.
3. Keep O2 sats 75-85%.
4. High PEEP, consistent MV.
5. High normal pCO2/low normal pH.
6. Hypoxic mix - e.g. FiO2 19% (not usually used these days).
7. Ensure adequately filled.
8. Inotropic support of R ventricle - low dose Dopamine or Dobutamine.
9. Correct acidosis with HCO3.
10. Look for signs multiorgan failure and treat accordingly.
KEMH Neonatal Guidelines - Cardiac Murmur
- What is Congenital Heart Disease (CHD)?
- How many children does it affect?
- 5 Risk factors for congenital heart disease?
KEMH Neonatal Guidelines - Cardiac Murmur
- What is involved in the Cardiac Assessment of all Babies? (5)
- 5 Features associated with innocent murmurs?
Cardiac Assessment of all Babies
1. Assessment of colour for cyanosis or pallor.
2. Assessment of peripheral pulses including femoral pulses (absent femoral pulses requires immediate senior review) including rate and regularity.
3. Assessment of the precordial impulse for heave or thrill, displaced apex beat.
4. Auscultation for normal heart sounds and murmur.
5. Predictors of congenital heart disease - harsh murmur quality, and timing (diastolic or continuous).
KEMH Neonatal Guidelines - Cardiac Murmur
- Management of Cardiac Murmurs - 4 Investigations?
CAHS Guidelines - Congenital Heart Disease: Presentation and Initial Management of Duct Dependent Lesions
- 2 Types of Duct Dependent Lesions?
CAHS Guidelines - Congenital Heart Disease: Presentation and Initial Management of Duct Dependent Lesions
- 7 assessments suggested to aid in differentiating cardiac from respiratory causes for cyanosis?
Cyanosis - Differentiating cardiac from respiratory causes for cyanosis can be problematic, especially as some infants have mixed causes. The following assessments are suggested:
1. A thorough clinical assessment.
2. Continuous pre and post ductal SaO2 levels.
3. Blood gas.
4. CXR to rule out lung disease and check heart size and shape.
5. ECG.
6. Referral to cardiology for echocardiogram which is diagnostic.
CAHS Guidelines - Congenital Heart Disease: Presentation and Initial Management of Duct Dependent Lesions
- 6 assessments suggested to diagnose Congestive Cardiac Failure (CCF)?
CAHS Guidelines - Congenital Heart Disease: Presentation and Initial Management of Duct Dependent Lesions
- What is a weak or absent femoral pulse with a strong right brachial pulse virtually always diagnostic of?
Murmurs and Femoral Pulses
Murmurs may indicate CHD but can be soft, non-specific or absent in duct-dependent lesions at presentation. Weak or absent femoral pulse with a strong right brachial pulse is virtually diagnostic of left heart lesions. However, femoral pulses will be
present whilst the PDA is wide open in left heart lesions.
CAHS Guidelines - Congenital Heart Disease: Presentation and Initial Management of Duct Dependent Lesions
- What is involved in the Initial Management of Suspected Duct Dependent Cardiac Lesions? (8)
CAHS Guidelines - Cardiac Syndromes Associated with Congenital Cardiac Defects
Outline the following syndromes and which congenital cardiac defects are associated with them:
1. Trisomy 13 (Patau Syndrome)?
2. Trisomy 18 (Edward Syndrome)?
3. Trisomy 21 (Down Syndrome)?
4. Turner Syndrome (46XO)?
CAHS Guidelines - Cardiac Syndromes Associated with Congenital Cardiac Defects
Outline the following syndromes and which congenital cardiac defects are associated with them:
1. 22q11 Deletion (DiGeorge / Velo-Cardio-Facial / CATCH 22)?
2. Crit-du-Chat Syndrome?
3. William’s Syndrome?
4. Wolf-Hirschhorn Syndrome?
CAHS Guidelines - Cardiac Syndromes Associated with Congenital Cardiac Defects
Outline the following syndromes and which congenital cardiac defects are associated with them:
1. Alagille Syndrome (Arteriohepatic Dysplasia)?
2. Carpenter Syndrome (Acrocephalosyndactyly Type II)?
3. Cornelia de Lange Syndrome?
4. Ehlers-Danlos Syndrome Type IV?
5. Ellis-van Creveld Syndrome (Chondroectodermal Dysplasia)?
6. Glycogen Storage Disease Type II (Pompe Disease)?
7. Holt-Oram Syndrome (Cardio-limb Syndrome)?
CAHS Guidelines - Cardiac Syndromes Associated with Congenital Cardiac Defects
Outline the following syndromes and which congenital cardiac defects are associated with them:
1. LEOPARD Syndrome (Multiple Lentigines Syndrome)?
2. Marfan Syndrome?
3. Noonan’s Syndrome?
4. Rubenstein-Taybi Syndrome?
5. Smith-Lemli-Opitz Syndrome?
CAHS Guidelines - Neonatal Seizures
- 4 Key Points?
- 9 Aetiological classifications of neonatal seizures?
- Neonatal seizures (NS) occur in 1.8-5 per 1000 live births, with majority occurring in the first few days of life.
- Seizures occur more frequently in the neonatal period than at any other time of life.
Key Points
1. The time, duration and classification of seizures should be recorded.
2. Often in the same neonate more than one seizure type may be seen.
3. Factors that provoke seizures (e.g. handling) and progression of events should also be noted.
4. Neurological observations should be recorded on MR494 – Neonatal Neurological Observation Chart.
CAHS Guidelines - Neonatal Seizures
- 8 Non-Epileptic movements which can mimic neonatal seizures?
- Clinical features?
- EEG?
Differentiating epileptic seizures from seizure like activities: While dealing with a neonate with abnormal movement or behaviour, an important step is to know whether they are seizures or paroxysmal non epileptic motor phenomenon. The following common abnormal movements need to be considered in the differential diagnosis of neonatal seizures.
CAHS Guidelines - Neonatal Seizures
- Diagnosis?
CAHS Guidelines - Neonatal Seizures
- History - 5 Maternal diseases?
- History - 4 Maternal medications?
- History of perinatal asphyxia?
CAHS Guidelines - Neonatal Seizures
- Clinical Examination?
- Emergency investigations of potential treatable conditions - 10 Metabolic? 7 Infections? 2 Intracranial haemorrhage?
Clinical Examination
A thorough examination of the nervous system as well as other systems is important. Initial investigation should focus on identifying conditions that are treatable and if untreated can lead to severe brain damage.
CAHS Guidelines - Neonatal Seizures
- Investigations to make a diagnosis, in order to facilitate prognostication and supportive treatment (curative therapy may not available)?
CAHS Guidelines - Neonatal Seizures
- Main principles of treatments?
- Anticonvulsants?
- The main principles of management are anti-seizure medication, supportive management, and treatment of the underlying aetiology. Supportive management might necessitate the administration of IV fluids, mechanical ventilation and correction of hypotension, if required. Conditions such as meningitis, hypoglycaemia, hypocalcaemia, hypomagnesemia, electrolyte imbalances and HSV encephalitis should be treated aggressively.
- Pharmacological treatment.
- Neonatal seizures still lack safe and effective treatment.
- Treatment options are limited: what to treat, which antiepileptic drugs (AEDs) to use and for how long, are the issues that are still debated.
CAHS Guidelines - Neonatal Seizures
- 4 Types of Seizures and their Clinical Features?
PCH ED Guidelines - Febrile convulsions
- What are Febrile convulsions?
- How common are they?
- How are they classified?
- Febrile convulsions flowchart?
- Febrile convulsions are seizures that occur in children aged between 6 months and 5 years that result from a sudden rise in temperature associated with an acute febrile (usually viral) illness.
- Febrile convulsions are common in childhood, and are common ED presentations.
- Most are simple febrile convulsions which are benign.
- Most occur on Day 1 of the illness.
PCH ED Guidelines - Febrile convulsions
- What is the difference between Simple and Complex Febrile Convulsions?
Simple Febrile Convulsions
- Duration less than 15 minutes (usually less than 15 minutes).
- Generalised (not focal).
- Only 1 seizure in 24 hours
- Occur in developmentally normal children.
- No neurological abnormalities post seizure.
**Complex Febrile Convulsions **
- Prolonged (> 15 minutes)
- Recur (> 1 seizure in 24 hours)
- Focal onset
PCH ED Guidelines - Febrile convulsions
- What is the Recurrence rate of Febrile Seizures?
- 6 Risk factors associated with Increased risk of recurrence?
- 3 Risk factors for Future risk of epilepsy?
- Assessment?
Recurrence rate
- 30% of children who have had a febrile convulsion will have a recurrence.
- Of those that have a recurrence 50% will occur within the first year, 90% within 2 years.
Increased risk of recurrence
1. Multiple initial seizures (occurs in 10-15% of febrile seizures)
2. < 12 months
3. Seizure with low grade fever
4. Family history of febrile seizures
5. Brief duration between fever onset and the febrile seizure.
6. Developmental delay
PCH ED Guidelines - Febrile convulsions
- History?
- Investigations?
- Initial management?
- Discharge Criteria?
PCH ED Guidelines - ECG: Indications and Interpretation
- List 10 common indications for paediatric electrocardiography?
- Normal Heart Rates (Beats Per Minute) for: Newborn? 2 years? 4 years? 6+ years?
Common indications for paediatric electrocardiography:
1. Syncope, seizures and “funny turns”
2. Cyanotic episodes
3. Chest pain or other symptoms related to exertion
4. Neonates that present with the combination of respiratory symptoms and mottled skin to exclude an underlying cardiac condition
5. Drug ingestion
6. Diagnosis and management of rheumatic fever, Kawasaki’s disease, pericarditis, myocarditis
7. Diagnosis and management of arrhythmia
8. Diagnosis and management of congenital heart disease
9. Family history of sudden death or life threatening event
10. Electrolyte abnormalities
PCH ED Guidelines - ECG: Indications and Interpretation
- What are 7 findings on ECG of a Full term newborn infant?
PCH ED Guidelines - ECG: Indications and Interpretation
- What are 4 normal findings on ECG at 1 week – 1 month?
- What are 4 normal findings on ECG at 1 - 6 months?
1 week – 1 month
1. Right axis retained
2. R waves remain dominant across to lead V6, although dominant S waves may be normal
3. T wave negative in lead V1
4. T wave voltage higher in limb leads
1 – 6 months
1. QRS axis rotates to leftward (less than +120 degrees)
2. R wave remains dormant in lead V1
3. R/S ratio in lead V2 close to 1 but may be >1 in lead V1
4. T waves negative across right chest leads.
PCH ED Guidelines - ECG: Indications and Interpretation
- What are 4 normal findings on ECG at 6 months – 3 years?
- What are 4 normal findings on ECG at 3 – 8 years?
6 months – 3 years
1. QRS axis usually > +90 degrees
2. R wave dominant in lead V6
3. R/S ratio in lead V1 close to or less than 1
4. Large voltages in praecordial leads persist
3 – 8 years
1. Adult QRS progression in praecordial leads: dominant S waves in lead V1, dominant R waves in lead V6
2. Large praecordial voltages persist
3. Q waves in left chest leads may be large (<5mm)
4. T waves remain negative in right praecordial leads
PCH ED Guidelines - ECG: Indications and Interpretation
- What are 4 normal findings on ECG at 8 - 16 years?
- What are 3 normal findings on ECG at for an adult?
8 – 16 years
1. QRS axis mean +60 degrees, range 0 to +90 degrees
2. Adult QRS progression
3. Large praecordial lead voltages, R waves in left leads larger than adult
4. T waves variable. Maybe upright in lead V1 but negative in lead V1-V4 (not abnormal)
Adult
1. QRS axis mean +50 degrees, range 0 to +100 degrees
2. Dominant left ventricle (LV)
3. T waves upright across praecordial leads
PCH ED Guidelines - ECG: Indications and Interpretation
- What are 4 normal features of the P wave in childhood?
- What are 4 normal features of the Q wave in childhood?
- If the Q wave amplitude > 5mm, which 2 things should you consider?
P Wave
1. P wave amplitude does not change significantly during childhood.
2. P waves are normally upright in leads I and aVF
3. Amplitude < 3mm, if taller consider right atrial hypertrophy (RAH)
4. Duration < 0.09 seconds, if wider consider left atrial hypertrophy (LAH)
PCH ED Guidelines - ECG: Indications and Interpretation
- What are the normal features of the QRS Axis in childhood?
- What are the normal features of the T Wave in childhood?
- 2 Differentials for Tall T waves in childhood?
- 5 Differentials for Flat T waves in childhood?
Tall T waves
1. Hyperkalaemia
2. LVH
Flat T waves
1. Hypokalaemia
2. Pericarditis
3. Myocarditis
4. Newborns
5. Hypothyroidism
PCH ED Guidelines - ECG: Indications and Interpretation
- Variation in P-P interval in children?
- 5 Common variations in rhythm which may be normal in childhood?
- Normal PR interval in children?
- 3 Differentials for a Prolonged PR interval in children?
- 2 Differentials for a Shortened PR interval in children?
Variation in P-P interval - The diagnosis of sinus arrhythmia is easily confirmed in most cases by observing the relation of the change to respiration (slowing in expiration, accelerating in inspiration).
Common variations in rhythm which may be normal:
1. Pronounced sinus arrhythmia
2. Short sinus pauses <1.8 seconds
3. First degree atrioventricular block (Prolonged PR interval)
4. Mobitz type 1 second degree atrioventricular block
5. Junctional rhythm
PCH ED Guidelines - ECG: Indications and Interpretation
- Are Extrasystoles normal in childhood?
- Normal QRS Duration in childhood? How does it vary over time?
- 3 Differentials for a Prolonged QRS duration in children?
- 2 Differentials for a Decreased amplitude QRS in children?
Extrasystoles
- Isolated ventricular premature beats may be identified on a routine resting ECG in 0.2-2.2% of normal children.
- Extrasystoles which conform to this pattern and suppress on exercise are almost certainly benign.
PCH ED Guidelines - ECG: Indications and Interpretation
- Normal QT interval in childhood?
- 7 Conditions that cause prolonged QTc?
- 3 ECG Signs Of Pericarditis?
- 4 ECG Signs Of Myocarditis?
- 4 ECG Abnormalities In Patients With Syncope?
Prolonged QTc is seen in:
1. Hypokalaemia
2. Hypomagnesaemia
3. Hypocalcaemia
4. Hypothermia
5. Head injury
6. Myocarditis
7. Commonly used drugs such as azithromycin, erythromycin, clarithromycin, fluconazole and domperidone
PCH ED Guidelines - Supraventricular tachycardia
- What is SVT?
- Which 2 drugs should you never use for children with SVT? Why?
- Management for when a Child Appears Shocked?
Management
- Assess and manage airway, breathing and circulation.
- A 12 lead electrocardiogram (ECG) in SVT and post conversion is essential.
- Monitoring with a rhythm strip during manoeuvres (i.e. in SVT and post conversion) allows later assessment of underlying rhythm in unclear cases.
PCH ED Guidelines - Supraventricular tachycardia
- Management for when a Child Does Not Appear Shocked?
- Administration of Adenosine?
Administration
- Administer via IV site closest to the patient’s heart (therapeutic failure may occur with administration into the lower extremities.
- Using a 3-way tap, administer adenosine undiluted over 1-2 seconds, immediately followed by a 10mL sodium chloride 0.9% flush.
- Monitor blood pressure immediately after the end of a flush.
- Measure blood pressure on the opposite arm to the adenosine infusion to avoid an adenosine bolus effect.
- If reversion to sinus rhythm occurs but is not sustained, there is little to be gained by repeating the same manoeuvre / drug.
RCH Guidelines - Syncope
- What is Syncope?
- Causes and Differential diagnoses: 4 Autonomic? 5 Cardiac? 7 Other?
RCH Guidelines - Syncope
- 5 Key and useful features on history to differentiate from a seizure?
- 5 Red flags for potential cardiac aetiology?
Vasovagal syncope is typically preceded by a painful or emotional stimulus and prodromal symptoms such as dizziness, weakness and visual changes.
Red flags for potential cardiac aetiology are:
1. lack of prodrome
2. palpitations or chest pain
3. exercise-induced syncope
4. past cardiac history
5. family history of early cardiac death, arrhythmia or sudden death
RCH Guidelines - Syncope
- Examination?
- 4 Investigations?
- Treatment algorithm?
Examination
- Orthostatic heart rate and blood pressure measurements.
- Complete cardiac and neurological examination.
Investigations
1. An ECG should be obtained in all children at least once. May not be required if done previously and there is no additional concern.
2. A blood glucose level can be useful if the child is seen shortly after the event.
3. Obtain a full blood count if anaemia is suspected.
4. Consider pregnancy testing
RCH Guidelines - Seizure: First Presentation
- Definition?
- Prevalence?
- Recurrene Risk?
- History?
- Examination?
Definition - A seizure is the physical and behavioural changes that occur after an episode of abnormal activity in the brain or part of the brain.
It is a symptom not a diagnosis.
Background - By the age of 16 years, approximately 1% of the population will have suffered a seizure without a fever.
Recurrence risk:
- 25% will have a second afebrile seizure in the next year
- 45% will have a second afebrile seizure in the next 14 years.
- 75% of those will have a third afebrile seizure.
- 88% of those are within two years.
RCH Guidelines - Seizure: First Presentation
- 7 Possible Investigations?
- 11 Differential Diagnoses?
- Management?
Investigations
1. Glucose
2. UEC, Calcium, Magnesium,
3. Phosphate
4. CT if clinically indicated
5. ECG
6. EEG
7. Metabolic screen if clinically indicated.
Differential diagnoses
1. Febrile convulsion
2. Meningoencephalitis
3. Breath holding
4. Syncope
5. Gastro-oesophageal reflux (GOR)
6. Arrhythmias
7. Stroke
8. Panic attack
9. Migraine
10. Psychosis
11. Pseudo seizures
RCH Guidelines - Seizure: First Presentation
- 11 Admission Criteria?
- Management?
- First Seizure Management Flowchart?
Admission criteria
1. Prolonged seizure > 15 minutes
2. GCS < 15 (1 hour post seizure)
3. Atypical febrile convulsion
4. Age < 1 year
5. > 1 seizure
6. Focal seizures
7. Signs of raised intracranial pressure (ICP)
8. Meningoencephalitis
9. Signs of aspiration
10. Non accidental injury (NAI)
11. High parental / carer anxiety
PCH Guidelines - Status epilepticus
- Definition?
- Background?
- Prevalence?
- Management Flowchart?
Definition - Convulsive status epilepticus is defined as a generalised tonic‐clonic convulsion lasting more than 30 minutes, or repeated tonic‐clonic convulsions over a 30 minute period without recovery of consciousness between each convulsion.
Background
- Status epilepticus is the most common neurological medical emergency.
- In approximately 30% of cases, status epilepticus is the initial presentation of a seizure disorder.
- Mortality is 1-3%.
- The estimated incidence is 20 per 100,000 children per year
PCH Guidelines - Status epilepticus
- 6 Causes of Status epilepticus?
- History?
- Examination?
- 3 Investigations?
- Management?
Causes of Status epilepticus:
1. prolonged febrile convulsion
2. epilepsy
3. central nervous system infection (e.g. meningitis)
4. trauma
5. metabolic
6. poisons.
Investigations
1. Always do a blood glucose level (BGL)
2. Venous blood gas
3. Consider other investigations according to the possible underlying aetiology e.g. infectious screen, anti-epileptic drug levels
RCH Guidelines - Altered conscious state
- 3 Key Points?
- Background?
- Causes?
RCH Guidelines - Altered conscious state
- Initial assessment and management?
- History?
- Examination?
Initial assessment and management
Initial screening of conscious state may be done using AVPU scale, particularly in younger children.
- A = Alert
- V = Responds to voice
- P = Responds to pain
- U = Unresponsive
Any impairment on AVPU scale should prompt a formal assessment of GCS.
RCH Guidelines - Altered conscious state
- 9 Investigations?
- Treatment algorithm - Approach to management of altered conscious state based on suspected cause?
BMJ Infographic - Managing febrile seizures
1 - Is this a febrile seizure?
- Definition?
- Seizure types?
2 - Consider alternative diagnoses
- Red flags suggestive of CNS infection?
3 - Educate and inform parents
- Recurrence?
- Risk factors?
- Rescue medications?
Most Common Causes of Heart Murmurs in Neonates & Children?
What is a Functional Neurological Disorder (FND)?
- 15 FND Symptoms?
Functional Neurological Disorder (FND):
- FND describes neurological symptoms like limb weakness, tremor, numbness or blackouts, related to the movement and sensation parts of the nervous system…..
- Caused by a PROBLEM with the FUNCTIONING of the nervous system.
- A “software” issue of the brain, not the hardware (as in stroke or MS).
- With positive diagnostic features typical of FND.
- Cause day to day difficulties for the person who experiences them.
Pathophysiology of FND?
What are the 2 types of Respiratory Problems in Nenonates?
- 7 Signs of respiratory distress in a neonate?
- 7 Components of respiratory distress?
Types of respiratory problems
1. Respiratory distress
2. Hypoventilation: Apnoea & Neuro-muscular
Signs of respiratory distress
1. Tachypnoea
2. Expiratory grunt
3. Recession: Intercostal (rib) & Subcostal
4. Nasal flare
5. Cyanosis
6. Stridor
7. Tracheal tug
What are 6 Management principles of Respiratory Distress in a Neonate?
- Options for respiratory support?
Management principles of Respiratory Distress in a Neonate
1. Neonatal nursery
2. Monitor RR, HR, oxygen saturations, BP
3. Monitor blood glucose level
4. Blood cultures and ANTIBIOTICS: Immediately if indicated OR After 4 hours even if no risk factors for sepsis
5. CXR
6. Get advice.
Neonatal respiratory distress syndrome (Surfactant deficiency disorder, Hyaline membrane disease)
- What is it?
- 6 Risk factors?
- Effect of gestation? When does the risk drop dramatically?
Hyaline membrane disease = Commonest cause of respiratory distress in neonates
Risk factors
1. Immaturity (↑ incidence with ↓GA)
2. Asphyxia
3. IDDM
4. Male
5. 2nd twin
6. APH
Risk drops off significantly after 34 weeks gestation.
Hyaline membrane disease
- Aetiology? (3)
- Pathophysiology: Results in 4 things?
Aetiology
1. Premature birth
2. Maternal diabetes mellitus: leads to ↑ fetal insulin, which inhibits surfactant synthesis
3. Cesarean delivery: results in lower levels of fetal glucocorticoids than vaginal delivery, in which higher levels are released as a response to stress from uterine contractions
Hyaline membrane disease:
- Presentation?
- Radiological features? (4)
- Complications? (4)
- Treatment? (4)
Hyaline membrane disease: Presentation
- Presents with respiratory distress from birth or soon after
- Onset of symptoms: usually immediately after birth
- Signs of increased respiratory effort: Tachypnea, Nasal flaring; subcostal/intercostal and jugular retractions
- Decreased breath sounds on auscultation
- Cyanosis
- Gets worse over first two days, peaks at 48-72 hours, then gets better
Radiological features
1. Small volume lungs
2. Homogenous “ground glass” appearance (diffuse reticulogranular opacification)
3. Air bronchograms
4. Interventions
What is Surfactant? When is it produced?
What happens when there is deficiency of surfactant?
Surfactant
- Pulmonary surfactant is a mixture of phospholipids and proteins produced by lamellar bodies of type II alveolar cells. These phospholipids reduce alveolar surface tension, preventing the alveoli from collapsing.
- Surfactant deficiency is most likely to occur in preterm infants, because:
- Surfactant production begins at approximately 20 weeks gestation.
- Distribution throughout the lungs begins at 28-32 weeks’ gestation and does not reach sufficient concentration until 35 weeks gestation.
Alveolar collapse in surfactant deficiency: Surfactant reduces alveolar surface tension. In surfactant deficiency, increased surface tension results in increased alveolar collapse during expiration and decreased alveolar expansion during inspiration.
Neonatal respiratory distress syndrome/Hyaline Membrane Disease
- Diagnostics?
Causes of Respiratory Distress in Neonates: Air Leak Syndrome
- 3 Causes?
- Presentation?
- Treatment: Emergency? Non-urgent?
Causes of Respiratory Distress in Meconium Aspiration Syndrome
- What percentage of deliveries?
- Definition?
- Complications? (3)
- Pathophysiology? (4)
- Radiological features? (5)
Meconium Aspiration Syndrome
* Meconium-stained amniotic fluid occurs in 12% of deliveries.
* Meconium aspiration defined by meconium aspirated from below the vocal cords.
* Present with respiratory distress and cyanosis following delivery through meconium-stained liquor.
Complications:
1. Air leak
2. PPHN
3. ± HIE, cardiac depression, renal failure
Pathophysiology
1. Pneumonitis
2. Airway obstruction
3. Atelectasis
4. Hyperinflation
Radiological features:
1. Patchy coarse infiltrates
2. Widespread consolidation
3. Hyperinflation
4. Pleural effusions
5. Air leak
Transient tachypnoea of the newborn (TTN)
- What is it?
- Risk factor?
- 5 Radiological features?
Transient tachypnoea of the newborn (TTN)
- Poor lung fluid clearance
- Rarely severe
- Self limiting - resolve within 24-36 hours
Risk factors
Caesarean section - Mechanical & Lack of hormonal signalling of labour.
Radiological features
1. Increased central vascular markings “star burst” appearance
2. Hyperaeration
3. Interstitial and pleural fluid
4. Prominent interlobar fissures
5. Cardiomegaly
5 Causes of Respiratory Depression in a Neonate?
- 3 causes of apnoea?
- Causes of Airway Obstruction in a Neonate: 1 Nose? 4 Larynx? 3 Trachea?
Respiratory Depression in a Neonate
1. Asphyxia - metabolic acidosis
2. Spinal cord disease - injury, SMA
3. NM junction - MG, infant botulism
4. Muscle - myotonic dystrophy
5. Apnoea
- Prematurity - immature brainstem
- Sepsis
- Metabolic/electrolyte disturbance
Hyaline Membrane Disease
- Treament?
- Complications?
Treatment = Endotracheal administration of artificial surfactant within 2 hours postpartum
- Physiologic O2 saturation in neonates is around 90%. A saturation of 100% is considered toxic for neonates!
A 6 year old presents with GCS 10 after a >15 minute seizure at home.
a) List important differential diagnoses.
A 6 year old presents with GCS 10 after a >15 minute seizure at home.
b) Describe factors which would increase the likelihood of further seizures, both acutely and long term.
An 11y presents with mild confusion and an inconsistent, stumbling gait. Apart from her parents recently separating, she has been completely well previously. What are some differential diagnoses, and is imaging indicated?
Imaging would be indicated often, particularly if the person is encephalopathic or has focal neurological signs. Imaging is not usually indicated for the diagnosis or management of Sydenham Chorea, but it is not unusual for it to be done in the management of functional neurological disorders in order to emphatically exclude some diagnoses.
A neonate is detected to have a cardiac murmur on routine discharge screening, with oximetry of 96% (right hand and right foot). Which descriptors will you need to assess and articulate in a referral to cardiology?
Describe your approach – diagnostic and management - to a 18 month child who presents with a 5 minute seizure in association with a febrile illness – including parental instructions.
Analysis: This stem mentions diagnosing – which is more than just stating that a child has had a febrile convulsion, because you also have to determine the cause of the fever (which could be a lot of things). The stem also mentions management, which includes diagnostic refinement, supportive treatments, specific treatments, education and other communication and follow-up.
The stem provides some clues: the age, the duration of the episode, which allow some conjecture that this may well have been a simple or typical febrile seizure, instead of a complex or atypical febrile seizure.
