Dr. Miada Mahmoud Rady EMS /481 Neonatal emergencies Neonatal Diseases Dr. Miada Mahmoud Rady EMS /481 Neonatal emergencies

Lecture Topics Apnea . Hypoglycemia . Prematurity and low birth weight. Seizers in newborn.

Apnea Definition : respiratory pause of greater than 20 seconds. Causes : Hypoxia or hypothermia. Narcotic or CNS depressants. Weakness of respiratory muscle. Septicemia. Metabolic disorders. CNS disorders.

Sequence of apnea events Tachypnea Primary apnea Reversible with stimulation Gasping Secondary apnea Irreversible with stimulation . Ventilation is must. Oxygen deprivation persists

Pathophysiology and Types When deprived of oxygen , either before or after birth , newborn demonstrate specific sequence of event leading to apnea: Transient period of rapid breathing. Primary apnea which has the following characteristics : Associated with mild bradycardia and decrease in neuromuscular tone . Reversible with simple stimulation and oxygenation.

Deep gasping breathing . Secondary apnea , which has the following criteria : Associated with sever bradycardia and hypotension and decline in neuromuscular tone . Does not respond to stimulation . Spontaneous resumption of breathing will never occur. Assisted ventilation is must.

Assessment and management Careful history. Examination with special focus on neurologic signs and signs of infections. It is difficult clinically to differentiate between primary and secondary apnea so always assume it is secondary and start resuscitation immediately.

Neonatal hypoglycemia

Introduction Newborns at significant risk of acute hypoglycemia due to: Poor glucose stores. Inability to stimulate the immature neonatal liver to release glucose. Increased metabolism that uses large quantities of available glucose.

Hypoglycemia Definition : blood glucose level of less than 45 mg/dL in full-term or preterm newborns. It result from imbalance between glucose supply and utilization due to : Inadequate intake or storage. Increased glucose utilization.

Etiology Disorders related to decreased glycogen stores: Small for gestational age Prematurity Postmaturity Increased use of glucose: Newborn of a diabetic mother: Large for gestational age Hypoxia Hyperthermia Sepsis

Clinical presentation Most newborns are asymptomatic until glucose level falls below 20 mg/dL., then it may result in seizures. Any case of seizers in newborn glucose test is crucial.

Clinical presentation Specific: Vomiting. Tremers Tachycardia Tachypnea Seizers Coma Nonspecific : Poor sucking . Irritability Irregular respiration. Cyanosis Apnea

Assessment Obtain baseline vital signs and oxygen saturation readings. Provide as necessary ( Additional oxygen ,Assisted ventilation , Blood pressure support and IV access If the blood glucose level is less than 40 mg/dL: An IV bolus of 10% dextrose solution (2 mL/kg) can be given. Recheck blood glucose level in about 30 minutes. Dextrose IV administration may need to be followed by a 10% dextrose infusion at 60 to 100 mL/kg/d.

Diaphragmatic hernia Definition : An abnormal opening in the diaphragm that causes herniaition of the abdominal contents into chest cavity. Mortality may be as high as 50%. Causes the heart and mediastinum to shift to the contralateral side of the hernia.

Signs and Symptoms Respiratory distress. Heart sounds shifted to the right. Decreased breath sounds on the left. Bowel sounds heard in the chest. Scaphoid abdomen. Child may be asymptomatic or suffering from sever distress.

Assessment and Management Resuscitate on 100% oxygen. if PPV is necessary, place an ET tube, and deliver a peak ventilatory pressure of 25 mm Hg or less. Place an orogastric tube, and provide intermittent suctioning to minimize distention. ( caused by PPV) Monitor heart rate continuously during transport. Definitive treatment is surgical correction, so transport to a facility with a neonatal intensive care and pediatric surgery.

Premature and low birth weight infants Premature newborns : newborns delivered before 37 weeks of gestation. Low birth weight : newborns weighing less than 5½ lb (2,500 g)

Causes of prematurity Idiopathic ( commonest ). maternal conditions associated with preterm labor and delivery as : Maternal infection (UTI) and Chorioamnionitis . Placental insufficiency . Preeclampsia and eclampsia. Polyhydraminos .

Complication of prematurity Respiratory distress syndrome Hypothermia Sepsis Intraventricular hemorrhage. Increased mortality

Causes and predisposing factors of low birth weight The most common etiology is prematurity. Predisposing factors include: Genetic factors Infection Cervical incompetence Abruption Multiple gestations (twins, triplets) Previous delivery of a premature infant

Complication Morbidity and mortality are related to degree of prematurity. Those who are delivered after 28 weeks of gestation and receive cardiovascular support survive long term. Those born at 24 weeks of gestation have high morbidity and mortality.

Assessment of prematurity

The degree of prematurity is determined by : Physical features: Maturity of skin Size of infant Degree of respiratory distress Information from family about gestational dating: Last menstrual period Estimated due date Ultrasound dating Information related to maternal or fetal complications

Management To optimize survival for a newborn delivered prematurely in the field: Provide Cardiorespiratory support. Provide a thermoneutral environment. Use only minimum pressure necessary to move chest when providing PPV because the risk of retinopathy of prematurity, worsened by long-term oxygen exposure.

Seizures In The Newborn Most characteristic sign of neurologic disease in the newborn and is usually related to an underlying abnormality.

Causes of seizers in newborn In the first 3 days of delivery are usually caused by: Hypoxic ischemic encephalopathy Hypoglycemia. Other metabolic disturbances e.g. disturbances in calcium , proteins , ammonia and other electrolytes .

Seizures that begin 3 days or longer after birth are likely from : Intracranial infections (meningitis). Intracranial hemorrhage. Development defects. Epilepsy.

Types and signs of seizers Subtle seizure : (eye deviation , blinking , sucking , pedaling leg movement and apnea). Tonic seizers : (Tonic limb extension OR arms flexion and leg extension ) Focal colonic seizers : localized jerking Myoclonic seizers : flexion jerks of upper or lower extremities.

Complication of seizers Seizures may interfere with: Cardiopulmonary function Feeding Metabolic function Prolonged seizures may cause brain injury.

Differential diagnosis The following are often mistaken for seizures in the newborn: Normal movements when a newborn is drowsy or asleep Jitteriness Gastroesophageal reflux and choking episodes

Management Obtain baseline vital signs and oxygen saturation readings. Provide additional oxygen, assisted ventilation, blood pressure evaluation, and IV access as necessary. f blood glucose level is less than 40 mg/dL, give an IV bolus of 10% dextrose solution and recheck in 30 minutes. Monitor respiratory status and oxygen saturation carefully. Maintain normal body temperature.