1. Neonatal emergencies
Dr. Miada Mahmoud Rady

2. Apnea Definition : respiratory pause of greater than 20 seconds.
Causes :
Hypoxia and hypothermia ( commonest cause ).
Maternal or infant narcotic exposure.
Airway or respiratory muscle weakness.
Septicemia .
Prolonged or difficult labor and delivery.
Central nervous system abnormalities.

3. Assessment and management
Careful history to find etiologic risk factors
Performing a physical exam focusing on :
Neurologic signs.
Signs and symptoms of infection.
Differentiate between primary and secondary hypoxia.

4. Primary apnea :
Brief period of hypoxia may have a period of rapid breathing followed by apnea and bradycardia.
Respond to drying and stimulation .
Secondary apnea :
Persistent hypoxia during period of primary apnea .
PPV using bag and mask may be indicated.

5. Pneumothorax evacuation
Etiology :
Lung infection.
Meconium aspiration.
Faulty PPV.
Signs of significant pneumothorax :
Severe respiratory distress unresponsive to PPV.
Unilateral decreased breath sounds.
Shift of heart sounds if pneumothorax on left side.

6. Management Address ABCS Needle thoracotomy Rapid transport
Watch out for reaccumulation during transport.

7. Meconium-stained amniotic fluid
More common in:
Post term newborns.
Those small for their gestational age.
Newborns stressed before or during delivery.
Carries high morbidity .

8. Pathophysiology and clinical sequences
If newborns pass stool before birth, they may inhale the meconium-stained amniotic fluid , this leads to :
Airway may become plugged, causing:
Hypoxia, which can lead to:
(a) Atelectasis
(b)Persistent pulmonary hypertension
(c) Hypoxemia
(d)Aspiration pneumonitis.
Ball-valve effects with an increased risk of pneumothorax.

9. Delayed drop in pulmonary vascular resistance , which can cause:
Right-to-left shunting across the foramen ovale or the patent ductus arteriosus causing persistent pulmonary hypertension of the newborn.

10. Ball and valve effect and pneumothorax
Meconium aspiration
Air way become plugged
Hypoxia
Ball and valve effect and pneumothorax
Delayed drop in vascular resistance
Right and left shunting and persistent pulmonary hypertension

11. Assessment and management
To decrease the risk of persistent pulmonary hypertension:
Ensure a clear airway.
Keep newborn warm.
Minimize stimulation.
Provide supplemental oxygen when necessary.
If meconium aspiration occurs, follow closely for signs of deterioration.

12. If meconium aspiration occur
Determine if fluid is thin and green-stained or thick with particulates.
Assess activity level :
If crying and vigorous, use standard interventions
( dry and stimulate ).
If depressed, do not dry or stimulate.

13. If the child activity is depressed :
Do not dry or stimulate.
Clear meconium from airway.
Intubate the trachea.
Start meconium suctioning via meconium aspirator and suction catheter.

14. If intubation is unsuccessful and the newborn is bradycardic, continue standard resuscitation :
Start with room air.
If hypoxia persists, provide blended oxygen or 100% oxygen to reverse hypoxia.
If the newborn remains bradycardic after effective PPV, initiate chest compressions and further interventions.

15. Suspect airway occlusion or pneumothorax if the newborn does not respond well to resuscitation.
Take steps to minimize hypothermia.
Frequently reassess to ensure the newborn’s condition has not changed.

16. Diaphragmatic hernia
Definition : An abnormal opening in the diaphragm that allows herniaition of the abdominal contents into chest causing the heart and mediatstinum to shift to other side.
Mortality : may be as high as 50%.

17. Clinical presentation
Postnatal 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.

18. Assessment and management
New born may be asymptomatic or it may present with sever hypoxia and respiratory distress.
Resuscitate on 100% oxygen :
Bag-mask ventilation should be avoided : will distend intestines and compromise ventilations .
If PPV is necessary, place an ET tube and Place an orogastric tube, and provide intermittent suctioning to minimize distention.

19. Monitor heart rate continuously during transport.
Transport to a facility with a neonatal intensive care and pediatric surgery.
Definitive treatment : surgical correction.

20. congenital diaphragmatic hernia

22. Respiratory distress and cyanosis
Causes :
Prematurity ( commonest cause).
Respiratory symptoms include :
Aspiration and airway obstruction .
Pneumonia and pneumothorax.
Tracheoesophageal fistula and Congenital diaphragmatic hernia.

23. Other causes:
Any process resulting in a delay in drop of pulmonary vascular resistance after birth leading to shunting of blood across the patent ductus arteriosus and patent foramen ovale .
Central nervous system depression .
Septic shock and severe metabolic acidosis .
Cardiac anomalies .

24. Management Treatment includes: Establishing patent airway
Ensuring adequate oxygen delivery
Establishing effective ventilation
Ensuring adequate circulation
If resuscitative efforts do not result in improvement, needle thoracentesis may be a necessary

25. Premature infants
Premature newborns: are new borns delivered before 37 weeks of gestation.
Etiology :
Idiopathic ( commonest ).
Maternal infection and Chorioamnionitis.
Maternal illness leading to dehydration.
Preeclampsia , eclampsia
Polyhydraminos .
Placental insufficiency .

26. Complication Increased mortality . Respiratory distress syndrome
Respiratory suppression and apnea
Hypothermia
Sepsis
Central nervous system affection e.g. Intraventricular hemorrhage

27. Low birth weight infant
Definitions : newborns weighing less than 2,500 g.
Predisposing factor :
prematurity
Genetic factors
Infection
Cervical incompetence
Placental abnormalities e.g. Placental abruption
Multiple gestations (twins, triplets)
Previous delivery of a premature infant
Drug use and smoking

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

29. Assessment and management of prematurity and low birth weight
Determining prematurity depend on :
Physical features:
Maturity of skin , size of infant and degree of respiratory distress.
Information from family about gestational dating:
Last menstrual period , estimated due date and ultrasound dating.
Information related to maternal or fetal complications.

32. To optimize survival in the field:
Provide Cardiorespiratory support.
Provide thermoneutral environment.
Use only minimum pressure necessary to move chest when providing PPV.

33. Management focuses on:
Clearing airway
Gentle stimulation
Providing supplemental oxygen and PPV if needed
Providing chest compressions
Maintaining a warm environment

34. Seizures in the newborn
Most distinctive sign of neurologic disease in the newborn and are usually related to an underlying abnormality
More common in premature newborns
Identified by direct observation in the field Diagnosis is confirmed by electroencephalogram in the hospital..
Prolonged seizures may cause brain injury.

35. Causes of neonatal seizers

36. Assessment and management
Quickly evaluate prenatal and birth history.
Obtain baseline vital signs and oxygen saturation readings.
Perform a careful physical exam .
Hypoglycemia must be recognized and treated quickly with Blood glucose measurement and dextrose administration.
If blood glucose level is less than 40 mg/dL., give an IV bolus of 10% dextrose solution and recheck in 30 minutes.

37. Provide additional oxygen, assisted ventilation, blood pressure evaluation, and IV access as necessary.
Before giving an anticonvulsant medication, consult medical control as it may interfere with respiratory and cardiac function
Monitor respiratory status and oxygen saturation carefully.
Maintain normal body temperature.
Keep family informed as you transport the newborn

38. Vomiting Common in newborns.
Persistent vomiting in the first 24 hours may indicate :
Upper digestive tract obstruction.
Increased intracranial pressure.
Persistent vomiting can lead to :
Excessive fluid loss and dehydration.
Electrolyte imbalances.

39. Causes of vomiting Esophageal atresia
Pathogenic gastroesophageal reflux (GER)
Infantile hypertrophic pyloric stenosis (IHPS)
Malrotation
Hirschsprung disease

40. Causes of vomiting
Sudden unexpected and forceful vomiting may occur in conjunction with:
Asphyxia
Meningitis
Hydrocephalus

41. Assessment and management
Stomach may be distended due to vomiting.
Suspect infection if newborn has a fever or hypothermia, or has been in contact with ill people.
Look for : ( Signs of acute abdomen or intestinal obstruction)
Abdominal tenderness , guarding
Minimal or absent bowel sounds
Temperature instability

42. Start management with ABCs.
Decompress the stomach using nasogastric or orogastric tube.
Do not administer antiemetic in the field.
Fluid resuscitation with normal saline may be given if there is signs of dehydration.
Place newborn on the side to prevent aspiration.
Transport to a facility that can manage a high-risk newborn.

43. Diarrhea
Diarrhea : excessive loss of electrolytes and fluid in the stool caused by increased frequency or fluidity of stool.
Five or six stools a day is normal, especially when breastfeeding.
Look carefully for signs of dehydration.

44. Causes of diarrhea in newborn
Viral infection (commonest) especially rotavirus.
Poisoning
Gastroenteritis
Lactose intolerance
Neonatal abstinence syndrome
Thyrotoxicosis
Cystic fibrosis

45. Signs of dehydration Ill general appearance and sunken eyes
Poor vital signs
Capillary refill of greater than 2 seconds
Dry mucous membranes and sunken fontanelles
Absent tears
Weight loss
Low urine output

48. Assessment and management
Estimate the number and volume of loose stools, decreased urinary output, and degree of dehydration based on:
Skin turgor
Mucous membranes
Presence of sunken eyes
Manage ABCS .
Fluid therapy may be needed .

49. Neonatal jaundice
Definition : yellowish discoloration of skin and mucous membrane due to increased serum bilirubin.
Causes :
Breast milk jaundice and physiological jaundice
Hemolysis and red blood cell deficiencies
Polycythemia
Cholestasis which can present after first 2 weeks.

52. Pathophysiology
physiological jaundice : is due to failure of immature liver to conjugate bilirubin
Considered pathological if :
Clinically visible in first 24 hours after birth
Total serum bilirubin increases by more than 5 mg/dL/d.
Total bilirubin exceeds 12 mg/dL in full-term infants.
Conjugated bilirubin exceeds 15 to 20 mg/dl.
Persists for more than 1 week in full-term infants and for more than 2 weeks in preterm infants.

53. Transport is essential for bilirubin measurement at the hospital.
Additional assessments not available in the field include:
Blood type and Rh of mother and infant
Coombs test on the infant
Hematocrit value
Reticulocyte count
Start on IV fluids if the neonate with significant jaundice.

54. Thermoregulation in new born

55. Thermoregulation in newborn
Thermoregulation limited in newborns
Average normal temperature of newborn 37°C .
Range for neonate—36.6°C to 37.2°.

56. Fever Fever : rectal temperature greater than 38ºC .
Oral temperature is 0.6 ºC lower than rectal temperature , and axillary is 1.1 ºC lower than rectal temperature in average.
High temperature in newborn and neonates may be normal finding caused by overheating or dehydration.

57. Clinical presentation
Signs and symptoms include:
Irritability
Somnolence
Decreased feeding
Warm to touch
Clinical presentation of causing disease.

58. Assessment Examine for presences of rashes especially:
Petechiae or Pinpoint pink or red skin lesions
Obtain a careful history about:
General activity
Feeding
Voiding and Stooling
Note increased respiratory rate and work of breathing.

59. Management
Obtain vital signs, and ensure adequate oxygenation and ventilation.
Provide free-flow supplemental oxygen and chest compressions as necessary.
Antipyretic agents are controversial in the field but do not give ibuprofen.
To cool the patient remove additional layers of clothing and improve room ventilation.

60. Hypothermia
Definition : A drop in body temperature to less than 25°C .
New borns are sensitive to environmental changes especially when wet immediately after delivery.
If a newborn is hypothermic, investigate for infection.

61. Presentation Cool to the touch Irritability and weak cry
Pale with acrocyanosis ( bluish discoloration of extremities)
Decreased respiratory effort
Apnea , cyanosis
Sclerema : (hardening of the skin associated with reddening and edema)

62. Management Address ABCS Administering warm IV fluids if indicated.
Once stabilized, the critically ill newborn should be placed in a prewarmed incubator.
If not available, place on mother’s chest and cover with a blanket.
Continue until temperature reaches normal or the feet are not cold.

63. Birth trauma
Birth trauma comes from injuries resulting from mechanical forces during the delivery process.
Most are self-limiting
Newborn injuries can occur because of:
Newborn size and maturity
Position during labor and delivery

64. Risk Factors for Birth Injury
Prematurity
Post maturity
Cephalopelvic disproportion
Prolonged labor
Breech presentation
Explosive delivery
Diabetic mother

65. Common Birth Injuries in the Newborn
Birth trauma injuries include:
Head
Excessive molding of the head
Caput succedaneum
Cephalhematoma
Linear skull fractures

66. Common Birth Injuries in the Newborn
Nerves
Brachial plexus injuries
Facial nerve palsy
Diaphragmatic paralysis
Laryngeal nerve injury
Spinal cord injury

67. Common Birth Injuries in the Newborn
Bones
Clavicle: most frequently fractured bone
Examination will show:
Crepitus
Palpable bony irregularity
Possible lack of arm movement on affected side

69. Pathophysiology of Cardiac Conditions in Newborns
Congenital heart disease (CHD) are the most common birth defect
Types :
Cyanotic
A cyanotic

72. Pulmonary stenosis
Definition : condition in which the pulmonic valve becomes damaged and narrowed
Patient will present with:
Jugular vein distention
Cyanosis
Right ventricular hypertrophy

75. Septal defects
Atrial septal defect (ASD): defect in septum separating two atria through which deoxygenated blood can shift from the right or left atrium to other atria
Ventricular septal defect (VSD): defect in septum separating two atria through which blood flows back into right ventricle when left ventricle contracts.

76. Ventricular septal defect

77. Septal defects
Patent ductus arteriosus (PDA): failure of closure of ductus arteriosus
Complication : Congestive heart failure

78. Coarctation of the aorta
Definition : Narrowing of the aorta body.
Complication : The heart must work harder to keep the blood flowing past the narrowed area causing heart failure .
Treatment is usually heart surgery.

81. Truncus arteriosus Pulmonary and aorta arteries are combined.
Increases blood flow into the lungs
Will require surgical intervention

83. Tricuspid atresia Tricuspid valve is missing.
Results in an undersized or absent right ventricle
Will have decreased blood flow into the lungs

84. Hypoplastic left heart syndrome
Left side of heart is completely underdeveloped
Unable to fulfill circulation needs
Heart transplant is necessary.

85. Tetralogy of Fallot Definition : Combination of four heart defects
Ventricular septal defect
Pulmonary stenosis
Right ventricular hypertrophy
Overriding aorta
Open heart surgery is required.

88. Management of congenital heart diseases
Rapid detection and transport are mandatory.
Communication with medical control is critical.