2. Neonatal Emergencies Beyond the A,B,C’s of Resuscitation in the DR and NICU

3. Case # 1  Summoned to the LDR STAT  term infant  no prenatal complications  cyanotic  severe respiratory distress  cyanosis, grunting, retractions, HR 140, good tone

4. Case # 1  Attempt PPV unsuccessful  Attempt intubation  can’t see past the base of the tongue  very small mandible

5. What is the name and etiology of this infant’s anatomical condition? Pierre Robin Sequence

6. Case # 1  Approach to this airway  place infant prone  nasal trumpet or 2.5 ETT  insert via nasal passage  tip at level of the posterior pharynx  call Peds ENT stat if you can’t secure an airway

7. Case # 1  Pierre-Robin  triad  macroglossia + cleft palate  glossoptosis  micrognathia  respiratory obstruction  tongue held against posterior pharyngeal wall secondary to marked neg pressure during insp effort

8. Case # 1  Treatment  support airway  Positioning  Nasal Airway  Tracheostomy  Nutrition  Prognosis  the more prolonged the resuscitation the worse the neurologic outcome

9. Case # 2  You are called to attend a delivery secondary to fetal distress  A, B, C’s of resuscitation initiated  Person managing the airway  increased epinephrine  tachycardia and tremors  excessive PPV

10. Case # 2  What complication would you anticipate?  What clinical signs are indicative of a pneumothorax?  cyanosis  bradycardia  decreased BS on affected side  Emergency intervention?

11. Needle Thoracostomy What equipment will you gather?

12. Case # 3 Summoned to the LDR STAT Corpsman meets you at the door and says “doc the babies intestines are all over the place”

13. How will you manage this?

14. Delivery Room Management: Gastroschisis  ABC’s of resuscitation  Warm, saline-soaked lap sponges, plastic wrap or bowel bag to cover the intestines  Decompression of the bowel ASAP  Avoid volvulus of the mesenteric vessels  Avoid tearing bowel mesentery or causing unnecessary damage to bowel  Remember importance of thermoregulation and controlling fluid losses

15. Gastroschisis EmbryologyEmbryology  Intestines herniate through the abdominal wall  Area weakened by involution of the right umbilical vein (theoretical)  Sequence occurs relatively early in gestation  Differs from omphalocele

17. OmphaloceleGastroschisis Incidence Covering Sac Fascial Defect Cord Attach. 1:6,000-10,000 Present (may be ruptured) Small to large Umbilical the sac 1:20,000-30,000 Absent Small (vascular compromise) Abd wall

18. Omphalocele Gastroschisis Herniated Bowel Other organs IUGR NEC Protected Liver often in sac Less common If sac is ruptured Edematous and matted Remain in abd. Common 18 %

19. Omphalocele Gastroschisis Assoc.. Anomalies GI Cardiac Trisomy 37 % (Midgut volvulus Meckel’s Diverticulum, atresia, duplications) 20 % 30 % 18 % (stenosis and atresias) 2 % No increase Overall 55% to 80% 10% to 15%

20. Prognosis Gastroschisis:  70% to 90% survival  morbidity related to prematurity and bowel compromise

21. Case # 4  Summoned to the LDR for a meconium delivery  Light mec is present and the infant cries immediately upon delivery  Within 15 seconds respiratory distress ensues

22. Case # 4  You initiate A, B, C’s of resuscitation  PPV is ineffective cyanosis is worsening  HR begins to decline  BS are decreased on the left compared to the right  You notice the abdomen looks like this

23. Diagnosis?

24. Diaphragmatic Hernia

25. Case # 4  Resuscitation  Intubation to overcome resp distress or failure  Bowel decompression to prevent gas from inflating the bowel  Physiologic consequences of D-Hernia  Pulmonary hypoplasia  Pulmonary hypertension  Air leak syndrome  Non-rotation of the bowel  Feeding difficulties

27. Case # 4  1 in 3,000  90% occur on the left side  Abdominal content within chest  Compresses both lungs  Pulmonary hypoplasia  Pulmonary hypertension  NO and/or ECMO  Definitive tx---surgical repair

28. Case # 5  You are called to see a newborn shortly after delivery for “coughing”  Mild respiratory distress  tachypnea and “gasping” respirations  You suction  coughing persists  oral secretions continue to pool in the back of the throat

30. Case # 5  What are your next steps?  Oral suction, pulse ox, OG, IV  Evaluation for infection  Blood culture, cbc, abx, chest film

32. Case # 5  Abdominal distention continues to increase followed by worsening resp distress and cyanosis  Next step?  Will intubation help decrease abdominal distention?

33. Case # 5  Causes of increased Resp distress?  Secretions  TEF leading to increased intestinal gas  Anal atresia----no decompression  How do you relieve the abdominal distention?  What syndrome would you consider?