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Critical Concepts in Pediatric Emergency Medicine

Management of the critically ill newborn after delivery

Neonatal emergencies are frightening and challenging to almost all acute care providers. This issue will focus on the neonate and provide a succinct review of resuscitation issues pertinent to clinical practice and board preparation/review.

Authors

Audrey Bowen, MD, FAAP, Assistant Professor of Pediatrics, University of Central Florida, Attending Physician, Florida Hospital, Children’s Emergency Center, Orlando, FL

Winslade Bowen, MD, FAAP, Attending Neonatologist, Florida Hospital Memorial Center, Daytona Beach FL.

Dr. Audrey Bowen and Dr. Winslade Bowen report no financial relationships relevant to this field of study.

Core Content Outline: Neonatal Resuscitation

Etiology

  • Know common etiologies of neonatal distress requiring resuscitation

Pathophysiology

  • Understand the pathophysiology of neonatal cardiopulmonary instability
  • Understand the role of thermal regulation in neonatal distress and instability

Recognition

  • Recognize signs and symptoms of neonatal distress
  • Recognize and interpret relevant monitoring studies for neonates in distress
  • Recognize the maternal risk factors associated with neonatal distress
  • Recognize and interpret relevant laboratory studies for neonates in distress

Management

  • Plan the step-wise intervention in treatment of neonatal distress
  • Plan the management of meconium aspiration
  • Know modalities for vascular access in the neonate
  • Know special management techniques for congenital anomalies leading to acute neonatal instability
  • Know the indications, applications, and complications for administration of volume expanders and blood products in newborn resuscitation

Neonatal Resuscitation Procedures

  • Know the anatomy and pathophysiology relevant to neonatal resuscitation procedures
  • Know the indications and contraindications for neonatal resuscitation procedures
  • Plan the key steps and know the potential pitfalls in performing neonatal resuscitation procedures
  • Recognize the complications associated with neonatal resuscitation procedures

Prevention and Management of Meconium Aspiration

  • Know the anatomy and pathophysiology relevant to the prevention and management of meconium aspiration
  • Know the indications and contraindications for prevention and management of meconium aspiration
  • Plan the key steps and know the potential pitfalls in the prevention and management of meconium aspiration
  • Recognize the complications associated with the prevention and management of meconium aspiration

Management of the Critically Ill Newborn After Delivery

Respiratory Distress Syndrome. Neonates with prematurity, maternal diabetes, Caucasian males, or genetic factors such as genetic disorder of surfactant production (surfactant protein B and C gene mutations) are at risk for developing respiratory distress syndrome (RDS). These infants may demonstrate respiratory distress in the form of tachypnea, retractions, nasal flaring, grunting, and cyanosis. The chest X-ray typically reveals lungs with low volume, a diffuse reticular granular pattern, and air bronchograms. (See Figure 1.)

Figure 1: Respiratory distress syndrome

IMG_4671.JPG

Management of RDS includes appropriate oxygenation and ventilation. Supplemental oxygen delivery via a simple mask, blow-by device, or nasal cannula may be sufficient for mild cases. However, positive pressure ventilation (PPV), in the form of bag-valve-mask ventilation, continuous positive airway pressure (CPAP) ventilation, and/or endotracheal intubation with mechanical ventilation, is usually indicated. Current recommendations, based on multicenter, randomized, controlled trials, indicate that the use of CPAP with subsequent selective surfactant administration in extremely premature infants results in lower rates of bronchopulmonary dysplasia (BPD)/death.5

National Guideline/Academic Resource

http://pediatrics.aappublications.org/content/133/1/171

http://pediatrics.aappublications.org/content/126/5/e1400.full.pdf+html

CME Question

A 16-year-old presents to the emergency department with abdominal pain and delivers a preterm male infant with significant respiratory distress. Which of the following statements is true?

  1. Intubation and oxygenation create adequate ventilation of the infant.
  2. Surfactant administration improves the respiratory outcome of this infant.
  3. The chest X-ray will not show hyperinflation.
  4. The infant usually presents with tachypnea, retractions, and cyanosis.
  5. All of the above

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Prevention and Management of Meconium Aspiration

The presence of meconium in the amniotic fluid may result in meconium aspiration syndrome. The management of these infants depends on whether the infant is vigorous or limp at birth.6 (See Figure 2.)

Figure 2. Meconium Aspiration Syndrome

IMG_4675.JPG

A vigorous (strong respiratory efforts, good muscle tone, and heart rate > 100 bpm) term infant with meconium-stained fluid is treated by providing warmth and clearing the mouth and nose of secretions with a bulb syringe or suction catheter. The infant is then dried, stimulated, and given to the mother.

A term infant who is limp (depressed muscle tone and/or heart rate < 100 bpm) at birth in the presence of meconium-stained fluid should be placed under a radiant warmer to keep the infant warm. The infant is placed on its back with the neck slightly extended in the “sniffing” position to open the airway. The oropharynx is cleared of meconium and the trachea is suctioned. Suctioning the trachea is achieved by inserting a laryngoscope and using a 12F or 14F suction catheter to clear the mouth and posterior pharynx. An endotracheal tube (ETT) is then inserted into the trachea. The ETT is then attached to a suction source via a meconium aspirator. Suction is applied for several seconds while the tube is in the trachea. The tube is slowly removed (counting one-one thousand, two-one thousand, three-one thousand, withdraw). This is repeated until minimal meconium is present in the airway or until the infant’s status changes, requiring further resuscitation methods. If the heart rate is < 100 bpm despite stimulation and there is gasping or apnea, then PPV is initiated.

National Guideline/Academic Resource

http://pediatrics.aappublications.org/content/early/2010/10/18/peds.2010-2972E.full.pdf

CME Question

A term infant is delivered in the emergency department. The amniotic fluid is meconium stained. Which of the following is true regarding the management of this patient?

(1) If the infant is vigorous, the infant is kept warm and the mouth and nose are cleared with a bulb syringe or suction catheter.

(2) If the infant is vigorous, the infant is kept warm and the trachea intubated with an ETT to suction the meconium.

(3) If the infant is limp and cyanotic, the infant is kept warm, the mouth and nose are cleared with a bulb syringe or suction catheter only.

(4) If the infant is limp and cyanotic, the infant is kept warm, the mouth and nose are cleared with a bulb syringe or suction catheter, and the trachea intubated for suctioning of the meconium from the trachea.

a. (1) and (2)

b. (2) and (3)

c. (1) and (4)

d. All of the above.

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Pneumothorax. Pneumothorax refers to air in the pleural cavity resulting in partial or total collapse of the lung. This occurs in 0.5-2% of term infants with only about 10% symptomatic. The incidence in preterm infants is 3-10%. It may iatrogenically occur in up to 10% of newborns receiving PPV, and PPV may worsen a pre-existing pneumothorax. Risk factors for a pneumothorax include RDS, meconium aspiration, pulmonary hypoplasia, congenital diaphragmatic hernia, pneumonia (especially staphylococcal pneumonia), lobar pulmonary emphysema, congenital cystic lung malformations, procedures such as mechanical ventilation, endotracheal suctioning, dilation of tracheal strictures, and cardiopulmonary resuscitation. The term tension pneumothorax refers to significantly increased intrathoracic pressure caused by a large pneumothorax. Infants may present with respiratory distress, retractions, tachypnea, cyanosis or pallor, tachycardia or bradycardia, poor or absent breath sounds on the affected side, asymmetric chest movement, heart sounds shifted to the right (in a left-sided pneumothorax), jugular venous distension, subcutaneous emphysema, respiratory acidosis, hypotension, or cardiopulmonary collapse.

Management of pneumothorax. A small pneumothorax is usually asymptomatic and does not require surgical treatment. Supplemental oxygen increases the rate at which the intrapleural air is reabsorbed and should be administered to all neonates with a pneuomothorax. Chest tube placement is indicated for large and symptomatic pneuomothoraces and intubation may be necessary. A tension pneumothorax is a life-threatening emergency, and emergency decompression with needle aspiration should not be delayed and then followed by chest tube placement.

CME Question

A term newborn presents in the emergency department at 1 hour of age. He was born at a birthing center and required resuscitation (bag-valve-mask ventilation) at birth. He is in obvious respiratory distress with substernal retractions and grunting respirations. His oxygen saturation is 70% on blow by oxygen. The chest X-ray is shown below.

IMG_4636.JPG

Definitive management of this condition is:

  1. 100% oxygen via mask CPAP.
  2. needle aspiration of the left hemithorax.
  3. right decubitus chest X-ray.
  4. needle aspiration of the right hemithorax, followed by right chest tube insertion.

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Congenital Diaphragmatic Hernia. Congenital diaphragmatic hernia (CDH) consists of a defect in the diaphragm that allows herniation of abdominal viscera into the chest cavity with associated pulmonary hypoplasia. It occurs in about 1 in 2200 births.7 The defect may be small or large with varying degrees of severity in clinical presentation. Most neonates with CDH develop respiratory distress within a few hours or days of birth. On examination, the patient may have a barrel-shaped chest, a scaphoid abdomen, absence of breath sounds on the affected side, and the heartbeat may be displaced to the right. CDH is often on the left side, but the right side is affected in 11% and it occurs bilaterally in 2%.7 The respiratory distress is determined by the size of the herniation and the degree of pulmonary hypoplasia. About 50% of children with CDH have associated defects including chromosomal abnormalities, congenital heart disease, and neural tube defects.

Chest X-ray in the affected infant will reveal abdominal contents in the hemithorax. A feeding tube placed in the stomach will appear in the chest cavity on X-ray. If it is a right-sided CDH, the X-ray may reveal a large thoracic mass with absent intra-abdominal liver shadow.

Once CDH is suspected during the routine resuscitation of a neonate with respiratory distress, immediate management includes intubation and ventilation with low peak pressures. Bag valve mask and PPV may cause intestinal distention and lung compression with increased respiratory distress and is therefore contraindicated. A delay in airway management may cause acidosis and development of persistent pulmonary hypertension (PPHN). A nasogastric tube should be placed to decompress the abdominal contents. Aggressive fluid resuscitation and hemodynamic support is usually necessary. Extracorporeal membrane oxygenation (ECMO), high-frequency ventilation, and nitric oxide8 are modalities often utilized in the management of these patients.

CME Question

A neonate presents with severe respiratory distress immediately after birth. Due to persistent cyanosis oxygen is given via CPAP using a facemask, but the infant’s condition worsens. The patient is intubated and oxygen saturations improve. X-ray of the chest is shown below.

IMG_0300.JPG

Which statement about this condition is true?

  1. It occurs in 1:200 births.
  2. Persistent pulmonary hypertension is a possible complication.
  3. It occurs more commonly on the right side.
  4. PPV with bag mask ventilation is advised.

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Omphalocele/Gastroschisis. An omphalocoele is a midline defect thatis covered by peritoneum and contains bowel and other intra-abdominal organs.It occurs in about 2-3 per 10,000 births. Eighty percent of these infants have associated anomalies such as heart disease, genitourinary abnormalities, and craniofacial or limb anomalies. Beckwith-Wiedemann syndrome may involve hemihypertrophy, hypoglycemia, macroglossia, and omphalocoele and may be associated with intrauterine growth retardation, pulmonary hypoplasia, and heart disease.

Gastroschisis is often due to a defect lateral to the umbilicus and occurs in 1-2 per 10,000 births.9The sac may be intact or ruptured.3Frequently other gastrointestinal problems such as volvulus, atresias, stenosisor perforations may occur, but extra-intestinal anomalies are infrequent.

Latex-free gloves should be used to handle the infant. The bowel should be encased in a bowel bag or covered with warm saline-soaked gauze and then wrapped in Kling gauze and a plastic wrap to support the bowel. Caution is recommended to avoid compromise of the mesenteric blood supply. No attempt should be made to reduce the sac or contents as this may result in compromise of the blood supply and respiratory distress. Continuous nasogastric suctioning is recommended. Urgent surgical consultation is required. Antibiotics such as ampicillin and gentamicinshould be administered.

Both omphalocoele and gastroschisis in a newborn require emergent surgical consultation.

CME Question

An infant is born with a ventral wall defect. Which of the following statements is true about this condition?

  1. Extra-intestinal anomalies such as cardiac disease are frequently seen with gastroschisis.
  2. An omphalocoele has a ventral wall defect that is usually lateral to the umbilicus.
  3. The combined incidence of ventral wall defects (omphalocoele/gastroschisis) is 1:1,000.
  4. Ventral wall defects require urgent surgical consultation.

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Choanal Atresia. Choanal atresia is caused by the persistence of the bucco-nasal membrane or bony septum in the posterior nares. Since infants are obligate nose breathers (except when crying), if choanal atresia is present, and the nasal passage has meconium or secretions, the infant may have significant respiratory distress. The presence of choanal atresia is suspected by the inability to pass a small suction catheter 5-8 Fr through the nares into the pharynx. Bilateral choanal atresia presents shortly after birth with intermittent cyanosis worsened with feeding and relieved by crying. If unilateral only, choanal atresia may not become symptomatic until the infant develops an upper respiratory infection. The placement of an oral airway may alleviate the respiratory distress and endotracheal intubation may be required if the latter is unsuccessful. A CT scan with intranasal contrast, which reveals narrowing of the posterior nasal cavity, confirms the diagnosis of choanal atresia.

CME Question

A term infant develops respiratory distress after birth, which is relieved when the infant is crying. Attempts to pass a 5 Fr suction catheter into the nares for suctioning are unsuccessful. You suspect choanal atresia. This is characterized by which of the following?

  1. Narrowing of the anterior nasal cavity on CT scan
  2. Intermittent cyanosis relieved by crying
  3. The inability to pass a small caliber suction catheter (5-8F), through the nares into the pharynx
  4. Both a and b
  5. Both b and c

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Preparing for Transfer to the Newborn Nursery or Neonatal Intensive Care Unit

An infant requiring resuscitation and stabilization after delivery must be transferred to a unit for close monitoring and further management. Transfer may be within the same institution or require transfer to another facility by ground or air transport. The hospital classification for level of neonatal intensive care unit (NICU) care is: Level 1 – no NICU, Level II – intermediate NICU, Level III – tertiary NICU.10 Indications for transfer to a NICU include:

  • Prematurity
  • Birth weight < 1500 g
  • Respiratory distress syndrome requiring ventilator support, respiratory failure, persistent pulmonary hypertension
  • Congenital heart disease and cardiac arrhythmias
  • Congenital anomalies, inborn errors of metabolism
  • Hypoxic ischemic injury, seizures
  • Infant of a diabetic mother
  • Requiring services such as ECMO or surgery not available at referring hospital.

The NICU level of care should be based on the degree of prematurity and coexisting conditions in conjunction with a neonatologist.

The ED physician should stabilize the infant to the best of his or her ability with the resources available at his or her hospital prior to transfer2 and discuss further recommendations with the accepting neonatologist. Factors to address prior to transfer include:

  • Maintaining an appropriate thermal environment for the infant
  • Providing adequate ventilation and oxygenation
  • Stabilizing blood pressure and volume status with fluids and inotropes, if needed
  • Ensuring adequate blood glucose levels
  • Obtaining cultures and starting appropriate antibiotics, if necessary.
  • An infant with a small pneumothorax requires chest tube placement prior to air transport (gases in closed spaces expand as altitude increases and barometric pressure decreases). A small pneumothorax may become a tension pneumothorax
  • Inserting nasogastric tube to decompress the stomach, especially prior to air transport
  • If indicated, obtaining umbilical venous and arterial access
  • Obtaining a copy of the chart, labs, and radiological studies, as well as appropriate consents from parents for transfer.

National Guideline/Academic Resource

http://pediatrics.aappublications.org/content/130/3/587.full.pdf+html

CME Question

A woman presents to a rural emergency department and delivers a preterm infant with significant respiratory distress. After stabilization, the infant must be transferred to a NICU for continued care. The indications for transfer include:

a. Prematurity

b. Birth weight < 1500 g

c. Respiratory distress syndrome.

d. Seizure

e. All of the above

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References

1. Kattwinkel J, Perlman JM, Aziz K, et al. Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular and Emergency Cardiovascular Care. Pediatrics 2010;126:e1400-1413.

2. Cloherty JP. Manual of Neonatal Care. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.

3. Dawson JA, Kamlin CO, Vento M, et al. Defining the reference range for oxygen saturation for infants after birth. Pediatrics 2010;125:e1340-1347.

4. Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg 1953;32:260-267.

5. Polin RA, Carlo WA; Committee on Fetus and Newborn; American Academy of Pediatrics. Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics 2014; 133:156-163.

6. Kattwinkel J. ed. Textbook of Neonatal Resuscitation. 6th ed. Elk Grove Village. IL: American Academy of Pediatrics; 2011.

7. Hedrick HL, Crombleholme TM, Flake AW, et al. Right congenital diaphragmatic hernia: Prenatal assessment and outcome. J Pediatric Surg 2004;39:319-323.

8. Campbell BT, Herbst KW, Briden KE, et al. Inhaled nitric oxide use in neonates with congenital diaphragmatic hernia. Pediatrics 2014;134:e420-e426.

10. Stark AR, American Academy of Pediatrics Committee on Fetus and Newborn. Levels of neonatal care. Pediatrics 2004;114:1341-1347.

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Release date: Sept. 1, 2015
Expiration date: Sept. 1, 2018
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