PGY-3 Pearl #17: The Sick Neonate
Okay, just gotta quickly preface this by saying babies are jerks!! They are super cute and great and then decompensate real fast and it might just be “poor feeding” because they’re on a nursing strike or it could be poor feeding because fulminant meningitis or sepsis or deadly inborn error of metabolism?!
Anyway... the general approach to managing the super sick neonate (0-28d) is still ABCDE’s. Assess and manage these things as you go along; the things you find during this assessment will give some clues to the underlying etiology.
ETIOLOGY: use whatever DDx approach floats your boat. I like to go by systems (e.g. CNS, CVS, resp, GI, etc.; some people use “VITAMIN C” or something to do this) or a mnemonic like THE MISFITS or NEO SECRETS. Doesn’t matter what you use as long as you use it consistently so you don’t miss anything!
MANAGEMENT: in the ER, you often do not have the luxury of information to figure out your Dx before you have to manage stuff. A few good tips:
Include pre- and post-ductal oxygen saturations and 4-limb blood pressures in your ABCDE assessment of ANY neonate that presents unwell. Cardiogenic shock looks just like any other kind of shock in the neonate.
Reassess, reassess, reassess! Did you give fluid? Reassess. Has it been >2 minutes since you last listened to breath sounds? Reassess. Did you look away from the vitals monitors? Reassess!
Sepsis should always be high on the differential for a sick neonate. Generally: fluids --> fluids --> fluids --> inotropes --> steroids.
If you suspect a cardiac cause:
Be judicious with fluids. You can always give more but once you are fluid overloaded it’s much more difficult to get the fluid back out. If you’re not VERY convinced of sepsis/distributive/hypovolemic shock it is reasonable to start with 10mL/kg boluses rather than 20mL/kg!
Prostaglandins have a very low likelihood of making things worse (the only real issues are risk of apnea, which you can manage with airway and ventilation, and the risk of worsening a TAPVR if that’s your underlying etiology; HOWEVER, even worsened pulmonary overcirculation is manageable in the ER--a completely closed duct with a duct-dependent lesion is NOT) with the potential to save the baby’s life. Give it (and have your intubation/LMA equipment ready!).
If you need to support perfusion/blood pressure/heart function, use the D’s: dopamine or dobutamine are probably the most effective and safest inotropes to give in the setting of cardiogenic shock.
Don’t forget metabolic disturbances/endocrine etiologies for shock!
Check your glucose early, and you should include a blood gas, lactate, electrolytes (Na, K, Cl, Ca, Phos, Albumin, Mg) as part of your initial work-up for these babies.
If that initial glucose is low, also consider sending an ammonia with a blood gas and lactate.
Correct the disturbances early! (Especially hypoglycemia!)
If you suspect an inborn error of metabolism, general rule of thumb: STOP FEEDS, START DEXTROSE (IV), send an ammonia, and call metabolics!
Thyrotoxicosis can present very similarly to septic shock!
Trauma and inflicted injuries can present very undifferentiated, particularly head injuries. A good history is important! Look for other signs of injury; no neonate should have bruising or fractures without an extraordinary explanation (ex/a motor vehicle accident)!
GI issues usually give you diagnostic clues on Hx and physical exam; issues generally fall into the following categories: GI (obstruction, infection/ischemia) and non-GI (extraintestinal)
Obstruction: can be anatomical (e.g. esophageal atresia, mass) or mechanical (e.g. intussusception, volvulus, incarcerated hernia)
Infection/ischemia: including NEC, other poor perfusion states (e.g. polycythemia)
Extraintestinal: vomiting can be due to metabolic disturbances, CNS injury, etc.
