This case is written by Dr. Rob Woods. He works in both the adult and pediatric emergency departments in Saskatoon and has been working in New Zealand for the past year. He is the founder and director of the FRCP EM residency program in Saskatchewan.
Why it Matters
This case highlights important manifestations of sepsis in a neonate. In particular, it reinforces that:
- Apneas, hypoglycemia, and hypothermia are commonly seen as a result of systemic illness in neonates
- Prolonged or persistent apneas with associated desaturations require management with either high-flow oxygen or intubation
- Fluid resuscitation and broad-spectrum antibiotics are important early considerations when managing toxic neonates
To be stated by the Paramedic with the Resus Nurse at bedside: “We picked up this term 3-day old male infant at their GPs office. Mom reports poor feeding for the past 12 hours, and two episodes of vomiting. They took him to the GPs office this morning and they found the temperature to be quite low at 33.1°C. They called us concerned about sepsis. We were only 5 minutes away so we have not obtained IV access. We did obtain a glucose level of 2.7. The child is lethargic and has very poor perfusion – peripheral cap refill is 7 seconds. We don’t have a cuff to get an accurate BP but the HR is 190.”
A 3-day-old term male infant is brought to the ED by EMS after being seen at their Family Physician’s office with a low temperature (33.1oC). The child has been feeding poorly for about 12 hours, and has vomited twice. He is lethargic on examination and poorly perfused with intermittent apneas lasting ~ 20 seconds. He requires immediate fluid resuscitation and broad-spectrum antibiotics. His perfusion will improve after IVF boluses, however the apneas will persist and necessitate intubation.
Initial CXR for the case found here:
(CXR source: http://emedicine.medscape.com/article/414608-overview)
Post-intubation CXR for the case found here:
(CXR source: https://radiopaedia.org/articles/neonatal-pneumonia)
This case is written by Dr. Stephen Miller. He is an emergency physician in Halifax. He is also the former medical director of EM Simulation and the current director of the Skilled Clinician Program for UGME at Dalhousie University. He developed his interest in simulation while obtaining his Masters of Health Professions Education.
Why it Matters
Moderate to severe hypothermia can be quite challenging to correct. This case highlights several important features of hypothermia management:
- The importance of searching for concurrent illness that may be causing the hypothermia or working against rewarming efforts
- The effect of hypothermia on trauma management
- Modifications to ACLS as required during hypothermic resuscitation
- The multitude of ways in which one can attempt to actively re-warm a patient
An approximately 30 year old female is brought into the ED at 4 AM by a man who found her lying at the side of the road. It is minus 30 degrees Celsius outside and she has no coat or shoes. The man does not know her and is unable to provide any additional history except that she was blue and having trouble breathing when he found her. She is noted to have a decreased LOC and laboured breathing. She has obvious deformities of her left forearm and right leg.
30 year-old female is brought into the ED at 4 AM by a man who found her lying at the side of the road with no coat or shoes. It is minus 30 degrees Celsius outside. On arrival she has a reduced LOC, laboured breathing, a right-sided pneumothorax, cyanotic extremities, a left radius & ulna fracture, and a right tib-fib fracture. The team is required to use both active and passive rewarming strategies. Regardless of the team’s efforts, the patient in this case will arrest. Upon ROSC, they are required to continue rewarming as well as to address the other traumatic injuries.
Download the case here: Hypothermia
CXR for the case found here:
(CXR source: http://radiopaedia.org/cases/pneumothorax-due-to-rib-fractures-1)
ECG for the case found here:
(ECG source: : http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/03/hypothermia-shiver-artefact.jpg)
Right lung U/S found here:
Left lung U/S found here:
RUQ FAST image found here:
Pericardial U/S found here:
(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.)