Non-Accidental Trauma

This case is written by Dr. Suzan Schneeweiss. She is a staff physician at Sick Kids Hospital in Toronto and is the Director of Education for the Division of Pediatric Emergency Medicine at the University of Toronto.

Why it Matters

The differential diagnosis for any sick neonate is always broad. This case, in particular, addresses the differential diagnosis and management of a seizing neonate. It highlights the following:

  • The need for anti-epileptics in a neonate with seizures in the context of trauma
  • The importance of including a septic work-up and broad antibiotic/antiviral coverage in the management of a seizing neonate
  • The need to consider non-accidental injury

Clinical Vignette

A 1 month-old male is brought into the ED due to poor feeding and lethargy. The baby was apparently well until this morning, when his mom noticed it was difficult to wake and feed him. There has been no fever. The baby vomited once this morning, and is voiding and stooling normally.

The nurse in triage notices abnormal movements and brings the baby in to your team in the resuscitation room.

Case Summary

The team has been called to help in the ED after a 1 month-old male is brought in seizing. The team is expected to manage the seizure, but then will subsequently realize on examination there are concerning signs for non-accidental trauma, specifically head injury. The team will be expected to establish definitive airway management and consult with PICU and local child protection services.

Download the case here: Non-Accidental Trauma

CXR for the case found here:

neonatal pneumonia

(CXR source: https://radiopaedia.org/articles/neonatal-pneumonia)

 

Newborn Sepsis with Apneas

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

Clinical Vignette

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.”

Case Summary

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.

Download the case here: Newborn Sepsis with Apneas

Initial CXR for the case found here:

Normal neonatal CXR

(CXR source: http://emedicine.medscape.com/article/414608-overview)

Post-intubation CXR for the case found here:

Post-intubation CXR neonate

(CXR source: https://radiopaedia.org/articles/neonatal-pneumonia)