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)

Coarctation of the Aorta

This case is written by Drs. Quang Ngo and Donika Orlich. Dr. Ngo is an attending emergency physician at McMaster Children’s Hospital and also serves as the Associate Program Director for the Department of Pediatrics. He is also a member of the advisory board here at EMSimCases. Dr. Orlich is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Having an approach to the toxic neonate is essential. More importantly, emergency physicians must be able to recognize subtle historical clues and physical exam features that point toward congenital heart disease in order to begin critical treatment rapidly. This case highlights the following:

  • The presentation of neonates with congenital heart disease including features like difficulty feeding, CHF, and tachypnea without increased work of breathing
  • The clinical features that may be present in a coarctation of the aorta, one specific type of congenital heart disease, and the resultant need to include four-limb BP’s as part of the work-up of toxic-appearing neonates
  • The importance of beginning a prostaglandin infusion in patients with suspected ductal-dependent congenital heart disease
  • One of the most common side effects of a prostaglandin infusion – apnea

Clinical Vignette

Your triage nurse comes to tell you about an infant she just put in the resuscitation room who she feels looks quite unwell. He is a 2 week old neonate brought to the ED by his mother. Mom was worried because he hasn’t been feeding very well and seems to just get sleepy when feeding. Now he just vomited his last feed and seems really lethargic. She thinks he just “doesn’t look the right colour”.

Case Summary

A 2-week-old neonate presents in shock requiring the learner to implement an initial broad work-up. The patient will also be hypoglycemic, and will seize if this is not promptly recognized. Physical exam and CXR findings will suggest coarctation of the aorta as the likely cause, and the learner should recognize the need for gentle fluid boluses and a prostaglandin infusion. Unless learners anticipate appropriately and intubate the patient prior to beginning the prostaglandins, the infant will become apneic after starting the infusion and require intubation.

Download the case here: Coarctation of the Aorta Case

ECG for the case found here:

coarc-ecg

(ECG source: http://www.omjournal.org/IssueText.aspx?issId=380)

Initial CXR for the case found here:

chf-neonate

(CXR source: http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/CXR/HLHS/CXR-HLHS-congested.jpg)

Post-intubation CXR for the case found here:

chf-neonate-post-intubation

(CXR source: http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/CXR/OtherCHF/NonstructuralCHF.jpg)

For more information on the management of Congenital Heart Disease Emergencies, see the excellent review by Emergency Medicine Cases found here.

CAH with adrenal crisis

This case is written by Dr. Quang Ngo from McMaster University. Dr. Ngo is a pediatric emergency physician in Hamilton, ON and one of the advisory board members at EMSimCases.

Why it Matters

This cases highlights three crucial management steps for a toxic neonate:

  • Maintaining a broad differential diagnosis (including hypoglycemia, sepsis, metabolic/cardiac conditions)
  • Consideration of hypoglycemia as a cause or consequence of a toxic neonate
  • Treatment of hypoglycemia in a neonate

This case also reviews management specific to congenital adrenal hyperplasia:

  • Recognition of laboratory abnormalities associated with adrenal crisis and initiation of steroid treatment

Clinical Vignette

A 1 week old neonate is brought to the emergency department because his parents are worried that he’s been vomiting and not keeping his feeds down. After he vomited his last feed, his parents noted he was quite lethargic and felt cold. His mom states he’s been increasingly sleepy since discharge and she’s been needing to wake him to feed. In between feeding, he sleeps and doesn’t “act like my other 2 kids did at that age.” The team is called to assess this patient urgently after being triaged because the nurse felt the patient looked unwell.

Case Summary

A lethargic 1 week old presents from home after recurrent emesis and progressive sleepiness. He is hypovolemic, hypothermic, and hypoglycemic. If his hypoglycemia is not quickly corrected, he begins to seize and will continue to do so until the team gives glucose. If they do not, the patient will go on to have a VF arrest. If the team identifies and treats the hypoglycemia, orders blood work, and fluid resuscitates the child, they receive blood results demonstrating hyperkalemia and hyponatremia. If they correctly identify and treat the patient as a possible adrenal crisis, the neonate is safely transferred to the PICU. If they fail to treat the hyperkalemia or fail to administer steroids, the patient will have a VF arrest.

Download the case here: CAH Case

ECG for case found here:

Hyperkalemia peaked T waves

(ECG source: http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)