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more knackered neonates…

Following on from our first knackered neonate – here are some rapid fire cases of unwell little ones…

Think to yourselves; what’s the diagnosis & what do I do right now to help ?

[DDET Case #1]

Respiratory distress in a newborn.

Case01

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[DDET Case #1 – Answer]

Right sided pneumothorax with mediastinal shift to the left.

Management.

    • Supplemental O2
    • IV access
    • Analgesia
    • Insertion of intercostal catheter.
        • 4th-5th intercostal space. Anterior axillary line.
        • SIZES:
            • 8-12F [Newborn]
            • 12-16F [Infant]

** ICC sizes taken from Clinical Practice Guideline “Chest Drain” – The Royal Children’s Hospital Melbourne. 

Case01-treated[/DDET]

[DDET Case #2]

4 week old male with vomiting & dehydration…

Case02 [/DDET]

[DDET Case #2 – Answer]

Pyloric Stenosis.

The most common cause of infantile gastrointestinal obstruction beyond the first month of life.

    • 1 in every 250 live births.
    • Etiology unclear.
    • Boys:Girls (4:1)
    • Familial.

Clinical Features.

    • 2-6 weeks of age
    • Gradually progressive vomiting –> then projectile (non-bilious).
    • Child appears well with increased appetite.
    • Later: visible peristalsis with firm olive-shaped mass palpable in RUQ.

Differential Dx.

    • Gastro-oesophageal reflux
    • Malrotation-Volvulus
    • Non-GIT causes
      • (eg. Head trauma, sepsis, meningitis, drugs or metabolic disorders)

Investigations.

    • Observation of child feeding is helpful (confirming true projectile emesis)
    • Ultrasound:
      • Pyloric length & diameter
    • Barium study
      • Characteristic “string sign,” reflecting passage of contrast material through the narrowed pylorus.
    • AXR
      • Gaseous insufflation can resemble ‘double-bubble’ (as above).
      • In late presentations shows enlarged body of stomach.

Management.

    • Fluid resuscitation
    • Correction of electrolyte abnormalities
      • Recall hypokalaemic, hypochloraemic metabolic alkalosis.
    • Surgical consultation –> Pyloromyotomy

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[DDET Case #3]

4 week old female breathless child with evidence of a recent left thoracotomy.

Case03[/DDET]

[DDET Case #3 – Answer.]

Diaphragmatic Hernia.

    • The initial congenital form can be diagnosed antenatally.
    • Results in intraabdominal contents entering the chest during the 2nd trimester.
      • Leads to pulmonary hypoplasia.
    • The ultimate determinant of morbidity/mortality is the degree of hypoplasia of the contralateral lung (& whether the liver is located in the thorax).
      • Lung volumes of > 45% of normal predicts survival.

Clinical features.

    • Persistent respiratory distress at birth w/ seesawing, side-to-side respirations.
    • Cyanosis is common.
    • Scaphoid abdomen, with bowel sounds heard in the chest.

Treatment.

    • Intubation (and avoidance of gastric insufflation).
    • Aim for PCO2 30-35mmHg to reduce pulmonary vascular resistance.
    • Placement of an orogastric tube.
    • Referral to Tertiary Paediatric Centre & Surgeon for operative repair.

Here is the repeat x-ray of our little fella just prior to transfer…

Case03-treated

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[DDET Case #4]

Newborn infant with tachypnoea & increased work of breathing…

Case04

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[DDET Case #4 – Answer.]

Transient Tachypnoea of the Newborn (TTN)

    • One of the most common causes of newborn tachypnoea.
    • A failure to cease production of foetal lung fluid after onset of labour.
    • Incidence increases significantly if child delivered via caesarian section (before 39 weeks)

Clinical Features.

    • Tachypnoea, cyanosis, increased work of breathing.
    • Often a diagnosis of exclusion.
    • DDx include sepsis, congenital heart disease & respiratory distress syndrome.

CXR.

    • Interstitial & alveolar oedema (symmetrical)

Treatment.

    • Supplemental oxygen.
      • CPAP
      • some patients require intubation…
    • Empiric ABx to cover for sepsis
    • Symptoms & CXR clears by 2-3 days.

Image for this case taken from learningradiology.com with thanks…

[/DDET]

[DDET References.]

  1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
  2. Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition.
  3. Current Diagnosis & Treatment: Obstetrics & Gynecology. 11th Edition.

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