Neonatal

Emergencies
Beyond the A,B,Cs of
Resuscitation
in the DR and NICU

Case # 1
Summoned

to the LDR STAT

term infant
no prenatal complications
cyanotic
severe respiratory distress

cyanosis, grunting, retractions, HR 140, good

tone

Case # 1
Attempt
Attempt

PPV unsuccessful
intubation

cant see past the base of the tongue

very small mandible

What is the name and etiology of this

infants anatomical condition?

Pierre Robin Sequence

Case # 1
Approach

to this airway

place infant prone

nasal trumpet or 2.5 ETT
insert via nasal passage
tip at level of the posterior pharynx

call Peds ENT stat if you cant secure an

airway

Case # 1
Pierre-Robin

triad
macroglossia + cleft palate
glossoptosis
micrognathia

respiratory obstruction

tongue held against posterior pharyngeal wall

secondary to marked neg pressure during insp
effort

Case # 1
Treatment

support airway
Positioning
Nasal Airway
Tracheostomy
Nutrition

Prognosis

the more prolonged the resuscitation the

worse the neurologic outcome

Case # 2
You

are called to attend a delivery

secondary to fetal distress
A, B, Cs of resuscitation initiated
Person managing the airway

increased epinephrine
tachycardia and tremors
excessive PPV

Case # 2
What

complication would you anticipate?

What

clinical signs are indicative of a

pneumothorax?
cyanosis
bradycardia
decreased BS on affected side

Emergency

intervention?

Needle Thoracostomy
What equipment will you gather?

Case # 3
Summoned to the LDR STAT
Corpsman meets you at the door and says
doc the babies intestines are all over the place

How will you manage this?

Delivery Room Management:

Gastroschisis

ABCs of resuscitation
Warm, saline-soaked lap sponges, plastic wrap
or bowel bag to cover the intestines
Decompression of the bowel ASAP
Avoid volvulus of the mesenteric vessels
Avoid tearing bowel mesentery or causing
unnecessary damage to bowel
Remember importance of thermoregulation
and controlling fluid losses

Gastroschisis
E
m
b
r
y
o
l
o
g
y

Intestines

herniate through the abdominal

wall
Area weakened by involution of the right
umbilical vein (theoretical)
Sequence occurs relatively early in
gestation
Differs from omphalocele

Omphalocele

Gastroschisis

Incidence

1:6,000-10,000

1:20,000-30,000

Covering
Sac

Present (may be
ruptured)

Absent

Fascial
Defect

Small to large

Small (vascular
compromise)

Cord Attach. Umbilical the sac

Abd wall

Omphalocele

Gastroschisis

Herniated
Bowel

Protected

Edematous and
matted

Other organs

Liver often in sac

Remain in abd.

IUGR

Less common

Common

NEC

If sac is ruptured

18 %

Assoc..
Anomalies

Omphalocele

Gastroschisis

Overall

55% to 80%

10% to 15%

37 % (Midgut

18 % (stenosis and

GI

volvulus Meckels
Diverticulum, atresia,
duplications)

atresias)

Cardiac

20 %

2%

Trisomy

30 %

No increase

Prognosis
Gastroschisis:

70% to 90% survival

morbidity related to prematurity and
bowel compromise

Case # 4
Summoned

to the LDR for a meconium

delivery
Light mec is present and the infant cries
immediately upon delivery
Within 15 seconds respiratory distress
ensues

Case # 4
You

initiate A, B, Cs of resuscitation
PPV is ineffective cyanosis is worsening
HR begins to decline
BS are decreased on the left compared to
the right
You notice the abdomen looks like this

Diagnosis?

Diaphragmatic Hernia

Case # 4

Resuscitation

Intubation to overcome resp distress or failure

Bowel decompression to prevent gas from inflating
the bowel

Physiologic consequences of D-Hernia

Pulmonary hypoplasia
Pulmonary hypertension
Air leak syndrome
Non-rotation of the bowel
Feeding difficulties

Case # 4
1

in 3,000
90% occur on the left side
Abdominal content within chest
Compresses both lungs
Pulmonary hypoplasia
Pulmonary hypertension

NO and/or ECMO

Definitive

tx---surgical repair

Case # 5
You

are called to see a newborn shortly

after delivery for coughing
Mild respiratory distress

tachypnea and gasping respirations

You

suction

coughing persists
oral secretions continue to pool in the back
of the throat

Case # 5
What

are your next steps?

Oral suction, pulse ox, OG, IV

Evaluation for infection

Blood culture, cbc, abx, chest film

Case # 5
Abdominal

distention continues to
increase followed by worsening resp
distress and cyanosis

Next
Will

step?

intubation help decrease abdominal distention?

Case # 5
Causes

of increased Resp distress?

Secretions
TEF leading to increased intestinal gas
Anal atresia----no decompression

How

do you relieve the abdominal

distention?
What syndrome would you consider?