The Collapsed Neonate

In this week's episode Dr Colin Gilhooley visited to discuss the approach to a collapsed neonate.

Colin breaks his approach down into 4 potential causes:

  • Sepsis - the most common cause; must always cover for sepsis 
    •  Triple antibiotic therapy - Cefotaxime, Gentamicin & Amoxicillin
    • Ask about pregnancy risk factors - was it a difficult pregnancy or labour?
  • Cardiology - murmur? Are the femoral pulses present? 
    • Check BP and O2 sats in all four limbs 
    • You can listen to our Paediatric Cardiology podcast here
    • Think Prostin if duct dependent lesion
  • Neurological/NAI - any history of hypoxia? Did the patient have Vitamin K at birth? Any focal neurology 
    • Shouldn't be bruising in the neonate - subconjunctival/petechial haemorrhage
    • ?Chest wall bruising
    • CT Head if evidence of harm and skeletal survey
    • If no Vitamin K, drop in Hb, Focal neurology - CT Head
    • Febrile seizures don't tend to happen in neonates 
  • Metabolic - any family history? Consanguinity in marriage?
    • Inborn errors of metabolism - Disorders of fat, protein or sugar metabolism; production of dangerous by products
    • Check Ammonia
    • Give 10% Glucose 
  • Use the gas; check Hb and Hct.  Glucose and Lactate could point to metabolic conditions 

Here's our Take Visually graphic based on our podcast:

The RCEM Learning SAQ page on the Shocked Neonate can be found here.

Paediatric Cardiology in the Emergency Department

In this episode Dr Colin Gilhooley joined us to discuss the approach to Cardiology in Children's Emergency Department.  

This approach looks at the age of presentation as a guide:

  • First few days of life - the closure of the patent ductus arteriosus takes place after 24 hours so if the patient has a duct dependent lesion then they will present early in life.  Whilst the PDA is patent there is mixing of oxygenated and de-oxygenated blood but once it's closed then the systemic circulation will be deoxygenated.  The patient will be cyanosed, hypoxic and in shock.  Remember oxygen saturations and blood pressures in all limbs.  This has to be remembered as a differential diagnosis in the collapsed neonate (more of this in the Collapsed Neonate podcast to come!)  Treatment initially is with Prostin (Prostaglandin E) and referral to a specialist Cardiology unit as soon as possible.  
  • 4-6 weeks of age - atrial and ventricular septal defects; presentation is in keeping with right heart failure and failure to thrive (FTT).  Any child who drops through 2 growth centiles is concerning and needs investigation anyway.  
  • Later on - always consider Cardiology in patients with FTT.  Colin always checks the femoral pulses of patients he sees.  Also keep the heart in mind with patients with shortness of breath, chest pain and lethargy.  Consider arrhythmias as well and family history.

Here is a link to more information on REVERT study on the modified valvalva.

Michele Domino gave an excellent talk at Das SMACC on picking up heart disease in children.  That talk currently isn't available on the SMACC website (keep checking) but until it is here is the graphical summary of the talk from the brilliant @WhistlingDixie4.

Here is the RCEMLearning page on murmurs in children.