Authored by Adriana Yock-Corrales*
Abstract
Patients in the neonatal period can present in the emergency department with many life-threatening conditions.Knowledge of these presentations by physicians that work in the emergency department is mandatory for the immediate approach of the critically ill infant. It is the responsibility of the emergency department team to identify these conditions and to stablish the best approach; this includes stabilization of the patient, differential diagnosis based, laboratory and images findings; and a well guided treatment. Serious bacterial infections, congenital cardiac disease, gastro intestinal emergencies (including malrotation with midgut volvulus and necrotizing enterocolitis), respiratory conditions, neurologic disorders and child abuse are the most common diagnosis in this type of scenarios. The main objective of this article is to review the most common conditions of the critical ill infant in the emergency department.
Introduction
Non-serious conditions are the cause of the majority of visits to the emergency department (ED) in these age group patients [1]. Although infection is the most reported cause of the ill appearance among neonates and young infants, there are other clinical conditions that have similar presentations and also represents serious entities of an unwell infant [2,3]. The ED personnel should be ready to identify conditions that increased the mortality in this population, and to have a step-approach to follow in this case without delaying treatment.
Recognition and Approach of the Critically Ill Neonate
Clinical history
The first step for any crucial diagnosis is the clinical history. The physician should always check for prenatal, perinatal and postnatal history. Prolonged membrane rupture or perinatal maternal fever is an important risk factor for sepsis. Prematurity and low birth weight are one of the major contributors to infant mortality [4,5]. Other important information is the Apgar score and need for resuscitation at birth, weight gain in the first week, frequency in urination and bowel movements, as well as feeding.Any change in the patient normal pattern could mean a serious condition that might need further evaluation.
A complete physical examination can help detecting anomalies that may risk the newborn life. Evaluation of neonatal size, weight, and vital signs as heart rate, respiratory rate, oxygen saturation level, blood pressure and temperature are necessary. The Pediatric Assessment triangle (PAT) is a well stablished method for rapid assessment that should be done in every child in the ED, this triangle includes theevaluation of the infant’s appearance, work of breathing and circulation to skin [6,7] (Figure 1).
Evaluation of the airway and breathing is very important. Work of breathing, respiratory rate and auscultation is essential. The normal respiratory rate is 40 to 60 breaths per minute in neonates. Physicians should verify that the patient has adequate ventilation and oxygenation, as well as need for positioning and suctioning. Abnormal sounds (snoring, grunting, stridor, audible wheeze and any abnormal sounds) associated with signs of increase work of breathing (sniffing position, nasal flaring, retractions, paradoxical chest movements) has to be interpreted as signs of respiratory distress [8].
Circulation, including hydration status, capillary refill time (normal less than 2 seconds), and heart rate should be evaluated. The normal neonatal heart rate is between 120 and 160 beats per minute, and the systolic blood pressure 60 to 90 mmHg [8]. Hypotension is a late finding in a patient with shock.
A direct guided neurological examination should be performed. Some aspects that should be included are muscular tone, cranial nerves, primitive reflexes and consciousness (Table1). Seizures may indicate abnormalities including low glucose and abnormal electrolyte levels, central nervous system infections, and metabolic disease [9].
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