An Initial Approach to the

Crashing Neonate and

Young InfantTimothy Ruttan MD

UTSW-Austin Pediatric Emergency Medicine

TCEP Annual Meeting

Galveston Texas

April 11 2014

Disclosures

No financial disclosures

General community EM physician

Pediatric EM Fellow at Dell

Childrenrsquos in Austin TX

Objectives

Recognize an algorithmic approach to the potentially

sick neonate and infant presenting to the general

emergency department

Efficiently and safely provide early diagnosis and

stabilization of sick infants prior to transfer to higher

level of care

Understand key elements of emergency department

preparedness for young children

Develop increased confidence to take care of critically

ill infants in the emergency department

Case

You are working a single coverage overnight at 3 am in

your community ED when parents bring in a 3 week old

infant with concern for poor feeding

The child looks moderately ill Vital signs show the child

is afebrile hellip

What is your approach How fast can you safely get the

child out of your department

httpsencrypted-tbn0gstaticcomimagesq=tbnANd9GcSe0BrQIQDtQwzoN_7LSRLqV3ers2eET8rXpHN48mvkxA6CkTxc

The problem

Truly sick infants are

uncommon in general and

even less so in community

emergency departments

Staff often have limited

pediatric skills and training

Equipment often missing

malfunctioning or hard to find

Stressful and high risk situation

for all involved

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcRAQecZO6HAxe7bBDAxmCgWC6-H8vrrWHMaAdHXCPcO3kiJ6dnfFw

Solution Algorithmic Approach

THE MISFITS

T Trauma

H Heart and Lung

E Endocrine

M Metabolic

I Inborn errors of metabolism

S Sepsis

F Formula mishaps

I Intestinal catastrophes

T Toxins and poisons

S Seizures

Tonia Brousseau and Ghazala Q Sharieff Pediatr Clin N Am 53 (2006) 69ndash84

THE MISFITS T for Trauma

Non accidental and accidental

Non accidental difficult to diagnosis

Approximately 30 of children with abusive head trauma

had previous physician contact

70 morbidity 30 mortality in some studies

Low threshold for imaging if infant is sick ndash donrsquot worry

about radiation

httpraddesknlimagesthmb_43d33bad1298cCNSinjuryjpg

THE MISFITS H for Heart and

Lung

Pulmonary bronchiolitis pertussis etc

Congenital Heart disease 1125 newborns

Often presents in the first 2-3 weeks with ductus arteriosus

closes

CHF can present in the first few months (or later)

Do not need to remember all the details

Key blood flow to lungs systemic circulation

When in doubt use prostaglandin and get to a cardiologist

httpwwwchildrenshospitalorg~mediaHealthTopics20KidsMDConditions20and20IllnessesPatent20ductus20arteriosus

Cyanotic heart disease

Right to left shunt with ductal dependent pulmonary blood flow

Hypoxia central cyanosis that does not correct with 100 oxygen

CXR lungs clear if ductal dependent pulmonary blood flow

Treatment

Prostaglandins

Hypotensive phenylephrine

epi dopamine

httpgraphics8nytimescomimages20070801healthadam18088jpg

Outflow obstruction pink or grey

Ductal dependent systemic circulation

Critical coarctation hypoplastic left heart

4 extremity blood pressure

Treatment

Prostaglandins

Pressors milrinone dobutamine

Avoid anything that raises SVR

httpoquizletcomJ64uZTzYeCeTcUssQuRO7A_mjpg

Pulmonary Overcirculation pink

baby CHF

Usually presents later in life

Left to right shunt causes pulmonary over-circulation

CXR with pulmonary congestion patients usually pink

(not cyanotic)

Treatment

Lasix 1 mgkg

Typical CHF treatment

httprsna2004rsnaorgrsna2004V2004dpsmedia2381050IMAGEcompareb_675_v102020045723JPG

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

Disclosures

No financial disclosures

General community EM physician

Pediatric EM Fellow at Dell

Childrenrsquos in Austin TX

Objectives

Recognize an algorithmic approach to the potentially

sick neonate and infant presenting to the general

emergency department

Efficiently and safely provide early diagnosis and

stabilization of sick infants prior to transfer to higher

level of care

Understand key elements of emergency department

preparedness for young children

Develop increased confidence to take care of critically

ill infants in the emergency department

Case

You are working a single coverage overnight at 3 am in

your community ED when parents bring in a 3 week old

infant with concern for poor feeding

The child looks moderately ill Vital signs show the child

is afebrile hellip

What is your approach How fast can you safely get the

child out of your department

httpsencrypted-tbn0gstaticcomimagesq=tbnANd9GcSe0BrQIQDtQwzoN_7LSRLqV3ers2eET8rXpHN48mvkxA6CkTxc

The problem

Truly sick infants are

uncommon in general and

even less so in community

emergency departments

Staff often have limited

pediatric skills and training

Equipment often missing

malfunctioning or hard to find

Stressful and high risk situation

for all involved

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcRAQecZO6HAxe7bBDAxmCgWC6-H8vrrWHMaAdHXCPcO3kiJ6dnfFw

Solution Algorithmic Approach

THE MISFITS

T Trauma

H Heart and Lung

E Endocrine

M Metabolic

I Inborn errors of metabolism

S Sepsis

F Formula mishaps

I Intestinal catastrophes

T Toxins and poisons

S Seizures

Tonia Brousseau and Ghazala Q Sharieff Pediatr Clin N Am 53 (2006) 69ndash84

THE MISFITS T for Trauma

Non accidental and accidental

Non accidental difficult to diagnosis

Approximately 30 of children with abusive head trauma

had previous physician contact

70 morbidity 30 mortality in some studies

Low threshold for imaging if infant is sick ndash donrsquot worry

about radiation

httpraddesknlimagesthmb_43d33bad1298cCNSinjuryjpg

THE MISFITS H for Heart and

Lung

Pulmonary bronchiolitis pertussis etc

Congenital Heart disease 1125 newborns

Often presents in the first 2-3 weeks with ductus arteriosus

closes

CHF can present in the first few months (or later)

Do not need to remember all the details

Key blood flow to lungs systemic circulation

When in doubt use prostaglandin and get to a cardiologist

httpwwwchildrenshospitalorg~mediaHealthTopics20KidsMDConditions20and20IllnessesPatent20ductus20arteriosus

Cyanotic heart disease

Right to left shunt with ductal dependent pulmonary blood flow

Hypoxia central cyanosis that does not correct with 100 oxygen

CXR lungs clear if ductal dependent pulmonary blood flow

Treatment

Prostaglandins

Hypotensive phenylephrine

epi dopamine

httpgraphics8nytimescomimages20070801healthadam18088jpg

Outflow obstruction pink or grey

Ductal dependent systemic circulation

Critical coarctation hypoplastic left heart

4 extremity blood pressure

Treatment

Prostaglandins

Pressors milrinone dobutamine

Avoid anything that raises SVR

httpoquizletcomJ64uZTzYeCeTcUssQuRO7A_mjpg

Pulmonary Overcirculation pink

baby CHF

Usually presents later in life

Left to right shunt causes pulmonary over-circulation

CXR with pulmonary congestion patients usually pink

(not cyanotic)

Treatment

Lasix 1 mgkg

Typical CHF treatment

httprsna2004rsnaorgrsna2004V2004dpsmedia2381050IMAGEcompareb_675_v102020045723JPG

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

Objectives

Recognize an algorithmic approach to the potentially

sick neonate and infant presenting to the general

emergency department

Efficiently and safely provide early diagnosis and

stabilization of sick infants prior to transfer to higher

level of care

Understand key elements of emergency department

preparedness for young children

Develop increased confidence to take care of critically

ill infants in the emergency department

Case

You are working a single coverage overnight at 3 am in

your community ED when parents bring in a 3 week old

infant with concern for poor feeding

The child looks moderately ill Vital signs show the child

is afebrile hellip

What is your approach How fast can you safely get the

child out of your department

httpsencrypted-tbn0gstaticcomimagesq=tbnANd9GcSe0BrQIQDtQwzoN_7LSRLqV3ers2eET8rXpHN48mvkxA6CkTxc

The problem

Truly sick infants are

uncommon in general and

even less so in community

emergency departments

Staff often have limited

pediatric skills and training

Equipment often missing

malfunctioning or hard to find

Stressful and high risk situation

for all involved

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcRAQecZO6HAxe7bBDAxmCgWC6-H8vrrWHMaAdHXCPcO3kiJ6dnfFw

Solution Algorithmic Approach

THE MISFITS

T Trauma

H Heart and Lung

E Endocrine

M Metabolic

I Inborn errors of metabolism

S Sepsis

F Formula mishaps

I Intestinal catastrophes

T Toxins and poisons

S Seizures

Tonia Brousseau and Ghazala Q Sharieff Pediatr Clin N Am 53 (2006) 69ndash84

THE MISFITS T for Trauma

Non accidental and accidental

Non accidental difficult to diagnosis

Approximately 30 of children with abusive head trauma

had previous physician contact

70 morbidity 30 mortality in some studies

Low threshold for imaging if infant is sick ndash donrsquot worry

about radiation

httpraddesknlimagesthmb_43d33bad1298cCNSinjuryjpg

THE MISFITS H for Heart and

Lung

Pulmonary bronchiolitis pertussis etc

Congenital Heart disease 1125 newborns

Often presents in the first 2-3 weeks with ductus arteriosus

closes

CHF can present in the first few months (or later)

Do not need to remember all the details

Key blood flow to lungs systemic circulation

When in doubt use prostaglandin and get to a cardiologist

httpwwwchildrenshospitalorg~mediaHealthTopics20KidsMDConditions20and20IllnessesPatent20ductus20arteriosus

Cyanotic heart disease

Right to left shunt with ductal dependent pulmonary blood flow

Hypoxia central cyanosis that does not correct with 100 oxygen

CXR lungs clear if ductal dependent pulmonary blood flow

Treatment

Prostaglandins

Hypotensive phenylephrine

epi dopamine

httpgraphics8nytimescomimages20070801healthadam18088jpg

Outflow obstruction pink or grey

Ductal dependent systemic circulation

Critical coarctation hypoplastic left heart

4 extremity blood pressure

Treatment

Prostaglandins

Pressors milrinone dobutamine

Avoid anything that raises SVR

httpoquizletcomJ64uZTzYeCeTcUssQuRO7A_mjpg

Pulmonary Overcirculation pink

baby CHF

Usually presents later in life

Left to right shunt causes pulmonary over-circulation

CXR with pulmonary congestion patients usually pink

(not cyanotic)

Treatment

Lasix 1 mgkg

Typical CHF treatment

httprsna2004rsnaorgrsna2004V2004dpsmedia2381050IMAGEcompareb_675_v102020045723JPG

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

Case

You are working a single coverage overnight at 3 am in

your community ED when parents bring in a 3 week old

infant with concern for poor feeding

The child looks moderately ill Vital signs show the child

is afebrile hellip

What is your approach How fast can you safely get the

child out of your department

httpsencrypted-tbn0gstaticcomimagesq=tbnANd9GcSe0BrQIQDtQwzoN_7LSRLqV3ers2eET8rXpHN48mvkxA6CkTxc

The problem

Truly sick infants are

uncommon in general and

even less so in community

emergency departments

Staff often have limited

pediatric skills and training

Equipment often missing

malfunctioning or hard to find

Stressful and high risk situation

for all involved

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcRAQecZO6HAxe7bBDAxmCgWC6-H8vrrWHMaAdHXCPcO3kiJ6dnfFw

Solution Algorithmic Approach

THE MISFITS

T Trauma

H Heart and Lung

E Endocrine

M Metabolic

I Inborn errors of metabolism

S Sepsis

F Formula mishaps

I Intestinal catastrophes

T Toxins and poisons

S Seizures

Tonia Brousseau and Ghazala Q Sharieff Pediatr Clin N Am 53 (2006) 69ndash84

THE MISFITS T for Trauma

Non accidental and accidental

Non accidental difficult to diagnosis

Approximately 30 of children with abusive head trauma

had previous physician contact

70 morbidity 30 mortality in some studies

Low threshold for imaging if infant is sick ndash donrsquot worry

about radiation

httpraddesknlimagesthmb_43d33bad1298cCNSinjuryjpg

THE MISFITS H for Heart and

Lung

Pulmonary bronchiolitis pertussis etc

Congenital Heart disease 1125 newborns

Often presents in the first 2-3 weeks with ductus arteriosus

closes

CHF can present in the first few months (or later)

Do not need to remember all the details

Key blood flow to lungs systemic circulation

When in doubt use prostaglandin and get to a cardiologist

httpwwwchildrenshospitalorg~mediaHealthTopics20KidsMDConditions20and20IllnessesPatent20ductus20arteriosus

Cyanotic heart disease

Right to left shunt with ductal dependent pulmonary blood flow

Hypoxia central cyanosis that does not correct with 100 oxygen

CXR lungs clear if ductal dependent pulmonary blood flow

Treatment

Prostaglandins

Hypotensive phenylephrine

epi dopamine

httpgraphics8nytimescomimages20070801healthadam18088jpg

Outflow obstruction pink or grey

Ductal dependent systemic circulation

Critical coarctation hypoplastic left heart

4 extremity blood pressure

Treatment

Prostaglandins

Pressors milrinone dobutamine

Avoid anything that raises SVR

httpoquizletcomJ64uZTzYeCeTcUssQuRO7A_mjpg

Pulmonary Overcirculation pink

baby CHF

Usually presents later in life

Left to right shunt causes pulmonary over-circulation

CXR with pulmonary congestion patients usually pink

(not cyanotic)

Treatment

Lasix 1 mgkg

Typical CHF treatment

httprsna2004rsnaorgrsna2004V2004dpsmedia2381050IMAGEcompareb_675_v102020045723JPG

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

The problem

Truly sick infants are

uncommon in general and

even less so in community

emergency departments

Staff often have limited

pediatric skills and training

Equipment often missing

malfunctioning or hard to find

Stressful and high risk situation

for all involved

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcRAQecZO6HAxe7bBDAxmCgWC6-H8vrrWHMaAdHXCPcO3kiJ6dnfFw

Solution Algorithmic Approach

THE MISFITS

T Trauma

H Heart and Lung

E Endocrine

M Metabolic

I Inborn errors of metabolism

S Sepsis

F Formula mishaps

I Intestinal catastrophes

T Toxins and poisons

S Seizures

Tonia Brousseau and Ghazala Q Sharieff Pediatr Clin N Am 53 (2006) 69ndash84

THE MISFITS T for Trauma

Non accidental and accidental

Non accidental difficult to diagnosis

Approximately 30 of children with abusive head trauma

had previous physician contact

70 morbidity 30 mortality in some studies

Low threshold for imaging if infant is sick ndash donrsquot worry

about radiation

httpraddesknlimagesthmb_43d33bad1298cCNSinjuryjpg

THE MISFITS H for Heart and

Lung

Pulmonary bronchiolitis pertussis etc

Congenital Heart disease 1125 newborns

Often presents in the first 2-3 weeks with ductus arteriosus

closes

CHF can present in the first few months (or later)

Do not need to remember all the details

Key blood flow to lungs systemic circulation

When in doubt use prostaglandin and get to a cardiologist

httpwwwchildrenshospitalorg~mediaHealthTopics20KidsMDConditions20and20IllnessesPatent20ductus20arteriosus

Cyanotic heart disease

Right to left shunt with ductal dependent pulmonary blood flow

Hypoxia central cyanosis that does not correct with 100 oxygen

CXR lungs clear if ductal dependent pulmonary blood flow

Treatment

Prostaglandins

Hypotensive phenylephrine

epi dopamine

httpgraphics8nytimescomimages20070801healthadam18088jpg

Outflow obstruction pink or grey

Ductal dependent systemic circulation

Critical coarctation hypoplastic left heart

4 extremity blood pressure

Treatment

Prostaglandins

Pressors milrinone dobutamine

Avoid anything that raises SVR

httpoquizletcomJ64uZTzYeCeTcUssQuRO7A_mjpg

Pulmonary Overcirculation pink

baby CHF

Usually presents later in life

Left to right shunt causes pulmonary over-circulation

CXR with pulmonary congestion patients usually pink

(not cyanotic)

Treatment

Lasix 1 mgkg

Typical CHF treatment

httprsna2004rsnaorgrsna2004V2004dpsmedia2381050IMAGEcompareb_675_v102020045723JPG

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

Solution Algorithmic Approach

THE MISFITS

T Trauma

H Heart and Lung

E Endocrine

M Metabolic

I Inborn errors of metabolism

S Sepsis

F Formula mishaps

I Intestinal catastrophes

T Toxins and poisons

S Seizures

Tonia Brousseau and Ghazala Q Sharieff Pediatr Clin N Am 53 (2006) 69ndash84

THE MISFITS T for Trauma

Non accidental and accidental

Non accidental difficult to diagnosis

Approximately 30 of children with abusive head trauma

had previous physician contact

70 morbidity 30 mortality in some studies

Low threshold for imaging if infant is sick ndash donrsquot worry

about radiation

httpraddesknlimagesthmb_43d33bad1298cCNSinjuryjpg

THE MISFITS H for Heart and

Lung

Pulmonary bronchiolitis pertussis etc

Congenital Heart disease 1125 newborns

Often presents in the first 2-3 weeks with ductus arteriosus

closes

CHF can present in the first few months (or later)

Do not need to remember all the details

Key blood flow to lungs systemic circulation

When in doubt use prostaglandin and get to a cardiologist

httpwwwchildrenshospitalorg~mediaHealthTopics20KidsMDConditions20and20IllnessesPatent20ductus20arteriosus

Cyanotic heart disease

Right to left shunt with ductal dependent pulmonary blood flow

Hypoxia central cyanosis that does not correct with 100 oxygen

CXR lungs clear if ductal dependent pulmonary blood flow

Treatment

Prostaglandins

Hypotensive phenylephrine

epi dopamine

httpgraphics8nytimescomimages20070801healthadam18088jpg

Outflow obstruction pink or grey

Ductal dependent systemic circulation

Critical coarctation hypoplastic left heart

4 extremity blood pressure

Treatment

Prostaglandins

Pressors milrinone dobutamine

Avoid anything that raises SVR

httpoquizletcomJ64uZTzYeCeTcUssQuRO7A_mjpg

Pulmonary Overcirculation pink

baby CHF

Usually presents later in life

Left to right shunt causes pulmonary over-circulation

CXR with pulmonary congestion patients usually pink

(not cyanotic)

Treatment

Lasix 1 mgkg

Typical CHF treatment

httprsna2004rsnaorgrsna2004V2004dpsmedia2381050IMAGEcompareb_675_v102020045723JPG

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

THE MISFITS T for Trauma

Non accidental and accidental

Non accidental difficult to diagnosis

Approximately 30 of children with abusive head trauma

had previous physician contact

70 morbidity 30 mortality in some studies

Low threshold for imaging if infant is sick ndash donrsquot worry

about radiation

httpraddesknlimagesthmb_43d33bad1298cCNSinjuryjpg

THE MISFITS H for Heart and

Lung

Pulmonary bronchiolitis pertussis etc

Congenital Heart disease 1125 newborns

Often presents in the first 2-3 weeks with ductus arteriosus

closes

CHF can present in the first few months (or later)

Do not need to remember all the details

Key blood flow to lungs systemic circulation

When in doubt use prostaglandin and get to a cardiologist

httpwwwchildrenshospitalorg~mediaHealthTopics20KidsMDConditions20and20IllnessesPatent20ductus20arteriosus

Cyanotic heart disease

Right to left shunt with ductal dependent pulmonary blood flow

Hypoxia central cyanosis that does not correct with 100 oxygen

CXR lungs clear if ductal dependent pulmonary blood flow

Treatment

Prostaglandins

Hypotensive phenylephrine

epi dopamine

httpgraphics8nytimescomimages20070801healthadam18088jpg

Outflow obstruction pink or grey

Ductal dependent systemic circulation

Critical coarctation hypoplastic left heart

4 extremity blood pressure

Treatment

Prostaglandins

Pressors milrinone dobutamine

Avoid anything that raises SVR

httpoquizletcomJ64uZTzYeCeTcUssQuRO7A_mjpg

Pulmonary Overcirculation pink

baby CHF

Usually presents later in life

Left to right shunt causes pulmonary over-circulation

CXR with pulmonary congestion patients usually pink

(not cyanotic)

Treatment

Lasix 1 mgkg

Typical CHF treatment

httprsna2004rsnaorgrsna2004V2004dpsmedia2381050IMAGEcompareb_675_v102020045723JPG

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

THE MISFITS H for Heart and

Lung

Pulmonary bronchiolitis pertussis etc

Congenital Heart disease 1125 newborns

Often presents in the first 2-3 weeks with ductus arteriosus

closes

CHF can present in the first few months (or later)

Do not need to remember all the details

Key blood flow to lungs systemic circulation

When in doubt use prostaglandin and get to a cardiologist

httpwwwchildrenshospitalorg~mediaHealthTopics20KidsMDConditions20and20IllnessesPatent20ductus20arteriosus

Cyanotic heart disease

Right to left shunt with ductal dependent pulmonary blood flow

Hypoxia central cyanosis that does not correct with 100 oxygen

CXR lungs clear if ductal dependent pulmonary blood flow

Treatment

Prostaglandins

Hypotensive phenylephrine

epi dopamine

httpgraphics8nytimescomimages20070801healthadam18088jpg

Outflow obstruction pink or grey

Ductal dependent systemic circulation

Critical coarctation hypoplastic left heart

4 extremity blood pressure

Treatment

Prostaglandins

Pressors milrinone dobutamine

Avoid anything that raises SVR

httpoquizletcomJ64uZTzYeCeTcUssQuRO7A_mjpg

Pulmonary Overcirculation pink

baby CHF

Usually presents later in life

Left to right shunt causes pulmonary over-circulation

CXR with pulmonary congestion patients usually pink

(not cyanotic)

Treatment

Lasix 1 mgkg

Typical CHF treatment

httprsna2004rsnaorgrsna2004V2004dpsmedia2381050IMAGEcompareb_675_v102020045723JPG

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

httpwwwchildrenshospitalorg~mediaHealthTopics20KidsMDConditions20and20IllnessesPatent20ductus20arteriosus

Cyanotic heart disease

Right to left shunt with ductal dependent pulmonary blood flow

Hypoxia central cyanosis that does not correct with 100 oxygen

CXR lungs clear if ductal dependent pulmonary blood flow

Treatment

Prostaglandins

Hypotensive phenylephrine

epi dopamine

httpgraphics8nytimescomimages20070801healthadam18088jpg

Outflow obstruction pink or grey

Ductal dependent systemic circulation

Critical coarctation hypoplastic left heart

4 extremity blood pressure

Treatment

Prostaglandins

Pressors milrinone dobutamine

Avoid anything that raises SVR

httpoquizletcomJ64uZTzYeCeTcUssQuRO7A_mjpg

Pulmonary Overcirculation pink

baby CHF

Usually presents later in life

Left to right shunt causes pulmonary over-circulation

CXR with pulmonary congestion patients usually pink

(not cyanotic)

Treatment

Lasix 1 mgkg

Typical CHF treatment

httprsna2004rsnaorgrsna2004V2004dpsmedia2381050IMAGEcompareb_675_v102020045723JPG

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

Cyanotic heart disease

Right to left shunt with ductal dependent pulmonary blood flow

Hypoxia central cyanosis that does not correct with 100 oxygen

CXR lungs clear if ductal dependent pulmonary blood flow

Treatment

Prostaglandins

Hypotensive phenylephrine

epi dopamine

httpgraphics8nytimescomimages20070801healthadam18088jpg

Outflow obstruction pink or grey

Ductal dependent systemic circulation

Critical coarctation hypoplastic left heart

4 extremity blood pressure

Treatment

Prostaglandins

Pressors milrinone dobutamine

Avoid anything that raises SVR

httpoquizletcomJ64uZTzYeCeTcUssQuRO7A_mjpg

Pulmonary Overcirculation pink

baby CHF

Usually presents later in life

Left to right shunt causes pulmonary over-circulation

CXR with pulmonary congestion patients usually pink

(not cyanotic)

Treatment

Lasix 1 mgkg

Typical CHF treatment

httprsna2004rsnaorgrsna2004V2004dpsmedia2381050IMAGEcompareb_675_v102020045723JPG

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

Outflow obstruction pink or grey

Ductal dependent systemic circulation

Critical coarctation hypoplastic left heart

4 extremity blood pressure

Treatment

Prostaglandins

Pressors milrinone dobutamine

Avoid anything that raises SVR

httpoquizletcomJ64uZTzYeCeTcUssQuRO7A_mjpg

Pulmonary Overcirculation pink

baby CHF

Usually presents later in life

Left to right shunt causes pulmonary over-circulation

CXR with pulmonary congestion patients usually pink

(not cyanotic)

Treatment

Lasix 1 mgkg

Typical CHF treatment

httprsna2004rsnaorgrsna2004V2004dpsmedia2381050IMAGEcompareb_675_v102020045723JPG

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

Pulmonary Overcirculation pink

baby CHF

Usually presents later in life

Left to right shunt causes pulmonary over-circulation

CXR with pulmonary congestion patients usually pink

(not cyanotic)

Treatment

Lasix 1 mgkg

Typical CHF treatment

httprsna2004rsnaorgrsna2004V2004dpsmedia2381050IMAGEcompareb_675_v102020045723JPG

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

THE MISFITS E for Endocrine

Congenital Adrenal Hyperplasia

Circulatory collapse in first two weeks of life (less severe can be delayed longer)

Clitoromegaly in girls small phallus in boys

Acidosis hyperkalemia hypoglycemia shock

Neonatal Thyrotoxicosis

16 mortality

Can occur in first two weeks

of life

Irritable CHF tachycardia

shock etc

httpwwwdshsstatetxusuploadedImagesContentFamily_and_Community_Health

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

THE MISFITS M for Metabolic

Electrolyte Imbalance

Often related to other underlying disorders

Hypoglycemia 25 mlkg of D10

Hyponatremia 3 saline at 1 mlkg to get to a sodium

of 125 (or 5-10 mlkg)

Hypocalcemia 100 mgkg of 10 calcium gluconate

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

THE MISFITS I for Inborn Errors

of Metabolism

Uncommon but still happens

Do not need to remember any of the details

VBG with lactate ammonia glucose electrolytes

Nice if you remember urine ketones LFTs bloodurine

amino and organic acids

NPO correct abnormalities fluids

httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcS2FdyIkFm_CPQ6iAmBDsAQmO9

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

THE MISFITS S for Sepsis

Most common etiology

Hypo or hyperthermia

Apnea alone

Full work-up with LP labs antibiotics

Acyclovir if sick consider vancomycin

Treat all sick kids for sepsis but consider the other MISFITS

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

THE MISFITS F for Feeding

Mishaps

Formula dilution hyponatremia

Giving free water sodas juice homemade etc

Underlying socialeducational issues

httpwwwthehealthyhomeeconomistcomwp-contentuploads201204homemadeformulaingredients2jpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

THE MISFITS I for Intestinal

Malrotation with midgut volvulus bilious vomiting until

proven otherwise needs a surgeon

Necrotizing enterocolitis (NEC)

Toxic Megacolon (Hirschprungrsquos)

Hyperbilirubinemia

httpwwwaaccorgpublicationscln2010junePublishingImagesJuneSeriesArticlejpg

THE MISFITS T for Toxins

Always think about tox causes

From mother ndash breastmilk from pregnancy

Environmental exposure CO cigarette smoke

Home remedies teething gel ndash methemoglobinemia

Abuse

httpsencrypted-tbn1gstaticcomimagesq=tbnANd9GcR7ZKjJ5yLfbfkLvkNNc1ELZi5E0ZMUoeK_UnSbBT

THE MISFITS S for Seizures

Difficult to recognize in infants

Often not generalized ndash eye movement tongue

movements apnea

Stop the seizure

Lorazapam phenobarbital fosphenytoin

Etiology

Sepsis 5-10

Glucose calcium sodium

CT or ultrasound of head

Emergency Department

Preparedness

Objectives

Recognize an algorithmic approach to the potentially

sick neonate and infant presenting to the general

emergency department

Efficiently and safely provide early diagnosis and

stabilization of sick infants prior to transfer to higher

level of care

Understand key elements of emergency department

preparedness for young children

Develop increased confidence to take care of critically

ill infants in the emergency department

Questions

References

Brousseau and Sharieff Newborn Emergencies The First

30 Days of Life Pediatr Clin N Am 53 (2006) 69ndash84

Haviland J Russell RI Outcome after severe non-

accidental head injury Arch Dis Child 1997 77(6)504 ndash

7

Jenny C et al Analysis of missed cases of abusive head

trauma JAMA 1999281(7)621 ndash 6

King WK et al Child abuse fatalities are we missing

opportunities for intervention Pediatr Emerg Care 2006

Apr22(4)211-4

THE MISFITS S for Seizures

Difficult to recognize in infants

Often not generalized ndash eye movement tongue

movements apnea

Stop the seizure

Lorazapam phenobarbital fosphenytoin

Etiology

Sepsis 5-10

Glucose calcium sodium

CT or ultrasound of head

Emergency Department

Preparedness

Objectives

Recognize an algorithmic approach to the potentially

sick neonate and infant presenting to the general

emergency department

Efficiently and safely provide early diagnosis and

stabilization of sick infants prior to transfer to higher

level of care

Understand key elements of emergency department

preparedness for young children

Develop increased confidence to take care of critically

ill infants in the emergency department

Questions

References

Brousseau and Sharieff Newborn Emergencies The First

30 Days of Life Pediatr Clin N Am 53 (2006) 69ndash84

Haviland J Russell RI Outcome after severe non-

accidental head injury Arch Dis Child 1997 77(6)504 ndash

7

Jenny C et al Analysis of missed cases of abusive head

trauma JAMA 1999281(7)621 ndash 6

King WK et al Child abuse fatalities are we missing

opportunities for intervention Pediatr Emerg Care 2006

Apr22(4)211-4

Emergency Department

Preparedness

Objectives

Recognize an algorithmic approach to the potentially

sick neonate and infant presenting to the general

emergency department

Efficiently and safely provide early diagnosis and

stabilization of sick infants prior to transfer to higher

level of care

Understand key elements of emergency department

preparedness for young children

Develop increased confidence to take care of critically

ill infants in the emergency department

Questions

References

Brousseau and Sharieff Newborn Emergencies The First

30 Days of Life Pediatr Clin N Am 53 (2006) 69ndash84

Haviland J Russell RI Outcome after severe non-

accidental head injury Arch Dis Child 1997 77(6)504 ndash

7

Jenny C et al Analysis of missed cases of abusive head

trauma JAMA 1999281(7)621 ndash 6

King WK et al Child abuse fatalities are we missing

opportunities for intervention Pediatr Emerg Care 2006

Apr22(4)211-4

Objectives

Recognize an algorithmic approach to the potentially

sick neonate and infant presenting to the general

emergency department

Efficiently and safely provide early diagnosis and

stabilization of sick infants prior to transfer to higher

level of care

Understand key elements of emergency department

preparedness for young children

Develop increased confidence to take care of critically

ill infants in the emergency department

Questions

References

Brousseau and Sharieff Newborn Emergencies The First

30 Days of Life Pediatr Clin N Am 53 (2006) 69ndash84

Haviland J Russell RI Outcome after severe non-

accidental head injury Arch Dis Child 1997 77(6)504 ndash

7

Jenny C et al Analysis of missed cases of abusive head

trauma JAMA 1999281(7)621 ndash 6

King WK et al Child abuse fatalities are we missing

opportunities for intervention Pediatr Emerg Care 2006

Apr22(4)211-4

Questions

References

Brousseau and Sharieff Newborn Emergencies The First

30 Days of Life Pediatr Clin N Am 53 (2006) 69ndash84

Haviland J Russell RI Outcome after severe non-

accidental head injury Arch Dis Child 1997 77(6)504 ndash

7

Jenny C et al Analysis of missed cases of abusive head

trauma JAMA 1999281(7)621 ndash 6

King WK et al Child abuse fatalities are we missing

opportunities for intervention Pediatr Emerg Care 2006

Apr22(4)211-4

References

Brousseau and Sharieff Newborn Emergencies The First

30 Days of Life Pediatr Clin N Am 53 (2006) 69ndash84

Haviland J Russell RI Outcome after severe non-

accidental head injury Arch Dis Child 1997 77(6)504 ndash

7

Jenny C et al Analysis of missed cases of abusive head

trauma JAMA 1999281(7)621 ndash 6

King WK et al Child abuse fatalities are we missing

opportunities for intervention Pediatr Emerg Care 2006

Apr22(4)211-4