Hypoactivity in a newborn

You were called to normal nursery unit to evaluate a 24 hours old full term female newborn for a major concern of hypoactivity. Baby was born by normal vaginal delivery to a 42 year old, G1P0, rubella and toxo immune, HBsAg negative, GBS positive mother. Mother received 2 doses of Pen G prior to delivery. Over the last 6 hours, baby received only a 2 minutes breastfeeding because of inability to catch the nipple. Baby didn't pass urine for the last 10 hours. PE: HR 160, BP 65/40(55), T 37, RR 50, SaO2=96%. Physical exam is remarkable for diminished skin turgor otherwise normal. What's your most probable diagnosis?

• Sepsis versus congenital heart disease
• Sepsis versus hypovolemia due to inadequate feeding
• Sepsis versus hypovolemia due to intracranial bleeding

Suprapubic Abdominal Pain

12 year old female, previously healthy, presented with 6 hours history of suprapubic severe abdominal pain without fever, nausea, vomiting or diarrhea. No other symptoms. She is due for her menstrual period. She had a milder pain in the same location last month during her menstrual period. On physical exam: T: 36.5, P: 110, BP: 130/90, RR: 25. There is suprapubic abdominal tenderness with rebound. Psoas sign is negative. Urinalysis is negative for WBC, leukocyte esterase and nitrate. CBC showed total WBC of 18800, polymorphonuclears are 88%. CT scan of abdomen and pelvis with IV and PO contrast is shown below:

What is the most probable diagnosis?

1. Dysmenorrhea
2. Urinary tract infections
3. Appendicitis
4. Abdominal mass

24 year old female ingested 15 tabs of Lorazepam (1 mg per tab) 10 hours before presentation to ER. She had 3 episodes of non-bloody non-bilious vomiting after ingestion. She started to be dizzy and drowsy one hour after ingestion. She has slurred speech but she's hemodynamically stable.

Fever and cough

5 year old male known to have G6PD deficiency presented with 5 days history of fever (maximum 39.5, every 6-8 hours) and 2 days history of upper respiratory symptoms (runny nose and dry cough). No other symptoms. Patient is active and has good oral intake with adequate urine output. Physical exam reveals erythematous pharynx without exudates on tonsills. Lungs are clear with good bilateral air entry. Vital signs: Temperature: 37.5, Pulse: 90, RR: 22, BP 110/70. His vaccinations are uptodate.

What's the most approriate next step of management?

• Do a chest x-ray.
• Discharge patient on symptomatic treatment
• Discharge patient on antibiotics

Lines in Neonates

Lines are used for many purposes in neonates. The most common use is to administer parenteral fluids. Withdrawing blood and monitor blood pressure are two more important things to consider. I will discuss the types and the use of common lines I used to deal with in my rotations in NICU.

Peripheral Intravenous Line: The most used type. It's used to administer fluids, medications or even  parenteral fluids. Here, we're limited with the concentration and osmolarity of fluids being administered. We can't use high osmolarity fluids like: D15% W or more. 

Peripheral Arterial Line: It's used for both arterial blood withdrawal and invasive blood pressure monitoring. The most common side is the radial artery. It's important to know how to manipulate the line carefully because they usually don't last long and it's painful to insert them again. Don't insert arterial line the the hypoperfused extremity.

Peripherally Inserted Central Catheter: This is a common practice. The line starts as peripheral IV but extends far to reach a central vessel. The cath usually is very thin. As we reach the central vascular system, we can use high osmolarity fluids as high dextro (>12.5%). The most common reason to use this is to secure a safe way to administer parenteral nutrition for baby. An x-ray is done post insertion to assess the position of the end of the catheter; it should be central but not in the heart!

Umbilical Venous Line: The most common central line used in the first week of life. It's administered right after birth if a line is needed for resuscitation. Later on, it's used most commonly for administration of parenteral nutrition. An abdominal x-ray is done post insertion to assess the position of the end of the cath before being used.

Etiology of Apneas and Bradycardeas in Prematurity

Apenea and bradycardias are main concern in premature infants.  Apnea is defined as the cessation of breathing for longer than 20 seconds, or a shorter duration in the presence of pallor, cyanosis, or bradycardia (1). In preterm infants less than 1,500 grams at birth, approximately 70% will have at least one clinically observed episode of symptomatic apnea while in the neonatal intensive care unit (NICU), and about 20% of these infants will have a specific medical cause. The other 80% of preterm infants with symptomatic apnea do not have a specific medical cause and by exclusion are then diagnosed as having AOP, the most important and prevalent disorder of respiratory control occurring in preterm infants.

Management of Anemia in Premature Infants

Anemia is the most common hematological disorder in premature infants. Physiologic and non-physiologic etiologies contributes the pathophsiologiy of this disorder. The physiologic anemia is called anemia of prematurity. The most important non-physiologic cause is bleeding into lab, i.e. iatrogenic blood withdrawal for studies.

Management


Blood transfusion