Clinical Case:
2-week-old male with history of “funny breathing” since birth presents to ED with 1 day of decreased feeding, now with 30 second apneic and cyanotic episode at home tonight.
** Neonates in shock MAY show obvious signs/sx of end-organ dysfunction (similar to adults), but their presentation may be subtle and progress rapidly!**
Signs/Symptoms of Shock in Neonate:
- History
- Poor feeding
- Respiratory distress (tachypnea, cyanotic/apneic episode)
- Altered mental status (irritability, difficulty awakening)
- Physical Exam
- Tachycardia
- Tachypnea
- Hypotension
- Poor Perfusion: Decreased capillary refill, mottled skin
Differential Diagnosis:
Think of “THE MISFITS” to recall critical diagnoses in the neonate in shock:
T – Trauma (accidental and non-accidental)
H – Heart disease and Hypovolemia
E – Endocrine (congenital adrenal hyperplasia, hypothyroid, etc)
M – Metabolic
I – Inborn errors of metabolism
S – Sepsis
F – Feeding problems, Formula mishaps (under- or over-dilution)
I – Intestinal catastrophes (NEC, volvulus, etc)
T – Toxins
S – Seizures
Diagnostic Evaluations:
- Physical exam:
- Pulse (brachial vs. femoral)
- BP differential (obtain 4-limb BPs)
- Hepatomegaly
- Hyperoxia test – if administration of 100% O2 does not change O2 sat or PaO2 on gas, think cardiac shunting
- Labs:
- iSTAT gas and lytes with lactate
- CBC
- BMP
- Cultures: Blood, Urine, & consider CSF (if stable)
- LFTs
- Ammonia
- Chest X- Ray
- Clues to cardiac etiology:
- Echocardiogram to look for congenital heart defect
Back to our case: CLUES OF CARDIAC ETIOLOGY:
- Infant worsened with IVF (hepatomegaly and increased respiratory distress)
- Hypoxia worsened despite intubation and high FiO2
- CXR as above
- Bedside Echo: Severe Coarctation of Aorta
Management:
- Prostaglandins (Alprostadil)– give as soon as you suspect cardiac (ductal-dependent lesion)
- Major AE: APNEA –> consider intubation prior to administration and/or transport
- Fluids – cautiously – try 10 mL/kg bolus rather than usual 20 mL/kg
- Pressors
- Call Cardiology!
- Stabilize infant and arrange for transfer to tertiary care center/pediatric cardiac surgery center
Quick Review of the Ductal-Dependent Lesions:
- Left sided obstructive ductal-dependent lesions:
- Clinical presentation of profound hypoperfusion and shock correlates with closure of the ductus
- Infants presenting at 1-2 weeks of age – think CARDIAC over Sepsis
- Prostaglandins work on the ductal epithelium to keep the ductus arteriosis OPEN and increases blood flow to the systemic circulation which saves the baby’s life!
* http://www.uofmchildrenshospital.org/healthlibrary/
Summary:
- Sign/sx of shock in infants may be subtle – need careful H & P and high index of suspicion!
- Top 3 Causes of Shock in Neonates: Cardiac, Sepsis & Metabolic
~ By: Beth Prabhu, MD & Robyn Wing, MD