The Neonate in Shock: When to think CARDIAC

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.

Sternal_retractions-3** 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

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

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