Following on from our first knackered neonate – here are some rapid fire cases of unwell little ones…
Think to yourselves; what’s the diagnosis & what do I do right now to help ?
Right sided pneumothorax with mediastinal shift to the left.
- Supplemental O2
- IV access
- Insertion of intercostal catheter.
- 4th-5th intercostal space. Anterior axillary line.
- 8-12F [Newborn]
- 12-16F [Infant]
** ICC sizes taken from Clinical Practice Guideline “Chest Drain” – The Royal Children’s Hospital Melbourne.
The most common cause of infantile gastrointestinal obstruction beyond the first month of life.
- 1 in every 250 live births.
- Etiology unclear.
- Boys:Girls (4:1)
- 2-6 weeks of age
- Gradually progressive vomiting –> then projectile (non-bilious).
- Child appears well with increased appetite.
- Later: visible peristalsis with firm olive-shaped mass palpable in RUQ.
- Gastro-oesophageal reflux
- Non-GIT causes
- (eg. Head trauma, sepsis, meningitis, drugs or metabolic disorders)
- Observation of child feeding is helpful (confirming true projectile emesis)
- Pyloric length & diameter
- Barium study
- Characteristic “string sign,” reflecting passage of contrast material through the narrowed pylorus.
- Gaseous insufflation can resemble ‘double-bubble’ (as above).
- In late presentations shows enlarged body of stomach.
- Fluid resuscitation
- Correction of electrolyte abnormalities
- Recall hypokalaemic, hypochloraemic metabolic alkalosis.
- Surgical consultation –> Pyloromyotomy
- The initial congenital form can be diagnosed antenatally.
- Results in intraabdominal contents entering the chest during the 2nd trimester.
- Leads to pulmonary hypoplasia.
- The ultimate determinant of morbidity/mortality is the degree of hypoplasia of the contralateral lung (& whether the liver is located in the thorax).
- Lung volumes of > 45% of normal predicts survival.
- Persistent respiratory distress at birth w/ seesawing, side-to-side respirations.
- Cyanosis is common.
- Scaphoid abdomen, with bowel sounds heard in the chest.
- Intubation (and avoidance of gastric insufflation).
- Aim for PCO2 30-35mmHg to reduce pulmonary vascular resistance.
- Placement of an orogastric tube.
- Referral to Tertiary Paediatric Centre & Surgeon for operative repair.
Here is the repeat x-ray of our little fella just prior to transfer…
Transient Tachypnoea of the Newborn (TTN)
- One of the most common causes of newborn tachypnoea.
- A failure to cease production of foetal lung fluid after onset of labour.
- Incidence increases significantly if child delivered via caesarian section (before 39 weeks)
- Tachypnoea, cyanosis, increased work of breathing.
- Often a diagnosis of exclusion.
- DDx include sepsis, congenital heart disease & respiratory distress syndrome.
- Interstitial & alveolar oedema (symmetrical)
- Supplemental oxygen.
- some patients require intubation…
- Empiric ABx to cover for sepsis
- Symptoms & CXR clears by 2-3 days.
Image for this case taken from learningradiology.com with thanks…
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
- Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition.
- Current Diagnosis & Treatment: Obstetrics & Gynecology. 11th Edition.
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