Neonatal Emergencies

‘THE MISFITS’ is a popular mnemonic to assist in identifying the cause of critical illness in the neonatal period.
T = Trauma (Accidental and Non Accidental)
H = Heart Disease, Hypovolemia, Hypoxia
E = Endocrine (Congenital Adrenal Hyperplasia, Thyrotoxicosis)
M = Metabolic (Electrolyte Imbalance)
I = Inborn Errors of Metabolism
S = Sepsis (Meningitis, Pneumonia, UTI)
F = Formula Mishaps (Under or Over dilution)
I = Intestinal Catastrophes (Intussusception, Volvulus, Necrotizing Enterocolitis)
T = Toxins / Poisons
S = Seizures
From: Tonia J. Brousseau, Ghazala Q. Sharieff Neonatal Emergencies accessed 29/12/09

Failure to Thrive

Infants whose weight does not increase as normally expected or those who lose weight should be investigated for four different causes1: insufficient intake, inability to absorb, increased caloric need, and inability to metabolise.
History, examination, and bedside investigations can often identify which group(s) of causes should be considered
1.Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician 2003;68:879-84.

Best way to insert NG tube in intubated patients

A randomised controlled trial on 200 anaesthetised, tracheally intubated adults compared four methods of nasogastric tube placement, looking at success rates, time to insertion, and complications.
The four groups were: control, using a ureteral guidewire as stylet, a slit endotracheal tube as an introducer, and head flexion with lateral neck pressure. All intervention groups were more successful than the control group. The time necessary to insert the NG tube was significantly longer in the slit endotracheal tube group, which also had the highest bleeding rate. Complications were fewest in the flexion group.
Nasogastric tube insertion using different techniques in anesthetized patients: a prospective, randomized study
Anesth Analg. 2009 Sep;109(3):832-5

Thoracostomy in blunt traumatic arrest

37 patients with blunt traumatic cardiac arrest underwent attempted resuscitation by a HEMS crew over a four year period. Chest decompression was performed in 18 cases (17 thoracostomy, one needle decompression). The procedure revealed evidence of chest injury in 10 cases (pneumothorax, haemothorax, massive air leak) and resulted in return of circulation and survival to hospital in four cases. All four cases died of associated major head injury, although one became a heart beating organ donor. Only half of the cases found to have pneumothorax demonstrated clinical signs of one prior to chest decompression.
The authors state: ‘Relying on clinical signs of the thorax alone will not identify all patients with these injuries, and our data support extending the practice into all patients with a suitable mechanism of injury together with external evidence of chest injury.’
Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest
Emerg Med J. 2009 Oct;26(10):738-40

Ballistic penetrating neck injury and the risk of immobilisation

British military physicians reported the outcomes of patients sustaining penetrating neck injury from the Iraq and Afghanistan conflicts. Three quarters were injured in explosions, one quarter from gunshots.
Of 90 patients, only 1 of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury. The authors conclude that penetrating ballistic trauma to the neck is associated with a high mortality rate, and their data suggest that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk, and cervical collars may hide potential life-threatening conditions.
Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma
Injury. 2009 Dec;40(12):1342-5

Prehospital Hypocapnia and Poor Outcome After Severe Traumatic Brain Injury

Patients admitted to a level 1 trauma centre with traumatic brain injury whose end-tidal CO2 was kept with the Brain Trauma Foundation recommended limits of 30-35 mmHg (3.9-4.6 kPa) had a lower mortality than those whose CO2 was outside this range. The group in which the target was not achieved had a greater injury severity, which may have contribute to the difficulty in optimising ETCO2.
Prehospital Hypocapnia and Poor Outcome After Severe Traumatic Brain Injury
J Trauma. 2009 Jun;66(6):1577-82

Effect on noradrenaline on tissue oxygen delivery

Some persist in thinking and teaching that the ‘vasopressor’ noradrenaline (norepinephrine) increases mean arterial pressure (MAP) simply by increasing systemic vascular resistance, leading to concerns that it may increase blood pressure at the expense of tissue perfusion. This assertion is contested by many, who now have further support from this study.
In 16 patients with septic shock, various measures of peripheral perfusion were recorded while the dose of noradrenaline was increased to achieve target MAPs. The use of noradrenaline to achieve incremental targets for MAP was associated with increases in global oxygen delivery, cutaneous microvascular flow, and tissue oxygenation in patients with established septic shock; there were no associated changes in the preexisting abnormalities of sublingual microvascular flow. The authors state that these findings suggest that in patients with septic shock, improvements in global hemodynamics and tissue oxygen delivery can be achieved with noradrenaline, without exacerbating microcirculatory flow abnormalities.
The effect of increasing doses of norepinephrine on tissue oxygenation and microvascular flow in patients with septic shock
Crit Care Med. 2009 Jun;37(6):1961-6

MAU faster than wards, but slower than ED

In many UK ¬†hospitals patients referred to hospital by their family doctors may bypass the emergency department (ED) and be admitted straight to admissions units, where additional staff duplicate the assessment and investigation that would have been done in the ED. The ED continues to see self-presenting and emergency ambulance cases as well as patients who ‘spill over’ when the admission units are full.
The effect of the introduction of a Medical Admissions Unit (MAU) on times to key interventions for four acute medical conditions was assessed. Interventions were delivered significantly faster in the ED than on the MAU, which in turn provided specific interventions faster than the general medical wards.
The authors rightly conclude that acute admissions should be assessed in a dedicated unit fit for purpose. It would appear from their data that if the purpose is timely intervention, then the ED is the most fit.
Improvement in time to treatment following establishment of a dedicated medical admissions unit
Emerg Med J. 2009 Dec;26(12):878-80

No benefit from drugs in pre-hospital cardiac arrest

A Norwegian randomised controlled trial over five years compared out-of-hospital nontraumatic cardiac arrest outcomes between ACLS protocols with and without access to intravenous drugs (epinephrine/adrenaline, atropine, amiodarone).
Patients randomised to the drug group had a higher rate of hospital admission with return of spontaneous circulation, but there was no significant difference in survival to discharge, survival with favourable neurological outcome, or one year survival.
Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest
JAMA. 2009 Nov 25;302(20):2222-9