We discuss an approach to the critically ill infant.
Ellen Duncan, MD, PhD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/The_Critically_Ill_Infant.mp3
Download
Leave a Comment
Tags: Pediatrics
Show Notes
The Critically Ill Infant: THE MISFITS
Trauma
‘T’ in the mnemonic stands for trauma, which includes both accidental and intentional causes.Considerations for Non-accidental Trauma:Stresses the importance of considering non-accidental trauma, especially given that it may not always present with obvious external signs.Anatomical Vulnerabilities:Highlights specific anatomical considerations for infants who suffer from trauma:Infants have proportionally larger heads, increasing their susceptibility to high cervical spine (c-spine) injuries.Their liver and spleen are less protected, making abdominal injuries potentially more severe.Heart
5 T’s of Cyanotic Congenital Heart Disease: Introduces a mnemonic to help remember key right-sided ductal-dependent lesions:Truncus Arteriosus: Single vessel serving as both pulmonary and systemic outflow tract.Transposition of the Great Arteries: The pulmonary artery and aorta are switched, leading to improper circulation.Tricuspid Atresia: Absence of the tricuspid valve, leading to inadequate development of the right ventricle and pulmonary circulation issues.Tetralogy of Fallot: Comprises four defects—ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta.Total Anomalous Pulmonary Venous Connection (TAPVC): Pulmonary veins do not connect to the left atrium but rather to the right heart or veins, causing oxygen-rich blood to mix with oxygen-poor blood.Other Significant Conditions:Ebstein’s Anomaly: Malformation of the tricuspid valve affecting right-sided heart function.Pulmonary Atresia/Stenosis: Incomplete formation or narrowing of the pulmonary valve obstructs blood flow to the lungs.Left-sided Ductal-Dependent Lesions:Conditions such as aortic arch abnormalities (coarctation or interrupted arch), critical aortic stenosis, and hypoplastic left heart syndrome are highlighted. These generally present with less obvious cyanosis and more pallor.Diagnostic and Management Considerations:Routine prenatal ultrasounds detect most cases, but conditions like coarctation of the aorta and TAPVC might not be apparent until after birth when the ductus arteriosus closes.Emphasizes the importance of a thorough physical exam: checking for murmurs, assessing hepatosplenomegaly, feeling for femoral pulses, measuring pre- and post-ductal saturations, and taking blood pressures in all four limbs.Treatment Recommendations:Early initiation of alprostadil (a prostaglandin) for patients with suspected ductal-dependent lesions to maintain ductal patency.Preparedness for potential complications from alprostadil treatment, such as apnea and hypotension, which may necessitate intubation and hemodynamic support.Endocrine
Focuses on acute salt-wasting crisis in undiagnosed Congenital Adrenal Hyperplasia (CAH).Electrolyte imbalances: ↓Na, ↑K, ↓HCO3, ↓Glu.Treatment: hydrocortisone (25mg for babies, 50mg for kids, 100mg for adults).Metabolic
Electrolyte abnormalities such as hypoglycemia (values: <60 in infants, <40 in neonates).Broad differential.Rule of 50s for correction: D% x #ml/kg fluid = 50.Inborn Errors of Metabolism
Major classes include organic acidurias (profound anion gap metabolic acidosis) and urea cycle defects (hyperammonemia)Recommendation: Draw gas and ammonia level.Sepsis
Emphasized as a critical condition in the differential diagnosis for ill infants, though placed later in the mnemonic for easier recall.Presentation and Diagnosis:Sepsis in infants often presents nonspecifically, making early detection challenging.Immediate drawing of blood cultures upon suspicion of sepsis.Initial Treatment:Prompt initiation of antimicrobials and fluids.Use of vancomycin for gram-positive and MRSA coverage, a third-generation cephalosporin or pip-tazo for broad bacterial coverage, and acyclovir for HSV. (tailor based on age and institutional guidelines)Supportive Care:Highlights the necessity of fluid resuscitation to stabilize the patient.Formula
Formula-Related Electrolyte Imbalances:Incorrect mixing of infant formula can cause hypo- or hypernatremia.Consequences of Electrolyte Imbalances:Both conditions can lead to severe outcomes including altered mental status, seizures, coma, and potentially death.Management Strategies:Treatment varies based on the sodium levels:Symptomatic hyponatremia is treated with hypertonic saline.Hypernatremia requires fluid resuscitation.Intestinal Catastrophe
Specific Conditions:Malrotation with Midgut Volvulus: Twisting of the intestines that can obstruct blood flow.Necrotizing Enterocolitis (NEC): Can occur in both full-term and preterm infants, involves inflammation and bacterial infection that can destroy bowel tissue.Hirschsprung-associated Enterocolitis: Complication of Hirschsprung’s disease involving blockage and infection.Intussusception: Older infants might only show altered mental status instead of the typical intermittent pain and lethargy.Symptoms:Common symptoms include bilious emesis (green vomit) or hematemesis (vomiting blood).Emergency Response:Urges early mobilization of pediatric surgery and radiology teams upon suspicion of these conditions.Toxins
Includes intentional or unintentional ingestion.One pill killers include: calcium channel blockers (CCB), tricyclic antidepressants (TCA), opiates, sulfonylureas, Class 1 antiarrhythmics, antimalarials, camphor, oil of wintergreen.Seizures
The second ‘S’ in the mnemonic refers to seizures, which can be triggered by various conditions such as hypoglycemia, sepsis, inborn errors of metabolism, and trauma.First-Line Treatment:Actively seizing patients should initially be treated with benzodiazepines.Second-Line Medications:Includes fosphenytoin, phenobarbital, levetiracetam (Keppra), and valproic acid.Management of Reversible Causes:Urges prompt treatment of any identifiable causes like hypoglycemia or electrolyte imbalances.Special Consideration:Notes the possibility of pyridoxine-dependent epilepsy in neonates, recommending pyridoxine (vitamin B6) for intractable seizures unresponsive to multiple antiepileptic drugs (AEDs).
Read More
View all episodes
