Neonatal resuscitation

Use this note for the non-delivery related resuscitation of the newborn; see newborn resuscitation for immediate after-delivery resuscitation. See newborn critical care quick reference for vital signs and drug doses, and equipment sizes.

Clinical Features

• Neonate in shock
• Neonate <1mo age

Differential Diagnosis

Sick Neonate

THE MISFITS

• Trauma
• Heart
  • Congenital heart disease
  • Hypovolemia
• Endocrine
  • hypoglycemia
  • Hypothyroidism
  • Congenital adrenal hyperplasia
• Metabolic
  • Sodium
  • Calcium
  • Glucose
• Inborn errors of metabolism
• Seizure
• Formula / feeding problems
  • Hyponatremia
  • Hypocalcemia
  • FPIES / Food protein-induced enterocolitis syndrome
• Intestinal Disasters
  • Duodenal atresia
  • Midgut volvulus
  • Necrotizing enterocolitis
  • Intussusception
• Toxin
• Sepsis

Diagnosis

1. Blood glucose (stat)
2. Sepsis workup
3. ECG
4. Ammonia to rule in Inborn Errors^
   1. Need to look up values for neonate. Ammonia is high as liver is immature (i.e. that's why neonates are jaundice)

If hypoxic or evidence of CHF assume CHD

• CHF in neonate = hepatomegaly, wheezing, gallop
• if unclear do Hyperoxia test
  • place infant on 100% O2 for 10 minutes
  • check ABG, if O2<100 torr, highly predictive of CHD
  • some use Pulse Ox <95%, less sensitive
• Abdominal xrays may help rule in intestinal disaster early

Management

1. Full sepsis work-up
   • IV antibiotics and fluids
2. Pressors if CHD suspected
3. Intubate and give PGE
   • Sides effects of PGE include apnea (10%)
4. If inborn errors suspected
   • IV dextrose at 1.5 maintenance
   • Dialysis if ammonia >500

Empiric Treatment for Unstable Neonates

Medication/Intervention	Indication	Dose/Size (for neonate)
Glucose	Hypoglycemia	5–10 mL/kg of 10% dextrose in water IV
3% normal saline	Symptomatic hyponatremia	3–5 mL/kg bolus IV
Calcium	Hypocalcemia	50–100 milligrams/kg calcium gluconate or 20 milligrams/kg calcium chloride IV
Cefotaxime	Infection	50 milligrams/kg IV
Ampicillin	Infection	50 milligrams/kg IV
Packed red blood cells	Anemia	10 mL/kg IV
Normal saline	Hypotension, dehydration	20 mL/kg IV
10% dextrose in one fourth normal saline	Metabolic disease	1.5 maintenance (6 mL/kg/h for the first 10 kg)
Endotracheal intubation	Hypoventilation or frequent apnea	3mm for preemie; 3mm for term neonate, 4mm for older infant

See Also

• Newborn Resuscitation
• PALS (Main)

External Links

• Pediatric Emergency Playbook Podcast: The Undifferentiated Sick Infant
  • The Undifferentiated Sick Infant (mp3 only)

Video

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