EM · Paediatric emergencies

Neonatal emergencies (the sick neonate in the emergency department)

Also known as Sick neonate · Neonatal collapse · Duct-dependent congenital heart disease · Neonatal sepsis · Congenital adrenal hyperplasia · Salt-wasting crisis · Necrotising enterocolitis · Neonatal seizures · Hypoxic ischaemic encephalopathy · Prostaglandin E1 infusion · Neonatal cardiac emergency

Neonatal emergencies are the life-threatening presentations of the first 28 days of life — the well-then-sick neonate who deteriorates as a ductus closes, an infection declares itself, a metabolic pathway fails, or an adrenal enzyme deficit unmasks. The four reversible, time-critical diagnoses are the duct-dependent congenital heart lesion (the hypoplastic left heart, the coarctation, the pulmonary atresia, the tricuspid atresia — collapse at 24 to 72 hours as the ductus arteriosus constricts, reversed by prostaglandin E1 0.01 to 0.05 mcg per kilogram per minute to keep the duct open), the neonatal sepsis (the group B streptococcus, the E. coli, the Listeria — full septic workup of the blood culture, the lumbar puncture and the suprapubic aspirate, then cefotaxime 50 mg per kilogram IV plus ampicillin 50 mg per kilogram IV, with aciclovir 20 mg per kilogram IV added if HSV is suspected), the congenital adrenal hyperplasia salt-wasting crisis (vomiting and dehydration with hyponatraemia and hyperkalaemia at one to two weeks, reversed by hydrocortisone 25 mg IV), and the neonatal seizure (the hypoglycaemia, the hypocalcaemia, the meningitis). The Fellowship candidate must recognise the sick neonate, start the specific therapy on suspicion rather than waiting for transfer, and pre-empt the side effects — the prostaglandin apnoea above all.