Pediatric emergency medicine trisk 648

Treatment in the ED should be directed at cardiorespiratory stabilization of the
infants, fluid resuscitation of neonates in septic shock, followed by assessment
for bacterial and viral causes of sepsis. Neonates with suspected HSV should be
admitted to the hospital and started on intravenous acyclovir therapy (60
mg/kg/day in three divided doses). Infants with keratitis or ocular disease should
also be given topical antiviral ophthalmic drops (1% trifluridine, 0.1%
iododeoxyuridine, or 3% vidarabine), in addition to intravenous acyclovir
therapy. Neonates should be placed on contact precautions. Infants receiving
therapy have a mortality rate of 29% in disseminated disease, 4% in CNS disease,
and <1% in SEM.

Neonatal Enteroviral Infection
Enteroviruses can be divided into the nonpolioviruses (coxsackie viruses,
“numbered” enteroviruses, echoviruses, parechoviruses) and polioviruses. The
incidence of infection in the United States is approximately 10% to 12%. These
viruses can be transmitted vertically during the third trimester of pregnancy,
resulting in infection during the immediate postpartum period. They can also be
transmitted horizontally by contact with secretions of infected people (including
the mother or other family members), or through the fecal–oral route. Infants
infected by horizontal transmission may present to the ED within 1 to 2 weeks
after nursery discharge. Infection peaks during the summer and fall months in
temperate areas, although this pattern is not as evident in neonates.
Enterovirus infections are more severe in neonates than in children,
particularly those of coxsackie B4 and echovirus E11. The most common types
reported are coxsackie B1 and echoviruses E11 strains. Absence of passive
maternal antibodies in the neonate’s blood stream (from lack of maternal
exposure or late maternal exposure prior to antibody response), exposure to a
high viral load, and virulent strains all increase the severity of infection. History
of a sick family member with a viral illness can help in making the diagnosis.
Signs and symptoms vary from mild fever to high fever with vomiting, diarrhea,
irritability, poor feeding, respiratory distress, lethargy, hypoperfusion, or shock.

Physical examination may show a diffuse maculopapular rash, hepatomegaly and
jaundice from acute hepatitis, respiratory distress, systemic hypoperfusion,
tachycardia or arrhythmia from myocarditis, coagulopathy in severe cases,
seizures, focal neurologic signs, or altered level of consciousness from
meningoencephalitis. Sepsis workup should be initiated including blood culture,
urine culture, and lumbar puncture. CSF studies reveal typical findings of viral
meningitis, with pleocytosis, elevated protein, and normal glucose levels although


some neonates have been reported to have a very low glucose level. Enteroviral
PCR sent from CSF samples is diagnostic. PCR can also be sent from serum,
urine, nasopharyngeal, and stool samples. Blood cultures are negative,
differentiating enteroviral from bacterial sepsis. It should be noted that 3% of
neonates evaluated for suspected bacterial sepsis will have an enteroviral
infection. Although viral cultures are the traditional methods of diagnosis, it may
take longer to obtain results. PCR is sensitive and is a faster test. Liver function
tests may reveal an acute elevation of transaminases and there may be
coagulopathy. CXR may reveal infiltrates or cardiomegaly with pulmonary
edema. Echocardiography is needed for cases with arrhythmia or signs of low
cardiac output. Enteroviral disease should be differentiated from other causes of
neonatal sepsis, acute fulminant hepatitis, and myocarditis. In mild cases,
spontaneous recovery is the rule. In severe cases, mortality rate can reach 50%
for those with myocarditis and 31% for those with fulminant hepatic failure and
coagulopathy. Sudden infant death syndrome has also been reported with
enteroviral infections. Management of the newborn is directed toward fluid
resuscitation, maintaining adequate blood pressure with pressors if needed, and
supportive care. Neonates should be admitted to an intensive care unit and
contact precautions instituted. High-dose intravenous immunoglobulin may be
administered once diagnosis has been determined.

Special Considerations
Delivery in the ED
Pediatric emergency physicians may find themselves in a position where they
must attend a precipitous delivery of a newborn. The following section reviews
the key points of delivering a fetus in a cephalic position.
KEY POINTS


Summon obstetrical and neonatal provider support.
Familiarize yourself with the location and contents of your department’s
standard delivery kit.
Review the basics of precipitous delivery on a periodic basis. Useful
videos are available online at
www.operationalmedicine.org/ed2/Video/delivery_of_a_baby_video.ht
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Always make sure that the mother and baby are not separated until
correct identification bands are placed on both patients.
Goals of Treatment
The mother and newborn are both in need of medical attention. Summon
assistance so both patients receive appropriate medical attention.
Clinical considerations
Assess maternal stage of labor immediately. Is the infant crowning? Is the
amniotic sac intact? How dilated is the cervix? If fetus is not visible, the mother
does not feel the need to bear down, and contractions are 10 or more minutes
apart, strongly consider transporting the mother to the nearest labor and delivery
unit. Presence of a crowning head is a sign of imminent delivery.
Triage Considerations. Obtain the following information from the mother:
gravity, parity, presence of multiple gestations, history of previous cesarean
delivery, prenatal care, current medications. Check for maternal fever, which can
suggest chorioamnionitis, and hypertension, which may be a sign of

preeclampsia. Headache, epigastric pain, and scotoma are additional findings
concerning for preeclampsia. If not addressed, preeclampsia can progress to
eclampsia in the mother with concurrent seizures, pulmonary edema, hepatic
rupture, stroke, renal failure, and death.
Clinical Assessment. Assess fetal heart rate with a stethoscope or Doppler US.
Normal fetal heart rate ranges from 110 to 160. Assess fetal position and note if
the fetal head has already descended into the pelvis.
Management. Obtain a standard delivery kit (which should include umbilical
cord tape or clamps, vitamin K for intramuscular injection, and erythromycin eye
ointment) and ensure you have plenty of warm towels/blankets to receive the


baby. Place an IV and draw maternal blood for blood type and antibody screen.
Position the mother on a table with stirrups, or if unavailable elevate her hips and
back with pillows/stacks of towels or upside down bedpan. The goal is to raise
the perineum above the surface of the bed so that there is room to move the infant
posteriorly during delivery manipulations. Remind the mother not to bear down
unless the fetal head is crowning. The pressure felt from descent of fetal head and
pain of contractions lead to a reflexive desire to push, but a controlled delivery is
preferable. If the head is crowning, the mother should be instructed to make only
modest expulsive efforts in an effort to avoid maternal or fetal trauma with an
uncontrolled delivery. Once the head is delivered, feel for umbilical cord around
the neck and, if present, gently slip it over the head.
Guide the head downward so the anterior shoulder slips out, then guide the
head upward so posterior shoulder passes over the perineum. At this point the
remainder of the infant should follow. Note the time of delivery. Place the baby
on the mother’s abdomen, double clamp and cut the cord, and turn your attention
to newborn care and assessment. Neonatal care should follow the neonatal
resuscitation algorithm. Most infants will only require drying and warming.
Remove wet linen, bulb suction the mouth and then the nose, do the full physical

assessment of the newborn, give vitamin K intramuscular injection of 1 mL in the
thigh, and give erythromycin ointment in both eyes. Be sure to inform the
neonatal providers if you have not given vitamin K or erythromycin. Always
make sure that the mother and baby are not separated until correct identification
tags have been placed on both. Placental separation and delivery occurs naturally
within 30 to 60 minutes after delivery. Seek obstetric help for any baby who has
an abnormal presentation, for example, footling breech, breech, or is in a
transverse presentation.
Abnormal Newborn Screening Results
Goals of Treatment. Newborns screenings are performed in every state. Current
newborn screening tests prior to discharge from the hospital include blood spot
screening for metabolic and genetic conditions, pulse oximetry for cyanotic
congenital heart defects, and hearing screening tests. There is variability from
state to state. While primary care physicians caring for the newborn should be
notified of results and usually arrange follow-up, ED physicians should be
prepared to manage neonates who present to the ED with abnormal screening
results.