Pediatric emergency medicine trisk 636

FIGURE 96.37 Bronchopulmonary dysplasia with hyperinflation. This 2-month-old child was
treated with mechanical ventilation during the first days of life for hyaline membrane disease.
The chest film shows generalized overaeration and coarse nodularity with multiple cystlike
areas throughout both lung fields.

Prophylactic administration of Palivizumab decreases the number of
admissions and acuity of RSV bronchiolitis in infants with BPD. Palivizumab is
administered monthly during RSV season. Clinicians should ask parents about
their child’s status. Referral to the primary care provider for Palivizumab is
warranted for any infant with BPD who was born less than 32 weeks and is
within their first year of life.
Persistent Pulmonary Hypertension of the Newborn
This entity is becoming increasingly recognized in the cyanotic neonate with
respiratory distress. It is more common in full-term infants in the hours to days
after birth. Hypoxia, meconium aspiration, congenital diaphragmatic hernia, and
pulmonary hypoplasia are common causes immediately after birth; however, any
condition that precipitates hypoxic respiratory failure may cause pulmonary
hypertension later (e.g., acute viral infections). The constriction of the pulmonary
arterial vasculature causes right-to-left shunting of deoxygenated blood through
the patent DA or foramen ovale, resulting in hypoxia and severe cyanosis, which
may improve with hyperventilation. Infants may continue to have low oxygen
saturations despite 100% inspired oxygen and aggressive mechanical ventilation.


When pulse oximetry readings are taken separately in each of the four
extremities, oxygenation can be 10% higher in the right arm, the preductal
extremity. Arterial blood gases will show hypoxemia with or without hypercarbia.
CXR will show variable findings according to the underlying etiology.
Aggressive treatment of PPHN should include fluid resuscitation, minimal
stimulation including darkening the room and adequate sedation, and maintaining
adequate systemic pressures with pressors if needed. Use of high-frequency

oscillatory ventilation, inhaled nitric oxide, and extracorporeal membrane
oxygenation may be lifesaving. Any neonate with desaturation, cyanosis, and
escalating acute respiratory failure should be admitted to the intensive care unit.


ABDOMINAL, GASTROINTESTINAL, AND GENITOURINARY
EMERGENCIES
Goals of Treatment
Patient with gastrointestinal emergencies may have massive fluid requirements
because of third spacing. Hypoglycemia and shock are common. Abdominal
distention can interfere with ventilation. Delays in definitive surgical intervention
are associated with worse outcome. Therefore, the goals of emergency care are to
aggressively fluid resuscitate, to provide adequate glucose, and to decompress the
abdomen with nasogastric drainage. Some patients will require intubation. Urgent
consultation with a pediatric surgeon and radiologist will aid in definitive
diagnosis and surgical treatment.
KEY POINTS
Bilious emesis in a newborn is a surgical emergency and presumed
malrotation until proven otherwise.
Decompression of obstructed bowel with a nasogastric tube will reduce
hydrostatic pressure and lower the risk of ischemia of the gut.
RELATED CHAPTERS
Signs and Symptoms
Crying: Chapter 20
Medical, Surgical, and Trauma Emergencies
Endocrine Emergencies: Chapter 89
Gastrointestinal Emergencies: Chapter 91

Malrotation and Volvulus
CLINICAL PEARLS AND PITFALLS

Midgut volvulus is a surgical emergency where operation takes
precedence over resuscitation, which can be continued in the operating
room, in order to preserve bowel.
Plain radiographs and US are nonspecific, and the upper GI series is
the reference standard for diagnosis.
Malrotation is nearly universal in patients after congenital
diaphragmatic hernia repair, however, the incidence of midgut volvulus
in this population is quite low.
Malrotation is a common comorbidity of heterotaxy syndrome, although
the natural history and rate of volvulus in this population are unknown.
Current Evidence
During embryonic development, the bowel undergoes two rotations prior to
fixation in the abdomen. If rotation and fixation are abnormal or incomplete, the
bowel can twist upon itself, resulting in obstruction and/or volvulus with bowel
ischemia and subsequent necrosis. Approximately 1 in 6,000 live births will have
clinically evident malrotation, and over half present within the first month of life.
All infants with congenital diaphragmatic hernia have abnormal rotation and
fixation, however, few go on to develop volvulus (incidence is <10% in this
population)—this is also true for infants with abdominal wall defects, such as
gastroschisis or omphalocele. This is thought to be due to the intra-abdominal
adhesions that develop post repair that hold the bowel in place and prevent it
from twisting upon itself. Gastric malrotation and volvulus is much less common,
but can be associated with congenital malformations of the diaphragm and
asplenia, as well as conditions that result in gastric distention. Colonic volvulus is
uncommon in the neonatal period.
Goals of Treatment
The primary goal of treatment is early recognition of malrotation prior to the
onset of volvulus and bowel ischemia in order to preserve bowel health. In

patients with malrotation without volvulus, early operation is the treatment of
choice. If there are signs of volvulus, time is critical and the goal is emergent
surgery, which takes precedence even over resuscitation, which can be continued
in the operating room. Midgut volvulus accounts for nearly 20% of short gut
syndrome in pediatrics.
Clinical Considerations