The Critically Ill Infant

We discuss an approach to the critically ill infant.

Hosts:
Ellen Duncan, MD, PhD
Brian Gilberti, MD

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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 im