Pediatric emergency medicine trisk 2472 2472
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Cyanosis accompanied by mottling in a lethargic neonate with tachycardia
indicates shock. Sepsis, hypovolemia, intra-abdominal surgical emergency, and
metabolic crisis from inborn errors of metabolism (IEM) should be considered in
addition to primary cardiorespiratory problems. Early recognition and volume
resuscitation are critical for treatment.
Methemoglobinemia is characterized by a cyanotic infant without underlying
cardiac or pulmonary disease. The infant can look cyanotic to gray, with an
almost normal-appearing pulse oximetry. Supplemental oxygen will not alter the
color. Methemoglobinemia is confirmed by venous or capillary blood gas or the
persistence of a chocolate-brown color of a blood drop on filter paper. Initial
treatment is first searching and removing the offending agent, which is most often
topical anesthetic agents, aniline dyes, and high levels of nitrate in the water
supplies. Levels of methemoglobinemia above 20% are associated with clinical
symptoms. If methemoglobinemia is greater than 30% of total hemoglobin,
consider a dose of methylene blue, 1 to 2 mg/kg, given over 5 minutes.
Jaundice
CLINICAL PEARLS AND PITFALLS
Jaundice within the first 24 hours of life is pathologic.
Evaluation of jaundice requires assessment of both direct and indirect
bilirubin.
Acceptable levels of indirect hyperbilirubinemia depend on both
prematurity and postnatal age.
Acute bilirubin toxicity results in lethargy and progressive
encephalopathy in the neonate. Untreated, persistent bilirubin
encephalopathy results in kernicterus, a permanent brain injury.
Galactosemia should be considered in infants who have jaundice that
persists beyond 3 weeks of age.
Current Evidence. Jaundice is a yellow appearance of the skin or sclera caused
by elevated bilirubin levels. Bilirubin accumulates with excessive hemolysis,
failure of hemoglobin to conjugate with glucuronic acid in the liver, or inadequate
excretion through the liver canaliculi or bile ducts. Unconjugated bilirubin is
reported as indirect, and indicates excessive red blood cell hemolysis or inability
of the liver to keep pace with conjugation of bilirubin produced by hemolysis.
