A newborn girl is evaluated in the delivery room for respiratory distress. The patient was born 15 minutes ago by spontaneous vaginal delivery at 37 weeks gestation to a mother who received no prenatal care. Temperature is 37 C (98.6 F), pulse is 176/min, and respirations are 70/min. Pulse oximetry is 82% on room air. Physical examination shows grunting; subcostal and suprasternal retractions; and cyanosis of the lips and tongue. The chest appears rounded and the abdomen appears flat. Auscultation reveals absent breath sounds on the left and clear breath sounds on the right. Heart sounds are loudest in the right chest. Which of the following is the best next step in management of this patient?

Question

A newborn girl is evaluated in the delivery room for respiratory distress.  The patient was born 15 minutes ago by spontaneous vaginal delivery at 37 weeks gestation to a mother who received no prenatal care.  Temperature is 37 C (98.6 F), pulse is 176/min, and respirations are 70/min.  Pulse oximetry is 82% on room air.  Physical examination shows grunting; subcostal and suprasternal retractions; and cyanosis of the lips and tongue.  The chest appears rounded and the abdomen appears flat.  Auscultation reveals absent breath sounds on the left and clear breath sounds on the right.  Heart sounds are loudest in the right chest.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d719_9ea7_bc81_7d64badedf7d_MD0003_00 This neonate's presentation is concerning for congenital diaphragmatic hernia (CDH), a rare but life-threatening diaphragmatic defect that allows abdominal contents to herniate into the chest. The resultant lung compression leads to pulmonary hypoplasia with vascular remodeling and pulmonary hypertension. CDH may be diagnosed on prenatal ultrasound or shortly after birth. Patients present with respiratory distress, cyanosis, and absent unilateral breath sounds due to the abdominal contents herniating into the affected side of the chest. Protrusion of abdominal viscera into the thorax also causes a concave abdomen and barrel-shaped chest on examination, as seen here. In most cases, the diaphragmatic defect is left-sided, causing deviation of the heart into the right thorax and right-sided heart sounds, also seen in this patient. The first step in management of CDH is endotracheal intubation. Mechanical ventilation should be used cautiously with limited pressures to avoid barotrauma to the hypoplastic lungs. Bag-and-mask ventilation is contraindicated because it pumps air into the gastrointestinal tract, leading to further lung compression. In addition, a gastric tube should be inserted and connected to continuous suction to prevent bowel distension. Surgical correction is the definitive treatment. (Choice A) Broad-spectrum antibiotics treat pneumonia, which can present with acute respiratory distress and temperature instability (eg, fever, hypothermia). Abnormal unilateral breath sounds (eg, crackles) may be present, but right-sided heart sounds would not be expected. (Choice B) Chest tube may be placed for pneumothorax, which can cause respiratory distress and hypoxia; tension pneumothorax can additionally cause deviation of the heart and requires emergency needle decompression. A scaphoid abdomen would not be seen. (Choice D) Pericardiocentesis is the treatment for cardiac tamponade, which causes tachypnea and muffled heart sounds. Breath sounds are typically normal. In addition, tamponade is rare in children and usually due to penetrating trauma. (Choice E) Prostaglandin E1 maintains a patent ductus arteriosus in patients with suspected ductal-dependent congenital heart disease (eg, transposition of the great arteries), which typically presents with cyanosis and tachypnea in the first few days of life. A murmur is often present, not absent breath sounds or displaced heart sounds. (Choice F) Surfactant is administered for respiratory distress syndrome, which most commonly presents in premature neonates with tachypnea, cyanosis, and increased work of breathing. Absent unilateral breath sounds in a full-term neonate makes this diagnosis unlikely. Educational objective: The first step in management of a newborn with suspected congenital diaphragmatic hernia is endotracheal intubation. A gastric tube should also be placed immediately to decompress the stomach and bowel. Bag-and-mask ventilation can exacerbate respiratory decline and should be avoided. References: Congenital diaphragmatic hernia. (http://www.ncbi.nlm.nih.gov/pubmed/22034651)

A Newborn Girl Is Evaluated in the Delivery Room for Respiratory