Obtain blood glucose, BMP, liver functions, blood gas, and ammonia levels and admit for further management Congenital Adrenal Hyperplasia Emergency providers should be familiar with the differential diagnosis of adrenal insufficiency due to congenital adrenal hyperplasia presenting as shock in a neonate This diagnosis should be suspected in infants presenting with poor feeding, vomiting, or lethargy In the severe, salt-wasting forms, there are characteristic metabolic derangements of hyponatremia, hyperkalemia, metabolic acidosis, and hypoglycemia On physical examination, female infants can exhibit ambiguous genitalia, depending on degree of virilization, but males usually have normal-appearing genitalia Neonates presenting in adrenal crisis will require urgent intervention Initial goals include correction of hypotension and dehydration, reversal of electrolyte and glucose abnormalities, and correction of cortisol deficiency Obtain bedside glucose determination Address hypoglycemia with 10% dextrose solutions, initial doses of mL/kg After correcting the hypoglycemia, a continuous infusion of dextrose should be started An initial fluid bolus of normal saline should be given and repeated as necessary to restore perfusion Intravenous hydrocortisone should be administered immediately, at an initial dose of 50 to 100 mg/m2 as an IV bolus (typically 25 mg for infants) followed by 50 to 100 mg/m2 IV per day divided every hours Suggested Readings and Key References Kemper AR, Mahle WT, Martin GR, et al Strategies for implementing screening for critical congenital heart disease Pediatrics 2011;128(5):e1259–e1267 Initial Assessment Levesque BM, Pollack P, Griffin BE, et al Pulse oximetry: what’s normal in the newborn nursery? Pediatr Pulmonol 2000;30(5):406–412 Soghier L, Pham K, Rooney S, eds Reference Range Values for Pediatric Care 1st ed Illinois, IL: AAP Bookstore, Ilk Groove; 2014 Zubrow AB, Hulman S, Kushner H, et al Determinants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicenter study Philadelphia Neonatal Blood Pressure Study Group J Perinatol 1995;15(6):470–479 Derm/Color Changes