Once you figure out the neonate that presented to your ED is sick, run through a differential of why then can be sick so you don’t anchor. I like to use TIMOT (Trauma, Infection, Metabolic, Organs, Tox) but use whatever works for you.
Use your detailed history looking for risk factors to help you narrow the differential down. Do a good hands-on physical exam. Work them up more than you would a standard baby and do things like you would to an adult such as a bedside US. These will all lead you to the diagnosis of a congenital cardiac disease
You have two options now: they either have a cyanotic lesion that requires prostaglandins and a dose of 0.05-0.2 mg/kg/min and will need to be intubated. Or they are in full blown heart failure and require lasix at 1 mg/kg and pressors, typically a combination of dobutamine and norepinephrine.
Don’t be a hero but don’t have imposter syndrome. You can manage these kids, but do so with support from your PICU, cardiac surgeon or transferring institution. What you are doing in the ED is temporizing to keep them alive to definitive therapy which is usually a combination of ECMO and/or surgery. Get them out of your department ASAP.
