Brief resolved unexplained event: Difference between revisions
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*Negative predictive value of 96.5%  
*Negative predictive value of 96.5%  
*Sensitivity of 89% , a Specificity of 61.9% , and a calculated  
*Sensitivity of 89% , a Specificity of 61.9% , and a calculated  
*'''14 (2%) patients were discharged incorrectly'''
*'''14 (2%) patients were incorrectly discharged'''


== Source ==
== Source ==

Revision as of 00:52, 26 April 2014

Background

  • Peak incidence: 1wk - 2mo
  • ALTE is a symptom, not a dx
  • Only 10% have repeat events
  • ALTE is not related to SIDS

Diagnosis

  • Episode that is frightening to caregiver and involves combination of:
    • Apnea
    • Color change
    • Muscle tone change
    • Choking or gagging

History

  • PMH
    • Prematurity, history of apnea, prior resp/feeding difficulties
    • Immunization status (pertussis)
  • FH
    • History of SIDS, cardiac, seizure, metabolic disease
  • Event
    • Duration, resus required
    • Temporal relationship with feeding, sleeping, crying, vomiting, choking
    • Central versus obstructive pattern of apnea
    • Episodic versus sustained change in mental status
  • ROS
    • Respiratory symptoms
    • Medication use

Risk Factors

  1. RSV infection
  2. Prematurity
  3. Recent anesthesia
  4. GERD
  5. Airway/maxillofacial anomalies

DDX[1]

Common[2]

  1. Idiopathic (~50%)
  2. GERD
  3. Seizure
  4. Respiratory tract infection
  5. Misinterpretation of benign process (e.g. periodic breathing)
  6. Vomiting/choking episode

Less Common

  1. Pertussis
  2. Inflicted injury
  3. Poisoning
  4. Serious bacterial infection
    1. Must consider in all febrile pts with ALTE
  5. Electrolyte abnormality (incl glucose)

Uncommon

  1. Arrhythmia
  2. Anemia
  3. Breath-holding spell (6mo - 4yrs)
  4. Metabolic disease

Work-Up

(Individualize testing by history and exam)

  1. CBC
  2. Chem 10
  3. UA
  4. CXR
  5. Pertussis nasal swab
  6. RSV nasal swab
  7. Consider:
    1. UCx/BC
    2. ECG
    3. LP
    4. LFTs
    5. MRI Brain

Management

  1. Stable patients without a clear diagnosis
    1. No evidence-based guidelines for proper w/u dispo decision
  2. Stable patients with a clear diagnosis
    1. Manage according to identified disease


Empiric Treatment for Unstable Patients without Clear Diagnosis

Medication/Intervention Indication Dose/Size (for neonate)
Glucose Hypoglycemia 5–10 mL/kg of 10% dextrose in water IV
3% normal saline Symptomatic hyponatremia 3–5 mL/kg bolus IV
Calcium Hypocalcemia 50–100 milligrams/kg calcium gluconate or 20 milligrams/kg calcium chloride IV
Cefotaxime Infection 50 milligrams/kg IV
Ampicillin Infection 50 milligrams/kg IV
Packed red blood cells Anemia 10 mL/kg IV
Normal saline Hypotension, dehydration 20 mL/kg IV
10% dextrose in one fourth normal saline Metabolic disease 1.5 maintenance (6 mL/kg/h for the first 10 kg)
Endotracheal intubation Hypoventilation or frequent apnea 3mm for preemie; 3mm for term neonate, 4mm for older infant

Disposition

Admission in most cases

Especially for:

  1. <48wk postconceptual age
  2. Ill-appearing
  3. Bronchiolitis or pertussis w/ apnea
  4. >1 event in past 24hr or multiple ALTEs
  5. Abnormalities in PMH
  6. Prolonged central apnea >20s
  7. ALTE requiring resus
  8. Family history of SIDS

Current Research

  • Neither of these decision rules have been validated

Mittal ALTE Decision Rule[3]

  • 300 Infants in a single center with 76% admission rate with 37 (12%) required significant intervention
Predictors for requiring intervention
  1. Prematurity
  2. Abnormal physical examination
  3. Color change to cyanosis,
  4. Absence of upper respiratory infection symptoms and the absence of choking
  • Negative predictive value: 96%
  • Specificity of 70.5%
  • 7 out of the 184 (3.8%) were incorrectly discharged

Kaji ALTE Decision Rule[4]

  • 832 patients from 4 different study sites, with a 79.2% admission rate
Predictors for requiring admission
  1. Obvious need for admission:
    1. Supplemental Oxygen requirement
    2. Resuscitation
    3. Hemodynamic Instability
    4. Positive RSV or Pertussis test
  2. Significant past medical history
    1. Congenital heart disease
    2. Down Syndrome
    3. Previous Intubation
  3. Chromosomal abnormaility
  4. Chronic Lung Disease
  5. > 1 ALTE in 24 hours
  • Negative predictive value of 96.5%
  • Sensitivity of 89% , a Specificity of 61.9% , and a calculated
  • 14 (2%) patients were incorrectly discharged

Source

  1. ↑ McGovern MC. et al. Smith MB. Causes of apparent life threatening events in children: a systemic review. Arch Dis Child. 2004;89(11):1043-1048
  2. ↑ Okada K et al. Discharge Diagnoses in infants with apparent life threatening event admissions and gastroesophageal reflux disease. Pediatric Emergency Care. 2012;28(1):17-21
  3. ↑ Mittal M. et al. A clinical decision rule to identify infants with apparent life-threatening events who can be safely discharged from the emergency department. Pediatric Emergency Care. 2012;28(7): 599-605
  4. ↑ Kaji A et al. Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med. 2013;61(4):379-387
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