Difference between revisions of "Brief resolved unexplained event"

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==Background==
 
==Background==
*BRUE was formerly known as Apparent life-threatening event (ALTE)<ref name="aap">Tieder et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. May 2016, Vol. 137(5)</ref>
+
*Abbreviation: BRUE
*BRUE definition has a strict age limit unlike ALTE and a BRUE should only be considered if there is not other likely explanation.
+
*BRUE was formerly known as Apparent life-threatening event (ALTE)<ref name="aap">[https://www.ncbi.nlm.nih.gov/pubmed/27244835 Tieder et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. May 2016, Vol. 137(5)]</ref>
*Peak incidence: 1wk - 2mo
+
*BRUE definition has a strict age limit (<1 y/o) and should only be considered if no other likely explanation  
 +
*Peak incidence: 1 wk - 2 mo
 
*BRUE is a symptom and requires evaluation for the actual diagnosis causing the event
 
*BRUE is a symptom and requires evaluation for the actual diagnosis causing the event
 
*Only 10% have repeat events
 
*Only 10% have repeat events
 
*BRUE is not related to [[SIDS]]
 
*BRUE is not related to [[SIDS]]
 +
 
===Definition===
 
===Definition===
 
BRUE diagnosis is only made by a clinician based on the features and is not based on the caregiver's perception of what happened. BRUE is an event occurring in an infant <1 year of age  when an observer reports a sudden, brief '''( <1 minute but typically <20–30 seconds)''', and now resolved episode of ≥1 of the following:<ref name="aap"></ref>
 
BRUE diagnosis is only made by a clinician based on the features and is not based on the caregiver's perception of what happened. BRUE is an event occurring in an infant <1 year of age  when an observer reports a sudden, brief '''( <1 minute but typically <20–30 seconds)''', and now resolved episode of ≥1 of the following:<ref name="aap"></ref>
 
*Cyanosis or pallor
 
*Cyanosis or pallor
 
*Absent, decreased, or irregular breathing
 
*Absent, decreased, or irregular breathing
*Marked change in tone (hyper- or hypotonia)
+
*Marked change in tone (hyper or hypotonia)
 
*Altered level of responsiveness
 
*Altered level of responsiveness
 
*Must have returned to baseline
 
*Must have returned to baseline
A BRUE should only be diagnosed when there is no explanation for a the event after full history and physical
+
''A BRUE should only be diagnosed when there is no alternative explanation for a the event after completing full history and physical.''
  
 
===ALTE to BRUE Definiton Changes===
 
===ALTE to BRUE Definiton Changes===
 
*BRUE has a strict age limit < 1yo
 
*BRUE has a strict age limit < 1yo
*There must be no other explanation for the event (not something as simple as nasal congestion, choking, viral infection or vomitting)
+
*There must be no other explanation for the event (not something as simple as nasal congestion, choking, viral infection or vomiting)
 
*Caregiver's perception of a BRUE does not make an event a BRUE without clinical suspicion
 
*Caregiver's perception of a BRUE does not make an event a BRUE without clinical suspicion
 
*Altered responsiveness is a new criteria
 
*Altered responsiveness is a new criteria
  
 
===Risk Factors===
 
===Risk Factors===
*RSV infection
+
*[[RSV]] infection
 
*Prematurity
 
*Prematurity
 
*Recent anesthesia
 
*Recent anesthesia
*GERD
+
*[[GERD]]
 
*Airway/maxillofacial anomalies
 
*Airway/maxillofacial anomalies
 
*Age < 10 wks
 
*Age < 10 wks
 
*History of apnea
 
*History of apnea
 
*Pallor, cyanosis, feeding difficulties
 
*Pallor, cyanosis, feeding difficulties
 +
*Family hx of sudden cardiac death
  
 
==Clinical Features==
 
==Clinical Features==
Episode that is frightening to caregiver and involves combination of:
+
''See definition above''
*Apnea
+
*Extensive list of historical features to be considered from [https://pediatrics.aappublications.org/highwire/markup/111204/expansion?width=1000&height=500&iframe=true&postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed Table 2 of the original BRUE article.]<ref name="aap"></ref>
*Color change
+
*Extensive list of physical exam features be considered from [https://pediatrics.aappublications.org/highwire/markup/111147/expansion?width=1000&height=500&iframe=true&postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed Table 3 of the original BRUE article.]<ref name="aap"></ref>
*Muscle tone change
 
*Choking or gagging
 
  
==Pertinent History==
 
''The history in an BRUE should focus extensively on the details surrounding the event, need for resuscition, prior events, possible related medical conditions, or historic findings that may indicate prior events.''
 
 
===Past Medical History===
 
===Past Medical History===
*Prematurity, history of apnea, prior resp/feeding difficulties?
+
''The history in an BRUE should focus extensively on the details surrounding the event, need for resuscitation, prior events, possible related medical conditions, or historic findings that may indicate prior events.''
 +
*Prematurity, history of apnea, prior resp/feeding difficulties
 
*Immunization status (particularly pertussis)
 
*Immunization status (particularly pertussis)
===Family HIstory===
+
 
*History of [[SIDS]], cardiac abnormalities, seizures, or metabolic disease?
+
===Family History===
 +
*History of [[SIDS]], cardiac abnormalities, seizures, or metabolic disease
 +
 
 
===Event===
 
===Event===
 
*Duration of the BRUE
 
*Duration of the BRUE
 
*Was resuscitation with CPR and rescue breaths required?
 
*Was resuscitation with CPR and rescue breaths required?
*What was the temporal relationship with feeding, sleeping, crying, vomiting, or choking
+
*Temporal relationship with feeding, sleeping, crying, vomiting, or choking
 
*Any episodes concerning for central versus obstructive patterns of apnea
 
*Any episodes concerning for central versus obstructive patterns of apnea
 
*Any progressive or episodic changes in mental status
 
*Any progressive or episodic changes in mental status
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
The differential diagnosis is quite extensive and although a broad workup is often started in the ED including evaluation for sepsis and occult infections and metabolic disorders, a cause is infrequently found<ref>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</ref>  
+
''The differential diagnosis is extensive, and although a broad workup is often started in the ED including evaluation for sepsis, occult infection, and metabolic disorders, a cause is infrequently found<ref>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</ref> ''
 
===Common<ref>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</ref>===
 
===Common<ref>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</ref>===
 
*Idiopathic (~50%)
 
*Idiopathic (~50%)
 
*[[GERD]]
 
*[[GERD]]
 
*[[Seizure]]
 
*[[Seizure]]
*Respiratory tract infection
+
*Respiratory tract infection (e.g. [[bronchiolitis]])
 
*Misinterpretation of benign process (e.g. periodic breathing)
 
*Misinterpretation of benign process (e.g. periodic breathing)
 
*[[Vomiting]]/choking episode
 
*[[Vomiting]]/choking episode
 
===Less Common===
 
===Less Common===
 
*[[Pertussis]]
 
*[[Pertussis]]
*Inflicted injury
+
*[[Nonaccidental trauma]]
*Poisoning
+
*[[Toxicity|Poisoning]]
*Serious bacterial infection
+
*Serious bacterial infection (e.g.[[Meningitis (Peds)|meningitis]],  [[Pneumonia (Peds)|pneumonia]], [[Bacteremia]], [[UTI (Peds)|UTI)]])
 
**Must consider in all febrile patients with BRUE
 
**Must consider in all febrile patients with BRUE
*Electrolyte abnormality (includes glucose)
+
*[[Electrolyte abnormalities]] (including [[hypoglycemia (Peds)|hypoglycemia]] and other glucose abnormalities)
 
===Uncommon===
 
===Uncommon===
 
*[[Arrhythmia]]
 
*[[Arrhythmia]]
 
*[[Anemia]]
 
*[[Anemia]]
*Breath-holding spell (6mo - 4yrs)
+
*[[Breath-holding spell]] (6mo - 4yrs)
*Metabolic disease
+
*[[inborn errors of metabolism|Metabolic disease]]
  
 
==Evaluation==
 
==Evaluation==
 
===Work-Up===
 
===Work-Up===
''Individualize testing by history and exam. These are generally not needed for the low risk patients.''
+
====Low Risk====
 +
''Individualize testing by history and exam. These are <u>generally not needed</u> for the low risk patients.''
 +
*Consider:
 +
**Obtain [[pertussis]]
 +
**[[ECG]]
 +
**Briefly observe on pulse oximetry (e.g. 1-3 hours)
  
Consider:
+
====Moderate or Higher Risk====
 
*CBC
 
*CBC
 
*Chem 10
 
*Chem 10
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**[[ECG]]
 
**[[ECG]]
 
**[[LP]]
 
**[[LP]]
**LFTs
+
**[[LFTs]]
**MRI Brain
+
**[[brain MRI|MRI Brain]]
  
===Low Risk Criteria===
+
===Diagnosis===
The following criteria place the child at low risk of adverse events<ref name="aap"></ref>
+
''See Definition in Background section''
 +
====Low Risk Criteria<ref name="aap"></ref>====
 
*Age >60 days
 
*Age >60 days
*Gestational age > 32 weeks
+
*Gestational age > 32 weeks and post-conceptional age >= 45 weeks
*First BRUE
+
*First BRUE ever
 +
**No prior BRUE or BRUE in clusters
 +
*BRUE duration <1 minute
 
*No CPR by a medical provider
 
*No CPR by a medical provider
*No concern for child abuse, family history of sudden unexplained death,or toxic exposures
+
*No concern for [[child abuse]], family history of sudden unexplained death,or toxic exposures
*No abnormal physical findings: (bruising, cardiac murmurs, organomegaly).
+
*No abnormal physical findings: (bruising, cardiac [[murmur]]s, [[hepatomegaly|organomegaly]])
  
 
==Management==
 
==Management==
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==Disposition==
 
==Disposition==
 
===Low Risk===
 
===Low Risk===
Discharged with shared parental decision making and close outpatient follow-up
+
*Discharged with shared parental decision making, CPR instructions, and close outpatient follow-up
  
 
===Not Low Risk===
 
===Not Low Risk===
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Especially for:
 
Especially for:
*<30 wks preterm<ref>Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted? Pediatrics. 2007;119(4):679–683pmid:17403838</ref>
+
*<30 weeks preterm<ref>Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted? Pediatrics. 2007;119(4):679–683pmid:17403838</ref>
 
*Ill-appearing or abnormal vitals (including pulse ox)<ref>Hunt CE et al. Collaborative Home Infant Monitoring Evaluation (CHIME) Study Group. Longitudinal assessment of hemoglobin oxygen saturation in healthy infants during the first 6 months of age. J Pediatr. 1999;135(5):580–586pmid:10547246</ref>
 
*Ill-appearing or abnormal vitals (including pulse ox)<ref>Hunt CE et al. Collaborative Home Infant Monitoring Evaluation (CHIME) Study Group. Longitudinal assessment of hemoglobin oxygen saturation in healthy infants during the first 6 months of age. J Pediatr. 1999;135(5):580–586pmid:10547246</ref>
*Bronchiolitis or pertussis with apnea
+
*[[Bronchiolitis]] or [[pertussis]] with apnea
 
*>1 event in past 24hr or multiple BRUE
 
*>1 event in past 24hr or multiple BRUE
 
*Abnormalities in past medical history  
 
*Abnormalities in past medical history  
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;Predictors for requiring admission
 
;Predictors for requiring admission
 
*Obvious need for admission:
 
*Obvious need for admission:
**Supplemental Oxygen requirement
+
**[[hypoxia|Supplemental Oxygen]] requirement
 
**Resuscitation
 
**Resuscitation
**Hemodynamic Instability
+
**[[shock|Hemodynamic Instability]]
**Positive RSV or Pertussis test
+
**Positive [[RSV]] or [[Pertussis]] test
 
*Significant past medical history
 
*Significant past medical history
**Congenital heart disease
+
**[[Congenital heart disease]]
**Down Syndrome
+
**[[Down syndrome]]
**Previous Intubation
+
**Previous [[intubation]]
*Chromosomal abnormaility
+
*Chromosomal abnormality
*Chronic Lung Disease
+
*Chronic lung disease (e.g. [[bronchopulmonary dysplasia]])
 
*> 1 BRUE in 24 hours
 
*> 1 BRUE in 24 hours
 
*Negative predictive value of 96.5%  
 
*Negative predictive value of 96.5%  
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==External Links==
 
==External Links==
[http://dontforgetthebubbles.com/brue-is-the-new-black/ Brue - Don't forget the bubbles]
+
[http://dontforgetthebubbles.com/brue-is-the-new-black/ Brue - Don't forget the bubbles]<BR>
 +
[http://thesgem.com/2019/12/sgem-xtra-strange-brue/ SGEM Xtra: Strange Brue from The Sketics' Guide to EM]
  
 
==References==
 
==References==

Latest revision as of 02:19, 22 December 2020

Background

  • Abbreviation: BRUE
  • BRUE was formerly known as Apparent life-threatening event (ALTE)[1]
  • BRUE definition has a strict age limit (<1 y/o) and should only be considered if no other likely explanation
  • Peak incidence: 1 wk - 2 mo
  • BRUE is a symptom and requires evaluation for the actual diagnosis causing the event
  • Only 10% have repeat events
  • BRUE is not related to SIDS

Definition

BRUE diagnosis is only made by a clinician based on the features and is not based on the caregiver's perception of what happened. BRUE is an event occurring in an infant <1 year of age when an observer reports a sudden, brief ( <1 minute but typically <20–30 seconds), and now resolved episode of ≥1 of the following:[1]

  • Cyanosis or pallor
  • Absent, decreased, or irregular breathing
  • Marked change in tone (hyper or hypotonia)
  • Altered level of responsiveness
  • Must have returned to baseline

A BRUE should only be diagnosed when there is no alternative explanation for a the event after completing full history and physical.

ALTE to BRUE Definiton Changes

  • BRUE has a strict age limit < 1yo
  • There must be no other explanation for the event (not something as simple as nasal congestion, choking, viral infection or vomiting)
  • Caregiver's perception of a BRUE does not make an event a BRUE without clinical suspicion
  • Altered responsiveness is a new criteria

Risk Factors

  • RSV infection
  • Prematurity
  • Recent anesthesia
  • GERD
  • Airway/maxillofacial anomalies
  • Age < 10 wks
  • History of apnea
  • Pallor, cyanosis, feeding difficulties
  • Family hx of sudden cardiac death

Clinical Features

See definition above

Past Medical History

The history in an BRUE should focus extensively on the details surrounding the event, need for resuscitation, prior events, possible related medical conditions, or historic findings that may indicate prior events.

  • Prematurity, history of apnea, prior resp/feeding difficulties
  • Immunization status (particularly pertussis)

Family History

  • History of SIDS, cardiac abnormalities, seizures, or metabolic disease

Event

  • Duration of the BRUE
  • Was resuscitation with CPR and rescue breaths required?
  • Temporal relationship with feeding, sleeping, crying, vomiting, or choking
  • Any episodes concerning for central versus obstructive patterns of apnea
  • Any progressive or episodic changes in mental status

Differential Diagnosis

The differential diagnosis is extensive, and although a broad workup is often started in the ED including evaluation for sepsis, occult infection, and metabolic disorders, a cause is infrequently found[2]

Common[3]

  • Idiopathic (~50%)
  • GERD
  • Seizure
  • Respiratory tract infection (e.g. bronchiolitis)
  • Misinterpretation of benign process (e.g. periodic breathing)
  • Vomiting/choking episode

Less Common

Uncommon

Evaluation

Work-Up

Low Risk

Individualize testing by history and exam. These are generally not needed for the low risk patients.

  • Consider:
    • Obtain pertussis
    • ECG
    • Briefly observe on pulse oximetry (e.g. 1-3 hours)

Moderate or Higher Risk

Diagnosis

See Definition in Background section

Low Risk Criteria[1]

  • Age >60 days
  • Gestational age > 32 weeks and post-conceptional age >= 45 weeks
  • First BRUE ever
    • No prior BRUE or BRUE in clusters
  • BRUE duration <1 minute
  • No CPR by a medical provider
  • No concern for child abuse, family history of sudden unexplained death,or toxic exposures
  • No abnormal physical findings: (bruising, cardiac murmurs, organomegaly)

Management

Low Risk

Low Risk infants can be safely discharged but there should be shared decision making with parents.

  • Also offer the family CPR training resources
  • Consider pertussis swab, ECG, and brief monitored observation in the ED.
  • No other consults, metabolic or hematologic labs or medications are necessary for discharge

Disposition

Low Risk

  • Discharged with shared parental decision making, CPR instructions, and close outpatient follow-up

Not Low Risk

Admission in most cases

Especially for:

  • <30 weeks preterm[4]
  • Ill-appearing or abnormal vitals (including pulse ox)[5]
  • Bronchiolitis or pertussis with apnea
  • >1 event in past 24hr or multiple BRUE
  • Abnormalities in past medical history
  • Prolonged central apnea >20 seconds
  • Need for resuscitation
  • Family history of SIDS

Current Research

  • Neither of these decision rules have been validated

Mittal ALTE Decision Rule[6]

  • 300 Infants in a single center with 76% admission rate with 37 (12%) required significant intervention
Predictors for requiring intervention
  • Prematurity
  • Abnormal physical examination
  • Color change to cyanosis,
  • 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[7]

  • 832 patients from 4 different study sites, with a 79.2% admission rate
Predictors for requiring admission

See Also

External Links

Brue - Don't forget the bubbles
SGEM Xtra: Strange Brue from The Sketics' Guide to EM

References

  1. 1.0 1.1 1.2 1.3 1.4 Tieder et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. May 2016, Vol. 137(5)
  2. 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
  3. 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
  4. Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted? Pediatrics. 2007;119(4):679–683pmid:17403838
  5. Hunt CE et al. Collaborative Home Infant Monitoring Evaluation (CHIME) Study Group. Longitudinal assessment of hemoglobin oxygen saturation in healthy infants during the first 6 months of age. J Pediatr. 1999;135(5):580–586pmid:10547246
  6. 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
  7. 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