Brief resolved unexplained event: Difference between revisions

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===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
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==Pertinent History==
==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.''
''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.''
===Past Medical History===
===Past Medical History===
*Prematurity, history of apnea, prior resp/feeding difficulties
*Prematurity, history of apnea, prior resp/feeding difficulties
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*[[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]]
*Non-accidental trauma
*[[Nonaccidental trauma]]
*Poisoning
*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]]
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**[[ECG]]
**[[ECG]]
**[[LP]]
**[[LP]]
**LFTs
**[[LFTs]]
**MRI Brain
**MRI Brain


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*<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 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>
*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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*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 abnormaility

Revision as of 02:40, 27 January 2019

Background

  • Abbreviation: BRUE
  • BRUE was formerly known as Apparent life-threatening event (ALTE)[1]
  • BRUE definition has a strict age limit 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 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

Clinical Features

Episode that is frightening to caregiver and involves combination of:

  • Apnea
  • Color change
  • Muscle tone change

Pertinent 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.

Past Medical History

  • 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

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

Consider:

Low Risk Criteria

The following criteria place the child at low risk of adverse events[1]

  • Age >60 days
  • Gestational age > 32 weeks
  • First BRUE
  • 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 and close outpatient follow-up

Not Low Risk

Admission in most cases

Especially for:

  • <30 wks 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
  • Obvious need for admission:
    • Supplemental Oxygen requirement
    • Resuscitation
    • Hemodynamic Instability
    • Positive RSV or Pertussis test
  • Significant past medical history
  • Chromosomal abnormaility
  • Chronic Lung Disease
  • > 1 BRUE 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

See Also

External Links

Brue - Don't forget the bubbles

References

  1. 1.0 1.1 1.2 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