Brief resolved unexplained event
Background
- BRUE was formally known as Apparent life-threatening event (ALTE)[1]
- Peak incidence: 1wk - 2mo
- ALTE is a symptom and requires evaluation for the actual diagnosis causing the event
- Only 10% have repeat events
- ALTE is not related to SIDS
Definition
An apparent life-threatening event (ALTE) is defined as an episode that is frightening to the observer and is characterized by some combination of apnea (central or obstructive), color change (cyanotic, pallid, erythematous or plethoric) change in muscle tone (usually diminished), and choking or gagging[2]
Risk Factors
- RSV infection
- Prematurity
- Recent anesthesia
- GERD
- Airway/maxillofacial anomalies
- Age < 10 wks
- Hx of apneas
- Pallor, cyanosis, feeding difficulties
Clinical Features
Episode that is frightening to caregiver and involves combination of:
- Apnea
- Color change
- Muscle tone change
- Choking or gagging
Pertinent History
The history in an ALTE 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
- 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 ALTE
- Was resuscitation with CPR and rescue breaths required?
- What was the 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 quite extensive and although a broad workup is often started in the ED including evaluation for sepsis and occult infecetions and metabolic disorders, a cause is infrequently found[3]
Common[4]
- Idiopathic (~50%)
- GERD
- Seizure
- Respiratory tract infection
- Misinterpretation of benign process (e.g. periodic breathing)
- Vomiting/choking episode
Less Common
- Pertussis
- Inflicted injury
- Poisoning
- Serious bacterial infection
- Must consider in all febrile pts with ALTE
- Electrolyte abnormality (includes glucose)
Uncommon
- Arrhythmia
- Anemia
- Breath-holding spell (6mo - 4yrs)
- Metabolic disease
Diagnosis
Individualize testing by history and exam
Management
- Stable patients without a clear diagnosis
- No evidence-based guidelines for proper w/u dispo decision
- Stable patients with a clear diagnosis
- Manage according to identified disease
Empiric Treatment for Unstable Patients
| 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:
- <48wk postconceptual age
- Ill-appearing
- Bronchiolitis or pertussis w/ apnea
- >1 event in past 24hr or multiple ALTEs
- Abnormalities in PMH
- Prolonged central apnea >20s
- ALTE requiring resus
- Family history of SIDS
Current Research
- Neither of these decision rules have been validated
Mittal ALTE Decision Rule[5]
- 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[6]
- 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
- Congenital heart disease
- Down Syndrome
- Previous Intubation
- Chromosomal abnormaility
- Chronic Lung Disease
- > 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
References
- ↑ Tieder et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. May 2016, Vol. 137(5)
- ↑ National Institute of Health. Infantile apnea and home monitoring. Natl Inst Health Consens Dev Conf Consens Statement. 1986 Oct 1. 6(6):1-10
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 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