rasika

1. CASE DESCRIPITION
• 2 months old male child brought to casualty with respiratory distress on tube/bag
ventilator referred from cuddalore GH.
• Previous day child had H/O seizure involving all 4 limbs, up rolling of eyes, drooling of
saliva-lasting for 5 mins, then child became unresponsive shifted to cuddalore GH
• Child had cardiac arrest and was retrieved with CPR and adrenaline and intubated and
put on mechanical ventilation, started on inotropes –after 1 day referred to our hospital
for further management
EVENT – child was waking up from sleep,
Prior to episode child was fed 1 hour back
• No H/O fever/cough/cold/respiratory distress prior to this episode.
• No H/O seizure previously.
• No previous hospitalization.
• H/O previous nebulisation - one episodes at 10 days of

2. • First born to 2◦ CM via LSCS i/v/o CPD with B.wt-
3.20kg, cried immediately after birth.
• H/O laryngomalacia since birth.
• Vaccinated up to date and developmentally normal
child.
• Positive examination: child was irritable, inspiratory
stridor with retractions, temp-103◦ F
• WORKING DIAGNOSIS:
Severe laryngomalacia, Post cardiac arrest,
Hypoxic seizure, Severe bronchiolitis.

3. • In PICU child was extubated and connected to prongs
and connected to nasal prongs.
• On day 3 of admission, child has sudden cardiac
arrest of HR<60/min and spo2 20%.lips and
peripheries cyanosed. child was retrieved with CPR
and 3 doses of adrenaline was given and intubated
and connected to mechanical ventilator.
• Since child had 2 major ALTE, planned to rule out
GERD,CARDIAC,CNS&CONGENITAL causes.
• Plan was to do imaging, LP,EEG,ECHO,ECG, MRI Brain.

4. • On day 6 of hospitalization child was extubated and
connected to NIV.
• Post extubation X-ray showed haziness and started
on Piptaz and Amikacin
• WORKING DIAGNOSIS:
Severe laryngomalacia/Post cardiac arrest/VAP
• At present child is on NIV & day 3 of
PIPTAZ & AMIKACIN.
• NOW day 11 of hospitalization- having distress with
desaturation in deep sleep up to 68% and pricked up
immediately. On nasopharyngeal CPAP with O2
4L/min

5. Brief Resolved Unexplained
Events (Formerly Apparent
Life-Threatening Events)
DR.D.RASIKAPRIYA
MD PAEDIATRICS
RESIDENT

6. OBJECTIVES
• Introduction
• Definition
• ALTE vs. BRUE
• BRUE diagnosis
• Risk stratification
• Recommendation for lower risk
• Work up for high risk
• Implementation and improvement
• Take home messages

7. INTRODUCTION
• Near miss sudden infant death syndrome
• In 1986 replaced with ALTE by National institutes of
health consensus conference on infantile apnea.
• ALTE was replaced with “ Brief Resolved Unexplained
Events” -2016

8. COMPONENTS INCLUSION
BRIEF <1 min, typically 20-30 secs
RESOLVED Child returned to his or her baseline state
of health after event
Normal vital signs and appearance
UNEXPLAINED Not explained by an identifiable medical
condition
EVENT CHARACTERIZATION:
1. Cyanosis or pallor
2. Absent , decreased or
irregular breathing
3. Marked changes in tone
4. Altered responsiveness
Central cyanosis/central pallor
Apnea – central/obstructive/mixed
Hypertonia /Hypotonia
BRUE

9. Definition
an event occurring in an infant < 1 year of age when the
observer reports -a sudden, brief, and now resolved
episode of >1 of the following:
1. Cyanosis or pallor
2. Absent , decreased or irregular breathing
3. Marked change in tone
4. Altered level of responsiveness

10. ALTE BRUE
Episode in first year of life that appears
potentially life threating to observer
Event <1 year where observer – sudden,
brief period
No explanation for event after
appropriate history and PE
Color change
Apnea
Alteration in muscle tone
Choking or gagging
Cyanosis or pallor
Absent ,decreased or irregular breathing
Marked change in tone
Altered level of responsiveness
Both chief complaint and diagnosis
Not always life threatening
Can have ongoing symptoms
Can have diagnosis
Diagnosis of exclusion
Excludes patients with an explanation or
diagnosis
Excludes symptomatic infants
ALTE VS BRUE

11. INITIAL EVALUATION
• History – of event
• Physical Examination

12. General description:
–Who reported the event?
–Witness of the event?
–State immediately before the event
–State during the event
–End of event
–State after event

13. • Recent history:
–Illness in preceding day
–Injuries, falls, previous unexplained bruising
• Past medical history:
–Birth details/growth and development
–Previous BRUE episodes
–Previous hospitalization
–Recent immunization

14. • Family history:
-Sudden death in family
-Developmental delay
-Inborn errors in family
-Genetic disorder
• Environmental history:
Housing / Exposure
• Social history

15. Contd..
• Considerations for possible child abuse:
Changing versions of the history/circumstances
History/circumstances inconsistent with child’s developmental
stage
History of unexplained bruising

16. • Physical examination:
–Head to Toe
–General examination
–Anthropometry
–Systemic examination- done to rule out causes or
underlying disease.

17. WARNING SIGNS:
• Time of evaluation-toxic appearance, lethargy,
unexplained recurrent vomiting, or respiratory
distress
• Physiological compromise
• Evidence of trauma
• Prior events
• Events or unexplained death in sibling
• Dysmorphic features

18. Well appearing Child have additional symptoms or abnormal vital signs
Clinician
characterizes the
event as BRUE
Event criteria absent
Event criteria present
Perform –history and PE
NO EXPLANATION- DIAGNOSIS - BRUE
Explanation or event identified
manage accordingly
BRUE < 1 YEAR
Not a BRUE

19. Risk stratification:
• Low Risk:
1. Age > 60 days
2. Prematurity
3. First BRUE
4. Duration <1 min
5. No CPR required
6. No concerning history
or PE.
• High risk:
1. Infant <2 months
2. 1 event
3. Concerns identified in
history or PE

20. RECOMMENDATIONS FOR LOWER RISK
• SHOULD:
–Educate caregivers about BRUE
–Offer resources for CPR training or caregiver
• MAY:
–12 lead ECG
–Briefly monitor of patients

21. Contd..
• SHOULD NOT:
–Blood investigation
–Drugs
• NEED NOT:
–Urinalysis , blood glucose, neuroimaging
–Admit in hospital for cardio respiratory monitoring

22. Initial screening in Higher risk
• NO specific diagnosis
- CBC, Urine routine, RBS, Electrolyte
- Urea, X ray chest, ECG

23. DD in Higher risk
DISEASE SYMPTOMS INVESTIGATION
Respiratory infection cough, congestion,
Upper or lower obstruction
Most commonly viral
RSV
PERTUSSIS
GERD Transient chocking or
gagging/feeding
Gross emesis or oral
regurgitation
Obstructive apnea
Vediofluroscopic
swallowing study
Esophageal PH monitoring
Multichannel intraluminal
impedance monitoring
Epilepsy/CNS disorders Recurrent events with loss
of muscle tone
unresponsiveness
EEG
Brain imaging
Child abuse History manipulation
Unexplained bruising or
bleeding
Neuro-imaging
X-ray
Social work screening

24. Work up for symptoms:
Fever, Toxic appearance, Respiratory distress,
Hypoxemia, Clustered acute events
Chest radiology
Events that occur during sleep Multichannel polysomnography
EEG
Hypoglycemia, Metabolic acidosis, Vomiting,
Lethargy
Evaluation for Inborn errors of
metabolism
Altered sensorium Toxicological screening
Cyanotic episodes ,Abnormal cardiac
examination /ECG abnormalities
Cardiac evaluation

25. Implementation and improvement
• Education
• Integrations of clinical workflow
• Administrative and Research

26. WORK UP DONE FOR THE CHILD in PICU:
• INTIAL WORK UP: ABG, chest X ray, CBC,CBG, S.Electrolyte
ABG- Showed resp acidosis.
CBC- Hb-11.6, TC- 13200, Plat- 4.49
2nd line investigation-ECG, S.electrolyte, EEG, Imaging, LP.
PLANNED – milk scan for GED
ALL negative- ECHO and HOLTER Monitor
Metabolic – congenital hypoventilation syndrome
Sleep study

27. TAKE HOME MESSAGE
• Careful history and Physical examination
• Child abuse- present as BRUE
• Identify low risk and high risk

28. THANK YOU

29. Corrections
• I am sending you an article from Uptodate
• Add few slides on how to manage and what
disorders to screen for and what tests you will
do in high risk situations