Pediatric Emergency

1. BRIEF RESOLVED UNEXPLAINED
EVENT OR BRUE (ALTE GUIDELINE
UPDATE)
DR MOHAMMAD AL KTIFAN
SPECIALIST IN PEDIATRIC EMERGENCY
AL WAKRA HOSPITAL HMC

2. CASE SCENARIO
A 3 months old ( full term, previous healthy ) is brought in by his
parents. He had an episode where his conscious level dropped, he
seemed to stop breathing and was limp and blue. This lasted for 20
seconds and scared the parents who were about to commence
mouth to mouth resuscitation.
He is now happy and looks fine. The vital signs are normal also
thorough physical examination is unremarkable.

3. WHAT'S THE PLAN ?
• Can this child go home?
• This presentation scares me, I must admit, then what …?
• What is the most likely diagnosis in this case?
• How would you evaluate and manage this patient?

4. INTRODUCTION
• Many infants present with acute events- unexpected change in
breathing, color or behavior.
• ALTE & BRUE : are not specific disorders but rather a "chief complaint"
that brings an infant to medical attention.
• Some of these events are unexplained (and designated BRUEs), but
others result from numerous possible causes including digestive,
neurologic, respiratory, infectious, cardiac, metabolic, or traumatic
(child abuse) disorders. Treatment is aimed at specific causes when
identified.
• Challenge is to identify the infants who may benefit from further
testing and prolonged observation

5. In some cases, the observer fears that the infant has died.

6. CHANGE IN TERMINOLOGY AND
DIAGNOSIS
• 1) ALTE definition, the infant is often, but not necessarily
asymptomatic on presentation. this definition was broad and
vague, and relied heavily on the subjective report of the caregiver
rather than on pathophysiology.
• 2) Symptoms although often concerning to parents, are not really
life-threatening and frequently a benign manifestation of normal
infant physiology or a self-limited condition.

7. CHANGE IN TERMINOLOGY AND
DIAGNOSIS
• 3) the doubt of recurring events or a serious underlying disorder
often provokes concern in caregivers and clinicians.
• 4) A more precise definition could prevent the overuse of medical
interventions by helping clinicians distinguish infants with lower risk.
• 5) Finally, the use of ALTE as a diagnosis may make the parents
believe that the event is really “life-threatening, ” even when it most
often was not
• For these reasons, a replacement of the term ALTE with a more
specific term could improve clinical care and management.

11. EPIDEMIOLOGY
• BRUE: has been described only in 2016, and thus there are no reports
describing the epidemiology.
• Studies estimated that ALTEs occur in 3:10,000 to 41:10,000 infants.

13. includes excludes
Brief Duration < 1min Duration >/= 1min
resolved Patient returned to baseline state after
the event
Normal vital signs
Normal appearance
additional symptoms :fever or recent fever ,
vomiting , stridor , wheezing, petechia or rash
….
Abnormal vital signs : hypotension ,
tachycardia or bradycardia , tachypnea
Unexplained Not explained by an identifiable medical
condition
Event consistent with GER, swallow
dysfunction , nasal congested . etc
History or physical examination concerning for
child abuse , congenital airway abnormality ,
etc
Event characterization
Cyanosis or pallor
Central cyanosis :blue or purple
coloration of face , gums , trunk
Central pallor :pale coloration of face
and trunk
Acrocyanosis or perioral cyanosis
Rupor
Absent, decreased or
irregular breathing
Central , obstructive , mixed obstructive
apnea
Periodic breathing of the newborn
Breath-holding spell
Marked change in tone Hyper or hypotonia Hypertonia associated with crying or gagging
due to feeding problems , tone changes
associated with breath holding spell
Altered of responsiveness Loss of consciousness Loss of consciousness associated with breath

14. EVALUATION : HISTORY
• Most important diagnostic tool – detail description of event
• The history should include information about any :
 previous apnoeic events.
Recent illness or symptoms .
The pregnancy and perinatal period.
The infants usual behaviour – sleep and feeding habits.
Family history (including a history of siblings with similar episodes ,
sudden death, early deaths , genetic ,metabolic ,cardiac and
neurologic problems ).
Asocial history (including the presence of smoking ,alcohol or
substance use in the home , and list of medications in the home ).

15. EXAMINATION
• Measurement of height ,weight, and head circumference and
comparison of these values to standards for age and gender .
• Measurement of vital signs , including pulse oximetry.
• Examination for physical signs of trauma (bruising, retinal
haemorrhage ,bulging anterior fontanel)
• Neurologic examination (including alertness and tone ).
• Evaluation for respiratory distress or upper airway obstruction ,
including assessment of facial dimorphism.
• Developmental assessment including assessment of developmental
reflexes.

17. LOWER RISK CRITERIA
• Infants who have experienced BRUE are considered low risk if they
have all of the following:
• no concerning features identified on history and physical examination
• Age >60 days.
• BORN ≥32 weeks and corrected age is ≥45 weeks.
• First event.
• Duration of BRUE <1 minute.
• No (CPR) required by a trained medical provider.

18. MANAGEMENT FOR LOW RISK
(BRUE)
• Recommended steps:
• Educate caregivers about BRUEs
• Offer resources for training in (CPR).
• Engage in shared decision-making about further
evaluation and disposition.
• Arrange for a follow-up check with a medical provider
within 24 hours

19. MANAGEMENT OF LOW RISK
(BRUE)
• Optional steps:
• place in observation (1-4 hours ) with continuous pulse oximetry and serial
observations.
• ECG with attention to QT interval.
• Testing for pertussis (in under immunized and/or exposed patient in
endemic regions and outbreaks).
• Respiratory virus testing , as for RSV, .This testing is not required in these
low-risk infants, who by definition have no respiratory symptoms and are >2
months of age

20. • Should not :
• Obtain blood investigations, urinalysis , CSF analysis or culture , EEG
Chest-Xray , Head CT
• Prescribe anti acid or antic epileptic medications
• Initiate home cardiorespiratory monitoring
• Need not
Admit the patient to hospital for monitoring

21. EVALUATION OF HIGH RISK BRUE
• If there are clinical features that suggest a specific diagnosis
(eg, URTI or child abuse), the evaluation may be targeted
toward that concern.
The clinical practice guideline did not provide
recommendations for infants meeting higher-risk criteria, so
the evaluation and management of higher risk patients
based upon expert opinion management decisions may vary
depending on patient

22. D/D FOR HIGH RISK ALTE/BRUE
• GER/Laryngospasm
• Neurological problems(seizures)
• Respiratory tract infections
• Child abuse
• Cardiac disease
• Upper airway obstruction
• Bacterial infection
• Metabolic disorders.
• Toxin ingestion

23. INITIAL EVALUATION AND OBSERVATION
HIGH RISK BRUE
Continuous pulse oximetry for at least 4 hours
ECG
Laboratory testing : CBC, CMP, CRP, Urinalysis ,blood Glu ,bicarbonate or
blood gases ,lactic acid (to screen for inborn errors of metabolism)
Respiratory virus testing panel (including RSV)
Pertussis testing (in under immunized and/or exposed patient in
endemic regions and outbreaks).
Screen for child maltreatment and feeding disorder.
If infant has change in sensorium ,evaluate for toxic ingestion .
If the diagnosis explains the event (no longer considered BRUE and
manage as needed )

24. SECONDARY EVALUATION AND MANAGEMENT FOR HIGHER
RISK PATIENTS
• Admit to hospital :
1. Continuous prolonged oximetry
2. Observation for repeat events
3. Clinical swallow evaluation and feeding consultation
• Evaluation based on event characterization:
If concern for silent aspiration due to feeding problem :VFSS(video fluoroscopy swallow
study )
If concerns for GERD: gastroenterology consultation
If concerns for central apnea : 1- CT or MRI of head 2-pulmonary consultation
If concerns for seizures : Neurology consultation and EEG
• No repeat events and no explanation within 24 h : 1- discharge home
2- CPR training 3- arrange close follow up within 24h

25. RECURRENCE RISK
• The risk for recurrence of (ALTE) ranges from 10 to 25 percent in different
reports.
• Substantially lower for infants meeting the narrower criteria for BRUE.
• Infants who present with multiple acute events preceding the hospital
admission are more likely to have an underlying disease as compared with
those with single events.

26. CASE SCENARIO
A 3 months old ( full term, previous healthy ) is brought in by his
parents. He had an episode where his conscious level dropped, he
seemed to stop breathing and was limp and blue. This lasted for
approximately 20 seconds and scared the parents who were about to
commence mouth to mouth resuscitation.
He is now happy and looks fine. The vital signs are normal also
thorough physical examination is unremarkable.

27. • Is low risk or high risk BRUES ?
• Management of low risk Brue ?
• Educate caregivers on Brues
• Offer resources for training in (CPR).
• follow-up check with a medical provider within 24 hours
May monitor for 1-4 hours with pulse ox and exams
Perform pertussis testing ,ECG

29. CONCLUSION
• The term BRUE should be used instead of ALTE whenever possible
• remember in the end, BRUE is unexplained events.
• Lower-risk BRUE infants generally do not require clinical investigations
and can be discharged home from the emergency department (ED).
• Infants < 2 months of age require special attention because they are at
increased risk for occult infection or undiagnosed congenital disorders
• . BRUEs are not risk factor for SIDS.
• Home monitoring is generally discouraged. It is more important to
encourage infant CPR training and remind caregivers of safe sleeping
practices
• BRUE is a diagnosis of exclusion just like another acute idiopathic
condition of infancy, the febrile seizure. Both have lower- and higher-
risk categories. The lower-risk groups of both of these conditions