Pediatric emergency medicine trisk 101

FIGURE 14.1 Approach to the diagnosis and management of apnea.

Has a Significant Apneic Episode Occurred?
The key to answering the two questions is invariably in the history ( Table 14.5 ).
A clear initial history from a firsthand caregiver without the predictable influence
of repeated questions is vital. This may not be a simple task, considering the
caregiver’s recent stressful experience. The following details should be included:
(i) where the event took place; (ii) how long the event lasted; (iii) whether the
infant was awake or asleep; (iv) whether there was an associated color change
and, if so, to what colors and in what order; (v) description of associated


movements, posture, or changes in tone; (vi) what resuscitative efforts were made
and the infant’s response to them; (vii) when the infant was last fed; (viii) how
quickly the infant returned to baseline behavior. The responses to these questions
may provide the physician with clues to the diagnosis. As an example, an 8month-old infant who was interrupted in a favorite activity, began to cry, turned
red and blue, and finally had several seconds of tonic–clonic motor activity likely
had a breath-holding spell. In contrast, a history of 40 minutes of cyanosis and
apnea in a now well-appearing child may be unreliable. Other recent events that
should be documented include symptoms of other illnesses, such as changes in
behavior, activity, and appetite, as well as recent trauma and immunizations.
TABLE 14.4
COMMON LIFE-THREATENING CONDITIONS THAT CAUSE APNEA
Pneumonia
Sepsis/meningitis
Hypoglycemia
Seizures
Intracranial hypertension
Shock
Ingestion (e.g., analgesics, sedatives, muscle relaxants)

TABLE 14.5
HISTORICAL FEATURES OF APNEA
History

Significant apnea

Duration of event

Greater than 20 sec or of any duration
associated with pallor, cyanosis, and/or
bradycardia
Either, but apnea during sleep is more
worrisome
Pallor or cyanosis
Seizure activity
Hypotonia, hypertonia
“He/she looked dead”
Color change or hypotonia requiring
cardiopulmonary resuscitation to improve
If shortly after feeding, consider
gastroesophageal reflux
Association with sleep, trauma

Was child asleep or awake?
Color change
Associated movements,
posture, or change in tone
Resuscitative efforts and
response

Interval since last feeding
Where event occurred

In many cases, the description of the event may be concerning, although the
child appears well. In this situation, hospitalization for further workup, as
outlined next, is warranted. A typical case might be the previously well 5-weekold child who was noted by the parents to be apneic during a nap. The infant was
described as limp and blue and “looked like he was dead.” There was no response
to tactile or verbal stimulation for 5 to 10 seconds, but after 15 to 20 seconds of
mouth-to-mouth breathing, the child coughed, gagged, and began to breathe. His
color improved over the next 30 seconds, and the parents rushed him to the
emergency department (ED). Although the baby now looks entirely normal, he
may be at grave risk for experiencing another episode of apnea.
The medical history also may provide important information regarding infants
at risk for significant or recurrent apnea. The physician should ask specifically
about previous similar episodes. Information about prenatal and perinatal events,
including gestational age, birth weight, labor and delivery issues, maternal health
and medication exposures, and nursery course, is helpful. A family history with
specific reference to seizures, infant deaths, and serious illnesses in young family
members also should be included. Information regarding medications, including


those available over the counter, and poisons available in the household may be
important in treating an older child. Finally, obtaining a detailed social history
may provide information that is pertinent to the care of the child.

Is There an Underlying Cause?
A careful physical examination identifies many treatable acute illnesses that can
cause apnea. One clue to serious systemic disease is abnormal body temperature,
including fever or hypothermia. Tachypnea may suggest either a respiratory or a
metabolic problem. Signs of shock should prompt consideration of potential

underlying etiology, including sepsis or hypovolemia from occult trauma.
Evaluation of the nervous system should include notation of mental status,
palpation of the fontanelles, and funduscopic examination. Dysmorphic features
might suggest an underlying congenital abnormality. Bruising may be indicative
of nonaccidental trauma. However, an entirely normal physical examination
provides no reassurance that the described event was clinically insignificant and
will not recur.
For the child with a diagnosis of BRUE and considered to be lower risk ( Table
14.2 ), it is recommended that minimal testing be done. Engaging caregivers and
utilizing a family-centered approach can help guide management, disposition, and
follow-up. Resources such as cardiopulmonary resuscitation (CPR) training
classes can be provided. Further testing should be guided by the history and
physical examination. A 12-lead EKG looking for dysrhythmias may be ordered.
Laboratory testing is not routinely performed, but may be indicated for specific
clinical concerns. Pertussis testing might be considered when there is an
appropriate history or possible exposure. For other potential diagnoses, tests to
consider in the ED include a measurement of blood glucose and serum
electrolytes. Any indication that the infant could have a serious infection should
be pursued with cultures of blood, urine, and cerebrospinal fluid. Urine and blood
for toxicologic analysis should be obtained from patients who may have been
exposed to toxic substances or medications. Noninvasive pulse oximetry is
adequate to identify hypoxemia, and significant metabolic acidosis will be
identified through analysis of serum electrolytes. The arterial or venous blood gas
examination does not serve as a screening test for a serious event and should only
be obtained on the basis of specific indications. Radiologic studies (such as of the
lateral neck, chest, abdomen, or neuroimaging) should be performed as indicated
by the history and physical examination.
The tasks of the emergency physician faced with a young patient who has had
an apneic episode are to identify whether he or she should be hospitalized and to
treat underlying conditions. If a careful history and physical examination suggest