Pediatric emergency medicine trisk 100

identify if they did not witness the episode and the neurologic examination is
normal in the postictal period. Apnea may be a symptom of several systemic
disease processes, including sepsis and metabolic abnormalities that result in
hypoglycemia. Congenital abnormalities must always be considered in newborns
and in young infants. Prolongation of the QT interval can cause a dysrhythmia
that manifests as a BRUE or ALTE. Finally, there have been well-substantiated
reports of apnea as the result of life-threatening child abuse such as Munchhausen
syndrome by proxy or inflicted head injury. Frequently, no cause for the apneic
episode is identified.
The risk of sudden infant death syndrome (SIDS) for an infant who has a
BRUE or ALTE is of great concern to both parents and physicians. Multiple
studies have identified no causal relationship between BRUE/ALTE and SIDS.
Furthermore, although the rate of SIDS in the United States has dropped
dramatically since 1992 when the American Academy of Pediatrics
recommended that infants be placed supine or on the side during sleep, there has
been no change in the incidence of ALTEs. In addition, the vast majority of SIDS
events occur at night, whereas infants typically experience BRUEs or ALTEs
during the day. The peak incidence of ALTEs is during the first 2 months of life
while SIDS occurs most frequently in older infants between 2 and 4 months of
life.


TABLE 14.1
COMPARISON BRUE VERSUS ALTE
BRUE
Definition

Inclusion criteria
(any finding)

ALTE

Diagnosis of exclusion—no Chief complaint and
other explanation for
diagnosis
event based on history
and physical examination
Based on clinician’s
Based on caregiver’s
characterization of the
perception of the event
event
Cyanosis or pallor
Any color change (cyanosis,
pallor, plethora,
erythema)
Absent, decreased, or
Apnea (central or
irregular respirations
obstructive)
Hyper or hypotonia
Change in muscle tone
Altered level of
Frightening to the caregiver
responsiveness
Choking or gagging

TABLE 14.2
CRITERIA FOR LOWER RISK INFANT WITH BRUE
Age >60 days
Gestational age ≥32 wks and postconceptional age ≥45 wks

First BRUE episode
Episode lasted <60 sec
No cardiopulmonary resuscitation (CPR) required by trained medical provider
No features in the history of concern (e.g., possible child abuse, family history
of sudden unexplained death, toxic exposures)
No worrisome physical examination findings (e.g., bruising, cardiac murmurs,
organomegaly)

EVALUATION AND DECISION


Initial Stabilization
The first priority of the emergency physician is immediate resuscitation of the
patient. If the patient is noted to be apneic and does not respond to stimulus,
reestablishing effective oxygenation and ventilation should be performed using
bag-mask ventilation. If respiratory effort is intact, the priority is to identify lifethreatening conditions ( Fig. 14.1 ) such as persistent or recurrent apnea, hypoxia,
sepsis, or hypoglycemia. In addition to assessment of the vital signs, including a
rectal temperature and blood pressure, the general appearance and mental status
should be noted. Regardless of the cause, apnea is life threatening; therefore, a
diagnostic investigation, guided by history and physical findings, should be
performed to evaluate the child for several common etiologies ( Table 14.4 ). The
next phase of evaluation addresses two key questions: (i) Is this episode of
clinical significance? (ii) What is the risk of recurrence? Factors to consider
include signs of another acute illness, the age of the child, other possible risk
factors for clinically significant or recurrent apnea, family history of congenital,
metabolic, respiratory, or cardiac diseases, and contributing social factors and
exposures ( Table 14.5 ).


TABLE 14.3

DIFFERENTIAL DIAGNOSIS OF APNEA
Central nervous
system

Upper airway

Lower airway

Other

Neonate, infant

Older child

Infection (meningitis,
encephalitis)
Seizure
Prematurity
Inflicted head injury
Increased intracranial
pressure (ICP)
Congenital anomaly (e.g.,
Arnold–Chiari)
Breath-holding spell
Laryngospasm (e.g.,
gastroesophageal reflux)
Infection (e.g., croup,
pertussis)
Congenital anomaly (e.g.,
Down syndrome)

Infection (pneumonia,
bronchiolitis)
Congenital anomaly
Infant botulism
Hypocalcemia,
hypoglycemia
Anemia
Sepsis
Dysrhythmia

Infection
Toxin
Tumor
Seizure
Increased ICP (trauma,
hydrocephalus)
Idiopathic hypoventilation
(“Ondine’s curse”)

Obstructive sleep apnea
Infection (epiglottitis,
croup)
Foreign body

Infection
Asthma
Guillain–Barré syndrome
Spinal cord injury
Flail chest
Dysrhythmia

Ingestion