Check out this great review on BRUE's or “brief resolved unexplained event” @EMBoardBombs by @blakebriggsMD and @Lmellick here, emboardbombs.com/papers/2020/9/…
Or follow along for a short #medtweetorial review on the highlights. #EM #EMPeds #EmergencyMedicine #MedTwitter
What is a BRUE? It reflects a general “catch-all” CC
The old term was ALTE (apparent life-threatening event), but this term was too broad and incorrectly assoc symptoms and SIDS.
It peaks in incidence at <2 months of age but can occur anytime within the first year
Clinical features that define BRUE (includes any of the following): typically <1 minute
- cyanosis or pallor
- absent, decreased, or irregular breathing
- change in tone
- altered mental status
Risk factors:
These include issues with feeding, maternal smoking history, premature birth or low birth weight, recent upper respiratory illness, age <2 months old, history of prior episodes, gastroesophageal reflux (GER), and seizures.
Causes are many, but the most common ones uncovered include GER, seizures, and respiratory infections
Child abuse is the cause in <10% of cases.
Cardiac disease, upper airway obstruction, metabolic diseases, bacterial infections <3% of cases.
The most important part of BRUE evaluation is H&P, as it allows the clinician to decide on the infant being low or high risk.
The H&P alone diagnosed ~20% of cases with another 50% of diagnoses were confirmed from testing that was prompted by the history/physical.
The decision to proceed with workup depends on if the presentation is deemed “high risk” or “low risk”.
What are the concerning historical and physical exam findings?
Child abuse, respiratory illness, trauma, ingestion, developmental delay, congenital anomalies, or family history of sudden unexplained death in a primary relative.
Concerning PE Findings include injuries (e.g. bleeding/bruising), bulging fontanelle, altered status, fever, respiratory distress, decreased pulses, or abdominal distension or masses.
Infants who are low risk do not benefit from any further investigation.
Recommended:
Extensive education about BRUE with caregivers, reinforce measures to prevent sudden infant death syndrome (SIDS), offer resources in CPR, and arrange f/u in 24 hours with PCP.
Parents should be told never to shake the infant if unresponsive.
Not recommended by the American Academy of Pediatrics (AKA do not do): any lab work, chest x-ray, echocardiogram, or any other diagnostic tests.
Here’s a bombshell: no cardiopulmonary monitoring for these pts at home.
If you are that concerned about the infant then ADMIT them
Optional:
If you are unsure about the patient, brief ED observation for 1-4 hours is not unreasonable, a 12-lead EKG is not unreasonable either.
For High-risk infants: Admit with cont monitoring, EKG, CBC, BMP, respiratory viral panel, & pertussis testing are all typically performed.
Further dx studies are tailored to the pt
Many of these tests are outside the scope of emergency medicine, as these will occur inpatient
If there are neuro findings/concerns for child abuse, CT head is warranted.
RSV/pertussis cause SIDs in premies, hence their testing.
Hypoglycemia & vomiting might suggest metabolic disease like inborn errors of metabolism
Suggestion of seizures prompt inpatient EEG
A word on GER… is a common cause of BRUE by mechanism of laryngospasm. There is no evidence that treating GER prevents future episodes.
Features that suggest GER include regurgitated food at the time of event, infant was awake, and feeding was recent or at time of event.
More on GER...
It is not recommended to start antihistamines or other anti reflux agents. Have them follow up with their pediatrician for further GERD discussion.
Prognosis
Recurrence risk ranges 10-25% in several studies for ALTE, with an overall death rate of <1%.
More on Prognosis:
There are no new studies on BRUE mortality rates at the time of this writing.
Risks for recurrence include respiratory illness, prematurity, & history of prior events.
There is no established relationship between BRUE and SIDS
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