Approach to Brief Resolved Unexplained Events (BRUEs) in ... · • Home apnea monitoring is generally discouraged • Patients with lower risk events should not receive home cardio

ApproachtoBriefResolvedUnexplainedEvents(BRUEs)inInfancy

Part1

DevelopedbyLarissaShapkaandDr.KarenForbesforPedsCases.com

LearningObjectives

• Part11. DescribetheclinicalpresentationofaBRUE2. Developadifferentialdiagnosisoftheseeventsbasedonetiology3. Discusskeyconsiderationsforhistoryandphysicalexamination

• Part21. ListappropriateinvestigationsforaBRUE2. OutlinekeypointsinthemanagementofaBRUE


Case


ClinicalFeaturesofBRUE

• BRUEstandsforbriefresolvedunexplainedevent

• Diagnosticcriteria:– Infantmustbe<1yearold– Episodemustbesudden,brief,andnowresolved– Eventischaracterizedbyatleastoneofthefollowingfeatures:• Cyanosisorpallor• Absent,decreased,orirregularbreathing• Changeinmuscletone,eitherhyperorhypotonia,or• Alteredlevelofresponsiveness

• BRUEisadiagnosisofexclusion


BRUEsvs.ALTEs

• BRUEswereformerlyknownasapparentlife-threateningevents(ALTEs)

• ThetermALTEwasproblematic:–Wasbroadandincludednonspecificsymptoms– Impliedconcernforachild’slifebeingatrisk• Ledtonon-effectiveinvestigationsorhospitalizations• Reinforcedparentalanxiety


BRUEsvs.ALTEs

• In2016theAmericanAcademyofPediatricsreleasednewguidelinesforthesetypesofepisodes

• ThenewguidelinesonBRUEs:– Outlinemoreprecisediagnosticcriteria– Outlineastrategyforidentifyinghigherandlowerriskpatients– RecommendhowtoinvestigateandmanageBRUEs


BRUESvs.SIDS

• BeforethetermsofBRUEorALTEexisted,theseeventswerecalled“near-missSIDS”or“abortedcribdeaths”

• Thesetermsarenolongerused

• Currently,thereisnoclearassociationbetweenBRUEsandSuddenInfantDeathSyndrome(SIDS)– BRUEsarenotariskfactorforSIDS– BRUEsarenotaprecursortoSIDS


DifferentialDiagnosisforFrighteningEpisodes

• Commoncauses:– Idiopathic– Gastroesophageal reflux– Respiratoryinfections– Seizure

• Morerarecauses:– Airwayissues– Bacterialinfections– Cardiac– Childabuse– Congenitalabnormalities– Drugsandtoxins– Gastrointestinal– Inbornerrorsofmetabolism– Metabolicandendocrine– Neurologic– Respiratory


DifferentialDiagnosisforFrighteningEpisodes

• Remember:– BRUEisdescriptionofanevent;it’snotadiseaseentityinandofitself– Bydefinition,BRUEsareunexplained– Ifyoudiscoveranexplanationfortheevent,it’snotaBRUE


EvaluationofaPossibleBRUE

1. History2. PhysicalExam3. Laboratoryandimaginginvestigations


History

• Makesureyouaskaboutwhathappened:1. Beforetheevent2. Duringtheevent3. Aftertheevent


DetailsofWhatHappenedBefore theEvent

• Whattheinfantwasdoingbeforetheevent–Weretheysleepingorawake?

• Wheretheywere

• Whethertheywerebehavingnormally

• Timinginrelationtoafeed

• Whatmadetheobservercheckonthebaby


DetailsofWhatHappenedDuring theEvent

• Levelofconsciousness

• Breathingefforts

• Colour

• Muscletone

• Limbandeyemovement

• Whereitoccurred

• Howlongitlasted


DetailsofWhatHappenedAfter theEvent

• Whethertheinfantrequiredintervention– Typeofmeasure:• Gentleorvigorousstimulation• Mouth-to- mouthresuscitation• Chestcompressions

– Howlongitwasperformedfor

• Howlongtheinfanttooktoreturntobaseline


OtherConsiderationsonHistory

• Associatedsymptomsthatcouldsuggestaparticularetiology (i.e.GERD,respiratorytractinfection,seizures)

• Pastmedicalhistory:– Pregnancyandbirthhistories– Recentillness– Significanthealthissues– Previoussimilarevents– Feedingdifficulties– Failuretothrive– Usualbehaviour,sleeping,feedinghabits–Medications


OtherConsiderationsonHistory

• Familyhistory:– Similarevents– SIDS– Earlyinfantdeaths– Genetic,metabolic,cardiac,orneurologicconditions.

• Socialhistory:– Smokinginhome– Concernsfornon-accidentalinjury– Recentstressorsinhome– Supportsinhome


Case


PhysicalExam

• Generalappearance• Returntobaseline– Anylingeringlimpness,colour change,orreducedalertness?

• Vitalsigns• Height,weight,andheadcircumference• Cardiacexam• Respiratoryexam• Neurologicalexam• Developmentalassessment.• Signsoftraumaormaltreatment;– Observecaregiver’sinteractionswithinfant

• Amoredetailedlistofphysicalexamconsiderationscanbefoundintheguidelines


Case


Summary

1. ClinicalpresentationofaBRUE2. Differentialdiagnosisbasedonetiology3. Considerationsforhistoryandphysicalexam

• BesuretocheckoutthesecondpodcastinthisseriesforanapproachtoinvestigatingandmanagingBRUEs!


ApproachtoBriefResolvedUnexplainedEvents(BRUEs)inInfancy

Part2


LearningObjectives

• Part11. DescribetheclinicalpresentationofaBRUE2. Developadifferentialdiagnosisoftheseeventsbasedonetiology3. Discusskeyconsiderationsforhistoryandphysicalexamination

• Part21. ListappropriateinvestigationsforaBRUE2. OutlinekeypointsinthemanagementofaBRUE


EvaluationofaPossibleBRUE

1. History2. PhysicalExam3. Laboratoryandimaginginvestigations– Decisionsbasedonriskstratificationofevents• Wasitahigherorlowerriskevent?


RiskAssessment

• RiskassessmentmeansclassifyingBRUEsaseitherhigherorlowerriskevents

• Whybother?– Helpsyoufigureoutwhichpatientsaremorelikelytohaveaseriousconditionasthecause

oftheepisode,andpossiblymoreeventsinthefuture

• Whattoconsider:– Historyandphysicalexamfindings– Eventcharacteristics– Patientcharacteristics


HigherRiskPatients

• Aninfantcouldbeconsideredhigherriskinoneofthreeways:

1. Iftheyhaveconcerningfeatures onhistoryorphysicalexam• Signsandsymptomsofanunderlyingcondition,or• Riskfactorspredisposinganinfanttoaseriouscondition (suchasthoseidentifiedonfamilyhistory)

2. If theBRUEwasarecurrentevent,lasted>1min,orrequiredCPRfromamedicalprovider,or

3. Iftheyare<60daysoldorwereborn<32weeksgestation(correctedgestationalage<45weeks)


LowerRiskPatients

• Lowerriskpatientswould:– Havenoconcerningfeaturesonhistoryandphysicalexam,– Presentwithafirsteventwhichlasted<1minanddidn’trequireCPR,and– Be>60daysoldandbornat32weeksgestationorlater(correctedgestationalageofatleast45weeks)


Investigations(LowerRiskPatients)

• Inlowriskpatients:– Extensivelaboratoryorimagingstudiesareunlikelytobehelpful– Extensiveworkupandhospitalizationcouldexposethemtounnecessaryrisk

– Thereareguidelinesastowhatyou:• Shoulddo• Mayconsider• Neednotdo• Shouldnotconsider

– Theguidelinesweredesigned:• Inresponsetotheseeventsbeingoverinvestigatedinthepast• Intheinterestofprovidinghighvaluecare



• Inlowriskpatients,youshould:–Makedecisionsaboutevaluation,managementandfollow-upinpartnershipwiththeinfant’scaregivers

– TeachcaregiversaboutBRUEsandofferinfoaboutCPRtraining• Moretocomewhenwediscussmanagement



• Inlowriskpatients,youmay:– Orderpertussistestingifyoususpectaninfectiouscause– OrderanECGaspartofacardiacworkup– Observeinfantsandmonitoroxygensaturationsforashortperiodoftime• Moretocomewhenwediscussmanagement



• Inlowriskpatients,youneednot:– Orderviralrespiratorytestingoraurinalysisaspartofaninfectiousworkup– Orderbloodglucose,serumbicarbonate,orserumlacticacidtocheckforinbornerrorsofmetabolism

– Orderneuroimagingforsuspectedchildabuse– Admitthepatientjusttoreceivecardiorespiratorymonitoring• Moretocomewhenwediscussmanagement



• Inlowriskpatients,youshouldnot:– Evaluateforanemiabasedonlabtests– ObtainbloodworkincludingCBC,electrolytes,renalfunction,ortestsforinbornerrorsofmetabolism

– SampleCSFtolookforasubclinicalbacterialinfection– Orderachestx-ray,bloodgases,echocardiogram,orpolysomnograph aspartofacardiopulmonaryevaluation

– OrderEEGforaneurologicworkup– Ordertestsforgastroesophageal reflux– Prescribeanti-epilepticsormedicationsforacidsuppression;or– Sendpatientshomeonhomeapneamonitors• Moretocomewhenwediscussmanagement


Investigations(HigherRiskPatients)

• Higherriskpatients:– Needmorethoroughinvestigationsforlesscommoncauses– Shouldbeworkedupbasedonyourdegreeofclinicalsuspicionofaconcerningunderlyingetiology• Focusonthatparticularareaofconcern


Case


Management

• Generalapproach:– Forlowriskpatients,managementisfocusedoneducation– Iftherearesignsandsymptomsthatsuggestanunderlyingetiology,itwillinvolve:• Treatingtheapparentcause• Possibleinpatientobservation

– Inallcases,providefollow-upandsupportforcaregivers


MedicalTreatment

• Ifconcernswereidentifiedonhistoryandphysicalexam:– Treatthesuspectedunderlyingcondition– Ifmoreeventsoccurdespiteintervention:• Reassessthediagnosis• Pursuefurtherinvestigationsaswarranted

• Ifnoconcernswereidentifiedonhistoryandphysicalexam:– Theeventismostlikelyisolatedandidiopathic– Nomedicaltreatmentisneeded–Manageparentalanxiety• Youmayconsiderabriefperiodofobservation


HospitalAdmission

• Ingeneral,onlyconsideradmittingpatientswhohavehighriskevents

• Onceadmitted:– Regularlyassesstheinfant–Monitortheircardiorespiratoryfunctionandoxygensaturations

• Regardlessofwhendischargeoccurs,arrangeclosefollow-upandsupport


HospitalAdmission

• Infantswithlowerriskeventsdon’tneedtobeadmittedjustforcardiorespiratorymonitoring

• However, itmaybereasonabletoadmitthemforaclearlydefinedperiodoftime(24-48hours)if:– Thereisagreatdealofparentalanxiety– Timelyoutpatientfollow-upisnotavailable

• Asanotheroptionforalower-riskpatient,youcanalsoconsidermonitoringthemforashortamountoftime(1-4hours)– Continuouspulseoximetry monitoringandserialobservation


HomeApnea Monitoring

• Homeapneamonitoringisgenerallydiscouraged

• Patientswithlowerriskeventsshouldnotreceivehomecardio-respiratorymonitoring– Itdoesnotseemtoimproveoutcomes– Itcanincreaseparentalanxiety

• Monitoringmaybewarrantedinasmallsubsetofhighriskcases– Thisdecisionwouldlikelybemadewithapediatricpulmonarymedicinespecialist–Makesureyouprovideproperinstructiontocaregivers


CaregiverEducation

• Reassurecaregiversthat:– BRUEdoesnotimplySIDSrisk– Homemonitoringisnotpreventativeandisgenerallydiscouraged

• Provideinformationabout:– Infantsafety,especiallysafesleepingpractices– Appropriateintervention• Notshakinginfantstorevivethemiftheyareunresponsive

– BasicCPRtraining– Psychosocialsupportsavailabletothem


Case


Prognosis

• Dependsontheunderlyingcauseoftheevent– Infantswithmoreseriousunderlyingcausestypicallyhavepooreroutcomes– Forthemajorityoflowerriskpatients,thereisnoreasontobelievetherewillbelong-termsequelae

• Giventheuncertainty,itcanbechallengingtocounselcaregiversaboutprognosis


Case


Summary

1. ABRUEisasudden,brief,andnowresolvedeventinaninfantyoungerthan1year

• Itinvolves1ormoreof:– Cyanosisorpallor– Absent,decreased,orirregularbreathing– Changeinmuscletone;or– Alteredlevelofresponsiveness

• BRUEsremainunexplainedafterhistoryandphysicalexam


Summary

2. AwidevarietyofconditionscanmanifestasaBRUE

• Butrememberthatintheend,theyareunexplainedevents


Summary

3. Adiagnosticworkupforaneventincludesadetailedhistoryandcompletephysicalexam

• Laboratoryorimaginginvestigationsmaybeconductedbasedonwhetherthepatientmeetsthecriteriaforhavingexperiencedalowerorhigherriskevent

• Keepinmindthatguidelinesrecommendagainsttakingcertainstepsinthecasesoflowriskevents


Summary

4. ThemanagementofaBRUEvaries

• Inhigherriskpatientswhereredflagsareidentifiedonhistoryandphysicalexam,managementshouldfocusonaddressingthese

• Inpatientobservationmaybewarrantedinsomecases

• Inallcasesitisimportanttoprovideeducationtocaregivers


Summary

5. CurrentlythereisnoclearassociationbetweenBRUEsandSIDS

• BRUEsarenotthoughttoleadtoorbeariskfactorforSIDS

• Homemonitoringisgenerallydiscouraged

• ItismoreimportanttoencourageinfantCPRtrainingandremindcaregiversofsafesleepingpractices


Thanksforlistening!

References:1. Tieder JS,Bonkowsky JL,Etzel RA.Briefresolvedunexplainedevents(formerlyapparentlife-threateningevents)andevaluationof

lower-riskinfants:Executivesummary.Pediatrics.2016;137(5):e20160591.2. Tieder JS,Bonkowsky JL,Etzel RA,etal.ClinicalPracticeGuideline:BriefResolvedUnexplainedEvents(FormerlyApparentLife-

ThreateningEvents)andEvaluationofLower-RiskInfants.Pediatrics.2016;137(5):e20160590.3. NationalInstitutesofHealthConsensusDevelopmentConferenceonInfantileApneaandHomeMonitoring,Sept29toOct1,1986.

Pediatrics.1987;79(2):292–299.4. Corwin,M.Acuteeventsininfancyincludingbriefresolvedunexplainedevent(BRUE).UpToDate.2016Oct11[cited2016Dec04].

Availablefrom:https://www.uptodate.com/contents/acute-events-in-infancy-including-brief-resolved-unexplained-event-brue?source=search_result&search=BRUE&selectedTitle=1~22

5. Scollan-Koliopoulos,M.,Koliopoulos,.EvaluationandManagementofApparentLife-threateningEventsinInfants.Pediatr Nurs.2010;36(2):77-84.

6. Tieder JS,AltmanRL,Bonkowsky JL,etalManagementofapparentlife-threateningeventsininfants:asystematicreview.JPediatr.2013;163(1):94–99,e91–e96.

7. AdamsM,ChadE,WardDO,&Garcia,K.L.SuddenInfantDeathSyndrome.AmFam Physician. 2015 Jun 1;91(11):778-783.8. Sarohia M,&PlattS.Apparentlife-threateningeventsinchildren:practicalevaluationandmanagement. Pediatr Emerg MedPract.

2014Apr;11(4):1-14;quiz15.ImageCredits:• PinkStock Photos,D.SharonPruitt.https://commons.wikimedia.org/wiki/File:Sleeping_baby_with_arm_extended.jpg


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Approach to Brief Resolved Unexplained Events (BRUEs) in ... · • Home apnea monitoring is generally discouraged • Patients with lower risk events should not receive home cardio