Brief resolved unexplained event: Difference between revisions
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[[Category:Peds]]
[[Category:Pediatrics]]

Revision as of 15:59, 22 March 2016

Background

  • Peak incidence: 1wk - 2mo
  • ALTE is a symptom, not a dx
  • Only 10% have repeat events
  • ALTE is not related to SIDS

Risk Factors

  • RSV infection
  • Prematurity
  • Recent anesthesia
  • GERD
  • Airway/maxillofacial anomalies
  • Age < 10 wks
  • Hx of apneas
  • Pallor, cyanosis, feeding difficulties

Clinical Features

Episode that is frightening to caregiver and involves combination of:

  • Apnea
  • Color change
  • Muscle tone change
  • Choking or gagging

History

  • PMH
    • Prematurity, history of apnea, prior resp/feeding difficulties
    • Immunization status (pertussis)
  • FH
    • History of SIDS, cardiac, seizure, metabolic disease
  • Event
    • Duration, resus required
    • Temporal relationship with feeding, sleeping, crying, vomiting, choking
    • Central versus obstructive pattern of apnea
    • Episodic versus sustained change in mental status
  • ROS
    • Respiratory symptoms
    • Medication use

Differential Diagnosis[1]

Common[2]

  • Idiopathic (~50%)
  • GERD
  • Seizure
  • Respiratory tract infection
  • Misinterpretation of benign process (e.g. periodic breathing)
  • Vomiting/choking episode

Less Common

  • Pertussis
  • Inflicted injury
  • Poisoning
  • Serious bacterial infection
    • Must consider in all febrile pts with ALTE
  • Electrolyte abnormality (includes glucose)

Uncommon

Diagnosis

Individualize testing by history and exam

  • CBC
  • Chem 10
  • UA
  • CXR
  • Pertussis nasal swab
  • RSV nasal swab
  • Consider:
    • UCx/BC
    • ECG
    • LP
    • LFTs
    • MRI Brain

Management

  • Stable patients without a clear diagnosis
    • No evidence-based guidelines for proper w/u dispo decision
  • Stable patients with a clear diagnosis
    • Manage according to identified disease

Empiric Treatment for Unstable Patients

Medication/Intervention Indication Dose/Size (for neonate)
Glucose Hypoglycemia 5–10 mL/kg of 10% dextrose in water IV
3% normal saline Symptomatic hyponatremia 3–5 mL/kg bolus IV
Calcium Hypocalcemia 50–100 milligrams/kg calcium gluconate or 20 milligrams/kg calcium chloride IV
Cefotaxime Infection 50 milligrams/kg IV
Ampicillin Infection 50 milligrams/kg IV
Packed red blood cells Anemia 10 mL/kg IV
Normal saline Hypotension, dehydration 20 mL/kg IV
10% dextrose in one fourth normal saline Metabolic disease 1.5 maintenance (6 mL/kg/h for the first 10 kg)
Endotracheal intubation Hypoventilation or frequent apnea 3mm for preemie; 3mm for term neonate, 4mm for older infant

Disposition

Admission in most cases

Especially for:

  • <48wk postconceptual age
  • Ill-appearing
  • Bronchiolitis or pertussis w/ apnea
  • >1 event in past 24hr or multiple ALTEs
  • Abnormalities in PMH
  • Prolonged central apnea >20s
  • ALTE requiring resus
  • Family history of SIDS

Current Research

  • Neither of these decision rules have been validated

Mittal ALTE Decision Rule[3]

  • 300 Infants in a single center with 76% admission rate with 37 (12%) required significant intervention
Predictors for requiring intervention
  • Prematurity
  • Abnormal physical examination
  • Color change to cyanosis,
  • Absence of upper respiratory infection symptoms and the absence of choking
  • Negative predictive value: 96%
  • Specificity of 70.5%
  • 7 out of the 184 (3.8%) were incorrectly discharged

Kaji ALTE Decision Rule[4]

  • 832 patients from 4 different study sites, with a 79.2% admission rate
Predictors for requiring admission
  • Obvious need for admission:
    • Supplemental Oxygen requirement
    • Resuscitation
    • Hemodynamic Instability
    • Positive RSV or Pertussis test
  • Significant past medical history
    • Congenital heart disease
    • Down Syndrome
    • Previous Intubation
  • Chromosomal abnormaility
  • Chronic Lung Disease
  • > 1 ALTE in 24 hours
  • Negative predictive value of 96.5%
  • Sensitivity of 89% , a Specificity of 61.9% , and a calculated
  • 14 (2%) patients were incorrectly discharged

References

  1. ↑ McGovern MC. et al. Smith MB. Causes of apparent life threatening events in children: a systemic review. Arch Dis Child. 2004;89(11):1043-1048
  2. ↑ Okada K et al. Discharge Diagnoses in infants with apparent life threatening event admissions and gastroesophageal reflux disease. Pediatric Emergency Care. 2012;28(1):17-21
  3. ↑ Mittal M. et al. A clinical decision rule to identify infants with apparent life-threatening events who can be safely discharged from the emergency department. Pediatric Emergency Care. 2012;28(7): 599-605
  4. ↑ Kaji A et al. Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med. 2013;61(4):379-387
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