Emergency Medical Services (EMS) Agency

CASE OF THE MONTH – OCTOBER 2019

 

Case Presentation:

Paramedics respond to a home where a father has called 911 after his 5-month-old infant son became unresponsive.  The parents note that shortly after feeding, the infant became pale and limp.  While the mother was attempting to stimulate the infant, the father promptly called 911.  The father says, “I don’t know if he was choking or not breathing!  He just wouldn’t respond.”  The infant was born full term with no significant past medical history. 

On arrival, paramedics find an active and alert infant being held by his mother.  The infant is normal in appearance with normal movement and cry.   He is easily consolable.  The infant makes eye contact and tracks objects.   He is breathing normally with no accessory muscle use or nasal flaring.  The infant’s skin appears normal with no signs of pallor, cyanosis, or mottling.  The remainder of the paramedics’ physical examination is normal.  His vital signs are HR 125, RR 30, SpO2 98%.  Capillary refill is <2 sec.  The parents are very concerned.

The first step in caring for this patient is completing a full assessment.  Pediatric assessments can be simplified if completed in a standardized format each time.  Pediatric assessments should be completed in accordance with MCG 1350.  A thorough assessment includes assessing the scene for hazards or signs of maltreatment, completing the Pediatric Assessment Triangle (PAT), vital signs, a SAMPLE history and a detailed physical examination.  The assessment will allow EMS personnel to form a general impression and initiate immediate treatments if necessary.  The EMS provider must then determine a provider impression and appropriate destination for the pediatric patient.

In this patient, EMS assessment indicates that the scene appears safe, the patient is stable (according to the PAT),

brue

Paramedics obtain a more detailed history from the parents.  The parents explain that the infant was born full term and has had no issues since birth.  They noted no change in health or behavior prior to the event.  He has fed normally throughout the day.  A few minutes after his most recent feeding, his mother was holding him over her shoulder to burp him.  The infant suddenly went limp and did not respond to stimulation.  His color appeared pale.  The mother called for help and the father called 911.  Approximately 30 seconds later the episode seemed to resolve.  The infant has demonstrated normal behavior since.  It has been about 10 minutes since the event.

A BRUE is defined as an event occurring in an infant <1 year of age when the observer reports a sudden, brief, and now resolved episode with ≥ 1 of the following1:

  • Cyanosis or pallor
  • Absent, decreased, or irregular breathing
  • Marked change in tone (hypertonia or hypotonia)
  • Altered level of responsiveness

Clinicians diagnose BRUE when no other explanation is determined for the event after a full history and physical examination is completed.  The term BRUE replaces what was formerly known as an Apparent Life-Threatening Event (ALTE), a term initially described in a National Institutes of Health Consensus Conference on Infantile Apnea in the 1980s.  The term ALTE was coined as a term to replace “near-miss sudden infant death syndrome (SIDS)”.  Since that time, data have demonstrated that infants with ALTE/BRUE events are not at higher risk for SIDS.  Thus, the term BRUE is much more appropriate.  The American Academy of Pediatrics (AAP) released clinical practice guidelines in 2016 to define BRUE and guide appropriate clinical management.

BRUE patients will need to have complete evaluations in the hospital setting to determine if they are “lower-risk” or “higher-risk” based on their medical history and physical examination.  Lower-risk patients typically have the following features:

  • Age > 60 days
  • Born ≥ 32 weeks gestation
  • No CPR received by trained medical provider
  • Event lasted < 1 minute
  • First event

In addition to assessing for the above features to determine risk, a full history and physical examination will be performed in the Emergency Department to determine if the patient is higher risk.  The emergency physician will investigate for other underlying causes of concern that may have accounted for the event to include, but not limited to, cardiac arrhythmias, underlying infection, respiratory pathology and child abuse.  If it is determined that the infant is lower risk, they can be discharged home.  This determination should be made after full assessment at the hospital.  The updated guidelines have been associated with decreased hospital admission rates and diagnostic testing with no increase in repeat visits or high-acuity diagnoses3.  The implications for prehospital management are not clear at this time, so BRUE patients should be assessed at a facility with expertise in risk stratifying these patients and appropriately managing them.

Once identifying a patient as having a BRUE, treatment should be in accordance to TP-1235P, Brief Resolved Unexplained Event (BRUE).  Though by definition, the patient’s symptoms should be resolved, one should assess the airway and manage as appropriate, administering oxygen if needed.  Cardiac monitoring should be initiated.  If there are any signs of poor perfusion, a Normal Saline bolus should be given.  Most BRUE patients will not require specific treatments by EMS.

 

Patients with BRUEs must be transported to the most accessible PMC if ground transport is ≤ 30 minutes in accordance with Ref. No. 510.  If ground transport is > 30 minutes, the patient may be transported to the most accessible EDAP.

Paramedics recognize the resolved symptoms from the history and identify that the patient has had a BRUE.  The patient is placed on a cardiac monitor that demonstrates normal sinus rhythm.  No other interventions are indicated.

Base contact is made prior to transport as required by TP-1235P.  The patient is transported to the PMC.

In the Emergency Department, the emergency physician confirms the diagnosis of BRUE after completing a full history and physical examination.  No other explanation for the symptoms is identified.  The infant is classified as a lower risk BRUE patient.  The patient is monitored with continuous pulse oximetry and serial observations in the emergency department.  The parents are given information about BRUEs2 and resources for CPR training.  The infant is discharged for routine outpatient follow-up with his pediatrician.

  • A thorough history should be obtained to identify BRUEs.  The diagnosis can be easily missed based on the appearance of the infant at the time of evaluation.
  • Other causes for the patient’s symptoms should be assessed for at the scene and treated accordingly.  Any signs of child abuse or neglect must be reported.
  • In Los Angeles County, BRUE patients should be transported to the most accessible PMC within 30 minutes after contacting the Base.
  • In the hospital, BRUE patients will be classified as lower risk or higher risk to determine clinical management.

References

1Tieder JS, et al.  Brief Resolved Unexplained Events (Formerly Apparent Life Threatening Events) and Evaluation of Lower-Risk Infants).  Pediatrics.  2016; 137(5)

2Patient Education Handouts.  Brief Resolved Unexplained Event: What Parents and Caregivers Need to Know.  American Academy of Pediatrics.  https://patiented.solutions.aap.org/handout.aspx?gbosid=239090 accessed Oct 7, 2019.

3Ramgopal S, et al.  Changes in the Management of Children With Brief Resolved Unexplained Events (BRUEs).  Pediatrics.  2019 Oct;144(4). Epub 2019 Sep 5.


Author:  Dr. Denise Whitfield, MD, MBA