ALTE has been deprecated and replaced with BRUE. Apparent Life-Threatening Events scared parents and led physicians to unnecessary testing. The American Academy of Pediatrics has issued the following guideline.
STEP 1: Meets DEFINITION of BRUE
- BRIEF: less than 1 minute episode
- RESOLVED: back to baseline/normal
- UNEXPLAINED: no other etiology (no URI, vomiting, etc)
- cyanosis or pallor (not erythema)
- absent, decreased or irregular breathing
- marked change in tone
- altered level of responsiveness
- in a normal child, less than 1 year old
STEP 2: Stratify as LOW risk
- more than 60 days old
- full term (gestational age more than 32w)
- 1st event and not in clusters
- less than 1 minute
- no CPR by *trained medical provider*
- no concerning features on H&P
STEP 3: Consider TREATMENT options for LOW risk
- SHOULD DO: educate care giver, shared medical decision making regarding can-do items, CPR training for parents
- CAN DO: pertussis testing, ekg, serial observation, pulse oximetry
- DONT HAVE TO DO: admit, viral PCR, glucose, HCO3, lactate, Hgb, CT head (unless judgement says differently), UA
- SHOULD NOT DO: WBC, CSF, Cx, BMP, urine organic acids, CXR, echo, EEG, GERD tests, H2 blockers, anti-epileptics, no home monitoring
HIGH risk patients consider
- cardiac arrhythmias (family history of sudden death)
- infection (URI Sx)
- others guided by context
- Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, Katz ES, Krilov LR, Merritt JL 2nd, Norlin C, Percelay J, Sapién RE, Shiffman RN, Smith MB; SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016 May;137(5). https://www.ncbi.nlm.nih.gov/pubmed/27244836
Used to risk stratify patients for further cardiac workup in the ER according to risk of major adverse cardiac events (MACE).
2: highly suspicious
1: moderately suspicious
0: slightly or non-suspicious
2: significant ST-depression
1: non-specific repolarization
2: > 65 years old
1: 45-65 years old
0: < 45 years old
Risk Factors (DM, recent smoker <1m, HTN, HLP, fam Hx, obesity)
2: 3+ risk factors (or prior CAD)
1: 1-2 risk factors
2: 3x normal limit
1: 1-3x normal limit
0: < normal limit
LOW: 0-3 → 1.7% to 2.5% MACE over next 6 weeks (discharge home)
MED: 4-6 → 16.6% to 20.3% MACE over next 6 weeks (observation)
HIGH: 7-10 → 50.1% to 72.7% MACE over next 6 weeks (early invasive strategies)
According to University of Maryland Shared Decision Making program for low risk chest pain, additional ECG and troponin testing can decrease low risk group to approximately 1.7% MACE. Stress testing brings it down to 1%.
- Backus BE, Six AJ, Kelder JH. Risk scores for patients with chest pain: evaluation in the emergency department. Current cardiology …. 2011.
- Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153-2158. doi:10.1016/j.ijcard.2013.01.255.
- Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191-196.
Remember that Oxygen Delivery is composed of two parts:
What is Shock?
[Oxygen Delivery] = [Oxygen Content] [Cardiac Output]
In the first video, let’s go over problems with that second part: cardiac output.
How can cardiac output go wrong? All of these can lead to decreased cardiac output.
- Cardiac: problems with the PUMP. The heart won’t push blood forward.
- Blood vessels: problems with the PIPES. The blood vessels are causing either obstruction to flow or are so massively dilated that blood just pools within or leaks out.
- Fluid volume: problems with the TANK. There’s not enough fluid to pump around.
The commonly taught categories of causes of cardiogenic, obstructive, distributive and hypovolemic fit into the above three physiologic groups.
How do you diagnose shock?
You can recognize shock by hypoperfusion of organ systems. So you’ll find measured blood pressure is low. Also, decreased blood flow to the
- kidneys leads to decreased urine output
- brain leads to altered mental status
- skin leads to cyanosis.
Remember that H&P are the best diagnostic tools we have. So search for potential signs and symptoms for diseases of the pump, pipes or tank. Ultrasound (the RUSH protocol) is very helpful as well. Treatment depends on identifying the cause.
How do you treat shock?
Treatment depends on the cause of hypoperfusion.
- PUMP problem? Maybe you need an inotrope or other cardiac support
- TANK problem? Then fill up the tank. Use whatever fluid you need, but remember crystalloid doesn’t carry oxygen.
- PIPE problem? Then, assuming you have a full tank, you need a pressor.
Here’s two short videos giving an overview of upper and lower GI bleeds.
I start every video with “Now let’s talk about…” Pretty annoying. I need a catch phrase.
The fine folks at Rosalind Franklin University invited me to speak on the Flipped Classroom and the use of technology. You can flip through the slides below or the handout here. You can also download them as a PPTX or PDF file if you’d like. I made some changes from the Rush talk.