1. Morning Report Karen Estrella-Ramadan 07/16/12

2. ALTE (acute life threatening event)

3. Definition Episode that is frightening to the observer and is characterized by some combination of apnea (central or obstructive), color change (cyanotic, pallid, erythematous or plethoric) change in muscle tone (usually diminished), and choking or gagging. – In some cases, the observer fears that the infant has died. Episode that is frightening to the observer and is characterized by some combination of apnea (central or obstructive), color change (cyanotic, pallid, erythematous or plethoric) change in muscle tone (usually diminished), and choking or gagging. – In some cases, the observer fears that the infant has died.

4. Estimated frequency among healthy term infants widely varies (0.5–6%) 50% of events may remain unexplained following a thorough evaluation. > frequent causes: – 50% Gastrointestinal: GER – 30% Neurologic: seizures, sepsis, meningitis – 20% Respiratory: viral lower respiratory infections, pertussis – 5% Cardiovascular: long QT syndrome, supraventricular tachycardia – 5% Metabolic/Endocrine – 3-5%+ Non-accidental trauma Other: anemia, Structural: CNS, cardiac, or airway anomaly

5. > kids are asymptomatic when they arrive to ER Your goal: – Careful H &P + PE – Systemic approach

6. Key questions History Where was the child? Crib, bed, sofa, alone vs with someone Events prior to episode: recent illness, immunizations, recent activities Usual sleep conditions: position, bed sharing Precise time of event; time before feeding, fever, bathing How was the baby found: awake or asleep; position of sleep: face covered, uncovered Reason that lead to discovery of child Who saw it? Who takes care of the child? How long it lasted? How long it took for baby to recover?

7. Description of event A caregiver’s description of the infants’ color, Who observed the event? Respiration, and muscle tone – central cyanosis (lips and oral mucous membranes) vs acrocyanosis Infants who are coughing, choking, or gagging may exhibit a ruddy or plethoric facial color that may be interpreted as “turning blue.” – Apnea? central (lack of respiratory effort) or obstructive (respiratory effort with inadequate airflow). Vs. periodic breathing Was the infant limp, or was muscle tone increased during or after the event? Were any seizure like movements observed? Was any resuscitation required, or did the event spontaneously resolve

8. Personal and family hx Was the infant born at term, or was the infant premature? Were any pregnancy or labor and delivery complications reported? Are any factors that predispose to neonatal sepsis noted? Has the infant previously exhibited symptoms of gastroesophageal reflux or aspiration of thin liquids? – coughing, choking, or gagging during or after feeding; frequent or excessive spitting-up; persistent nasal stuffiness; or frequent hiccups. – Acid reflux disease is suggested by excessive irritability, arching, and straining behaviors displayed during or following a feeding Are the newborn metabolic screening findings normal? Does the family have a history of seizures, metabolic disorders, previous sudden infant death syndrome (SIDS), or unexplained death in infancy or childhood ?

9. Physical exam: key points VS including pulse oximetry!! SKIN: lesions, signs of trauma HEENT: fontanelle (normal, bulging, or sunken), eyes: fundus - suspect retinal hemorrhages; nose and mouth: look for blood or milk Lungs: RR, pattern of breathing, and adequacy of air exchange. – stridor, wheezes, or crackles CV: HR, BP, O2 sat 4extremties, distal pulses, cap refill, cardiac: murmurs? Abdominal: distension or tenderness GU: hernia, testicular torsion Neuro: assessment of the infants’ responsiveness. Tone, reflexes, any focal or lateralizing findings are present. Skeletal: deformities, bruising, ROM

10. Infectious – Sepsis – Meningitis/Encephalitis – RSV/ Pertussis – UTI GI – GER – Volvulus – Intussusception – Swallowing dysfunction Cardiovascular – Prolonged QT, WPW – Arrythmia – Myocarditis – Vascular Ring Metabolic – Primary Inborn Error of Metabolism Secondary to other endocrine, electrolyte, or metabolic disorder Toxic Exposure – Carbon monoxide – Medications: herbal Neurologic – Seizure – Vasovagal syncope – Chiari /hindbrain malformation associated apnea – Hydrocephalus – CNS hemorrhage Respiratory – Breath holding spells – Congenital airway abnormalities – Central hypoventilation – Upper airway obstruction – Vocal cord dysfunction – Laryngotracheomalacia – Foreign body Child abuse – Suffocation – Intoxication – Physical Injury – Shaken Baby – Munchausen by proxy

11. Based on your differential you may do CBC: viral or bacterial infection or anemia BMP: hypoglycemia, hyponatremia, hyperkalemia, acidemia, hypocalcemia, lactic acidosis LFT ABG: acidosis or retention of CO Serum or urine toxicology studies for suspected ingestions Specific bacterial or viral cultures to assess for RSV, pertussis, bactemia, or urinary tract infection LP: meningitis EKG to assess for long QT syndrome and preexcitation that suggests supraventricular tachycardia or other dysrhythmia EEG to assess for epileptiform activity Imaging: pulmonary infections, cardiac, surgical abdomen, skeletal survey Upper GI contrast studies to assess for swallowing dysfunction, thin liquid aspiration, or upper-intestinal anatomic malformations Impedance pH monitoring to assess for gastroesophageal reflux disease Neuroimaging to assess for hemorrhage or structural CNS abnormality Polysomnography to assess for sleep-based disturbances in cardiorespiratory control

12. And now? Most infants with ALTE should be hospitalized for more evaluation and observation If there is reliable follow-up and the child is completely well-appearing and the details of the event indicate a benign occurrence, it may be possible to follow as an outpatient. If resuscitation required was significant, patients should be monitored closely in a ICU. Continuous monitoring is important!

13. Discharge Prior to discharge: – Discuss CPR training for caretakers – Red flags – Stop smoking – Appropriate feeding technique

14. Do All Infants With Apparent Life-Threatening Events Need to Be Admitted? Claudius I., Keens T. Pediatrics Vol. 119 No. 4 April 1, 2007 pp. 679 -683 (doi: 10.1542/peds.2006-2549) 59 patients in the ED, 8 had reasons for hospitalizations Risks for admission: freq visits to ER related to ALTe, < 30 days old

15. References http://emedicine.medscape.com/article/1418 765-overview#a30 http://emedicine.medscape.com/article/1418 765-overview#a30 http://pediatrics.uchicago.edu/chiefs/docume nts/ALTEMR-Danielle.pdf http://pediatrics.uchicago.edu/chiefs/docume nts/ALTEMR-Danielle.pdf http://www.aafp.org/afp/2005/0615/p2301.h tml http://www.aafp.org/afp/2005/0615/p2301.h tml