Download STEP BY STEP MANAGEMENT OF DKA

STEP BY STEP
MANAGEMENT OF
ALTE
Dr. D. Alvarez
September 2006
ALTE
• An episode that is frightening to the observer and is
characterized by some combination of:
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Apnea
Color change
Marked change in muscle tone
Choking or gagging
• In some instant the observer fears that the infant has died.
• Recovery occurs only after stimulation or ressuscitation.
• Recurrence of ALTE is very frequent and occurs in 3060% of all ALTE.
• True frequency of recurrence is probably even higher since
many true documented apnea not leading to full blown
ALTE go undetected by parents.
ALTE – Definition (Other)
• Episode frightening to the observer plus 1
or more of the following
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Apnea central > obstructive
Color changes: blue or pale
Sudden limpness)
Chocking – gagging
• Recurrence 13 %
INITIAL PROCES
1. Call from the ED/4-B requesting bed for a
patient with Diagnosis of ALTE
2. Resident / Supervisor (if applicable) obtains
information on patients condition, on the
phone or going to the ED/4-B, (as activity in
the unit warrants).
3. Information needed:
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Detail history from the observer (who was with
the infant during the “episode”)
ALTE - History should include
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Duration of the event
Time of the day
Time after feeding (any changes in feeding if any)
Adequacy of lighting
Infant position within his / her surroundings (soft bedding, pillows?)
Did episode began while awake or asleep
Changes in Color
Changes in muscle tone
Need for any type of resuscitation (describe)
Was any blood or pink frothing coming from infants mouth or nose
Appropriateness of caregiver’s concerns
Fly. Hx of SIDS or serious illness with coma
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Any associated respiratory symptoms.(URI – Coughs)
Focus PE (ALTE)
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Alertness
Tone
Bruising
Scalp swelling
Disuse of extremities
Fundoscopy, retinal hemorrhages
Chest exam, stridor.
Selected Causes of ALTE
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RSV, Pertusis
Sepsis with apnea
Syndromes compromising the upper airway (Pierre-Robin)
Breath holding spells
Seizures
Intracraneal hemorrhages, vascular abnormalities, child
abuse, Vit K deficiency.
Exaggerated laryngeal chemoreceptor with or without
GER
Drug. (Phenothyazede)
Tachyarreithmias, SVT, prolongued QT intervale.
Inborn errors of metabolism
Hypoventilation during bed sharing.,soft bedding
Apnea of Infancy
• An ALTE episode with no found cause.
• Unexplained episode of cessation of
breathing for > 20 sec, or shorter respiratory
pause associataed with bradycardia,
cyanosis, pallor, and/or marked hypotonia in
an infant whose age during initial event is >
37 wks postconceptional age.
ED Events.
4.- Review of ED-Events
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Assessment on presentation to ED
Intervention / therapies and response
Studies / labs done (Start laboratory flow sheets record)
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CBC with diff and
Electrolytes.
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Look for hypoglycemia, metabolic acidosis.
Source of infection: UA, blood cultures.
CxR Look for any lung pathology and heart side
EKG
5.- Communicate with PICU Attending and inform on
patient’s condition.
6.- Inform PICU Nurses that patient was accepted and
up-date them on patient’s condition.
ASSESSMENT
&
MANAGEMENT
INITIAL MANAGEMENT
OVERALL ASSESSMENT /
FOCAL SIGNS
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Patient’s looks well at
baseline condition
Afebrile -No Focal signs
INTERVENTIONS
• Observe /monitor
• F/U initial studies
CBC, Lytes, Cultures, EKG, RSV
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Identify/investigate and
• Treat the identifiable causes.
such as: RSV, Pneumonia,
GER, etc.**
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Ill, sick looking with no
indefinable causes.
• ? Sepsis / Management
• ? Metabolic workup
–ABG, LFT, Amonia level,
– Lactic and Pirubic Acid
– Urine metabolic screening,
GENERAL / OVERALL ASSESSMENT AND
FOCAL FINDINGS
Identify/investigate and treat focal abnormalities such as:
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Possible bacterial infection early sepsis?
Respiratoy symptoms
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Cardiovascular abnormalitis
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Close respiratory monitoring
CxR
Respiratory therapy according to pathology: URI?, LRI
Cardiomegaly, EKG abnormalities
Continue investigations according to physical exam
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R/O CNS infections >LP ? Head CT
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Metabolic screening: ABG, Lactic Acid, LFT, ammonia level
Basic Recommended Evaluation for
ALTE
• Admit to observation and cardiorespiratory
monitoring
• Careful history, physical and neurologic
examination
• Complete blood count
• Blood glucose, electrolytes, Calcium
• CxR, ECG,
• Arterial Blood gases
• EEG
• Multichannel recording including oxygenation.
Evaluation of ALTE in Selected
Cases:
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Septic workup (blood, urine, CSF cultures)
Barium Swallow
Lateral neck x Rays
Milk scan
PH probe
U/S or CT scan of brain
Echocardiogram
Blood amonia and urine Amino acid if recurrent.
“Indication” for home C-R
monitoring
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History of ALTE
Multichanel documentation of clinical significant Apnea
Twin of SIDS
Apnea of Prematurity
Periodic breathing associadited with hypoxia
Feeding associated with apnea and bradycardia
Technology dependent children
ISAM (Selected cases)
Sibling of SIDS (Selected Cases)
Home Monitor Settings:
• Heart Rate Alarm
– High: 220 bpm
– Low:
• 70 bpm (< 2 mo)
• 60 bpm (2-8 mo)
• 50 bpm (> 8 mo)
• Apnea:
– > 15 sec – record
– > 20 sec – alarm
• If SaO2 is monitored: Alarm set at < 85 %
ALTE
Begin Monitor
2-3 months no true alarms
Event Record Normal
Discontinue
Monitor
Abnormal Event Recording
True Alarms
Continue Monitoring