Download ALTE 7/16/12 Morning Report

Morning Report
Karen Estrella-Ramadan
07/16/12
ALTE
(acute life threatening event)
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.
• Estimated frequency among healthy term infants widely
varies (0.5–6%)
• 50% of events may remain unexplained following a
thorough evaluation.
• > frequent causes:
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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
• > kids are asymptomatic
when they arrive to ER
• Your goal:
– Careful H &P + PE
– Systemic approach
Key questions
History
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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?
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
Personal and family hx
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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?
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
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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
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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
Based on your differential you may do
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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
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!
Discharge
• Prior to discharge:
– Discuss CPR training for caretakers
– Red flags
– Stop smoking
– Appropriate feeding technique
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
References
• http://emedicine.medscape.com/article/1418
765-overview#a30
• http://pediatrics.uchicago.edu/chiefs/docume
nts/ALTEMR-Danielle.pdf
• http://www.aafp.org/afp/2005/0615/p2301.h
tml