Download Apparent Life Threatening Events (ALTE)

Apparent Life Threatening
Events (ALTE)
Adaobi Okobi, M.D.
Pediatrics Chief Resident
St. Barnabas Hospital
Objectives
Define an ALTE
Recognize key components in the
history and physical exam
Review work up and differential
diagnosis
Discuss the use of monitors
Definition
An episode that is frightening to the
observer and is characterized by a
combination of apnea, color change,
change in muscle tone, choking or
gagging
Epidemiology
Incidence: 0.6-2.46 per 1,000 live
births in children under 1 year
Average age: 8 weeks
M:F 1:1
History
Chief complaint
Apnea?
Respiratory effort?
Color change and distribution
Change in tone and
distribution
Choking or gagging?
Duration of episode?
Vomiting?
Relationship to feeds?
Eye deviation?
Loss of consciousness?
Fever?
Trauma?
State of alertness before the
event?
Place of occurrence
Type of resuscitation and who
performed it
Review of prehospital record
Current condition of the child
(in caretaker’s opinion)
Presence of a monitor?
Medications taken by child or
breastfeeding mother
Previous history of ALTE and
type of evaluation
PMHx (including prematurity)
FamHx (including SIDS)
SocHx
Physical Exam
Vital signs including pulse oximetry
General appearance including any features
consistent with a genetic or metabolic syndrome
Evaluate for trauma including retinal hemorrohage,
hemotympanum, contusions, acute abdomen, etc
Evaluate the lungs and assess nasal congestion
Evaluate the heart for murmurs, quality of femoral
pulses
Neuro exam!!
Apnea
Central- lack of brainstem-mediated
respiratory effort; abnormal if >20 sec
or shorter duration with physiologic
compromise
Obstructive- attempts to breathe
against a blocked airway; always
abnormal!
Mixed- combination of central and
obstructive apnea in the same
episode
Differential Diagnosis
GI (33%)
Gastroesophageal
reflux
Gastroenteritis
Dysphagia
Vomiting
Neurologic (15%)
Seizure
Intracranial hemorrhage
Central
apnea/hypoventilation
syndromes
Hydrocephalus
Brain tumor
Vasovagal reflex
Meningitis/encephalitis
Myopathy
Congenital
malformation of
brainstem
Differential Diagnosis (cont’d)
Respiratory (11%)
RSV
Pertussis
Aspiration pneumonia
Foreign body
Other upper or lower resp
tract infections
Otolaryngologic (4%)
Laryngomalacia
Subglottic stenosis
Cardiac (1%)
Arrhythmia (ie Prolonged
QTc)
Congenital cardiac
disease
Cardiomyopathy
Myocarditis
Metabolic or endocrine
Electrolyte abnormality
Hypoglycemia
Inborn Error of
Metabolism
Infectious
Sepsis
UTI
Differential Diagnosis (cont’d)
Other
Shaken baby
syndrome
Intentional
Suffocation
Munchausen by
proxy
Physiologic event
(ie acrocyanosis,
periodic breathing)
Breath holding spell
Other (cont’d)
Anemia
Unintentional
smothering
Toxin ingestion
Hypothermia
Overfeeding
Idiopathic (23%)
Work Up
Observation with
continuous pulse oximetry
and cardiorespiratory
monitor
Dependent on history and
physical exam
May include:
CBC with diff
Chemistry panel
Metabolic screen
Toxin screen
Blood culture
Urine culture
CSF culture
Viral respiratory cultures
CXR
Neuro imaging (CT vs
MRI)
GI imaging
EKG
EEG
Pneumogram
Discharge Criteria
Anticipatory Guidance to avoid future
events (ie no co-sleeping, back to
sleep, no toys or pillows in crib, etc)
Consider apnea monitor
Teach families:
How to recognize events that warrant
investigation
Appropriate stimulation techniques
Cardiopulmonary resuscitation
Apnea Monitors
Recommended for use in:
Preterm infants with high risk of
recurrent episodes of apnea,
bradycardia, and hypoxemia
Infants who are technology-dependent
Infants with unstable airways
Infants with rare medical conditions that
affect their regulation of breathing
Infants with symptomatic chronic lung
disease
Apnea Monitors: Disadvantages
No evidence that apnea monitors
effectively prevent SIDS
Although parents report feeling more
secure with apnea monitors, psychological
testing revealed that they report increased
depression and hostility in the first 2 weeks
of their infants coming home
Average monthly price of operation per
monitor ranges from $300 to $400,
excluding physician fees
Summary
ALTE is a constellation of symptoms and
not a true diagnosis
The history and physical exam give
important clues to the diagnosis
The work up can be extensive if the history
and physical do not correlate
Apnea monitor use can be helpful in a
specific population however its use in the
setting of ALTE can be controversial
Questions
A young couple brings their 4-week-old daughter to the
emergency department because she stopped breathing
while feeding. They report that they initiated
cardiopulmonary resuscitation but were unable to get a
response from her. The infant is apneic, cyanotic, and
limp. You also note on physical examination that her left
arm and left leg are bruised. After you intubate her and
gain intravenous access, you consider the differential
diagnosis of apnea. Of the following, the test that is
most important to obtain to determine the cause of the
infant’s apneic event is:
A. Ammonia measurement.
B. Chest radiography.
C. Computed tomography scan of the head.
D. Electrocardiography.
E. Upper gastrointestinal radiographic series.
Questions
You are evaluating a 6-week-old boy who was brought to your clinic by
his mother after a choking episode several hours earlier. She reports
that shortly after feeding, he coughed and appeared to be choking and
gasping for breath for 5 seconds. The episode resolved, and he has
been breathing normally since. He is a well-appearing, alert infant who
has normal vital signs and no fever. Except for mild nasal congestion,
his physical examination findings are normal. His mother reports that
he spits up occasionally. Of the following, the most appropriate
management of this patient’s ALTE is:
A. Admission to the hospital for a 48-hour observation without
laboratory evaluation.
B. Admission to the short-stay unit for 24 hours of continuous
cardiorespiratory and pulse oximetry monitoring.
C. Discharge from the clinic with an apnea monitor for 2 months.
D. Education of the mother and discharge from the clinic with
gastroesophageal reflux precautions.
E. Full sepsis evaluation, including lumbar puncture, and admission to
the hospital for administration of intravenous antibiotics.
References
DeWolfe, C. and Chidekel, A. Apparent
Life-Threatening Event, Infant Apnea, and
Pediatric Obstructive Sleep Apnea
Syndrome. Pediatric Hospitalist Medicine.
Pg. 453-459
Fu, L and Moon, R. Apparent LifeThreatening Events (ALTEs) and the Role
of Home Monitors. Pediatrics in Review.
2007;28: 203-208