Morning Report

Karen Estrella-Ramadan07/16/12

ALTE(acute life threatening event)

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.

• 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:– 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• 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• 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

• 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

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

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/1418765-overview#a30

• http://pediatrics.uchicago.edu/chiefs/documents/ALTEMR-Danielle.pdf

• http://www.aafp.org/afp/2005/0615/p2301.html