Brief Resolved Unexplained Event (BRUE)

Table of Contents

Aliases

Apparent Life-Threatening Event, ALTE

Patient Care Goals

  1. Recognize patient characteristics and symptoms consistent with a BRUE
  2. Promptly identify and intervene for patients who require escalation of care
  3. Choose proper destination for patient transport

Patient Presentation

Inclusion Criteria

  1. Suspected BRUE: An event in an infant less than 1 yo reported by a bystander as sudden, brief (less than 1 min), completely resolved upon EMS arrival that includes one or more of the following:
    1. Absent, decreased, or irregular breathing
    2. Color change (central cyanosis or pallor)
    3. Marked change in muscle tone (hyper- or hypotonia)
    4. Altered level of responsiveness

Exclusion Criteria

  1. Any of the following present upon EMS evaluation:
    1. Abnormal vital signs for age (including fever)
    2. Vomiting
    3. Signs of trauma
    4. Noisy breathing
  2. Identifiable cause for the event, which may include:
    1. Gastric reflux (spitting up)
    2. Swallowing dysfunction
    3. Nasal congestion
    4. Periodic breathing of the newborn
    5. Breath-holding spell
    6. Change in tone associated with choking, gagging, crying, feeding
    7. Seizure (eye deviation, nystagmus, tonic-clonic activity)
  3. History or exam concerning for child abuse or neglect
  4. Color change that involved only redness (e.g. in the face) or isolated perioral or hand/feet cyanosis

Patient Management

Assessment

  1. History
    1. History of circumstances and symptoms before, during, and after the event, including duration, interventions done, and patient color, tone, breathing, feeding, position, location, activity, level of consciousness
    2. Other concurrent symptoms (fever, congestion, cough, rhinorrhea, vomiting, diarrhea, rash, labored breathing, fussy, less active, poor sleep, poor feeding)
    3. Prior history of BRUE
    4. Past medical history (prematurity, prenatal/birth complications, gastric reflux, congenital heart disease, developmental delay, airway abnormalities, breathing problems, prior hospitalizations, surgeries, or injuries)
    5. Family history of sudden unexplained death or cardiac arrhythmia in other children or young adults
    6. Social history: who lives at home, recent household stressors, exposure to toxins/drugs, sick contacts)
    7. Considerations for possible child abuse (multiple/changing versions of the story; reported mechanism of injury does not seem plausible, especially for child’s developmental stage)
  2. Exam
    1. Full set of vital signs (per Universal Care guideline, includes: T, P, RR, BP, O2 sat)
    2. General assessment:
      1. Signs of respiratory distress (grunting, nasal flaring, retracting)
      2. Color (pallor, cyanosis, normal)
      3. Mental status (alert, tired, lethargic, unresponsive, irritability)
    3. Head to toe exam, including:
      1. Physical exam for signs of trauma or neglect
      2. Pupillary response

Treatment and Interventions

  1. Monitoring
    1. Cardiac monitor
    2. Continuous pulse oximetry
    3. Check blood glucose
    4. Serial observations during transport for change in condition
  2. Airway
    1. Give supplemental oxygen for signs of respiratory distress or hypoxemia – Escalate from a nasal cannula to a non-rebreather mask as needed [see Airway Management guideline]
    2. Suction the nose and/or mouth (via bulb, suction catheter) if excessive secretions are present
  3. Utility of IV placement and fluids
    1. Routine IVs should not be placed on all BRUE patients
    2. IVs should only be placed in children for clinical concerns of shock, or when administering IV medications

Notes – Brief Resolved Unexplained Event (BRUE)