Notes – Brief Resolved Unexplained Event (BRUE)

Brief Resolved Unexplained Event (BRUE)

Patient Safety Considerations

  1. Regardless of patient appearance, all patients with a history of signs or symptoms of BRUE should be transported for further evaluation
  2. Destination considerations
    1. Consider transport to a facility with pediatric critical care capability for patients with high risk criteria present:
      1. Less than 2 months of age
      2. History of prematurity (less than or equal to 32 weeks gestation or corrected gestational age less than or equal to 45 weeks)
      3. More than 1 BRUE, now or in the past
    2. All patients should be transported to facilities with baseline readiness to care for children

Notes/Educational Pearls

Key Considerations

  1. BRUE is a group of symptoms, not a disease process
  2. High risk BRUE patients may require ED or hospital intervention
  3. All patients should be transported to an ED
  4. It is very important to have a high index of suspicion for abuse in children presenting with a Brief Resolved Unexplained Event (BRUE). Of the very serious causes of BRUE, child abuse has been found in as many as 11% of cases. One retrospective review noted that a call to 911 for BRUE was associated with an almost 5 times greater odds of abusive head trauma being diagnosed as the cause of the BRUE, clearly emphasizing the high index of suspicion EMS providers must have when responding to these calls.
  5. Contact direct medical oversight if parent/guardian is refusing medical care and/or transport, especially if any high-risk criteria are present (see above)

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914197 – Medical- Apparent Life-Threatening Event (ALTE)
    • NOTE: BRUE is the updated term replacing ALTE and NEMSIS will not be able to change the label for this code until at least mid-2018. Most ePCR software systems allow changing the displayed label for a value and local systems will be able to do this. The background NEMSIS code will remain the same however, regardless of whether the guideline is called ALTE or BRUE.

Key Documentation Elements

  • Document key aspect of history
    • Color change
    • Apnea
    • Change in muscle tone
    • Caregiver resuscitation efforts
    • History of prematurity
    • Prior BRUE events
    • Past medical history
  • Document key aspects of the exam to assess for a change after each intervention:
    • Full set of vital signs (T, RR, BP, P, O2 sat)
    • Respiratory effort
    • Mental status
    • Color
    • Presence of signs of trauma or neglect

Performance Measures

  • Complete set of vital signs recorded
  • Appropriate transport destination relative to risk criteria

References
Key Reference

  1. Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants: a systematic review. Pediatrics. 2016;137(5):e20165090.

Supplemental References

  1. Al-Kindy H, Gelinas J, Hatzakis G, Cote A. Risk factors for extreme events in infant hospitalized for apparent life-threatening events. J Pediatr. 2009;154(3):332-7.
  2. American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee, Emergency Nurses Association Pediatric Committee. Joint policy statement – guidelines for care of children in the emergency department. Pediatrics. 2009;124(4):1233-43.
  3. American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee, Emergency Nurses Association Pediatric Committee. Joint Policy Statement – Guidelines for Care of Children in the Emergency Department. Ann Emerg Med. 2009;54(4):543-52.
  4. Bonkowsky J. Guenther E, Filloux F, Srivastatva R. Death, child abuse, and adverse neurologic outcome of infants after an apparent life-threatening event. Pediatrics. 2008;122(1):125-31.
  5. Denver Metro Airway Study Group. A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region. Prehosp Emerg Care. 2009;13(3):304-10.
  6. Ehrlich PF, Seidman PS, Atallah O, Haque A, Helmkamp J. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004;39(9):1376-80.
  7. Gausche-Hill M, Lewis RJ, Stratton, SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome. JAMA. 2000;283(6):783-90.
  8. Gausche-Hill M, Schmitz C, Lewis RL. Pediatric Preparedness of US Emergency Departments: A 2003 Survey. Pediatrics. Dec 2007;120(6):1229-37.
  9. Guenther E, Powers A, Srivastava R, Bonkowsky JL. Abusive head trauma in children presenting with an apparent life-threatening event. J Pediatr. 2010;157(5):821-5.
  10. Ho J, Casey B. Time saved with use of emergency warning lights and sirens during response to requests for emergency medical aid in an urban environment. Ann Emerg Med. 1997;32(5):585-8.
  11. Hunt RC, Brown LH, Cabinum ES, et al. Is ambulance transport time with lights and siren faster than that without? Annals of Emergency Medicine, 1995 25(4), 507-11.
  12. Kaji A, Claudius I, Santillanes G, et al. Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med. 2013;61(4):379-87.
  13. Kaji A, Claudius I, Santillanes G, et al. Do infants less than 12 months of age with an apparent life-threatening event need transport to a pediatric critical care center? Prehosp Emerg Care. 2013;Vol 17(3):304-11.
  14. Kuzma K, Sporer KA, Michael GE, Youngblood GM. When are prehospital intravenous catheters used for treatment? J Emerg Med. 2009;36(4):357-62.
  15. Lacher ME, Bausher JC. Lights and siren in pediatric 911 ambulance transports: Are they being misused? Ann Emerg Med. 1997;29(2):223-7.
  16. Meislin AHW, Hinsberg P. A prospective in-field comparison of intravenous line placement by urban and nonurban emergency medical services personnel. Ann Emerg Med. 1994;24(2): 209-14.
  17. Middleton KR, Burt CW. Availability of pediatric services and equipment in emergency departments: United States, 2002-03. Adv Data. 2006;367:1-16.
  18. Mittal M, Sun G, Baren JM. A clinical decision rule to identify infants with apparent life-threatening event who can be discharged from the emergency department. Pediatric Emerg Care. 2012;28:599-605.
  19. Parker K, Pitetti R. Mortality and child abuse in children presenting with apparent life-threatening events. Ped Emerg Care. 2011;27(7):591-5.
  20. Stiell IG, Spaite DW, Field B, Nesbitt LP, Munkley D, Maloney J, et al. Advanced life support for out-of-hospital respiratory distress. N Engl J Med. 2007;356(21):2156-64.
  21. Stratton S, Taves A, Lewis R, Clements H, Henderson D, McCollough M. Apparent life-threatening events in infants: high risk in the out-of-hospital environment. Ann Emerg Med. 2004;43:711-7.
  22. Tieder JS, Altman RL, Bonkowsky JL, et al. Management of apparent life-threatening events in infants: a systematic review. J Pediatr. 2013;163:94-9.