Emergency Department and Inpatient Pathway for Evaluation of Infants with a Brief, Resolved, Unexplained Event (BRUE)
Infant (< 1 year old) with a BRUE
Does Not Meet BRUE Criteria
- Additional symptoms present
- Abnormal vital signs, including fever
- BRUE criteria absent
- Explanation for event identified
Meets BRUE Criteria
Sudden, brief, and now resolved episode of one or
more of the following in an infant < 1 year age:
more of the following in an infant < 1 year age:
- Cyanosis or pallor
- Absent, decreased or irregular breathing
- Marked change in tone (hyper- or hypotonia)
- Altered responsiveness
- No explanation for the event with full history and exam
- Age > 60 days
- Gestational age
- Born ≥ 32 weeks gestation and post-conception age ≥ 45 weeks
- No cardiopulmonary resuscitation (CPR) by trained medical provider
- Event lasted < 1 minute
- First event
- No repeat events
- No concerning history
- Baseline exam for infant
- Any of the lower-risk criteria not met
- Concerning history, physical examination findings
ED Management Recommendations
ED Management Recommendations
- Review the nature of event with caregivers
- Reassurance and shared decision-making
- Observe infant in ED for 1-2 hours on continuous pulse ox and cardiac monitor and during PO trial
- Routine laboratory testing is generally not needed
- If concerning cardiac family history, consider electrocardiogram (ECG)
- Consider pertussis screen, if history of exposure
- Review Differential Diagnosis
- Continuous pulse ox and cardiac monitor for at least 2 hours and during feeding
- Evaluation as Clinically Indicated
- Social work consult for non-accidental trauma, other concerns
- Electrocardiogram (ECG) if family history of sudden death
- Appropriate viral testing based on symptoms, pertussis risk
- Additional labs, if concern for underlying disease: CBC, BMP, VBG, lactic acid
Disposition Considerations
Considerations for Admission
- No repeat event during ED stay
- Successful PO trial
- Evaluation negative for any concerning illness
- Parent comfortable with discharge to home
- Recurrent event(s) during ED stay or prior 24 hours
- Observation needed to characterize events
- Specific abnormality identified during medical observation
- Sub-specialty consultation, additional studies recommended
- Provider or family uncomfortable with home observation
Discharge
- Review BRUE discharge instructions
- Follow-up with primary medical doctor within the week
- Safe sleep, co-sleeping teaching
Admission Guidance
- Continuous pulse ox and cardiac monitoring
- Consider consultation based on history and physical
- Social work consultation
- Feeding evaluation, if BRUE events occur during a feed or if there are concerns for oral feeding skills or safety
- Consider targeted interventions based on history
and physical- Sleep study or pneumogram
- CT or MRI brain, EEG
- Cardiology consultation/echocardiographic study
- Education
- Cardiopulmonary resuscitation (CPR)
- Safe sleep, co-sleeping teaching
- Resources as indicated
Discharge
- No repeat events in 24 hours and no explanation
- All interventions completed and consults reviewed
- Review BRUE discharge instructions with family
- Follow-up with primary medical doctor within the week
- Education completed
Posted: March 2017
Reviewed: May 2021
Authors: E. Kane, MD; M. Mittal, MD; G. Sharer, RN; J. Beus, MD; C. Gildner, MD; E. R. Hendricks, LSW; J Fischer, MD; J. Welc, SLP; M. Congdon, MD; E. Korn, MD; E. Hardy, CRNP; H. Harrison, MD; H. Wagoner, MD; J. Owusu-McKenzie, MD; J. Posner, MD; J. Butler, RN; K. Osterhoudt, MD; K. Conaway, MD; L. Goldstein, MD; M. Patel, MD; M. Mcway, MD; N. Hughes, MD
Reviewed: May 2021
Authors: E. Kane, MD; M. Mittal, MD; G. Sharer, RN; J. Beus, MD; C. Gildner, MD; E. R. Hendricks, LSW; J Fischer, MD; J. Welc, SLP; M. Congdon, MD; E. Korn, MD; E. Hardy, CRNP; H. Harrison, MD; H. Wagoner, MD; J. Owusu-McKenzie, MD; J. Posner, MD; J. Butler, RN; K. Osterhoudt, MD; K. Conaway, MD; L. Goldstein, MD; M. Patel, MD; M. Mcway, MD; N. Hughes, MD
Evidence
- A Framework for Evaluation of the Higher-Risk Infant After a Brief Resolved Unexplained Event
- Clinical Practice Guideline: Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants
- Management of Apparent Life-threatening Events in Infants: a Systematic Review
- A Clinical Decision Rule to Identify Infants With Apparent Life-Threatening Event Who Can Be Safely Discharged From the Emergency Department
- Should Infants Presenting with an Apparent Life-Threatening Event Undergo Evaluation for Serious Bacterial Infections and Respiratory Pathogens?
- Apparent Life-Threatening Event: Multicenter Prospective Cohort Study to Develop a Clinical Decision Rule for Admission to the Hospital
- Role of Pneumography and Esophageal pH Monitoring in the Evaluation of Infants With Apparent Life-Threatening Event: A Prospective Observational Study
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