Emergency Department and Inpatient Pathway for Evaluation of Infants with a Brief, Resolved, Unexplained Event (BRUE)

Infant < 1 yr with a BRUE
Does Not Meet BRUE Criteria
  • BRUE criteria absent
  • Additional symptoms present
    • Abnormal vital signs
    • Physical exam other than baseline
  • Explanation for event identified
Meets BRUE Criteria
  • Sudden, brief, and now resolved episode of one or
    more of the following in an infant < 1 yr 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 wks gestation and post-conception age ≥ 45 wks
  • No cardiopulmonary resuscitation (CPR) by trained medical provider
  • Event lasted < 1 min
  • First event
  • No repeat events
  • No concerning history
  • Any of the lower-risk criteria not met
  • Concerning history
    • e.g., FH of sudden cardiac death or concern for social, feeding, or respiratory problems
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 hrs on continuous pulse ox and cardiac monitor and during PO trial
  • Routine laboratory testing is generally not needed
    • Consider pertussis screen, if history of exposure
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 hrs
  • Observation needed to characterize events
  • Specific abnormality identified during
    medical observation
  • Sub-specialty consultation, additional
    studies recommended
  • Provider or family uncomfortable with
    home observation
  • MDCalc BRUE 2.0  
Admission Guidance
  • Review BRUE discharge instructions
  • Follow-up with primary medical doctor within the week
  • Safe sleep, co-sleeping teaching
  • Continuous pulse ox and cardiac monitoring
  • Consider consultation based on history and exam
    • Social work consultation, if concern for abuse or family needs support
    • Feeding evaluation, if BRUE events occur during feed or if there are concerns for oral feeding skills or safety
  • Consider targeted interventions based on history
    and physical, specialist input
    • Sleep study or pneumogram
    • EEG, neuroimaging
    • ECG, echocardiographic study
  • MDCalc BRUE 2.0  
  • Education
    • Cardiopulmonary resuscitation (CPR)
    • Safe sleep, co-sleeping teaching
    • Resources as indicated
  • No repeat concerning events during hospital stay
  • All interventions completed and consults reviewed
  • Review BRUE discharge instructions with family
  • Follow-up with primary medical doctor within
    the week
  • Education completed