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:
  • 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
Revised: March 2019 (Reviewed), January 2020, June 2020
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