"Apparently Life-Threatening Events" (ALTEs) and SIDS and apnea =============================================================== ώ non-ALTEs - Stopping breathing for 5 seconds without changing color is not an ALTE - Periodic breathing, a normal infant breathing pattern, is not an ALTE - Choking on bottle: not an ALTE - Acrocyanosis (especially when cold) not an ALTE - A bit of pallor around the mouth is not an ALTE unless associated with apnea. ώ ALTE Definition - A National Institutes of Health consensus conference in September 1986 defined an apparent life-threatening event as “an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer fears that the infant has died. [Mittal MK, Shofer FS, Baren JM. Serious Bacterial Infections in Infants Who Have Experienced an Apparent Life-Threatening Event. Annals of emergency medicine 2009;54:523-7.] ώ ALTE References ώ ALTE - Ray Pitteti from CHP says: admit them all - Consider prolonged QT syndrome, check QT on EKG - Abuse: cause of an event in 3-5%: + physical abuse/shaken baby + intentional suffocation + Munchausen by proxy: could be poisoned - CHP protocol: do dilated funduscopic exam on all in a study: found some hemorrhages. - Of CHP Ray Pitteti's CHP 600-ALTE database, the only 5 who died died from child abuse. - Feeding history, family history (ALTEs, breath-holding, prolonged QT, SIDS) ώ SIDS: - thought to be related to maldevelopment of brainstem arousal centers. - deficits in serotonin receptors in ventral medulla. - die due to lack of arousal when they choke during sleep: can't gasp. - some of the same features found in ALTEs - have to also have some cause for obstruction. - leading cause of death under 1 year of age. - maternal smoking increases risk by 3x - late or no maternal care a risk - fluffy bedding a big risk: smothering - stuffed animals in bed and crib bumpers also bad - blacks and American Indians have increased risk - bed sharing a risk, co-sleeper recommended - SIDS higher with secondary caregiver - back to sleep campaign 1994: sleeping on back preventative; sleeping on side also bad - pacifiers: reduce risk of SIDS by half. Minimal impact on teeth development. May increase risk of OM. Does not shorten breastfeeding duration. ώ Breath-holding spells - from iron deficiency. - 6 months - 5 years of age: cyanotic breathholding spells, hold breath in expiration, turn blue and seizure - Pallid breathholding spell: vagal, associated with injury, more serious (may fall and hurt self): may need to be on atropine derivative. - false apnea alarm: just admit and sort it out later - ώ Out-of-Hospital ALTE’s [Stratton SJ etal.Ann Emerg Med 2004] - Sixty (7.5%) of 804 infants encountered by EMS during the study c period met criteria for an apparent life-threatening event. - Mean age was 3.1±3.3 months - Of the infants with apparent life-threatening event, 50 (83.3%) infants appeared to be in no distress, 8 (13.3%) infants were in mild distress, and 2 (3.3%) infants were in moderate distress. - Critical conditions associated with apparent lifethreatening event included pneumonia or bronchiolitis (12%), seizure (8%), sepsis (7%), intracranial hemorrhage (3%), bacterial meningitis (2%), dehydration (2%), and severe anemia (2%). - Infants with ALTE’s and significant diagnoses may not be symptomatic on ED arrival, attention to the paramedic and caregiver report is imperative ώ Who to admit? [Claudius. Pediatrics] - 59 Previously healthy patients <12 months of age (small study) Patients observed for subsequent events, significant interventions, or final diagnoses that would have mandated their admission (eg, sepsis). 8 children met the aforementioned outcome measures, thus requiring admission - The high-risk criteria of age of <1 month [corrected] and multiple apparent life-threatening events yielded a negative predictive value of 100% to identify the need for hospital admission. - CONCLUSIONS: >30-day-old infants who have experienced a single apparent life- threatening event may be discharged safely from the hospital, which would decrease admissions by 38%. commment from ACEP 2009: don't let this drive decision to send home, admit them all, too small a study. - Don't really need to do an LP as very low yield unless multiple episodes, but it's traditional. - Very strong statement, considering there were only 59 patients! - Consider our medicolegal environment before making the decision to discharge home! - This study did not address the medicolegal burden of sending home an infant from the ED who subsequently dies because a thorough investigation has not been made Recommendations from ACEP 2009: - Base the workup on the H &P - Perform septic workup, electrolytes, glucose, magnesium, calcium, CXR, EKG, consider head CT/US, pertussis and RSV swabs - Consider tox screen, particularly check for over the counter preparations - ADMIT all patients with an ALTE even with a negative workup. The history will help differentiate between a simple choking episode, periodic breathing and a breath-holding spell. ώ Differential of ALOC “Tips From The Vowels” T-Trauma/Tumor I-Insulin and hypoglycemia P-Poisoning/Psychogenic S-Shock I-Intussusception A-Alcohol/Abuse E-Epilepsy/Encephalopathy I-Infection/Intussusception Inborn Errors of Metabolism O-Opiates U-Uremia ώ Causes of ALOC in the Newborn “THE MISFITS” • T-Trauma/NAT • H-Heart disease/ Hypovolemia • E-Electrolyte disturbances • M-Metabolic disturbances (CAH) • I-Inborn errors of metabolism • S-Sepsis • F-Formula dilution or over concentration • I-Intestinal catastrophes • T-Toxins ( home remedies) • S-Seizures/CNS abnormalities ώ TREATMENT OF HYPOGLYCEMIA • Normal BS: >30mg/dl in infants, >40mg/dl in older children • Replace with 0.25-1 gm/kg of dextrose • Newborns use D10 to avoid ICH and vein damage: 3-10cc/kg • Infants and young children use D25: 2-4cc/kg ώ CONGENITAL HEART DISEASE • Occurs in 8/1000 live births • Blue baby: right to left shunting ex: TOF, TGA, TAPVR, single ventricle, pulmonary atresia, TA, Truncus Arteriosus • Mottled or gray baby: systemic outflow tract obstruction ex: Coarctation, aortic stenosis • Pink baby: CHF with left to right shunting ie VSD, PDA, endocardial cushion defect NEWBORN PHYSIOLOGY • First breath=> decrease PVR due to increased O2=> increased PBF. – Functional ductus closure at 10-15 hours – Anatomic closure at 2-3 weeks of age • Clamping of cord=> increased SVR=> increased LV afterload and LA pressure. Foramen ovale closes at 3 months of age Specific syndromes: • Tetralogy of Fallot (6-10%) • Transposition of the great arteries (3-5%) • Tricuspid atresia (1-2 %) • Truncus arteriosus (1-2%) • Total anomalous pulmonary venous return • Pulmonary atresia or stenosis (5-7%) CONGENITAL HEART DISEASE: Clinical Presentation • Difficulty feeding • Sweating with feeds • Tachypnea • Sudden onset of pallor, lethargy or central cyanosis • Poor weight gain – Most infants lose 10% of birth weight in first week and then gain 20-30 gms day for 1-2 months. Birth weight should be regained by 10-14 days of life Cardiac VS Pulmonary Central Cyanosis CARDIAC PULMONARY Worsens with crying Improves with crying No response to O2 Responsive to O2 Comfortable at rest Respiratory distress May have abnormal EKG Normal EKG Abnormal CXR Normal cardiac silhouette Normal CO2 Low or elevated CO2 CONGENITAL HEART DISEASE Diagnosis- ABG’s • Hyperoxia test:Obtain baseline ABG & repeat in 10 minutes on high-flow oxygen – Increase of 30 torr or more, and O2 saturation increase greater than 10% implies pulmonary process – Minimal or no increase in PaO2 or saturation implies possible cardiac lesion CONGENTIAL HEART DISEASE Diagnosis-Pulse Oximetry • Measure O2 saturation in right hand & foot • Patients with coarctation, PDA or interrupted aortic arch have lower saturations in the feet • Patients with TGA may have higher saturations in the feet due to oxygenated blood passing from ductus to descending aorta CONGENITAL HEART DISEASE Treatment • ABC’s! • Start PGE1 infusion: 0.05ug/kg/min • Administer Lasix 1mg/kg if CHF present, also consider dopamine, morphine, dobutamine • Perform septic workup and start antibiotics • Admit to PICU/NICU CONGENTIAL HEART DISEASE PGE1 Complications • Apnea in up to 12% of patients – Be prepared to intubate! • Hypotension • Seizures • Fever SUPRAVENTRICULAR TACHYCARDIA • Narrow complex with heart rates greater than 220 BPM in infants, >180 BPM in kids • P-waves difficult to see • 50% are idiopathic, 20% acquired, 20% anatomic • History is nonspecific: poor feeding, lethargy, sweating, pallor • Sinus tachycardia usually has an identifiable cause- fever, hypovolemia, anxiety SVT Treatment • Vagal maneuvers • Adenosine: 0.1mg/kg then 0.2mg/kg • Cardioversion with 0.5-1J/kg • No verapamil in infants • Procainamide: 10-15mg/kg over 30-45” • Amiodarone- 5mg/kg over 20-60 minutes