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Apparent Life-Threatening Event (ALTE-BRUE)
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
Acute limb ischemia
Acute mesenteric ischemia
Aortic dissection
Aortic stenosis
Atrial fibrillation and flutter
Bradyarrhythmia and heart block
Cardiac arrest
Deep vein thrombosis
Myocarditis
Pericarditis
Pulmonary embolism
Stable angina
Superficial thrombophlebitis
Superior vena cava syndrome
Supraventricular tachycardia
Syncope (cardiogenic)
Unstable angina
Ventricular tachycardia
Respiratory Presentations
Acute bronchitis
Acute respiratory failure
Aspiration pneumonia
Asthma exacerbation
Bronchiolitis
Community-acquired pneumonia
COVID-19 pneumonia
COPD exacerbation
Croup
Croup (laryngotracheobronchitis)
Epiglottitis
Hemothorax
Hospital-acquired pneumonia
Pleural effusion
Pneumothorax (traumatic)
Pulmonary contusion
Spontaneous pneumothorax
Neurological Presentations
Bell's palsy
Benign paroxysmal positional vertigo
Brain abscess
Cauda equina syndrome
Cervical radiculopathy
Concussion (mild traumatic brain injury)
Encephalitis
Guillain-Barré syndrome
Hemorrhagic stroke (intracerebral)
Ischemic stroke
Lumbar radiculopathy
Malignant spinal cord compression
Migraine
Peripheral neuropathy (acute)
Retropharyngeal abscess
Schizophrenia (acute exacerbation)
Seizure (breakthrough:known epilepsy)
Seizure (first-time)
Spinal cord injury
Status epilepticus
Subarachnoid hemorrhage
Tension headache
Transient ischemic attack
Traumatic brain injury (moderate-severe)
Vestibular neuritis
Viral meningitis
Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
Peptic ulcer disease
Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
Fournier gangrene
Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
Impetigo
Infected diabetic foot ulcer
Infectious mononucleosis
Influenza
Necrotizing fasciitis
Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
Spontaneous bacterial peritonitis
Tick-borne illness (Lyme disease)
Tinea infection
Tuberculosis
Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Apparent Life-Threatening Event (ALTE-BRUE)
POCUS
Procedures
Calculators
Resuscitation
ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
Airway and breathing threats
▶
Apnea or irregular breathing at presentation
▶
Absent or decreased breathing during event
Ongoing apnea is NOT a BRUE and warrants resuscitation
Oxygenation failure
▶
SpO2 < 90% on room air
Persistent cyanosis or pallor
If infant apneic or not breathing at presentation, bag-mask ventilation
▶
Reposition airway and suction secretions
Escalate to pediatric resuscitation
Circulation and perfusion threats
▶
Shock physiology
▶
Capillary refill > 3 seconds
Weak or absent femoral pulses
Sepsis screening in neonate
▶
Temperature instability
Lethargy or poor feeding
If septic neonate, fluids and antibiotics within 1 hour
▶
10 to 20 ml/kg isotonic bolus
Empiric ampicillin plus gentamicin or cefotaxime
Key early branching
▶
Resolved and well-appearing
▶
Normal vitals and normal exam now
Candidate for BRUE classification
Symptomatic or ill-appearing
▶
Fever, respiratory distress, or persistent altered tone
This is an explained event and NOT a BRUE
If any explanatory finding present, directed workup rather than BRUE pathway
▶
Choking or gagging with feeds suggests GER or aspiration
Investigate the identified cause
Monitoring and targets
Monitoring bundle
▶
Continuous pulse oximetry
▶
SpO2 target 92% to 100%
Alarm for desaturation events
Cardiorespiratory monitor
▶
Apnea and bradycardia detection
Heart rate trend
Serial examinations during observation
▶
Tone and responsiveness trend
Color and work of breathing trend
Escalation triggers
▶
Recurrent event during observation
▶
Reclassify as higher-risk
Admit for monitoring
New abnormal vital sign
▶
Hypoxemia
Bradycardia or apnea
Caregiver history inconsistency
▶
Concern for non-accidental trauma
Activate child protection pathway
Immediate consults
Consultation triggers
▶
Abnormal ECG
▶
Pediatric cardiology
Channelopathy concern
Suspected abuse
▶
Child protection team
Social work
Seizure-like features
▶
Pediatric neurology
EEG planning
History
Event characterization
Witness and reliability
▶
Direct observation vs found in state
▶
Identity of historian
Single vs multiple caregivers present
State before event
▶
Awake vs asleep
Position supine, prone, or upright
Event phenomenology
▶
Color change
▶
Cyanosis or pallor qualifies
Red or flushed does not qualify
Breathing during event
▶
Absent, decreased, or irregular
Labored breathing suggests alternate cause
Tone change
▶
Hypertonia or hypotonia
Repetitive movements suggest seizure
Responsiveness
▶
Decreased or altered responsiveness
Loss of consciousness
Duration and termination
▶
Duration
▶
Typically < 20 to 30 seconds
Duration >= 1 minute is higher-risk
Termination
▶
Spontaneous resolution
Required stimulation, back blows, or CPR
Post-event state
▶
Immediate return to baseline
Prolonged lethargy or irritability
Associated symptoms and feeding
Preceding illness
▶
Fever, congestion, or rhinorrhea
▶
Viral URI association
Pertussis exposure
GI symptoms
▶
Vomiting or diarrhea
Decreased intake in prior days
Feeding history
▶
Relation to feeds
▶
Choking or gagging with feeds suggests GER
GER-related event precludes BRUE diagnosis
Technique and volume
▶
Overfeeding or rapid feeding
Difficulty latching
Important negatives
▶
No choking or gagging
▶
Choking suggests GER or infection
Required for true BRUE
No fever or respiratory symptoms
▶
Symptomatic infant is not a BRUE
Risk factors and birth history
Demographic and gestational risks
▶
Age
▶
Age <= 60 days is an AAP higher-risk criterion
Recent evidence questions age as independent predictor
Prematurity
▶
Gestational age < 32 weeks
Corrected age < 45 weeks
Event-related risks
▶
Multiple or clustered events
▶
Strongest predictor of serious diagnosis
Risk difference 3.7%
CPR by trained provider
▶
Higher-risk criterion
Distinguish from CPR by untrained bystander
Family and social history
▶
Sudden unexplained death in young relatives
▶
Long QT syndrome concern
Brugada syndrome concern
Abuse risk factors
▶
Caregiver stress or substance use
Prior child protective services involvement
Sibling history
▶
SIDS in sibling
Prior BRUE or ALTE in sibling
Physical Exam
Vitals and general appearance
Stability snapshot
▶
Vital signs
▶
Heart rate and respiratory rate
SpO2 and temperature
Blood pressure
▶
Four-extremity if cardiac concern
Must be normal to classify as BRUE
General assessment
▶
Pediatric assessment triangle
▶
Appearance
Work of breathing and circulation
Well vs ill-appearing
▶
Ill appearance precludes BRUE
Persistent abnormality warrants workup
Systematic organ exam
HEENT and neurologic
▶
Anterior fontanelle
▶
Bulging suggests raised intracranial pressure
Cranial ultrasound if abnormal
Oropharynx
▶
Torn frenulum suggests abuse
Palate integrity
Neurologic findings
▶
Tone hypertonia or hypotonia
Pupil reactivity and abnormal movements
Cardiorespiratory
▶
Respiratory findings
▶
Stridor or wheezing
Retractions or grunting
Cardiovascular findings
▶
Murmur or gallop
Irregular rhythm and femoral pulses
Skin and musculoskeletal
▶
Bruising
▶
Pre-mobile infant bruising highly suspicious for abuse
Petechiae pattern
Occult injury
▶
Tenderness or swelling
Occult fractures in abuse
PITFALLS
Premature reassurance
▶
Normal exam does not exclude serious cause
▶
6% have serious underlying diagnosis
Risk-stratify before discharge
Missing non-accidental trauma
▶
Inconsistent history
Pre-mobile bruising
Misclassification
▶
Labeling explained event as BRUE
▶
Choking with feeds is GER not BRUE
Fever indicates infection not BRUE
Overtesting lower-risk infants
▶
Most routine tests have < 1% yield
Avoid low-yield workup
Differential Diagnosis
Cannot-miss diagnoses
Non-accidental trauma
▶
Abusive head trauma
▶
Intracranial hemorrhage
Retinal hemorrhage
Inflicted suffocation
▶
Munchausen by proxy
Recurrent unexplained events
Cardiac arrhythmia
▶
Long QT syndrome
▶
QTc > 460 ms in infants
Family history of sudden death
Supraventricular tachycardia
▶
Pre-excitation on ECG
Wolff-Parkinson-White pattern
Serious infection
▶
Sepsis or meningitis
▶
Especially in neonates
Fever or temperature instability
Pertussis
▶
Apnea with cough
Incomplete immunization
Organ-system differentials
Gastrointestinal
▶
Gastroesophageal reflux
▶
Most common identified etiology up to 50%
Choking or arching with feeds
Surgical abdomen
▶
Malrotation with volvulus
Intussusception
Neurologic
▶
Seizure
▶
Most common serious diagnosis at about 1.1%
Repetitive movements during event
Structural or infectious
▶
Intracranial hemorrhage
CNS infection or hydrocephalus
Respiratory
▶
Infection
▶
RSV or viral URI
Pertussis
Airway abnormality
▶
Laryngomalacia or tracheomalacia
Foreign body aspiration
Metabolic and cardiac
▶
Inborn errors of metabolism
▶
Hypoglycemia
Electrolyte abnormality
Congenital heart disease
▶
Murmur or cyanosis
Poor feeding with diaphoresis
Coding references
Diagnostic codes
▶
BRUE coding
▶
ICD-10 R68.13 apparent life-threatening event in infant
SNOMED CT brief resolved unexplained event concept
Related coding
▶
ICD-10 P28.4 other apnea of newborn
ICD-10 R09.2 respiratory arrest
Laboratory Tests
Lower-risk testing strategy
Routine testing not indicated
▶
Metabolic panels
▶
0% diagnostic yield
Number needed to test 852
AAP recommendation against routine bloodwork
▶
Grade B for lower-risk BRUE
Avoid reflexive panels
Higher-risk targeted labs
Infection workup
▶
Complete blood count with differential
▶
Infection or anemia
Leukopenia as severe sepsis marker
Cultures
▶
Blood culture if sepsis suspected
Urinalysis and urine culture
Metabolic workup
▶
Basic metabolic panel
▶
Electrolytes and glucose
Calcium for metabolic derangement
Acid-base assessment
▶
Blood gas and lactate
Metabolic acidosis in IEM or sepsis
Specialized labs
▶
Inborn error screen
▶
Ammonia and lactate
Acylcarnitine profile and urine organic acids
Pertussis PCR
▶
Apneic episodes
Known exposure or < 3 months
CSF studies
▶
Meningitis or encephalitis concern
Especially neonates
Diagnostic Tests
Scoring Systems
AAP BRUE risk stratification
▶
Lower-risk criteria all required
▶
Age > 60 days
Gestational age >= 32 weeks and corrected age >= 45 weeks
First event with no prior episodes
Duration < 1 minute
No CPR by trained provider
Normal history and physical exam
Higher-risk classification
▶
Any lower-risk criterion not met
Tailor workup to clinical concern
Test performance
▶
Excellent negative predictive value 98%
Poor positive predictive value 5%
Overclassifies about 92% as higher-risk
Outcome data
▶
Serious diagnosis prevalence
▶
About 6% of cases
Seizure and airway abnormality most common
Recurrence and mortality
▶
Recurrence about 14% within 3 months
Mortality about 1 per 1851 infants
MRI
MRI brain role
▶
Indications
▶
Suspected seizure with abnormal neurologic exam
Secondary evaluation after abnormal screening
Advantages
▶
No ionizing radiation
Superior parenchymal detail
Limitations
▶
Sedation often required in infants
Limited acute availability
Not for lower-risk
▶
Avoid routine neuroimaging
▶
AAP recommends against in lower-risk BRUE
Reserve for focal findings
CT
CT head non-contrast
▶
Indications
▶
Suspected non-accidental trauma
Acute intracranial pathology
Findings
▶
Intracranial hemorrhage
Skull fracture
Radiation stewardship
▶
Weigh radiation against yield
Cranial ultrasound first in open fontanelle when feasible
Not routine in lower-risk
▶
Avoid reflexive CT
▶
Low yield without focal concern
AAP recommends against routine imaging
Ultrasound
Cranial ultrasound
▶
Indications
▶
Neonate with intracranial hemorrhage concern
Open anterior fontanelle as window
Findings
▶
Intraventricular or parenchymal hemorrhage
Hydrocephalus
Advantages
▶
No radiation or sedation
Bedside availability
Echocardiography
▶
Indications
▶
Murmur or abnormal ECG
Structural heart disease concern
Findings
▶
Congenital structural lesion
Ventricular function assessment
Disposition
Discharge criteria lower-risk BRUE
Copy
Eligibility
▶
Meets all lower-risk criteria
▶
Age > 60 days and term
First event under 1 minute without CPR
Stable observation
▶
Normal vitals and exam throughout
No recurrent event during observation
Caregiver readiness
▶
Education completed
▶
Infant CPR resources offered
Return precautions reviewed
Reliable follow-up
▶
Arranged within 24 hours
Reliable caregiver observation
Admission criteria
Higher-risk features
▶
Any higher-risk criterion present
▶
Age <= 60 days or prematurity
Duration >= 1 minute or CPR by provider
Recurrent event in ED
▶
Cardiorespiratory monitoring
Observation for further episodes
Clinical and social concern
▶
Ill-appearing or abnormal vitals
▶
Directed workup
Not a BRUE
Safety concern
▶
Suspected non-accidental trauma
Unreliable caregiver observation or follow-up
Specialist consultation triggers
Disposition consults
▶
Cardiac and neurologic
▶
Abnormal ECG to pediatric cardiology
Seizure-like features to pediatric neurology
Protection and airway
▶
Suspected abuse to child protection team
Recurrent airway events to pulmonology or ENT
Metabolic
▶
Suspected IEM to genetics or metabolism
Abnormal newborn screen follow-up
Treatment
Lower-risk BRUE management
Observation strategy
▶
Brief monitored observation
▶
1 to 4 hours of continuous pulse oximetry
Serial examinations
No routine admission solely for monitoring
▶
AAP Grade B recommendation
Shared decision-making with caregivers
Testing restraint
▶
May obtain ECG
▶
Low cost and detects channelopathy
AAP weak recommendation Grade D
Do not obtain routine tests
▶
No routine bloodwork or chest radiograph
No echocardiography, EEG, or neuroimaging
Caregiver measures
▶
No home cardiorespiratory monitor
▶
Not recommended in lower-risk BRUE
Not a substitute for evaluation
Education
▶
CPR training resources
Safe sleep practices
Higher-risk BRUE management
Tiered evaluation
▶
Tier 1 time-sensitive
▶
Assess for child maltreatment
ECG for arrhythmia and infection workup
Tier 2 less time-sensitive
▶
Dysphagia and airway evaluation
EEG for suspected seizure
Admission and coordination
▶
Inpatient monitoring
▶
Cardiorespiratory monitoring
Observation for recurrence
Multidisciplinary involvement
▶
Cardiology, neurology, and GI as indicated
Child protection team when indicated
Targeted therapies by cause
Infection
▶
Empiric neonatal sepsis coverage
▶
Ampicillin 50 mg/kg IV every 6 to 8 hours
Gentamicin 4 mg/kg IV daily or cefotaxime 50 mg/kg IV every 8 hours
Pertussis
▶
Azithromycin 10 mg/kg PO once daily for 5 days
Apnea monitoring
Seizure
▶
Acute termination if active
▶
Lorazepam 0.1 mg/kg IV
Repeat once if seizure persists
Neurology coordination
▶
EEG before maintenance therapy
Avoid empiric long-term antiepileptics
Reflux
▶
Conservative measures first
▶
Upright positioning after feeds
Smaller more frequent feeds
Acid suppression only if GER confirmed
▶
GER-explained event is not a BRUE
Avoid empiric reflux medication for true BRUE
Special Populations
Pregnancy
Maternal-fetal context
▶
Applicability
▶
BRUE affects infants not the pregnant patient
Relevant to peripartum and perinatal history
Perinatal risk factors
▶
Maternal substance use affecting neonate
Gestational age at delivery
Postnatal counseling
▶
Safe sleep education
▶
Supine positioning
No co-sleeping
Family history screening
▶
Channelopathy in relatives
Sudden infant death history
Geriatric
Not applicable to age group
▶
BRUE is an infant diagnosis
▶
Defined for infants < 1 year
No geriatric application
Caregiver context
▶
Elderly caregivers may be historians
Assess caregiver capacity
Analogous adult events
▶
Adult transient unresponsiveness
▶
Syncope workup pathway differs
Do not apply BRUE criteria to adults
Pediatrics
Age-specific definition
▶
BRUE applies to infants < 1 year
▶
Resolved event with normal exam
Diagnosis of exclusion
Neonatal caution
▶
Lower threshold for sepsis workup
Higher-risk by age <= 60 days
Weight-based dosing
▶
Fluid resuscitation
▶
10 to 20 ml/kg isotonic bolus
Reassess perfusion after each bolus
Glucose correction
▶
Dextrose 2 ml/kg of D10 IV for hypoglycemia
Recheck glucose after correction
Distinct from SIDS
▶
BRUE is not SIDS
▶
Separate entities
Counsel caregivers explicitly
Background
Epidemiology
Frequency and definition shift
▶
Terminology
▶
ALTE replaced by BRUE per 2016 AAP guideline
BRUE is a diagnosis of exclusion
Outcome burden
▶
Serious underlying diagnosis in about 6%
Mortality about 1 per 1851 infants over 3 months
Recurrence and predictors
▶
Recurrence
▶
About 14% within 3 months
Most have benign course
Strongest predictor
▶
Multiple or clustered events
Prematurity contributes risk
Pathophysiology
Heterogeneous mechanisms
▶
Airway and reflux
▶
Laryngeal chemoreflex from refluxate
Airway obstruction
Neurologic
▶
Seizure activity
Central apnea
Cardiac
▶
Channelopathy-induced arrhythmia
Structural disease
Immature physiology
▶
Respiratory control immaturity
▶
Periodic breathing tendency
Exaggerated reflex apnea
Limited reserve
▶
Rapid desaturation
Vulnerable to minor insults
Therapeutic Considerations
Evidence-based restraint
▶
Avoid low-yield testing
▶
Most routine tests have < 1% yield
ECG yield 0.2% but catastrophic miss potential
Risk stratification first
▶
Lower-risk needs minimal workup
Higher-risk needs tailored evaluation
Avoiding harm
▶
No home apnea monitors
▶
Not a substitute for evaluation
Lacks outcome benefit
Reduce overtesting
▶
Iatrogenic risk from cascades
Caregiver anxiety amplification
Caregiver-centered care
▶
Address parental anxiety directly
▶
Reassurance grounded in low mortality
Most events are benign
Shared decision-making
▶
Discuss observation vs admission
Document caregiver preference
Patient Discharge Instructions
copy discharge instructions
Copy
BRUE home care
▶
Your baby had a brief event that has now resolved
Examination today was normal
Most babies do well after these events
Keep all follow-up appointments
Safe sleep practices
▶
Place baby on the back to sleep
Use a firm flat sleep surface
No loose bedding, pillows, or soft toys
No co-sleeping in an adult bed
Return to ER immediately if
▶
Another episode occurs
Baby turns blue or pale
Baby has trouble breathing or stops breathing
Baby becomes hard to wake or very floppy
Baby develops fever, poor feeding, or vomiting
Follow up
▶
See your doctor within 24 hours
Primary care follow-up within 1 week
Learn infant CPR using offered resources
References
Guidelines and key sources
Guideline sources
▶
AAP clinical practice guideline
▶
Tieder JS et al. Brief Resolved Unexplained Events. Pediatrics 2016
Lower-risk evaluation framework
Higher-risk framework
▶
Merritt JL et al. Framework for the higher-risk infant. Pediatrics 2019
Tiered evaluation approach
Evidence summaries
▶
Outcome studies
▶
Tieder JS et al. Risk factors and outcomes. Pediatrics 2021
Nama N et al. Infant outcomes and diagnostic yield. JAMA Pediatrics 2026
Validation studies
▶
Nama N et al. External validation of BRUE prediction rules. JAMA Pediatrics 2025
Comino-Hidalgo I et al. Impact of the BRUE definition. Eur J Pediatr 2025
Coding standards
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Diagnostic coding
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ICD-10 R68.13 apparent life-threatening event in infant
SNOMED CT brief resolved unexplained event concept
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Management Protocols
Apparent Life-Threatening Event (ALTE-BRUE)