Apparent Life-Threatening Event (ALTE-BRUE)MANAGEMENT

RESPIRATORY PRESENTATIONS · 12 SECTIONS

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567 items

☷ Legend

01Approach to the Critical Patient/attcp60

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

02History/hx74

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

03Physical Exam/exam52

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

04Differential Diagnosis/ddx56

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

05Laboratory Tests/lt31

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

06Diagnostic Tests/dt67

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

07Disposition/dispo38

Discharge criteria lower-risk BRUE

›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

08Treatment/t56

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

09Special Populations/sp43

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

10Background/b52

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

11Patient Discharge Instructions/pdi20

copy discharge instructions

›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

12References/r18

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

›Diagnostic coding

›ICD-10 R68.13 apparent life-threatening event in infant

›SNOMED CT brief resolved unexplained event concept

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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