A pparent L ife T hreatening E vent

1. ApparentLifeThreateningEvent Philip J, Froman, MD, FACEP EMS Medical Director pfroman@emsmdc.com Edited from a presentation by Jim Morehead; Oklahoma EMSC Resource Center; OU Health Sciences Center

2. Objectives • Define ALTE • Describe common demographic data • Discuss challenges associated with ALTE • Describe common symptomatology of ALTE • List common etiology associated w/ALTE

3. Objectives (Continued) • Discuss ALTE vs SIDS • Explain importance of medical history • Explain necessity for taking this clinical situation seriously • Describe necessity for definitive evaluation

4. ALTE Defined • ALTE defined in 1986 by NIH • Consensus Development Conference • New definition replaced existing terms • “Near miss SIDS” • “Aborted cot death”

5. EMS Encounter Statistics • 7.5% of infant encounters • Mean age was 3 months, 55% males • 83.3% in NAD, 13.3% in mild, 3.3% in moderate • Appearance, respirations, VS were normal • 35% had significant pathology

6. Hospital Demographic Data • True incidence unknown • Only data = cases admitted hospital or ED • Reported incidence = 0.5-8% • Most commonly children <1 yr age • Peak at 1-10 weeks age • Males > females

7. Demographic Data (Continued) • Increased risk children • Premature infants (+) • Undergo general anesthesia • RSV • Rapid feeding infants • Choking during feeding infants • Frequently coughing infants

8. Definition ALTE • Episode frightens observer • Exhibits some combination of symptoms • APNEA • COLOR CHANGE • MARKED MUSCLE TONE CHANGE • CHOKING or GAGGING

9. Definition of Apnea of Infancy • Unexplained episode • Cessation of breathing >20 seconds • Associated with • Bradycardia • Cyanosis • Pallor • Marked hypotonia

10. Challenges • Accurate episode description often unreliable • Pt often appears well at presentation to EMS • Events are non-specific • It is a complaint, not a diagnosis • Describes cluster of symptoms • Many possible causes w/alarming risks

11. Possible Symptoms • Usually infant appears well • Observer describes event as frightening • Often thinks infant died • May say “Appeared funny; not right” • Possible only one observer views symptoms • Good & thorough history is essential

12. Possible Symptoms(Continued) • APNEA • Central • Obstructive (less frequently) • COLOR CHANGE • Usually cyanosis or pallor • Occasionally erythematous or plethoric • MARKED MUSCLE TONE CHANGE • Usually marked floppiness • Occasionally rigidity • CHOKING,COUGHING, or GAGGING

13. Etiology • Manifestation of other underlying condition(s) • Chief Complaint, NOT a Diagnosis • Finding underlying cause(s) important • Approx 50% definitive etiology discovered • Intervention may eliminate future events • Approx 50% definitive etiology unknown • ALTE Idiopathic

14. Etiology Dx’d • GI most common in up to 50% cases • Gastroesophageal Reflux Disorder (GERD) • Gastric Volvulus • Intussusception • Swallowing Abnormalities • Other GI Abnormalities

15. Etiology Dx’d (Continued) • Neurologic - 30% cases • Seizure Disorder (including Febrile) • CNS Bleeding or Infection • Neuro conditions affecting respiratory • Budd-Chiari syndrome • Hindbrain or Brainstem malformation • Vasovagal reflexes or Malignancies • VP shunt malfunction

16. Etiology Dx’d (Continued) • Respiratory - approx 20% cases • Respiratory compromise by infection • RSV • Pertussis • Mycoplasma • Croup • Other Pneumonias

17. Etiology Dx’d (Continued) • Obstructive Sleep Apnea (OSA) • Breath holding spells • Conditions affecting respiratory control • Prematurity • Central hypoventilation

18. Etiology Dx’d (Continued) • Vocal cord abnormalities • Laryngotracheomalacia • FBAO • Airway obstruction by congenital abnormalities

19. Etiology Dx’d (Continued) • Cardiac - up to 5% cases • Arrhythmia • Prolong QT syndrome • W-P-W syndrome • Congenital Heart Disease (CHD) • Myocarditis • Cardiomyopathy

20. Etiology Dx’d (Continued) • Metabolic abnormalities less than 5% cases • Inborn metabolic errors • Endocrine, electrolyte disorders • Other infections • UTI • Sepsis

21. Etiology Dx’d (Continued) • Child Abuse less than 5% cases • Munchausen syndrome by proxy • Suffocation • Intentional salt poisoning • Medication OD • Physical Abuse • Head Injury • Smothering • Intentional or Unintentional

22. Etiology Dx’d (Continued) • Other • Food allergy (uncommon) • Anaphylaxis • Medication • Prescription • Over-the-counter (O-T-C) • Herbal remedies

23. Normal – Misinterpreted as Abnormal • Irregular breathing of REM sleep • Periodic breathing • Respiratory pauses (5-15 seconds) & longer pauses after sighing • Transient choking, gagging, coughing during feeding

24. Periodic Breathing • Brief, cyclic episodes • Intermittent apnea (5-10 secs) followed by • Burst of rapid breathing (10-15 secs) • No color change or significant change in HR • Usually resolves by 36 weeks gestational age

25. GERD & ALTE • Acid reflux → respiratory pause → airway closure → swallowing This can explain an awake apneic event Menon/Thach. J Pediatrics 1985;106:625-629

26. GERD & ALTE (Continued) • Regurgitation: → increased mucosal adhesive forces → upper airway collapse • Hypothesis: • Infants w/more pliable upper airways, w/increased laryngeal inflammation due to chronic regurgitation have increased risk for obstructive apnea

27. GERD & ALTE (Continued) • Most infants w/GERD do not have ALTE • No epidemiologic relationship between GERD & SIDS established

28. ALTE vs SIDS • Relationship UNKNOWN • ALTE: benign to near fatal • Heterogeneous group of problems • 82% occur between 8 a.m. and 8 p.m. • SIDS: fatal • 80% occur between midnight and 6 a.m.

29. ALTE vs SIDS (Continued) • Increased incidence both central & obstructive sleep apnea (OSA) w/ALTE • Strong family hx ALTE & SIDS show higher incidence OSA • Sudden unexpected death beyond 1st year of life is NOT SIDS

30. ALTE vs SIDS (Continued) • SIDS prevention interventions • Such as “Back to Sleep” • Not resulted in decreased incidence of ALTE • Risk factors for different for each • Not different diseases of same condition

31. Detailed History • Detailed description of event • Appearance at time of discovery • Color change – how much, where, what color • Muscle & body movements • Resuscitation/stimulation & response • Home monitoring present

32. Detailed History (Continued) • Muscle tone • Eye movement • General responsiveness after event • Relationship to feeding • Fever, URI • Any other medical problems

33. Additional History • Pregnancy/perinatal care • Infant behavior/sleep/feeding • Social history • Smoking • Alcohol or substance use • Medications

34. Additional History (Continued) • Family history • Including siblings or ALTE in other siblings • Early deaths • Genetic disease • Cardiac or neurological problems

35. Examination • Obtain detailed hx • Age/development characteristics • Vital signs • Upper airway/facial evaluation • Overall appearance

36. Diagnostic Evaluation • Thorough hx & physical exam essential • Diagnosis made in 21% • Confirmation testing based on hx & physical exam brings total to 49% • Entirely normal physical exam (50%)

37. Management Considerations • Is this immediate life-threatening situation? • Was episode truly life-threatening or merely frightening? • Is this over-reaction to normal event? • Is this abnormal phenomenon? • Detailed history of event?

38. Protocol ACTION/TREATMENT: • ABCs • If needed: IV access, rate titrated to perfusion as needed. • Leave the child in caretaker’s arm in position of comfort for evaluation, then car seat for transport. • Provide blow-by oxygen as tolerated; pulse oximetry • Cardiac monitor. • Refer to appropriate treatment protocols for specific intervention.

39. Protocol (Continued) • TRANSPORT: • • There are different transport protocols • Need to be conservative • Transport to nearest appropriate facility via EMS! • • Private transport acceptable for asymptomatic patients IF: • • Transportation is available now • • The parents / caretaker are reliable • • Parents / caretaker understand the importance of evaluation

40. Summary • ALTE frightening event to observer • Underlying cause in 50% • Idiopathic in remaining 50% • Detailed hx mandatory • Always take described events seriously • Detailed examination & definitive evaluation mandatory

41. Suggested References • Stratton S & Taves A “Apparent Life-Threatening Events in Infants: High Risk in the Out-of-Hospital Environment.” Annals of EM. 2004; 43:6;711-716. • Hall K & Zalman B. “Evaluation andManagement of Apparent Life-Threatening Events in Children.” Am Acad Fam Phys;Vol 71;Num 12;June 2005. • Kiechl-Kohlendorfer U, et al. “Epidemiology of apparent life threatening events.” Arch Dis Child. 2005;90;297-300. • Davies F & Gupta R. “Apparent life threatening events in infants presenting to an emergency department.” Emerg Med. 2002;19;11-16.

42. References (Continued) • Brand D, et al. “Yield of Diagnostic Testing in Infants Who Have Had an Apparent Life-Threatening Event.” Pediatrics. Vol 115;Num 4;April 2005. • Harrington C, et al. “Altered Autonomic Function and Reduced Arousability in Apparent Life-Threatening Event Infants with Obstructive Sleep Apnea.” Am J Respir Care Med. Vol 165;pp 1048-54;2002. • De Piero A, et al. “ED Evaluation of Infants After an Apparent Life-Threatening Event.” Am J Emerg Med;Vol 22;Num 2;March 2004. • McGovern M & Smith M. “Causes of apparent life threatening events in infants: a systematic review.” Arch Dis Child. 2004;89;1043-48