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STEP BY STEP MANAGEMENT OF ALTE

STEP BY STEP MANAGEMENT OF ALTE. Dr. D. Alvarez September 2006. ALTE. An episode that is frightening to the observer and is characterized by some combination of: Apnea Color change Marked change in muscle tone Choking or gagging

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STEP BY STEP MANAGEMENT OF ALTE

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  1. STEP BY STEPMANAGEMENT OF ALTE Dr. D. Alvarez September 2006

  2. ALTE • An episode that is frightening to the observer and is characterized by some combination of: • Apnea • Color change • Marked change in muscle tone • Choking or gagging • In some instant the observer fears that the infant has died. • Recovery occurs only after stimulation or ressuscitation. • Recurrence of ALTE is very frequent and occurs in 30-60% of all ALTE. • True frequency of recurrence is probably even higher since many true documented apnea not leading to full blown ALTE go undetected by parents.

  3. ALTE – Definition (Other) • Episode frightening to the observer plus 1 or more of the following • Apnea central > obstructive • Color changes: blue or pale • Sudden limpness) • Chocking – gagging • Recurrence 13 %

  4. INITIAL PROCES • Call from the ED/4-B requesting bed for a patient with Diagnosis of ALTE • Resident / Supervisor (if applicable) obtains information on patients condition, on the phone or going to the ED/4-B, (as activity in the unit warrants). • Information needed: • Detail history from the observer (who was with the infant during the “episode”)

  5. ALTE - History should include • Duration of the event • Time of the day • Time after feeding (any changes in feeding if any) • Adequacy of lighting • Infant position within his / her surroundings (soft bedding, pillows?) • Did episode began while awake or asleep • Changes in Color • Changes in muscle tone • Need for any type of resuscitation (describe) • Was any blood or pink frothing coming from infants mouth or nose • Appropriateness of caregiver’s concerns • Fly. Hx of SIDS or serious illness with coma • Any associated respiratory symptoms.(URI – Coughs)

  6. Focus PE (ALTE) • Alertness • Tone • Bruising • Scalp swelling • Disuse of extremities • Fundoscopy, retinal hemorrhages • Chest exam, stridor.

  7. Selected Causes of ALTE • RSV, Pertusis • Sepsis with apnea • Syndromes compromising the upper airway (Pierre-Robin) • Breath holding spells • Seizures • Intracraneal hemorrhages, vascular abnormalities, child abuse, Vit K deficiency. • Exaggerated laryngeal chemoreceptor with or without GER • Drug. (Phenothyazede) • Tachyarreithmias, SVT, prolongued QT intervale. • Inborn errors of metabolism • Hypoventilation during bed sharing.,soft bedding

  8. Apnea of Infancy • An ALTE episode with no found cause. • Unexplained episode of cessation of breathing for > 20 sec, or shorter respiratory pause associataed with bradycardia, cyanosis, pallor, and/or marked hypotonia in an infant whose age during initial event is > 37 wks postconceptional age.

  9. ED Events. 4.- Review of ED-Events • Assessment on presentation to ED • Intervention / therapies and response • Studies / labs done (Start laboratory flow sheets record) • CBC with diff and • Electrolytes. • Look for hypoglycemia, metabolic acidosis. • Source of infection: UA, blood cultures. • CxR Look for any lung pathology and heart side • EKG 5.- Communicate with PICU Attending and inform on patient’s condition. 6.- Inform PICU Nurses that patient was accepted and up-date them on patient’s condition.

  10. ASSESSMENT&MANAGEMENT

  11. INITIAL MANAGEMENT

  12. GENERAL / OVERALL ASSESSMENT AND FOCAL FINDINGS Identify/investigate and treat focal abnormalities such as: • Possible bacterial infection early sepsis? • Respiratoy symptoms • Close respiratory monitoring • CxR • Respiratory therapy according to pathology: URI?, LRI • Cardiovascular abnormalitis • Cardiomegaly, EKG abnormalities • Continue investigations according to physical exam • R/O CNS infections >LP ? Head CT • Metabolic screening: ABG, Lactic Acid, LFT, ammonia level

  13. Basic Recommended Evaluation for ALTE • Admit to observation and cardiorespiratory monitoring • Careful history, physical and neurologic examination • Complete blood count • Blood glucose, electrolytes, Calcium • CxR, ECG, • Arterial Blood gases • EEG • Multichannel recording including oxygenation.

  14. Evaluation of ALTE in Selected Cases: • Septic workup (blood, urine, CSF cultures) • Barium Swallow • Lateral neck x Rays • Milk scan • PH probe • U/S or CT scan of brain • Echocardiogram • Blood amonia and urine Amino acid if recurrent.

  15. “Indication” for home C-R monitoring • History of ALTE • Multichanel documentation of clinical significant Apnea • Twin of SIDS • Apnea of Prematurity • Periodic breathing associadited with hypoxia • Feeding associated with apnea and bradycardia • Technology dependent children • ISAM (Selected cases) • Sibling of SIDS (Selected Cases)

  16. Home Monitor Settings: • Heart Rate Alarm • High: 220 bpm • Low: • 70 bpm (< 2 mo) • 60 bpm (2-8 mo) • 50 bpm (> 8 mo) • Apnea: • > 15 sec – record • > 20 sec – alarm • If SaO2 is monitored: Alarm set at < 85 %

  17. ALTE Begin Monitor 2-3 months no true alarms Event Record Normal Abnormal Event Recording True Alarms Continue Monitoring Discontinue Monitor

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