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Apparent life-threatening event

Apparent life-threatening event. Muhammad Waseem, MD Lincoln Hospital Bronx New York. ALTE. Terrifying episodes for both the family and the ED physician Observer fears that the infant has died. Apparent life-threatening event. An episode that is frightening to the observer Apnea

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Apparent life-threatening event

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  1. Apparent life-threatening event Muhammad Waseem, MD Lincoln Hospital Bronx New York

  2. ALTE • Terrifying episodes for both the family and the ED physician • Observer fears that the infant has died

  3. Apparent life-threatening event • An episode that is frightening to the observer • Apnea • Color change (cyanosis) • Change in muscle tone  limp • Choking or gagging

  4. ALTE • Not a diagnosis • Description of a characteristic presentation

  5. ALTE • 0.5 -0.6% of all infants • True frequency & prevalence unknown • Peak incidence 2-3 months

  6. ALTE • Apnea • Cessation of respiration for 20 seconds or more • Bradycardia • Pallor or cyanosis

  7. ALTE • Periodic breathing • Rhythmic respiration with short pauses (3-10 s) • Not associated with bradycardia, pallor or cyanosis • Should not be confused with apnea

  8. ALTE • No typical presentation • “Stopped breathing” (most common) • Stable condition in ED (most common)

  9. ALTE • Can occur during sleep, wakefulness or feeding

  10. ALTE • Relation with SIDS (major fear) • 1-2% (mild) • 8-10% (severe) • Identification of cause does not necessarily eliminate the risk

  11. ALTE • Does a life threatening condition exist? • Was the episode clinically significant? • Can an underlying cause be determined?

  12. ALTE -History • Asleep or awake • Red, pale or blue • Relation to feeding • Spontaneous recovery or CPR • Associated movements/ change in tone • “difficult to take care”

  13. ALTE-Physical Examination • Fever or hypothermia • Tachypnea • Poor feeding, irritability or  sleepiness • Tone • Fontanels & fundi

  14. ALTE • Can be a symptom of many specific disorder • Specific identifiable cause (50%)

  15. ALTE • GER • Infections (CNS, pulmonary, sepsis) • Hypocalcemia, hypoglycemia, anemia • Seizure •  ICP • Dysrhythmia • Child abuse

  16. GER • Physiologic versus pathologic • Infantile versus childhood • Infantile reflux resolve by first birthday

  17. GER • Awake apnea • Usually reflux related • Sleep apnea? • Nocturnal reflux is uncommon

  18. GER • Sandifer syndrome

  19. GER • Intraesophageal pH study • Gold standard • Difficult to prove

  20. Infections • RSV  apnea • < 3 months • Non obstructive • During quiet sleep • Sepsis • Pertussis

  21. Seizure • 4-7% of all infants with ALTE •  risk of SIDS • Clinical diagnosis • Neonatal seizure  apnea

  22. Inborn Error of Metabolism • Medium chain acyl CoA dehydrogenase deficiency (MCADD) • 4% of severe ALTE • 5% of SIDS

  23. Inborn Error of Metabolism • Only apparent during metabolic stress • Fasting • Non ketotic hypoglycemia in previously healthy infant

  24. Inborn Error of Metabolism • First episode is severe • Family history of ALTE &/or SIDS

  25. Child abuse • Up to 5% of SIDS deaths • Most difficult to diagnose • Key to diagnosis is high index of suspicion

  26. ALTE Evaluation • Whether the event represents an ALTE or not? • Not every infant needs all these tests • No routine evaluation • Should be guided by history & physical

  27. ALTE • CBC? • EKG? • Chest X-ray? • Upper GI? • EEG? • pH probe?

  28. ALTE • Most important is accurate history • Absolute determination of significant episode may not be possible in ED • Often the best investigation is a short period in hospital with monitoring

  29. ALTE • Admit any child with ALTE criteria • Further evaluation & monitoring • Parent education

  30. Quiz -ALTE • 2 year old with c/o “stopped breathing” • Screaming after toy taken by playmate • Stopped breathing  limp & blue 15 sec • Resolved spontaneously • Now alert & normal exam

  31. Breath holding Spells • Frightening experience for the parents • 3% of all children • Ages1 and 5 years • May begin before 6 months (25%)

  32. Breath holding Spells • Always provoked by pain, angeror frustration (unpleasant stimulus) • Prolonged expiratory apnea • Rapid development of cyanosis • Normal physical & neurological exam

  33. Breath holding Spells • Prolonged expiratory efforts without inspiratory efforts • Interruption in favorite activity cry red & blue

  34. Quiz -ALTE • 5 month-old male infant couldn’t breath about an hour after feeding • Mother describes “Struggling or gasping to breath” • Well on arrival • Afebrile, HR 110, RR 24, BP 74/46 • Wt 4.3 kg & oral thrush

  35. Quiz -ALTE • 16 month old girl with cerebral palsy • Stiff  limp (almost 5 minutes) • Mother described as “she was dead” • “Out of it” for next hour • No fever, trauma or other recent ill contacts

  36. Quiz -ALTE • A 3 month old infant “stopped breathing while sleeping”. Mother describes as weak and blue and “looked dead” • Improved with mouth to mouth breathing • Well appearing in ED

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