ASSESSMENT OF APPARENT LIFE-THREATENING EVENTS AT AN ACUTE CARE SETTING

Javier Benito-Fernández1 M.D., Mikel Santiago-Burruchaga2 M.D., Jesus Sánchez-Etxaniz2 M.D., Carlos Vazquez-Cordero1 M.D., Santiago Mintegi-Raso2 M.D., 1- Paediatric Emergency Department; 2- Division of Paediatric Pulmonology.

Goal: To report our experience with a systematic approach protocol for the assessment of

Apparent Life-Threatening Events (ALTE) at our Paediatric Emergency Department (PED).

Study design: Prospective, observational case series study of a systematic approach protocol for infants under age 12 months whose parents sought emergency care at our PED

between 01/04/05 and 31/06/06 following an ALTE.

Conclusions: 1.The majority of the infants with a first episode of ALTE present in a generally good condition and have normal

physical examination findings. 2.The absence of data suggesting underlying disease, following detailed history and examination, identify a pool

of infants who may be handled conservatively. This group may be monitored as outpatients, after admitting them for a short period of observation.

3.The low yield of pathological tests make routine LIs would be possible to be avoided and its accomplishment would be reserved to the cases that presented an abnormal evolution during the period of observation.

Fourth Mediterranean Emergency Medicine Congress (MEMC IV) in Sorrento, Italy, 15-19 September 2007.

n (%) Idiopathic (42) Secondary (24) OR(95% CI) p

Age (weeks) 6,39 6,35 7,32 5,58 ----- 0,53

Pregnancy (weeks) 38,54 2,21 37,04 3,74 ----- 0,05

Pregnancy < 37 weeks 6 (14%) 8 (34%) 3 (0,89-10,07) 0,06

Birth weight (grams) 3203,78 534,5 2795 773,03 ----- 0,019

Birth weight < 2500 grams

5 (12%) 6 (25%) 2,47 (0,66-9,18) 0,2

Admittance to Neonatal Unit

3 (7,3%) 10 (38,4%) 9,29 (2,23-38,7) 0,001

Maternal breastfeeding 26 (65%) 9 (37,5%) 0,37 (0,13-1,04) 0,032

Previous ALTEs 9 (21,9%) 7 (26,9%) 1,51 (0,48-4,76) 0,64

Previous behavioural abnormalities

11 (26,8%) 9 (34,6%) 1,69 (0,58-4,96) 0,49

URTI in days prior to episode

14 (34%) 14 (56%) 2,80 (1,00-7,88) 0,08

Duration of episode 103,46 ± 213 116,85 ± 179 ----- 0,8

Relationship to sleep 15 (37,5%) 5 (20%) 0,47 (0,15-1,53) 0,155

Major signs on examination

5 (12%) 8 (32%) 3,7 (1,05-13,07) 0,05

Recurrence in PED 2 (4,8%) 6 (24%) 6,6 (1,22-36,28) 0,021

Intervention in PED 3 (7%) 10 (40%) 9,29 (2,23-38,7) 0,01

Haemoglobin (gr/dl) 13,43 ± 2,8 11,4 ± 2 ----- 0,06

Lactate (mg/dl) 34,39 ± 14,44 41,72 ± 28,43 ----- 0,1

pH 7,36 ± 0,07 7,31 ± 0,13 ----- 0,05

Bicarbonate (mEq/L) 25,53 ± 3,17 23,75 ± 5,66 ----- 0,1

Blood glucose (mg/dl) 90,46 ± 23,17 104,08 ± 46,56 ------ 0,11

Ammonia (mg/dl) 59,03 ± 26,41 90,45 ± 115 ------ 0,1

•GER 8 (12%)

•Upper Respiratory tract infection (URTI) 4 (6%)

•Pneumonia 2 (3%)

•RSV bronchiolitis

•Bordetella pertussis infection

•Influenza

•Bronchopulmonary dysplasia (BPD)

•Congenital Adrenal Hyperplasia (CAH)

•Congenital Metabolic Disease (CMD)

•Sepsis

•Carbon monoxide poisoning

•Bordetella pertussis infection

•Methadone poisoning

•Subdural haematoma

Secondary ALTEs 24 (36%)

Abuse: 3%

4521

Admitted to Observation Unit

Admitted to Infant ward

7 to PICUMean length of stay 11.3±5 h.4 to infant ward

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

1. Lactate (>30mg/dl) 2. Platelets (>500 x103)3. Ammonia (>80 mg/dl)4. pH (<7.30)5. Leucocytes (<5 x103 or >15 x103)6. Bicarbonate(<20 mEq/L)7. Chest x-ray8. Blood glucose (<50 or >140 mg/dl)9. ALT (>50 IU)10.Haemoglobin (<9 gr/dl)11.ECG12.Carboxyhaemoglobin 13.RSV test14.Bordetella culture15. Influenza Test 16.CRP (>2 mg/dl)

Patological

Performed

LI abnormal

LI normal

Related diagnosis

Laboratory Investigations (LI)

•Pneumonia (2)•Bronchiolitis•Pertussis•Flu•CMD•CAH•CO poisoning•Sepsis

3531

9

14

52

Abnormalities at examination (21%)

Normal examination

Recurrences at the PED (12%)

8 •Pertussi•CAH•GER•Bronchiolitis•Pneumonia•BPD

11 LI abnormal

10 admitted

• Unexplained infant deaths in first degree family members • Perinatal risk factors• Previous ALTEs

• Need for resuscitation manoeuvres• Abnormal examination and/or LIs• Need for any type of intervention in the PED• Recurrent episodes in the PED

Risk factors

clinical historyand physicalexamination normal: 29

LI didn´t contribute to diagnose ofany of the 5 Secondary EAL