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2006 Apparent Life Threatening Event Philip J, Froman, MD, FACEP EMS Medical Director Edited from a presentation by Jim Morehead; Oklahoma.

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Presentation on theme: "2006 Apparent Life Threatening Event Philip J, Froman, MD, FACEP EMS Medical Director Edited from a presentation by Jim Morehead; Oklahoma."— Presentation transcript:

1 2006 Apparent Life Threatening Event Philip J, Froman, MD, FACEP EMS Medical Director Edited from a presentation by Jim Morehead; Oklahoma EMSC Resource Center; OU Health Sciences Center

2 2006 Objectives Define ALTE Describe common demographic data Discuss challenges associated with ALTE Describe common symptomatology of ALTE List common etiology associated w/ALTE

3 2006 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 2006 ALTE Defined ALTE defined in 1986 by NIH –Consensus Development Conference New definition replaced existing terms –“Near miss SIDS” –“Aborted cot death”

5 2006 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 2006 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 2006 Demographic Data (Continued) Increased risk children –Premature infants (+) Undergo general anesthesia RSV –Rapid feeding infants –Choking during feeding infants –Frequently coughing infants

8 2006 Definition ALTE Episode frightens observer Exhibits some combination of symptoms –APNEA –COLOR CHANGE –MARKED MUSCLE TONE CHANGE –CHOKING or GAGGING

9 2006 Definition of Apnea of Infancy Unexplained episode –Cessation of breathing >20 seconds –Associated with Bradycardia Cyanosis Pallor Marked hypotonia

10 2006 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 2006 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 2006 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 2006 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 2006 Etiology Dx’d GI most common in up to 50% cases –Gastroesophageal Reflux Disorder (GERD) –Gastric Volvulus –Intussusception –Swallowing Abnormalities –Other GI Abnormalities

15 2006 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 2006 Etiology Dx’d (Continued) Respiratory - approx 20% cases –Respiratory compromise by infection RSV Pertussis Mycoplasma Croup Other Pneumonias

17 2006 Etiology Dx’d (Continued) –Obstructive Sleep Apnea (OSA) –Breath holding spells –Conditions affecting respiratory control Prematurity Central hypoventilation

18 2006 Etiology Dx’d (Continued) –Vocal cord abnormalities –Laryngotracheomalacia –FBAO –Airway obstruction by congenital abnormalities

19 2006 Etiology Dx’d (Continued) Cardiac - up to 5% cases –Arrhythmia Prolong QT syndrome W-P-W syndrome –Congenital Heart Disease (CHD) –Myocarditis –Cardiomyopathy

20 2006 Etiology Dx’d (Continued) Metabolic abnormalities less than 5% cases –Inborn metabolic errors –Endocrine, electrolyte disorders –Other infections –UTI –Sepsis

21 2006 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 2006 Etiology Dx’d (Continued) Other –Food allergy (uncommon) –Anaphylaxis –Medication Prescription Over-the-counter (O-T-C) Herbal remedies

23 2006 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 2006 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 2006 GERD & ALTE Acid reflux → respiratory pause → airway closure → swallowing This can explain an awake apneic event Menon/Thach. J Pediatrics 1985;106:

26 2006 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 2006 GERD & ALTE (Continued) Most infants w/GERD do not have ALTE No epidemiologic relationship between GERD & SIDS established

28 2006 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 2006 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 2006 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 2006 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 2006 Detailed History (Continued) Muscle tone Eye movement General responsiveness after event Relationship to feeding Fever, URI Any other medical problems

33 2006 Additional History Pregnancy/perinatal care Infant behavior/sleep/feeding Social history –Smoking –Alcohol or substance use –Medications

34 2006 Additional History (Continued) Family history –Including siblings or ALTE in other siblings –Early deaths –Genetic disease –Cardiac or neurological problems

35 2006 Examination Obtain detailed hx Age/development characteristics Vital signs Upper airway/facial evaluation Overall appearance

36 2006 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 2006 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 2006 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 2006 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 2006 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 2006 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; Hall K & Zalman B. “Evaluation and Management of Apparent Life-Threatening Events in Children.” Am Acad Fam Phys;Vol 71;Num 12;June Kiechl-Kohlendorfer U, et al. “Epidemiology of apparent life threatening events.” Arch Dis Child. 2005;90; Davies F & Gupta R. “Apparent life threatening events in infants presenting to an emergency department.” Emerg Med. 2002;19;11-16.

42 2006 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 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 ;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 McGovern M & Smith M. “Causes of apparent life threatening events in infants: a systematic review.” Arch Dis Child. 2004;89;


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