Presentation is loading. Please wait.

Presentation is loading. Please wait.

Apparent Life Threatening Event

Similar presentations

Presentation on theme: "Apparent Life Threatening Event"— Presentation transcript:

1 Apparent Life Threatening Event
Condition noted for over 50 years under other terms… Isolated observations of condition just began over last 20 years… Philip J, Froman, MD, FACEP EMS Medical Director Edited from a presentation by Jim Morehead; Oklahoma EMSC Resource Center; OU Health Sciences Center 2006

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

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 2006

4 ALTE Defined ALTE defined in 1986 by NIH
Consensus Development Conference New definition replaced existing terms “Near miss SIDS” “Aborted cot death” Older terminology potentially misleading as implied close association with SIDS, yet research continues to discount this increasingly. 2006

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 2006

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 2006

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

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

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

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 2006

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 2006

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 2006

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 2006

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

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 2006

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

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

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

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

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

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 2006

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

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 2006

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 2006

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

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 2006

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

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. 2006

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 2006

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 2006

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 2006

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

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

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

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

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%) 2006

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? 2006

• 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. 2006

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 2006

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 2006

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; Hall K & Zalman B. “Evaluation and Management 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; Davies F & Gupta R. “Apparent life threatening events in infants presenting to an emergency department.” Emerg Med. 2002;19;11-16. 2006

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 ;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; 2006

Download ppt "Apparent Life Threatening Event"

Similar presentations

Ads by Google