Apparent Life-Threatening Event

Apparent Life-Threatening Event (ALTE)

Being specialists of emergencies we are facile with managing events that have the potential to threaten a person’s life.  It is interesting, then, that when a child presents to the ED with an Apparent Life-Threatening Event (ALTE), we suddenly do not feel as comfortable.  The child looks awesome… but the parents thought they needed to perform CPR… what do I do with that child?  The potential differential is HUGE… should we just order every test known to man? Should we just call our colleagues to admit and punt any further decision making?  Should we just convince everyone that the kid is fine, discharge to home, and then hope we can sleep tonight? Here is my approach, submitted humbly:

Step 1 – Medical stabilization (goes without saying really).

  • For the ill appearing, do what it is you do best, stabilize!… Don’t forget to check fingerstick glucose and drawn extra blood for potential inborn errors of metabolism work-up.
  • Most often, though, the child will appear well upon arrival.  Do not allow the delightful coos of the child to extinguish your vigilance!

Step 2 – Classify event as an ALTE or not.

  • A report of a 3 week old “not breathing” naturally warrants great attention; however, a history consistent with periodic breathing warrants nothing more than reassurance. So know the current accepted definition of ALTE and determine if this episode fits the definition or not.
    • Definition: “an episode that is frightening to the observer and that is characterized by some combination of apnea (central or obstructive), color change (usually cyanotic or pallid, but occasionally erythematous or plethoric) marked change in muscle tone (usually marked limpness), choking, or gagging,  In some cases, the observer fears that the infant has died.”
  • Pathologic Apnea – apnea associated with cyanosis, bradycardia, marked pallor or hypotonia, OR being greater than 20 seconds in duration.

Step 3 – Thorough H+P

  • Appreciating that ALTE is not a diagnosis, but rather a description of symptoms that can be generated by a vast number of conditions, a thorough history and physical exam are what will help determine the most appropriate evaluation.
    • The initial H+P is able to direct the evaluation in 70% of the cases!
  • Consider the potential differential as you progress with you history and physical and actively search for clues that will help increase your odds. {List below is naturally abridged!}
    • GI(most common pathology)
      • GERD accounts for 20-54%
      • Interestingly, while we think GERD is “benign” it has been shown that ALTE patients diagnosed with GERD still benefited from hospitalization (6% had events during hospitalization, 9% had recurrent ALTEs, 3% received a new diagnosis)
    • Neurologic(2nd most common)
      • Seizures
      • CNS lesions and/or bleeds
    • Respiratory(#3)
      • Airway anomalies
      • Obstructive sleep apnea
    • Infectious
      • Serious Bacterial Infections (sepsis, meningoencephalitis, bacteremia, UTI, pneumonia, pertussis)
      • Viral illnesses (RSV, croup)
    • Cardiac
      • Congenital Heart Disease
      • Arrhythmia
    • Metabolic
      • Inborn Error of Metabolism
      • Endocrine abnormalities
    • Child Abuse
      • Small absolute number of ALTEs, but carries significant associated mortality.
    • Accidental Poisoning
      • One study showed 8.4% had positive drug screen. 4.7% were positive for OTC cold preparations!

Step 4 – Tailor your Evaluation

  • Currently there is no standard management strategy for ALTE (primarily because the differential is too vast).
  • In patients with inconclusive history and physical exams, resist the desire to order collections of non-specific tests.
  • Often a hospitalization offers the ability to observe to better characterize the event and patient’s risk factors to lead to better selection of studies.
  • A few specific questions to ask yourself:
    • “Do I need to evaluate this patient for serious bacterial infections?”
      • If neonate (<1 month old), and Full term, then YES! ALTE + neonate = Full Sepsis work up in my book.
      • If h/o prematurity (GA < 37wks) and ≤ 60 days of age, then Yes!
        • Even without fever! “Don’t trust a premie!
      • Patient with multiple ALTEs on the same day – Yes!
      • Certainly, if the child appears toxic then Yes!
    • “Do I need to worry about Non-Accidental Trauma?
      • Simply put, ALWAYS! More practically, it should be highly considered when:
        • Physical exam findings concerning for abuse exist
        • History fluctuates and warrants consideration for abuse.
        • Child has history of previous ALTEs!
      • Check fundoscopic exam on ALTEs!
      • If concerned, order head CT, skeletal survey, and consult child protective services.

Step 5 – Disposition

  • All patients that you have deemed have a history consistent with ALTE warrant admission.
  • Some have advocated for disposition from the ED if the child is not a neonate and had only one isolated ALTE episode and have no other concerning findings. The study that is the basis of this approach included only 59 patients, which is a really small sample size to account for the great diversity of conditions that are encompassed by the term ALTE.  It also does not account for the fact that there is not a standardized approach for these patients which could help offset some of the significant medicolegal liability. Additionally, even patients with the “benign” diagnosis of GERD have been shown to have benefited from hospitalization.

 

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Kahn, A., Recommended clinical evaluation of infants with an apparent life-threatening event. Consensus document of the European Society for the Study and Prevention of Infant Death, 2003. Eur J Pediatr, 2004. 163(2): p. 108-15.
 
Gray, C., F. Davies, and E. Molyneux, Apparent life-threatening events presenting to a pediatric emergency department. Pediatr Emerg Care, 1999. 15(3): p. 195-9.
 
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Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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