Evaluation and Management of an Apparent Life Threatening Event

1
Evaluation and Management of an Apparent Life
Threatening Event
2
Definition

• National Institutes of Health
• Event that is frightening to the observer
• Characterized by some combination of apnea
  (central vs. obstructive), color change
  (cyanosis, pallor, erythema, plethora), marked
  change in muscle tone (limp), choking or gagging.
• Usually occurs in infants who are 8 weeks of age

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Case

• 3 ½-wk old, ex-35 wk preemie, seen at the CEC due
  to the apnea monitor going off. No other
  symptoms were noted at home but the patient had
  an AB at the CEC requiring tactile stimulation.
  Patient was limp and blue around the lips during
  the lt30 sec episode. Patient d/ced from NICU 3
  days prior.

4
Remember

• ALTE is not a diagnosis
• Manifestation of other conditions
• Careful history and PE are key to determine if
  there is an underlying condition that can be
  specifically treated

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History

• Get the details from the witness
• True apnea vs. periodic breathing
• Central apnea (effortless) vs. obstructive apnea
  (choking, gagging , stridor)
• Severity color change, self-resolved or
  required stimulation/resuscitation

6

• Birth Hx maternal infection, premature,
  maternal use of alcohol/illicit drugs
• Past Medical Hx trauma, surgeries, underlying
  medical conditions
• Feeding Hx poor weight gain
• Family Hx seizures, metabolic diseases,
  siblings with ALTE
• Social Hx exposure to tobacco smoke, stresses
  at home, other caregivers, medications at home

7
Case

• NICU stay x 3wks, small PDA, sent home on an
  apnea monitor
• Family Hx maternal () PPD but no TB disease,
  on INH () DM paternal GM no seizures
• Social no smoking, no other caregivers, lives
  with mom and dad, firstborn

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Differential Diagnosis

• Broad
• 50 of cases idiopathic
• GERD, neurologic problems, and infections almost
  account for the other 50

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Physical exam

• Vitals, general appearance, mental status
• Anthropometric measurements
• Dysmorphic features
• Signs of trauma
• AFSF?, retinal hemorrhages
• Upper airway congestion, wheezes
• Murmur, pulses, cap refill
• Neurologic exam CN intact?, alert?

10
Case

• VS stable, SGA
• Decreased movement of the R lower lip when
  crying, AFSF
• CTA, no murmur, cap refill brisk
• Internally rotated R forearm, thumb attached to
  hand by a skin tag

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Management

• Full sepsis work-up CBC, CRP, Blood Cx, CSF Cx,
  Urine Cx, CXR, UA
• Electrolytes, EKG
• Ampicillin (up to 7 wks of age), Cefotaxime,
  Rocephin, Acyclovir
• Additional tests can be ordered based on history
  and PE
• Appropriate consultations
• SS consult for apnea monitor, CPR for guardians

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Case

• UTI treated with Cefotaxime for 7 days
• Neurology and Genetics consult made
• Parents given CPR refresher