Resuscitation
The parents of a 6 month old baby girl bring her to the Emergency Department. They describe her having a 30 second episode when she stopped breathing and turned blue. You are considering if this could be a Brief Resolved Unexplained Event (BRUE). Which of the following is NOT a characteristic required to diagnose BRUE?
Answer:
The diagnosis of a Brief Resolved Unexplained Event (BRUE) can only be used as a diagnosis if there is no explanation for the event after a thorough history and examination. BRUE is defined as an episode in an infant less than 12 months old characterised by:- Duration < 1 minute (typically 20-30 seconds)
- Sudden onset, accompanied by a return to a baseline state
- Not explained by identifiable medical conditions
- Central cyanosis or pallor
- Absent, decreased or irregular breathing
- Marked change in tone (hyper or hypotonia)
- Altered level of consciousness
Brief Resolved Unexplained Event (BRUE)
Resuscitation
Last Updated: 12th February 2021
A brief resolved unexplained event (BRUE) is when an infant younger than one year has a marked change in breathing, tone, colour or level of responsiveness, followed by a complete return to a baseline state. The event occurs suddenly, lasts less than 1 minute, and is frightening to the person caring for the infant.
Definition
The diagnosis of a Brief Resolved Unexplained Event (BRUE) can only be used as a diagnosis if there is no explanation for the event after a thorough history and examination.
BRUE is defined as an episode in an infant less than 12 months old characterised by:
- Duration <1 minute (typically 20-30 seconds)
- Sudden onset, accompanied by a return to a baseline state
- Not explained by identifiable medical conditions
AND includes one or more of the following:
- Central cyanosis or pallor
- Absent, decreased or irregular breathing
- Marked change in tone (hyper or hypotonia)
- Altered level of consciousness
Differential diagnosis
- Physiological e.g. gagging, laryngospasm, neonatal periodic breathing
- Cardiac e.g. congenital heart disease, arrhythmias, prolonged QT, vascular ring
- Respiratory e.g. inhaled FB, airway obstruction incl. laryngomalacia, congenital malformation
- Infection e.g. pertussis, pneumonia, URTI/LRTI (esp. RSV), meningitis/encephalitis, UTI, septicaemia, gastroenteritis
- CNS e.g. head injury, seizures, cerebral malformations, central hypoventilation syndrome
- Non-accidental injury e.g. inflicted injury incl. drug ingestion, factitious illness (Munchhausen by proxy), suffocation
- Gastrointestinal e.g. gastro-oesophageal reflux, intussusception, testicular torsion
- Metabolic/toxins e.g. hypoglycaemia, hypocalcaemia, hypokalaemia, inborn error(s) of metabolism, intentional and unintentional drug overdose.
History
- General description of event
- Who reported/witnessed event?
- Where did it occur?
- What was patient doing immediately before event started?
- Awake or asleep?
- Position: supine / prone / upright/ moving?
- Feeding? How long since last feed? Vomiting or anything near the mouth?
- Any recent illnesses/trauma?
- During event
- Choking or gagging?
- Awake or asleep?
- Moving or quiet?
- Conscious?
- Responsive to voice?
- Muscle tone? Any repetitive movements?
- Distressed?
- Breathing? Struggling to breathe?
- Skin colour: normal/pale/blue/red?
- Colour of lips?
- Bleeding from nose, ears or mouth?
- Eye movements ie. open, closed, blinking, deviated, flickering?
- End of event
- Duration?
- How did it stop: spontaneous/ when picked up / back slaps/ mouth to mouth / chest compressions?
- Sudden or gradual cessation?
- Any treatment given: medications / sugary drink or food?
- After event
- Back to normal? How long did this take?
- Condition after event: pale / sleepy/ floppy/ poorly responsive/ vomiting etc?
- Anything noticed by parents/carers during period prior to return to baseline? If not returned to normal, what is different?
- Past medical history
- Family history
- Social and environmental history
Risk stratification
Factors which make the event higher risk:
- Infants < 2 months of age
- History of prematurity esp. if < 32 weeks at birth
- More than 1 event
Patients may be classified as lower risk BRUE if they have no concerning features on history or examination PLUS:
- Age > 60 days
- Born ≥ 32 weeks gestation and corrected gestational age ≥ 45 weeks
- No CPR by trained health care professional
- First event
- < 1 minute total duration
A low risk event is unlikely to represent a severe underlying disorder; and is unlikely to recur. Therefore based on the above risk stratification of patients; it is possible to guide what further investigation of the event, if any, is required.
Investigations
- Lower risk:
- No investigations required, however capillary blood glucose and urinalysis may be performed if clinical concern.
- Higher risk:
- Discuss with senior doctor (ED Consultant or OOH senior paediatric registrar).
- Consider: FBC, UEC, CRP, glucose, nasopharyngeal aspirate, blood gas, ECG plus any further investigations felt appropriate based on clinical presentation.
Management
By definition if a patient requires ongoing treatment, the episode is NOT a BRUE. Lower risk patients do not routinely need admitting for cardiorespiratory monitoring.
- Lower risk:
- Discharge home only if:
- Low clinical suspicion of serious underlying disorder.
- Parents reassured and happy to care for child at home. If not for discussion with medical team for period of inpatient observation.
- Provide parents carers with education / advice on BRUE.
- Lower risk does not mean no risk. Lower risk patients could be considered for a period of observation within the ED department if required.
- Discharge home only if:
- Higher risk:
- Following discussion with ED Consultant or OOH senior paediatric registrar, consider admission for observation, cardiorespiratory monitoring and further investigations as guided by presentation.
- Involve and refer to relevant specialties as appropriate if underlying cause identified.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
