Apparent Life-Threatening Event (Case 18)

Chapter 48 Apparent Life-Threatening Event (Case 18)



Craig C. DeWolfe, MD, MEd




Case


A 1-month-old infant presents with an episode in which he turned blue, went from stiff to limp, and may have stopped breathing.




Differential Diagnosis




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Speaking Intelligently


An apparent life-threatening event (ALTE) is not a diagnosis; it is a description of an event with many potential causes. A National Institutes of Health Consensus Statement defines it as an episode that is frightening to the observer and characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually limpness), choking, or gagging. Our goal is to determine the underlying cause and/or risk for harm. I carefully reconstruct the event, because a detailed history usually saves immeasurable time, testing, and anxiety. I try to understand what frightened the parents, and what resuscitation, if any, was needed. Causes are typically self-limited and benign, but life-threatening events and diagnoses do occur. I highlight the myriad of possible tests and need for a judicious yet thorough evaluation. Ideally, the extent of my evaluation will match the parents’ level of concern. The evaluation of each case is individualized; there are no clinical practice guidelines for ALTE evaluation and management.



Patient Care



Clinical Thinking



• First evaluate the airway, breathing, and circulation (ABCs). Ensure the infant is stable and on a cardiorespiratory monitor.

• Reconstruct the presentation from the primary witness.

• Was there apnea? Apnea is defined as cessation of breathing for 20 seconds or longer.

• The type and distribution of color change will help differentiate significant hypoxia from less-concerning etiologies. Isolated cyanosis around the lips and extremities is not indicative of true desaturation, whereas cyanosis of the lips, tongue, face, and/or trunk is considered central cyanosis.

• Methodically approach a differential diagnosis, considering central, obstructive, or mixed apnea events.

• Consider child abuse.


History



• Note any change in tone, rhythmic shaking, and its distribution.

• Was there choking, gagging, coughing, or vomiting? Was milk noted at the mouth? Was the infant recently fed?

• Any loss of consciousness?

• Is there fever or hypothermia to suggest infection?

• Is there a prior history of trauma, intentional or unintentional?

• What was the location and/or sleep position?

• What type of resuscitation was required, and by whom? Include initial cardiorespiratory assessment details.

• Review prehospital emergency medical service records.

• What is the infant’s current condition, and how long did it take the child to return to baseline?

• Any prior history of ALTE? What intervention was required? Is there a home apnea monitor?

• Review birth history. Is the infant premature?

• Identify preexisting medical conditions, such as GER or seizures.

• Has the infant or breastfeeding mother taken any medications?

• Any family history of ALTE, sudden infant death syndrome (SIDS), or infant death?


Physical Examination



• Evaluate ABCs, and check vital signs, including pulse oximetry.

• Determine the infant’s general arousal and state.

• Search for dysmorphic features to suggest a metabolic or genetic condition. Pay special attention to craniofacial abnormalities.

• Obtain growth curves, including head circumference, which may suggest microcephaly or hydrocephalus.

• Check tympanic membranes for hemotympanum, eyes for pupil reactivity, and funduscopic examination for retinal hemorrhages.

• Examine the head, skin, and musculoskeletal system for evidence of trauma.

• Focus on the neurologic examination for tone, degree and symmetry of movement, deep tendon reflexes, and developmental milestones.


Tests for Consideration



• If concerned about a history of poor perfusion or a metabolic disorder:
• Blood gas $222

• Lactate $211

• Complete blood count (CBC): Leukocytosis or leukopenia in infection; hemoglobin if traumatic $116

• An occult urinary tract infection has been linked to patients presenting with an ALTE with no fever and/or residual clinical manifestations. Occult bacteremia and meningitis have been documented much less frequently. If concerned about infection:
• Blood culture $152

• Urine culture $148

• Cerebrospinal fluid (CSF) culture $152

• CSF Gram stain $180

• CSF cell count $150

• CSF protein and glucose $75

• Herpes simplex virus polymerase chain reaction (PCR) $300

• Electroencephalogram (EEG): If concern for seizure $727

• Electrolytes, glucose, calcium, and magnesium: If concerned for seizure $392
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Related posts:

  1. The Special Needs Child
  2. Diarrhea (Case 6)
  3. Pediatric Poisonings (Case 54)
  4. Note Writing

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Apparent Life-Threatening Event (Case 18)

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