Pediatric Pearl – July 2018

Brief Resolved Unexplained Event (BRUE)

The Artist Formerly Known as Apparent Life-Threatening Event (ALTE)

By: Kerri Clayton PGY-3

In 2016 The American Academy of Pediatrics (AAP) released clinical practice guidelines on Brief Resolved Unexplained Events (BRUE) in low-risk infants, and at this time changed the name from Apparent Life-Threatening Event (ALTE). This is the first AAP guideline that specifically addresses these events. The new guideline and change in terminology from ALTE are based on a literature review of ALTEs from 1970 through 2014.

Why the change the name?

  • More precise
  • Has age limits
  • It highlights the reassuring qualities of the episode: Brief and Resolved

What is a BRUE?

  • An Event lasting <1 minute in an infant <1 year of age that is associated with at least one of the following:
  • Central Cyanosisor Pallor
    • Discoloration of face, gums and/or trunk.
    • NOT acrocyanosis, only peri-oral cyanosis or rubor
  • Absent, Decreased,or Irregular breathing
    • Central, obstructive or mixed apnea
    • NOT periodic breathing or breath holding spell
  • Marked change in tonesuch as hypertonia or hypotonia
  • Altered level or responsiveness
  • It MUST resolve, and the patient must be at baseline, have a reassuring history, physical exam, and vital signs during Emergency department evaluation. 
  • IMPORTANT: The term BRUE is used only when there is no other likely explanation, meaning that a clinician is unable to explain the cause of the event after an appropriate H&P.
    • Examples:
    • respiratory symptoms and fever; NOT a BRUE.
    • choking or gagging associated with spitting up; NOT a BRUE

History

  • Event characteristics
  • Preceding illness or injury
  • Event description
  • location, position, feeding, environment
  • choking, gagging
  • tone, movement
  • mental status
  • level of distress
  • color change – blue, pallor, red
  • breathing ability – apnea, shallow breathing or difficulty breathing
  • duration, intervention return to baseline
  • Pertinent past
  • Prematurity (<32 wks)
  • Previous episode/BRUE
  • Newborn screening results
  • Growth and development
  • Breathing problems
  • Reflux
  • Medications
  • Family
  • Sudden unexplained death
  • Cardiac disease, arrhythmias
  • Metabolic/genetic disease
  • Social
  • Environment, exposures, illness contacts
  • Family structure, individuals at home
  • Caretakers, stressors
  • Consideration for possible child abuse

Physical Exam

  • Vital signs – Temp, HR, RR, BP, O2 sat
  • Growth – weight, head circumference
  • General appearance – craniofacial abnormalities, age-appopriate responsiveness
  • Head/neck – shape, fontanels, evidence of injury, neck mobility
  • Eyes – pupillary response, conjunctival hemorrhage
  • ENT – TMs, congestion/coryza, blood presence, torn
  • Chest/CVS – increased work of breathing, abnormal breath sounds, abnormal rhythrm, rate, auscultation findings
  • Abdomen/GU – organomegaly, masses, distension, tenderness, GU abnormalities
  • Extremities – muscle tone, deformity
  • Neurologic – alertness, tone, reflexes, movement and strength symmetry
  • Skin – color, perfusion, bruising, erythema

BRUE CLASSIFICATION

  • It is determined that a patient had a BRUE, now the patient can be categorized as either low risk or high risk.
  • If the patient does not meet low risk criteria, then by default they are High Risk!
    • Low Risk criteria:
  • Older than 60 days
  • Gestational Age 32 weeks or greaterand a Postconceptional Age of 45 weeks or greater.
  • First BRUE
  • Not requiring CPRby a trained medical provider
  • NO concerning historic features; history concerning for potential abuse, family historyof sudden death in first degree relatives, previous Child Protective Services or Law Enforcement involvement
  • NO concerning physical examination findings; Remember to do a good genital exam and look for signs of abuse!

A Patient with a possible BRUE arrives, what do you do next?

Triage Acuity

  1. Medical Stabilization as needed; ABC’s
  2. History and Physical;
    • Abnormal vital sings? NOT a BRUE
    • H&P meets BRUE criteria, and no other explanation found; BRUE!
  3. Risk Stratify
    • Does the patient fit Lower Risk criteria?
      • Yes: Lower Risk
      • No: High Risk

Disposition
High Risk:

    • No AAP guidelines for management of high risk infants
    • Consider broad differential, manage accordingly
    • Hospitaliz

Low Risk:
Strong Recommendation:

    • Educate caregivers about BRUE
    • Use shared decision making to guide disposition; If family is comfortable and patient able to have follow up in 12-24 hours then may discharge to home
    • Do not order unnecessary tests or treatments; CBC, CMP, CXR, CSF, ECHO, EEG, GERD Studies, home apnea monitoring, Acid suppression therapy, anti-epileptics…
  • Weak Recommendations:
    • Monitor patient in emergency department for 1-4 hours with serial exams and continuous pulse ox monitoring
    • 12 lead ECG
    • Pertussis testing
    • Avoid hospitalization solely for cardiopulmonary monitoring

AAP Flowsheet

 References:

  1. Tieder, J. S., Bonkowsky, J. L., Etzel, R. A., Franklin, W. H., Gremse, D. A., Herman, B., . . . Smith, M. B. (2016, April 25). Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Retrieved from http://pediatrics.aappublications.org/content/early/2016/04/21/peds.2016-0590
  2. (2017, July 24). Retrieved from http://pedemmorsels.com/brue/
  3. (n.d.). Retrieved from https://www.aliem.com/2017/02/pem-brief-resolved-unexplained-event-brue/brue/

 


Pediatric Pearl – June 2018

 Diabetic Ketoacidosis (DKA) in the Pediatric Patient
By: Hima Khamar, PGY2

 Goals of Treating a Patient with DKA

  1. Correct Dehydration
  2. Correct Ketoacidosis
  3. Normalize Blood Sugar
  4. Avoid Complications
  5. Treat Precipitating Event

What defines DKA?
Hyperglycemia à glucose >200mg/dL
Ketosis à presence of ketones in urine
Acidosis à pH <7.3 OR HCO3 <15 mmol/L

Triage/Severity Level

Critical Actions for Hour 1
1. Assess
ABCs, VS, level of dehydration
– Mental status, neuro exam, GCS
– Risk for cerebral edema
– Monitor, VS q15 mins, I/O q 1 hr

2. IV Access
– 2 PIVs

3. Initial Labs
– POC glucose, blood or urine for ketones
– VBG, CBC, BMP, Ca, Mg, PO4, CBC, HbA1C

4. IV Fluids
– NS at 10 mL/kg

HISTORY

  1. New Diagnosis
  • Polyphagia, polydypsia, polyuria
  • Weight loss, anorexia, vomiting
  • Fatigue, malaise
  1. Known Diagnosis
  • Insulin use, most recent dose, insulin pump
  • Home glucose level
  • Home urine ketones
  • Type DM and age at diagnosis
  • Previous hospitalizations
  • Previous episodes of DKA
  1. Hydration Status
  • PO intake, UO
  • Vomiting, nausea
  1. Infectious Symptoms
  2. Ingestions
  3. Trauma
  4. For Post-pubertal Female: Riks for Pregnancy, STI

 PHYSICAL EXAM

  • VS, ABCs, mental status (drowsy, lethargic, obtunded, coma)
  • Breathing, tachypnea, Kussmaul respirations
  • Perfusion: capillary refill, pulses, temperature
  • Neuro exam: pupils, CN, motor, GCS

REHYDRATION

Initial fluid resuscitation

  • Bolus 10 ml/kg of NS, then initiate two bag system discussed below

Maintenance fluids

  • After initial bolus, begin 1.5-2x maintenance with NS with additional electrolytes as needed
  • How to calculate maintenance cc/hr, use patient’s weight in kg OR just use MD calc:
    • 4 mL/kg for the first 10 kg + 2 mL/kg for the next 10 kg + 1 mL/kg for each kg over 20 kg
    • So for a 30 kg child, 40cc + 20cc + 10cc = 70cc/hr maintenance

ELECTROLYTES

Sodium –        Typically low initially due to urinary losses and fluid shift to extracellular space due to high serum osmolality

–        Na correct = Na measured + (1.6 x [(glucose – 100)/100])

Potassium –        May be low, normal or high, but total body stores are low due to renal losses

–        <3.5, supplement before starting insulin

–        3.5-5.5, add K to the maintenance fluids

–        >5.5, do nothing; if too high then may need to correct

Bicarbonate –        May be low, normal or high, but total body stores are low due to renal losses
BUN, Creatinine –        Elevated due to dehydration
Magnesium –        Low due to renal losses, replace as needed
Phosphorus –        Low due to renal losses, replace as needed

NORMALIZE BLOOD SUGAR & CORRECT ACIDOSIS

Insulin

  • Initiate regular insulin at rate of 0.1 u/kg/hr one hour AFTER the start of the fluid resuscitation
  • Do not use insulin bolus (increases risk of cerebral edema) 

Glucose

    • Aim to lower glucose 50-100 mg/dL per hour
    • Use the “two bag” system
      • Bag #1: NS with electrolytes
      • Bag #2: D10NS with electrolytes
    • Begin dextrose bag 2 when glucose is < 300 mg/dL

      CEREBRAL EDEMA

    • Leading cause of morbidity and mortality in DKA
    • Etiology unclear, attributed to fluids shifts in the setting of cellular osmolar imbalance resulting in cerebral hypoperfusion and prolonged acidosis with ischemia
    • Typically occurs 4-12 hours after treatment is initiated
    • May be present before treatment, or occur as late as 24-48 hours after treatment initiated

 Risk factors

    • Age < 3 years
    • Prior history of DKA
    • pH < 7.0
    • Failure of corrected Na to fall to normal range during treatment
    • Administration of bicarbonate therapy
    • Elevated BUN at presentation
    • Low PaCO2 levels at presentation
    • Administration of insulin (bolus or infusion) in first hour of fluid treatment
    • Initial glucose > 1000 mg/dL

Diagnosis

MONITOR

  • BS Q1H
  • neuro status Q1H
  • SMA7 with acetone level Q4HMONITOR
        • BS Q1H
        • neuro status Q1H
        • SMA7 with acetone level Q4H

 

 

Pediatric Pearl – May 2018

PEDIATRIC INTUBATION

By: Dr. Lani Mendelson PGY3

HOW DO PEDIATRIC AIRWAYS DIFFER FROM ADULT AIRWAYS?

  1. Airway diameter = smaller
    1. Small diameter of airways results in higher resistance to air flow and increased chance of airway obstruction
    2. Airway edema results in proportionately greater obstruction
  2. Mandible = smaller
  3. Head = larger
  4. Neck = already in flexed position so add towels under shoulder to bring neck in neutral position
  5. Tongue = larger in comparison to head
  6. Larynx = funnel shaped larynx with anterior angulation
  7. Epiglottis = long, floppy, and u-shaped
  8. Vocal cords = angled, pink not white (harder to spot)
  9. Cricoid cartilage = narrowest portion, rather than the vocal cords
  10. Trachea = highly compliant (risks ‘kinking’)
    1. Short and in line with right bronchus

LARYNGOSCOPE SIZE

AGE SIZE
Premie/newborn Miller 0
1 month – 2 years Miller 1 or 1.5
3-6 years Miller 2, Mac 1
6-12 years Miller 2, Mac 2-3
>12 years Mac 3

*The Miller is recommended due to the more anterior airway and the floppy epiglottis of the child and infant. For a child older than 6 years of age, both Mac and Miller can be used.

ENDOTRACHEAL TUBE SIZE

Uncuffed ETT = (AGE/4) + 4

Cuffed ETT = (AGE/4) + 3.5

*If in doubt, use a tube that fits through the nose

*Premie size 3, newborn size 3.5

ENDOTRACHEAL TUBE DEPTH

ETT size x 3

AGE/2 + 12

MEDICATIONS

Atropine – not routinely recommended

  • Infants and children can develop bradycardia from medication effects (especially succinylcholine), vagal stimulation of the hypopharynx/epiglottis, and hypoxia
  • Should be considered in:
    • 1) all patients <1 year of age
    • 2) children <5 years of age receiving succinylcholine
    • 3) adolescents receiving a second dose of succinylcholine (max does 1mg)
    • 4) patients who are experiencing bradycardia prior to intubation
  • Atropine should be given 1-2 minutes prior to any sedative or paralytic agent

Etomidate

  • Sedative used most commonly for patients with hypotension or head trauma
  • Risks: adrenocortical suppression hence consider a different agent in sepsis

Ketamine

  • Sedative used most commonly for patients with hypotension or severe asthma
  • Risks: tachycardia, hypertension, laryngospasm, and excessive salivation

Propofol

  • Sedative for status epilepticus or head trauma/increased intracranial pressure
  • Not recommended for < 3 years old secondary to decreased clearance
  • Risks: hypotension

Benzodiazepines

  • Sedative for status epilepticus
  • Risks: hypotension

Succinylcholine

  • Shorter duration of action
  • Risks: Higher risk of malignant hyperthermia compared to other paralytics, hyperkalemia, congenital neuromuscular disorders

Rocuronium

  • Longer duration of action

Benzodiazepines (midazolam, lorazepam), ketamine, dexmedetomidine, propofol, and opiates (fentanyl, morphine) are commonly used for post-intubation sedation/analgesia regimens

GO BACK TO THE BASICS. REMEMBER TO HAVE ALL YOUR BACK UPS READY.

  1. Positioning
  • Remember necks tend to be flexed in neutral flat position (especially in those <8 yrs)
  • Place towel or sheet beneath shoulders to align external auditory canal with sternal notch
  1. Have nasal and oral airways of the appropriate size ready
  2. Pre-oxygenation
  • Same as adults. Use your nasal cannula for apneic oxygenation. Use NRB if needed as well.
  • Would be amazing if have high flow nasal cannula available throughout intubation to prevent desaturations and prolong safe apneic times, but this is not a requirement
  • May need to give some slight sedation for a fussy child with versed or Ativan to allow for pre-oxygenation
  1. Have suction ready
  2. Have BVM ready with the right size mask
  • Jaw thrust can help with displacing the tongue along with aligning airways
  1. If you can’t remember dosing, remember the Broselow Tape
  2. Can’t see the cords, you may have inserted the blade or scope too far, pull back slowly; also remember they maybe pink and not white so harder to identify
  3. Post-intubation remember to ensure tube is not too deep
  • Confirm using color change, bilateral breath sounds, US, CXR