- Email: [email protected]
ED evaluation of infants after an apparent life-threatening event
ED Evaluation of Infants After an Apparent Life-Threatening Event ANDREW D. DE PIERO, MD,*† STEPHEN J. TEACH, MD, MPH,*† AND JAMES M. CHAMBERLAIN, MD*† The objective of this study was to determine the rate of positive ED diagnostic evaluations and significant interventions during the hospitalization of infants after an apparent life-threatening event (ALTE). The study was performed at a single, tertiary care children’s hospital. Patients under 6 months of age were identified for a potential ALTE from the ED chief complaint log. The charts of patients meeting the definition of an ALTE were abstracted for data pertaining to the patient’s history, physical examination, ED diagnostic evaluation, and admission. The yield of the ED diagnostic evaluation and hospitalization was noted. A positive ED evaluation was defined as a diagnostic intervention that resulted in a specific treatment for a defined condition. Significant medical interventions were derived from a validated instrument assessing the risk of admission for pediatric patients presenting to an ED. Such interventions included, but were not limited to, parenteral antibiotics for documented infections, supplemental oxygen, endotracheal intubation, airway suctioning, and intensive-care unit admission. Over a 5-year period with 253,408 patient visits, 523 patents met the initial search criteria for a potential ALTE. From this group, 483 charts were reviewed (92.4%) and 150 patients met the definition for an ALTE. The mean age of the patients was 61.7 days and 115 (76.7%) were admitted. Of the patients with an ALTE, 122 patients had ED diagnostic tests performed and three had a positive result (2.5%; 95% confidence interval [CI]; 0.5-7.0). The rate of significant medical interventions among admitted patients was 7.% (9 of 115, 95% CI, 3.6-14.3). No patients with a positive ED diagnostic evaluation were discharged from the ED. Risk factors for significant medical interventions included prematurity, a positive medical history, and age >60 days. The overall rate of either positive ED diagnostic evaluations or significant medical interventions during hospitalizations of infants after an ALTE is low. A majority of these patients can be best managed with a limited ED diagnostic evaluation and a period of observation. (Am J Emerg Med 2004;22:83-86. © 2004 Elsevier Inc. All rights reserved.)
Infants commonly present to the ED for initial evaluation after an apparent life-threatening event (ALTE). An ALTE is defined as “an episode that is frightening to the observer, that is characterized by some combination of apnea (centrally or occasionally obstructive), color change (usually
From the *Division of Emergency Medicine, Children’s National Medical Center, and the †Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC. Received December 15, 2002; accepted February 3, 2003. Dr. DePiero is currently affiliated with the Division of Pediatric Emergency Medicine, Department of Pediatrics, AI DuPont Hospital for Children, Wilmington, Delaware. Address reprint requests to Andrew D. DePiero, Division of Pediatric Emergency Medicine, Department of Pediatrics, AI DuPont Hospital for Children, 1600 Rockland Rd., Wilmington, DE 19899. Email: [email protected] Key Words: ALTE, resource utilization. © 2004 Elsevier Inc. All rights reserved. 0735-6757/04/2202-0004$30.00/0 doi:10.1016/j.ajem.2003.12.007
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.”1 However, despite a standard definition, these events are heterogeneous. Their frightening nature often precludes an accurate description of the episode. Coupled with the fact that the patients are often well-appearing at the time of their presentation to the ED, these patients create a management dilemma for emergency practitioners. Some data exist regarding the initial evaluation of infants after an ALTE.2-5 However, in this study, we identify patients who fit the definition for an ALTE in a two-step process involving first the chief complaint logs and then historical information provided in the ED by the care provider. Previous studies have identified patients after the diagnosis of an ALTE has already been established.2-4 This information is often not available to the emergency practitioner, and we consider our approach to be more representative of the information available to emergency practitioners at the time of evaluation of these patients. We hypothesize that the ED diagnostic evaluation is of limited use and that the rate of significant medical interventions among hospitalized patients is low. In an attempt to identify a group of patients more likely to require medical intervention, the risk factors of age, prematurity, or positive medical history were assessed. METHODS The study was performed retrospectively at a single, urban, tertiary care children’s hospital. Patients less than 6 months of age were selected for the study based on the information from the ED’s chief complaint logs over a period from January 1994 to December 1998. These logs document the patient’s name, date of birth, date of visit, and the presenting complaint as described by either the patient’s parents/care provider or the referring physician. The charts of all patients presenting or referred to the ED with any of the following chief complaints were considered as a potential ALTE and were selected for review: ALTE, alarms, apnea, blue, cyanosis, red, pale, gray, stopped breathing, choking, gagging, limp, stiff, or cardiopulmonary resuscitation performed. For inclusion in the final study group, the patients had to present with a history of either an apnea monitor alarm or an episode associated with two or more of the following factors: apnea, color change (blue, red, gray, pale), change in muscle tone, choking/gagging, or the performance of cardiopulmonary resuscitation at the time of the episode. Only patients experiencing a single episode within the previous 24 hours and presenting with stable vital signs at the time of 83
AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 22, Number 2 ■ March 2004
84
TABLE 1. ED Diagnostic Modalities: Abstraction List and Frequency of Utilization (n ⫽ 150) Diagnostic Test
No. of Patients (%)
Complete blood count Blood culture Serum electrolytes Urine culture Chest radiograph Urinalysis Cerebrospinal fluid studies Respiratory syncytial virus antigen Electrocardiogram Arterial blood gas Total bilirubin Pertussis direct fluorescent antibody and culture Serum ammonia Liver function tests
115 (76.7) 93 (62.0) 83 (55.3) 78 (52.0) 73 (48.7) 67 (44.7) 57 (38.0) 38 (25.3) 13 (8.7) 9 (6.0) 6 (4.0) 4 (2.7) 1 (0.7) 0
the first ED assessment were included in the study. The patients were excluded if the care providers stated that the alarms had signaled for transient bradycardia only. For all patients meeting the inclusion criteria, the medical record was abstracted for information pertaining to the ED visit and any related hospitalization. Historical information included demographics, description of the event (color change, apnea, performance of cardiopulmonary resuscitation, change in tone, duration of the event, association with feeding or emesis, and seizure activity) and medical history (previous ALTE, seizures, reflux, prematurity [less than 37 weeks gestation], a home apnea monitor, other chronic disease), medications, and the history of a sibling with sudden infant death syndrome (SIDS) or an ALTE. Patients were considered to have a positive medical history if they were premature or if they carried a specific diagnosis (eg, gastroegophagel reflux, seizures, apnea, previous ALTE). Vital signs, including pulse oximetry, and abnormalities in the physical examination were noted. The results of all diagnostic interventions performed or ordered in either the ED or during hospitalization were recorded. A list of diagnostic interventions abstracted from the medical record is provided in Table 1. The hospital discharge diagnosis, the occurrence of another ALTE, and the need for a significant medical intervention during admission were also abstracted. A diagnostic intervention was considered as part of the ED evaluation if the test was ordered while the patient was in the ED or within the first 6 hours of admission to the hospital. A positive ED evaluation was defined as a result from a diagnostic intervention that resulted in a specific treatment for a defined condition. A list of significant medical interventions is provided in Table 2. This list was derived from a locally validated instrument assessing risk of admission for pediatric patients from the ED.6 The study received approval by the Institutional Review Board. RESULTS The search of the chief complaint logs generated the review of 253,408 patient visits over a 60-month period.
TABLE 2.
Significant Medical Interventions
Absolute neutrophil count ⬍500 Acute coma Airway suctioning Arterial or central venous line Burns ⬎10% body surface area or any full-thickness Cardiac catherization Cardiopulmonary resuscitation Endotracheal intubation Intensive unit care Intravenous boluses of calcium, potassium, magnesium, or sodium bicarbonate Intravenous fluids for documented dehydration Intravenous infusions of insulin Mechanical ventilation or continuous positive airway pressure Nasogastric or orogastric tube Nebulizations more than every 3 hours Nothing-by-mouth status ⬎6 hours in neonate, ⬎8 hours in an infant Parenteral analgesics Parenteral antiarrhythmic agents Parenteral antibiotics for documented infection (⬎ 1 dose) Parenteral anticonvulsants Parenteral inotropic agents Platelets ⬍20,000 Stroke Supplemental oxygen above baseline Transfusion of blood products Tube thoracostomy Adapted from Chamberlain JM, Patel KM. Ruttimann UE, Pollack MM. Pediatric risk of admission (PRISA): a measure of severity of illness for assessing the risk of hospitalization from the emergency department. Ann Emerg Med 1998; 32: 161-169
The logs for 1 month could not be located. From this search, 523 patients (0.21%) met the initial search criteria for a potential ALTE. A convenience sample of 483 of these charts (92.4%) was reviewed with 150 patients meeting the inclusion criteria. Both the review of the chief complaint logs and of the charts was performed by a single investigator (AD). The demographics of the patient population are shown in Table 3. Of the 150 patients meeting criteria for an ALTE, 122 (81.3%) had a diagnostic evaluation in the ED (Table 1). The diagnoses of patients discharged from the ED after evaluation of a potential ALTE are shown in Table 4. The ED evaluation yielded a positive result in 3 of 122 (2.5%; 95% confidence interval [CI], 0.5-7.0) patients. The diagnoses and brief case descriptions are shown in Table 5. A total of 115 (76.7%) patients were admitted after the ED evaluation and 9 patients (7.8%, 95% CI, 3.6-14.3) had significant medical interventions during their admission af-
TABLE 3.
Patient Demographics (n ⫽ 150)
Mean age (days) Male, no. (%) Prematurity, no. (%) Previous ALTE, no. (%) Abbreviation: ALTE, apparent life-threatening event.
61.7 81 (54) 49 (32.7) 29 (19.3)
DE PIERO, TEACH, AND CHAMBERLAIN ■ ED EVALUATION OF INFANTS AFTER AN ALTE
TABLE 4. Discharge Diagnoses In Patients Not Admitted After Evaluation of Potential ALTE (n ⫽ 28) Diagnosis
No. of Patients
Reflux* Vomiting/choking episode Upper respiratory infection* Apnea alarms only Normal examination/well child Coughing episode Thrush Otitis media, possible febrile seizure Viral syndrome
11 9 5 5 2 1 1 1 1
TABLE 5.
85
Significant Diagnoses From ED Evaluation
Diagnosis
Specific Treatment
Pertussis
Antibiotics
Hypoglycemia
Intravenous glucose
Anemia
Transfusion
Comment 2-month-old girl, repeated cyanotic episodes during ED evaluation 51⁄2-month-old girl with history of prematurity, presenting with diarrhea and cyanosis 2-month-old girl with history of prematurity and anemia (requiring multiple transfusions)
*One patient diagnosed with both upper respiratory infection and reflux.
ter a negative ED evaluation. The diagnoses and case descriptions are shown in Table 6. No patient was discharged from the hospital with a diagnosis of bacteremia, sepsis, or bacterial meningitis. Patients less than 60 days of age were at lower risk for significant medical interventions than those more than 60 days old (relative risk [RR], 0.12, CI, 0.03-0.52) as were patients who were full term without a significant medical history. (RR, 0.23; CI, 0.52-0.99). Prematurity alone could be a risk factor for significant medical intervention (RR, 2.95; CI 1.00-8.68). DISCUSSION Other studies have considered the evaluation and discharge diagnoses of patients after an ALTE.2-5 However, the diagnosis of ALTE was often established retrospectively. As in the study by Davies and Gupta,5 we use historical criteria to establish a diagnosis of ALTE. This approach is more representative of clinical situations encountered by emergency practitioners. In these patients, the diagnosis of ALTE has often not been firmly established. TABLE 6.
In evaluating this group of patients, the ED diagnostic evaluation has a limited role beyond the information provided by the history and physical examination. In the three patients with a positive evaluation, the historical factors and physical examination directed the diagnostic evaluation leading to the etiology of the ALTE (cough with repeated cyanotic episodes in a patient with pertussis, hypoglycemia in a patient with acute diarrheal episode, and anemia in a patient with a history of anemia and requiring transfusions). These data support an approach that limits diagnostic testing to those patients in which the history and physical examination suggest an etiology for the ALTE. The results of this study lend support to previous work recommending admission for all patients after an ALTE7,8 because a clinically significant number of patients required an intervention while admitted. Prematurity could prove to be a significant risk factor for a positive ED evaluation and significant intervention during admission. Of the three patients with a positive ED evaluation, two had a history of prematurity. Further study will be necessary to evaluate this potential risk factor.
Medically Significant Interventions After Negative ED Evaluation
Discharge Diagnosis
Specific Treatment/ Intervention Mandating Admission
ALTE, craniostenostosis
Supplemental oxygen
Pulmonary hemosiderosis
NPO status
Apnea, gastroesophageal reflux Apnea, gastroesophageal reflux, aspiration, Parainfluenza infection Apnea Apnea Bronchiolitis
Supplemental oxygen
Comments 6-day-old girl, full term, abnormal frontal sutures noted on examination 21⁄2-month-old boy, full term, history of previous ALTE, bloodtinged secretions noted on clothing 31⁄2 month old male, history of prematurity
Supplemental oxygen
4-month-old girl, history of prematurity, abnormal respiratory examination in ED
Intubation Supplemental oxygen Supplemental oxygen
3-month-old boy, history of prematurity, apneic episodes in ED 5-month-old boy, no significant history 11⁄2-month-old boy; history of prematurity, abnormalities on respiratory examination 31⁄2-month-old girl, history of prematurity and hydrocephalus, abnormalities on respiratory examination 5-month-old girl, history of apnea and reflux
Bronchiolitis
Supplemental oxygen
Apnea, gastroesophageal reflux
Supplemental oxygen
Abbreviations: ALTE, apparent life-threatening event; NPO, nothing by mouth.
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AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 22, Number 2 ■ March 2004
Notable limitations exist in this study. This study was performed from information at a single institution that is a tertiary care center. The identification of these infants from a retrospective chart review is problematic. We chose to include only those patients who had a single episode within the 24 hours before arrival in the ED to avoid capturing those patients with cardiorespiratory instability requiring aggressive and immediate interventions. In so doing, we could have excluded a subset of patients. We required patients to have a combination of factors from the NIH Consensus Statement1 in an effort to minimize the number of patients who had simple choking or gagging episodes while feeding. Again, this could have inappropriately excluded some patients from the study. Not all patients were admitted and long-term follow up was not available. Finally, small numbers of patients with positive diagnostic evaluations limit the power of the study. An ED diagnostic evaluation could be appropriate for some patients after an ALTE, especially when directed from factors in the patient’s history or physical examination. However, many of these patients could be best managed with a limited ED evaluation and a period of inpatient observation.
REFERENCES 1. Little GA, Ballard RA, Brooks JG, et al: National Institute of Health Consensus Development: course on infantile apnea and home monitoring, September 1986. Pediatrics 1987;79:292-299 2. Lewis JM, Ganick DJ: Evaluation of Infants with “presumed near-miss” Sudden Infant Death Syndrome. Am J Dis Child 1986; 140:484-486 3. Gray C, Davies F, Molyneux E: Apparent life-threatening events presenting to a pediatric emergency department. Pediatr Emerg Care 1999;15:195-199 4. Kahn A, Montauk L, Blum D: Diagnostic categories in infants referred for an acute event suggesting near-miss SIDS. Eur J Pediatr 1987;146:458-460 5. Davies F, Gupta R: Apparent life-threatening events presenting to an emergency department. Emerg Med J 2002;19:11-16 6. Chamberlain JM, Patel KM, Ruttimann UE, Pollack MM: Pediatric risk of admission (PRISA): a measure of severity of illness for assessing the risk of hospitalization from the emergency department. Ann Emerg Med 1998;32:161-169 7. Samuels MP, Poets CF, Noies JP, et al: Diagnosis and management after life- threatening events in infants and young children who received cardiopulmonary resuscitation. BMJ 1993;306:489492 8. Wennergren G, Milerad J, Westphall I, Tunell R: Consensus statement on clinical management. Acta Paediatr Suppl 1993;389: 114-116
Infants commonly present to the ED for initial evaluation after an apparent life-threatening event (ALTE). An ALTE is defined as “an episode that is frightening to the observer, that is characterized by some combination of apnea (centrally or occasionally obstructive), color change (usually
From the *Division of Emergency Medicine, Children’s National Medical Center, and the †Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC. Received December 15, 2002; accepted February 3, 2003. Dr. DePiero is currently affiliated with the Division of Pediatric Emergency Medicine, Department of Pediatrics, AI DuPont Hospital for Children, Wilmington, Delaware. Address reprint requests to Andrew D. DePiero, Division of Pediatric Emergency Medicine, Department of Pediatrics, AI DuPont Hospital for Children, 1600 Rockland Rd., Wilmington, DE 19899. Email: [email protected] Key Words: ALTE, resource utilization. © 2004 Elsevier Inc. All rights reserved. 0735-6757/04/2202-0004$30.00/0 doi:10.1016/j.ajem.2003.12.007
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.”1 However, despite a standard definition, these events are heterogeneous. Their frightening nature often precludes an accurate description of the episode. Coupled with the fact that the patients are often well-appearing at the time of their presentation to the ED, these patients create a management dilemma for emergency practitioners. Some data exist regarding the initial evaluation of infants after an ALTE.2-5 However, in this study, we identify patients who fit the definition for an ALTE in a two-step process involving first the chief complaint logs and then historical information provided in the ED by the care provider. Previous studies have identified patients after the diagnosis of an ALTE has already been established.2-4 This information is often not available to the emergency practitioner, and we consider our approach to be more representative of the information available to emergency practitioners at the time of evaluation of these patients. We hypothesize that the ED diagnostic evaluation is of limited use and that the rate of significant medical interventions among hospitalized patients is low. In an attempt to identify a group of patients more likely to require medical intervention, the risk factors of age, prematurity, or positive medical history were assessed. METHODS The study was performed retrospectively at a single, urban, tertiary care children’s hospital. Patients less than 6 months of age were selected for the study based on the information from the ED’s chief complaint logs over a period from January 1994 to December 1998. These logs document the patient’s name, date of birth, date of visit, and the presenting complaint as described by either the patient’s parents/care provider or the referring physician. The charts of all patients presenting or referred to the ED with any of the following chief complaints were considered as a potential ALTE and were selected for review: ALTE, alarms, apnea, blue, cyanosis, red, pale, gray, stopped breathing, choking, gagging, limp, stiff, or cardiopulmonary resuscitation performed. For inclusion in the final study group, the patients had to present with a history of either an apnea monitor alarm or an episode associated with two or more of the following factors: apnea, color change (blue, red, gray, pale), change in muscle tone, choking/gagging, or the performance of cardiopulmonary resuscitation at the time of the episode. Only patients experiencing a single episode within the previous 24 hours and presenting with stable vital signs at the time of 83
AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 22, Number 2 ■ March 2004
84
TABLE 1. ED Diagnostic Modalities: Abstraction List and Frequency of Utilization (n ⫽ 150) Diagnostic Test
No. of Patients (%)
Complete blood count Blood culture Serum electrolytes Urine culture Chest radiograph Urinalysis Cerebrospinal fluid studies Respiratory syncytial virus antigen Electrocardiogram Arterial blood gas Total bilirubin Pertussis direct fluorescent antibody and culture Serum ammonia Liver function tests
115 (76.7) 93 (62.0) 83 (55.3) 78 (52.0) 73 (48.7) 67 (44.7) 57 (38.0) 38 (25.3) 13 (8.7) 9 (6.0) 6 (4.0) 4 (2.7) 1 (0.7) 0
the first ED assessment were included in the study. The patients were excluded if the care providers stated that the alarms had signaled for transient bradycardia only. For all patients meeting the inclusion criteria, the medical record was abstracted for information pertaining to the ED visit and any related hospitalization. Historical information included demographics, description of the event (color change, apnea, performance of cardiopulmonary resuscitation, change in tone, duration of the event, association with feeding or emesis, and seizure activity) and medical history (previous ALTE, seizures, reflux, prematurity [less than 37 weeks gestation], a home apnea monitor, other chronic disease), medications, and the history of a sibling with sudden infant death syndrome (SIDS) or an ALTE. Patients were considered to have a positive medical history if they were premature or if they carried a specific diagnosis (eg, gastroegophagel reflux, seizures, apnea, previous ALTE). Vital signs, including pulse oximetry, and abnormalities in the physical examination were noted. The results of all diagnostic interventions performed or ordered in either the ED or during hospitalization were recorded. A list of diagnostic interventions abstracted from the medical record is provided in Table 1. The hospital discharge diagnosis, the occurrence of another ALTE, and the need for a significant medical intervention during admission were also abstracted. A diagnostic intervention was considered as part of the ED evaluation if the test was ordered while the patient was in the ED or within the first 6 hours of admission to the hospital. A positive ED evaluation was defined as a result from a diagnostic intervention that resulted in a specific treatment for a defined condition. A list of significant medical interventions is provided in Table 2. This list was derived from a locally validated instrument assessing risk of admission for pediatric patients from the ED.6 The study received approval by the Institutional Review Board. RESULTS The search of the chief complaint logs generated the review of 253,408 patient visits over a 60-month period.
TABLE 2.
Significant Medical Interventions
Absolute neutrophil count ⬍500 Acute coma Airway suctioning Arterial or central venous line Burns ⬎10% body surface area or any full-thickness Cardiac catherization Cardiopulmonary resuscitation Endotracheal intubation Intensive unit care Intravenous boluses of calcium, potassium, magnesium, or sodium bicarbonate Intravenous fluids for documented dehydration Intravenous infusions of insulin Mechanical ventilation or continuous positive airway pressure Nasogastric or orogastric tube Nebulizations more than every 3 hours Nothing-by-mouth status ⬎6 hours in neonate, ⬎8 hours in an infant Parenteral analgesics Parenteral antiarrhythmic agents Parenteral antibiotics for documented infection (⬎ 1 dose) Parenteral anticonvulsants Parenteral inotropic agents Platelets ⬍20,000 Stroke Supplemental oxygen above baseline Transfusion of blood products Tube thoracostomy Adapted from Chamberlain JM, Patel KM. Ruttimann UE, Pollack MM. Pediatric risk of admission (PRISA): a measure of severity of illness for assessing the risk of hospitalization from the emergency department. Ann Emerg Med 1998; 32: 161-169
The logs for 1 month could not be located. From this search, 523 patients (0.21%) met the initial search criteria for a potential ALTE. A convenience sample of 483 of these charts (92.4%) was reviewed with 150 patients meeting the inclusion criteria. Both the review of the chief complaint logs and of the charts was performed by a single investigator (AD). The demographics of the patient population are shown in Table 3. Of the 150 patients meeting criteria for an ALTE, 122 (81.3%) had a diagnostic evaluation in the ED (Table 1). The diagnoses of patients discharged from the ED after evaluation of a potential ALTE are shown in Table 4. The ED evaluation yielded a positive result in 3 of 122 (2.5%; 95% confidence interval [CI], 0.5-7.0) patients. The diagnoses and brief case descriptions are shown in Table 5. A total of 115 (76.7%) patients were admitted after the ED evaluation and 9 patients (7.8%, 95% CI, 3.6-14.3) had significant medical interventions during their admission af-
TABLE 3.
Patient Demographics (n ⫽ 150)
Mean age (days) Male, no. (%) Prematurity, no. (%) Previous ALTE, no. (%) Abbreviation: ALTE, apparent life-threatening event.
61.7 81 (54) 49 (32.7) 29 (19.3)
DE PIERO, TEACH, AND CHAMBERLAIN ■ ED EVALUATION OF INFANTS AFTER AN ALTE
TABLE 4. Discharge Diagnoses In Patients Not Admitted After Evaluation of Potential ALTE (n ⫽ 28) Diagnosis
No. of Patients
Reflux* Vomiting/choking episode Upper respiratory infection* Apnea alarms only Normal examination/well child Coughing episode Thrush Otitis media, possible febrile seizure Viral syndrome
11 9 5 5 2 1 1 1 1
TABLE 5.
85
Significant Diagnoses From ED Evaluation
Diagnosis
Specific Treatment
Pertussis
Antibiotics
Hypoglycemia
Intravenous glucose
Anemia
Transfusion
Comment 2-month-old girl, repeated cyanotic episodes during ED evaluation 51⁄2-month-old girl with history of prematurity, presenting with diarrhea and cyanosis 2-month-old girl with history of prematurity and anemia (requiring multiple transfusions)
*One patient diagnosed with both upper respiratory infection and reflux.
ter a negative ED evaluation. The diagnoses and case descriptions are shown in Table 6. No patient was discharged from the hospital with a diagnosis of bacteremia, sepsis, or bacterial meningitis. Patients less than 60 days of age were at lower risk for significant medical interventions than those more than 60 days old (relative risk [RR], 0.12, CI, 0.03-0.52) as were patients who were full term without a significant medical history. (RR, 0.23; CI, 0.52-0.99). Prematurity alone could be a risk factor for significant medical intervention (RR, 2.95; CI 1.00-8.68). DISCUSSION Other studies have considered the evaluation and discharge diagnoses of patients after an ALTE.2-5 However, the diagnosis of ALTE was often established retrospectively. As in the study by Davies and Gupta,5 we use historical criteria to establish a diagnosis of ALTE. This approach is more representative of clinical situations encountered by emergency practitioners. In these patients, the diagnosis of ALTE has often not been firmly established. TABLE 6.
In evaluating this group of patients, the ED diagnostic evaluation has a limited role beyond the information provided by the history and physical examination. In the three patients with a positive evaluation, the historical factors and physical examination directed the diagnostic evaluation leading to the etiology of the ALTE (cough with repeated cyanotic episodes in a patient with pertussis, hypoglycemia in a patient with acute diarrheal episode, and anemia in a patient with a history of anemia and requiring transfusions). These data support an approach that limits diagnostic testing to those patients in which the history and physical examination suggest an etiology for the ALTE. The results of this study lend support to previous work recommending admission for all patients after an ALTE7,8 because a clinically significant number of patients required an intervention while admitted. Prematurity could prove to be a significant risk factor for a positive ED evaluation and significant intervention during admission. Of the three patients with a positive ED evaluation, two had a history of prematurity. Further study will be necessary to evaluate this potential risk factor.
Medically Significant Interventions After Negative ED Evaluation
Discharge Diagnosis
Specific Treatment/ Intervention Mandating Admission
ALTE, craniostenostosis
Supplemental oxygen
Pulmonary hemosiderosis
NPO status
Apnea, gastroesophageal reflux Apnea, gastroesophageal reflux, aspiration, Parainfluenza infection Apnea Apnea Bronchiolitis
Supplemental oxygen
Comments 6-day-old girl, full term, abnormal frontal sutures noted on examination 21⁄2-month-old boy, full term, history of previous ALTE, bloodtinged secretions noted on clothing 31⁄2 month old male, history of prematurity
Supplemental oxygen
4-month-old girl, history of prematurity, abnormal respiratory examination in ED
Intubation Supplemental oxygen Supplemental oxygen
3-month-old boy, history of prematurity, apneic episodes in ED 5-month-old boy, no significant history 11⁄2-month-old boy; history of prematurity, abnormalities on respiratory examination 31⁄2-month-old girl, history of prematurity and hydrocephalus, abnormalities on respiratory examination 5-month-old girl, history of apnea and reflux
Bronchiolitis
Supplemental oxygen
Apnea, gastroesophageal reflux
Supplemental oxygen
Abbreviations: ALTE, apparent life-threatening event; NPO, nothing by mouth.
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AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 22, Number 2 ■ March 2004
Notable limitations exist in this study. This study was performed from information at a single institution that is a tertiary care center. The identification of these infants from a retrospective chart review is problematic. We chose to include only those patients who had a single episode within the 24 hours before arrival in the ED to avoid capturing those patients with cardiorespiratory instability requiring aggressive and immediate interventions. In so doing, we could have excluded a subset of patients. We required patients to have a combination of factors from the NIH Consensus Statement1 in an effort to minimize the number of patients who had simple choking or gagging episodes while feeding. Again, this could have inappropriately excluded some patients from the study. Not all patients were admitted and long-term follow up was not available. Finally, small numbers of patients with positive diagnostic evaluations limit the power of the study. An ED diagnostic evaluation could be appropriate for some patients after an ALTE, especially when directed from factors in the patient’s history or physical examination. However, many of these patients could be best managed with a limited ED evaluation and a period of inpatient observation.
REFERENCES 1. Little GA, Ballard RA, Brooks JG, et al: National Institute of Health Consensus Development: course on infantile apnea and home monitoring, September 1986. Pediatrics 1987;79:292-299 2. Lewis JM, Ganick DJ: Evaluation of Infants with “presumed near-miss” Sudden Infant Death Syndrome. Am J Dis Child 1986; 140:484-486 3. Gray C, Davies F, Molyneux E: Apparent life-threatening events presenting to a pediatric emergency department. Pediatr Emerg Care 1999;15:195-199 4. Kahn A, Montauk L, Blum D: Diagnostic categories in infants referred for an acute event suggesting near-miss SIDS. Eur J Pediatr 1987;146:458-460 5. Davies F, Gupta R: Apparent life-threatening events presenting to an emergency department. Emerg Med J 2002;19:11-16 6. Chamberlain JM, Patel KM, Ruttimann UE, Pollack MM: Pediatric risk of admission (PRISA): a measure of severity of illness for assessing the risk of hospitalization from the emergency department. Ann Emerg Med 1998;32:161-169 7. Samuels MP, Poets CF, Noies JP, et al: Diagnosis and management after life- threatening events in infants and young children who received cardiopulmonary resuscitation. BMJ 1993;306:489492 8. Wennergren G, Milerad J, Westphall I, Tunell R: Consensus statement on clinical management. Acta Paediatr Suppl 1993;389: 114-116