ALERT |
| If the patient is apneic, treatment must commence at once |
Signs and Symptoms
- Apnea may be current, historical, or impending
- Can be with or without changes in heart rate or tone
History
- Duration of apnea
- State:
- Asleep, awake, crying
- Relationship to feeds and position (supine, prone)
- Respiratory effort:
- None, shallow breathing, increased work of breathing, struggling to breathe, choking
- Presence and location of color change (pallor, cyanosis)
- Position of eyes
- Description of movements and muscle tone
- Interventions done by the caregiver
- Antecedent symptoms such as fever or cough
- Antecedent trauma
- Past medical history, including prematurity, cardiopulmonary, GI, or neurologic conditions
- Any past history of BRUEs in this patient or sudden unexplained deaths in family members
Physical Exam
- Vital signs with temperature
- Growth parameters:
- Weight pattern
- OFC (head circumference) pattern
- Pulse oximetry
- Exam of airway and lungs:
- Assess impending apnea
- Stridor or other evidence of upper airway obstruction
- Fast or slow respirations
- Use of accessory muscles
- Adventitial lung sounds
- Exam of heart:
- Irregular rhythm
- Murmur
- Evidence of CHF
- Neurologic exam:
- Assess mental status
- Assess for trauma, seizure, or toxidrome
- Muscle tone and reflexes
- Funduscopic exam
Essential Workup
- Complete history and physical exam
- The historical factors and exam will direct the diagnostic evaluation and treatment
- Check/clear out upper airway as appropriate
- Remove or suction any obstruction as appropriate
- Ensure proper head positioning with special consideration for occult trauma
Diagnostic Tests & Interpretation
Lab
Perform as appropriate for presentation:
- Dextrostix
- CBC
- Urinalysis
- CSF studies
- Blood, urine, and CSF cultures
- Electrolytes (including calcium)
- BUN, creatinine
- Blood gas
- RSV and respiratory viral studies
- Pertussis and chlamydia tests
- Toxicologic screen (urine drug screen, acetaminophen, salicylates, toxic alcohols)
- Consider LFTs and ammonia
Imaging
Perform as appropriate for presentation:
- CXR
- Head CT or MRI
- ECG
- UGI or swallowing study
- Polysomnography in follow-up in patient with suspected central or obstructive sleep apnea
- EEG in follow-up
- Bone survey and other studies as indicated
Differential Diagnosis
- Multiple etiologies as previously noted
- Special considerations:
- Breath-holding spells:
- Reflexive, brief, cessations of breathing that occur in children in response to an emotional stimuli (crying, temper tantrum, etc.)
- Cyanotic and pallid types
- Paroxysmal event occurring in 0.1-5% of healthy children 6 mo-6 yr of age
- First episode normally before 18 mo
- If recurrent, consider screening for anemia
- Periodic breathing may be seen in neonates:
- 3 or more respiratory pauses lasting >3 s with <20 s of respiration between pauses
- No color, heart rate, or tone change
- May be normal event
- In neonate with clear apnea, sepsis should generally be excluded
ALERT |
| In a neonate, strongly consider occult sepsis |
Prehospital
- Respiratory support as indicated:
- High-flow oxygen if breathing resumes
- Check/clear out upper airway
- Bag-mask ventilation
- Endotracheal intubation if continued apnea
- IV access, cardiac monitoring
- Look for signs of an underlying cause:
- Medications
- Document a basic neurologic exam:
- GCS
- Pupils
- Extremity movements
- Gross signs of trauma
- Talk with family/prehospital personnel for information
Initial Stabilization/Therapy
- Establish unresponsiveness
- Check/clear out upper airway
- Remove or suction any obstruction
- Ensure proper head positioning
ED Treatment/Procedures
- If currently apneic, ventilate with the bag-valve mask device and high-flow oxygen
- Endotracheal intubation is required if apnea persists
- Resuscitation medications and antibiotics as indicated
- Support and counseling if breath holding or BRUE suspected
Medication
- Antibiotic doses in ED:
- Dextrose: 2-4 mL/kg D25W IV or 5-10 mL/kg D10W IV
- Neonates: 1 mo 2-4 mL/kg D10W IV
- Naloxone: 0.01-0.1 mg/kg IV/IM/SC/ET
- Caution: May precipitate withdrawal symptoms in patients with chronic opiate use
Disposition
Admission Criteria
- Patients who were or may become apneic should be admitted to an inpatient unit for appropriate monitoring. Those with persistent abnormal vital signs need intensive care monitoring
- Variables that identify most children requiring admission include those with an obvious need for admission including abnormal vital signs or a significant medical history, or >1 BRUE in 24 hr. Consider admission or prolonged observation if <30 d or <44 gestational weeks with BRUE
- Recommend referral for pediatric evaluation and follow-up as indicated. Interventions may include further studies (i.e., EEG), antireflux medications, and home monitoring
Discharge Criteria
In patients without true apnea who are at low risk and have no abnormalities noted during the period of observation and evaluation, discharge may be considered, assuming that parents are compliant and comfortable with their child and follow-up and support are definitively established
Issues for Referral
Primary care physician and subspecialist, reflecting suspected etiology
- ClaudisI, MittalMK, MurrayR, et al. Should infants presenting with an apparent life-threatening even undergo evaluation for serious bacterial infections and respiratory pathogens ? J Pediatr. 2014;164:1231-1233.
- KahnA; European Society for the Study and Prevention of Infant Death. Recommended clinical evaluation of infants with an apparent life-threatening event. Consensus document of the European Society for the Study and Prevention of Infant Death, 2003 . Eur J Pediatr. 2004;163(2):108-115.
- KajiAH, ClaudiusI, SantillanesG, et al. Apparent life-threatening event: Multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital . Ann Emerg Med. 2013;61:379-387.
- McGovernMC, SmithMB. Causes of apparent life threatening events in infants: A systematic review . Arch Dis Child. 2004;89(11):1043-1048.
- TiederJS, AltmanRL, BonkowskyJL, et al. Management of apparent life-threatening events in infants: A systemic review . J Pediatr. 2013;163(1):94-99.
- TiederJS, BonkowskyJL, EtzelRA, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants . Pediatrics. 2016;137(5):e20160590.
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