Brief Resolved Unexplained Event Clinical Pathway — Emergency and Inpatient

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Provider Resources

Related Pathway

Abuse, Physical, Emergency

Infant < 1 yr with a BRUE

Exclusions

History/Physical Examination

Does Not Meet BRUE Criteria

BRUE criteria absent
Additional symptoms present
- Abnormal vital signs
- Physical exam other than baseline
Explanation for event identified

Meets BRUE Criteria

Sudden, brief, and now resolved episode of one or
more of the following in an infant < 1 yr age:
- Cyanosis or pallor
- Absent, decreased or irregular breathing
- Marked change in tone (hyper- or hypotonia)
- Altered responsiveness
- No explanation for the event with full history and exam

Lower-risk Infant

Higher-risk Infant

Age > 60 days
Gestational age
- Born ≥ 32 wks gestation and post-conception age ≥ 45 wks
No cardiopulmonary resuscitation (CPR) by trained medical provider
Event lasted < 1 min
First event
No repeat events
No concerning history

Any of the lower-risk criteria not met
Concerning history
- e.g., FH of sudden cardiac death or concern for social, feeding, or respiratory problems

ED Management Recommendations

Review the nature of event with caregivers
Reassurance and shared decision-making
Observe infant in ED for 1-2 hrs on continuous pulse ox and cardiac monitor and during PO trial
Routine laboratory testing is generally not needed
- Consider pertussis screen, if history of exposure

Review Differential Diagnosis
Continuous pulse ox and cardiac monitor for at least 2 hrs and during feeding
Evaluation as Clinically Indicated
- Social work consult for non-accidental trauma, other concerns
- Appropriate viral testing based on symptoms, pertussis risk
- Additional labs as needed

Disposition Considerations

Considerations for Admission

No repeat event during ED stay
Successful PO trial
Evaluation negative for any concerning illness
Parent comfortable with discharge to home

Recurrent event(s) during ED stay or prior 24 hrs
Observation needed to characterize events
Specific abnormality identified during
medical observation
Sub-specialty consultation, additional
studies recommended
Provider or family uncomfortable with
home observation
MDCalc BRUE 2.0

Discharge

Admission Guidance

Review BRUE discharge instructions
Follow-up with primary medical doctor within the week
Safe sleep, co-sleeping teaching

Continuous pulse ox and cardiac monitoring
Consider consultation based on history and exam
- Social work consultation, if concern for abuse or family needs support
- Feeding evaluation, if BRUE events occur during feed or if there are concerns for oral feeding skills or safety
Consider targeted interventions based on history
and physical, specialist input
- Sleep study or pneumogram
- EEG, neuroimaging
- ECG, echocardiographic study
MDCalc BRUE 2.0
Education
- Cardiopulmonary resuscitation (CPR)
- Safe sleep, co-sleeping teaching
- Resources as indicated

Discharge

No repeat concerning events during hospital stay
All interventions completed and consults reviewed
Review BRUE discharge instructions with family
Follow-up with primary medical doctor within
the week
Education completed

Posted: March 2017
Last Revised: February 2024

Authors:
- E. Kane, MD;
- M. Mittal, MBBS;
- G. Sharer, MSN;
- R. Hendricks, MSW;
- J. Welc, CCC-SLP;
- M. Congdon, MD;
- E. Hardy, CRNP;
- J. Owusu-McKenzie, MD;
- J. Butler, RN;
- K. Conaway, MD;
- L. Goldstein, MD;
- M. Patel, MD;
- M. Mcway, MD;
- N. Hughes, MD

Editors: Clinical Pathways Team

Evidence

Community Resources

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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Emergency Department and Inpatient Pathway for Evaluation of Infants with a Brief, Resolved, Unexplained Event (BRUE)

Evidence

Community Resources