Emergency Department and Inpatient Pathway for Evaluation of Infants with a Brief, Resolved, Unexplained Event (BRUE)
Infant < 1 yr with a BRUE
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
- 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
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
Evidence
- Clinical Practice Guideline: Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants
- A Framework for Evaluation of the Higher-Risk Infant After a Brief Resolved Unexplained Event
- Diagnostic Testing for Evaluation of Brief Resolved Unexplained Events
- Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study
- Explanatory Diagnoses Following Hospitalization for a Brief Resolved Unexplained Event
- Risk Prediction After a Brief Resolved Unexplained Event
Community Resources