Brief Resolved Unexplained Events: Practical Evaluation and Management in the Emergency Department

Table of Contents

 

About This Issue

The 2016 American Academy of Pediatrics Brief Resolved Unexplained Event (BRUE) guideline provides new terminology and a framework for identifying and managing infants who are at lower risk for a repeat event or for having a serious underlying disorder. This issue reviews the definition of a BRUE, summarizes the risk-stratification criteria for infants who experience a BRUE, and provides management recommendations for patients with a lower-risk BRUE. It also discusses literature published since 2016 that expands on that guidance to include the higher-risk group. In this issue, you will learn:

Detailed definitions of the terms in BRUE

Lower-risk BRUE criteria

Conditions in the differential diagnosis for BRUEs

Historical features to consider in the evaluation of a patient experiencing a potential BRUE

Physical examination features of higher-risk diagnoses as well as possible evaluations for those conditions

Guidance for risk-stratification of infants who experienced a BRUE

Recommendations for management of patients with lower-risk BRUEs

Recommendations for disposition of infants who experienced a BRUE

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Definition of a Brief Resolved Unexplained Event
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. Initial Stabilization
   2. History
   3. Physical Examination
   4. Risk Stratification
10. Management
    1. Cardiopulmonary Assessment Recommendations
    2. Nonaccidental Trauma Assessment Recommendations
    3. Neurologic Assessment Recommendations
    4. Infectious Disease Assessment Recommendations
    5. Gastrointestinal Assessment Recommendations
    6. Inborn Errors of Metabolism Assessment Recommendations
    7. Anemia Assessment Recommendations
    8. Patient- and Family-Centered Care Recommendations
11. Defining Lower-Risk and Higher-Risk Patients
12. Disposition
13. Summary
14. 5 Things That Will Change Your Practice
15. Time- and Cost-Effective Strategies
16. Risk Management Pitfalls for Infants With a Possible Brief Resolved Unexplained Event
17. Case Conclusions
18. Clinical Pathway for Diagnosis, Risk Classification, and Management of a Brief Resolved Unexplained Event
19. Tables and Figures
20. References

Abstract

In a 2016 clinical practice guideline, the American Academy of Pediatrics (AAP) created and introduced the term brief resolved unexplained event (BRUE). This guideline defined specific criteria for diagnosis of BRUE and provided a set of guidelines for evaluation of these infants as well as characteristics that indicate a BRUE will have a low risk for a repeat event or a serious underlying disorder. This issue reviews the definition and broad differential diagnosis of a BRUE, highlights the criteria for risk stratification of infants who experience a BRUE, summarizes the management recommendations for patients with a lower-risk BRUE, and examines the available literature that evaluates the impact of the AAP guidelines in the years since its publication.

Case Presentations

A 3-week-old girl is brought in by EMS after her parents witnessed an episode during which she started coughing and gagging shortly after feeding, then turned blue in the face...

• After witnessing the episode, her mother began CPR. The parents report that the episode lasted 5 minutes. They tell you the girl is an otherwise healthy baby and was acting well prior to this event. She was born at full term, with no complications during delivery.
• The baby has normal vital signs and a normal physical examination, including heart, lungs, and neurologic examination.
• You wonder whether this episode would be considered a BRUE. What testing should be done in the ED, and under what circumstances should the patient be admitted to the hospital?

A 9-week-old, full-term, previously healthy girl is brought to the ED by her concerned parents after she had an episode of going limp in her mother’s arms…

• The mother reports that the baby was very pale and appeared to be not breathing, prompting her to begin CPR. After approximately 30 seconds, the girl’s color and tone returned to normal, and she began crying and breathing normally.
• When the infant arrived at the ED, she was back to her baseline, according to her parents, and she has a normal physical examination and vital signs.
• Based on the 2016 AAP guidelines, does this meet the criteria for classification as a “lower-risk” BRUE? If so, what key actions should you follow in the management of this patient?

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Risk Management Pitfalls for Infants With a Possible Brief Resolved Unexplained Event

1. “I ordered basic labs just to be sure this patient with a lower-risk BRUE did not have a serious underlying diagnosis.” Ordering “basic labs” in a lower-risk infant “just to be sure” can be misleading and potentially lead to unnecessary admissions or further testing. Instead, consider obtaining only an ECG and/or pertussis testing if appropriate, and keeping the patient for a brief period of monitoring in the ED.

7. “The triage nurse noted a heart rate of 200 beats/min when the 3-month-old checked in, but it was probably because the baby was crying. It was down to 185 beats/min, and the rest of the history and examination were normal. Since this was a low-risk BRUE, I sent the patient home.” This patient’s vital signs were abnormal on arrival to the ED and their elevated heart rate persisted, but they were still diagnosed with BRUE and discharged. The persistent vital sign abnormality precluded this event from being deemed “resolved,” and this was therefore not a BRUE.

9. “This infant met all the criteria for a lower-risk BRUE and had a normal ECG in the ED. I decided to refer them to cardiology for an outpatient echocardiogram; you can never be too careful with an infant this young!” Lower-risk infants without any cardiac risk factors (eg, family history of sudden death), a normal physical examination, and normal ECG should not be referred for further cardiac testing, as this is unlikely to be of significant diagnostic yield.

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants. Pediatrics. 2016;137(5):e20160590. (Clinical practice guideline) DOI: 10.1542/peds.2016-0590

6. * Ramgopal S, Soung J, Pitetti RD. Brief resolved unexplained events: analysis of an apparent life threatening event database. Acad Pediatr. 2019;19(8):963-968. (Secondary analysis of prospective cohort study; 762 patients) DOI: 10.1016/j.acap.2019.08.001

8. * Bochner R, Tieder JS, Sullivan E, et al. Explanatory diagnoses following hospitalization for a brief resolved unexplained event. Pediatrics. 2021;148(5):e2021052673. (Multicenter retrospective cohort study; 980 patients) DOI: 10.1542/peds.2021-052673

16. * Duncan DR, Liu E, Growdon AS, et al. A prospective study of brief resolved unexplained events: risk factors for persistent symptoms. Hosp Pediatr. 2022;12(12):1030-1043. (Prospective longitudinal cohort study; 124 patients) DOI: 10.1542/hpeds.2022-006550

19. * Brand DA, Fazzari MJ. Risk of death in infants who have experienced a brief resolved unexplained event: a meta-analysis. J Pediatr. 2018;197:63-67. (Meta-analysis and systematic review; 12 studies) DOI: 10.1016/j.jpeds.2017.12.028

20. * Tieder JS, Sullivan E, Stephans A, et al. Risk factors and outcomes after a brief resolved unexplained event: a multicenter study. Pediatrics. 2021;148(1):e2020036095. (Multicenter retrospective cohort study; 2036 patients) DOI: 10.1542/peds.2020-036095

21. * Nama N, Hall M, Neuman M, et al. Risk prediction after a brief resolved unexplained event. Hosp Pediatr. 2022;12(9):772-785. (Multicenter retrospective cohort study with clinical prediction model derivation; 3283 patients) DOI: 10.1542/hpeds.2022-006637

22. * Mittal MK, Tieder JS, Westphal K, et al. Diagnostic testing for evaluation of brief resolved unexplained events. Acad Emerg Med. 2023;30(6):662-670. (Multicenter retrospective cohort study secondary analysis; 2036 patients) DOI: 10.1111/acem.14666

23. * Patra KP, Hall M, DeLaroche AM, et al. Impact of the AAP guideline on management of brief resolved unexplained events. Hosp Pediatr. 2022;12(9):780-791. (Retrospective observational cohort study; 27,941 encounters) DOI: 10.1542/hpeds.2021-006427

42. * Merritt JL, Quinonez RA, Bonkowsky JL, et al. A framework for evaluation of the higher-risk infant after a brief resolved unexplained event. Pediatrics. 2019;144(2):e20184101. (Clinical practice guideline) DOI: 10.1542/peds.2018-4101

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Keywords: brief resolved unexplained event, BRUE, apparent life-threatening event, ALTE, risk stratification, key action statements, lower-risk BRUE, TEN-4-FACESp, cardiopulmonary assessment, nonaccidental trauma, nonaccidental trauma assessment, neurologic assessment, infectious disease assessment, gastrointestinal assessment, inborn errors of metabolism assessment, anemia assessment, family-centered care, patient-centered care, higher-risk patients, high-risk diagnoses