Core EM - Emergency Medicine Podcast

Show Notes

What is a BRUE?

• BRUE stands for Brief Resolved Unexplained Event.


• It typically affects infants <1 year of age and is characterized by a sudden, brief, and now resolved episode of one or more of the following:
  
  
  
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    Cyanosis or pallor

    
    
  
  
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    Irregular, absent, or decreased breathing

    
    
  
  
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    Marked change in tone (hypertonia or hypotonia)

    
    
  
  
  • Altered level of responsiveness
  
  
  
  

Risk Stratification: Low Risk vs. High Risk

Risk stratification is the most important step in management. While only 6-15% of cases meet strict “Low Risk” criteria, identifying these patients allows us to avoid unnecessary invasive testing.

Low Risk Criteria

To be considered Low Risk, the infant must meet ALL of the following:

1. 
   

   Age: > 60 days old

   
   


2. 
   

   Gestational Age: GA > 32 weeks (and Post-Conceptional Age > 45 weeks)

   
   


3. 
   

   Frequency: This is the first episode

   
   


4. 
   

   Duration: Lasted < 1 minute

   
   


5. 
   

   Intervention: No CPR performed by a trained professional

   
   


6. 
   

   Clinical Picture: Reassuring history and physical exam

   
   

Management for Low Risk:

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  Generally do not require extensive testing or admission.

  
  


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  Prioritize safety education/anticipatory guidance.

  
  


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  Ensure strict return precautions and close outpatient follow-up (within 24 hours).

  
  

High Risk Criteria

Any infant not meeting the low-risk criteria is automatically High Risk.

Additional red flags include:

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  Suspicion of child abuse

  
  


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  History of toxin exposure

  
  


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  Family history of sudden cardiac death

  
  


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  Abnormal physical exam findings (trauma, neuro deficits)

  
  

Management for High Risk:

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  Requires a more thorough evaluation.

  
  


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  Often requires hospital admission.

  
  


• Note: Serious underlying conditions are identified in approx. 4% of high-risk infants.

Differential Diagnosis: “THE MISFITS” Mnemonic

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  T – Trauma (Accidental or Non-accidental/Abuse)
  
  


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  H – Heart (Congenital heart disease, dysrhythmias)
  
  


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  E – Endocrine
  
  


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  M – Metabolic (Inborn errors of metabolism)
  
  


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  I – Infection (Sepsis, meningitis, pertussis, RSV)
  
  


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  S – Seizures
  
  


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  F – Formula (Reflux, allergy, aspiration)
  
  


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  I – Intestinal Catastrophes (Volvulus, intussusception)
  
  


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  T – Toxins (Medications, home exposures)
  
  


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  S – Sepsis (Systemic infection)
  
  

Workup & Diagnostics

Step 1: Stabilization

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  ABCs (Airway, Breathing, Circulation)

  
  


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  Point-of-care Glucose

  
  


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  Cardiorespiratory monitoring

  
  

Step 2: Diagnostic Testing (For High Risk/Symptomatic Patients)

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  Labs: VBG, CBC, Electrolytes.

  
  


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  Imaging:

  
  
  
  
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    CXR: Evaluate for infection and cardiothymic silhouette.

    
    
  
  
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    EKG: Evaluate for QT prolongation or dysrhythmias.

    
    
  
  
  
  


• Neuro: Consider Head CT/MRI and EEG if there are concerns for trauma or seizures.

Clinical Pearl: Only ~6% of diagnostic tests contribute meaningfully to the diagnosis. Be judicious—avoid “shotgunning” tests in low-risk patients.

Prognosis & Outcomes

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  Recurrence: Approximately 10% (lower than historical ALTE rates of 10-25%).

  
  


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  Mortality: < 1%. Nearly always linked to an identifiable cause (abuse, metabolic disorder, severe infection).

  
  


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  BRUE vs. SIDS: These are not the same.

  
  
  
  
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    BRUE: Peaks < 2 months; occurs mostly during the day.

    
    
  
  
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    SIDS: Peaks 2–4 months; occurs mostly midnight to 6:00 AM.

    
    
  
  
  
  

Take-Home Points

1. 
   

   Diagnosis of Exclusion: You cannot call it a BRUE until you have ruled out obvious causes via history and physical.

   
   


2. 
   

   Strict Criteria: Stick strictly to the Low Risk criteria guidelines. If they miss even one (e.g., age < 60 days), they are High Risk.

   
   


3. 
   

   Education: For low-risk families, the most valuable intervention is reassurance, education, and arranging close follow-up.

   
   


4. 
   

   Systematic Approach: For high-risk infants, use a structured approach (like THE MISFITS) to ensure you don’t miss rare but reversible causes.

   
   

Show Notes

Show Notes

Core Concepts and Initial Approach

• Definition: Obstruction of pulmonary arteries, usually from a DVT in the proximal lower extremity veins (iliac/femoral), but may be tumor, air, or fat emboli.


• Incidence & Mortality: 300,000–370,000 cases/year in the USA, with 60,000–100,000 deaths annually.


• Mantra: “Don’t anchor on the obvious. Always risk stratify and resuscitate with precision.”


• Risk Factors: Broad, including older age, inherited thrombophilias, malignancy, recent surgery/trauma, travel, smoking, hormonal use, and pregnancy.

Clinical Presentation and Risk Stratification

• Presentation: Highly variable, showing up as anything from subtle shortness of breath to collapse.


• Acute/Subacute: Dyspnea (most common), pleuritic chest pain, cough, hemoptysis, and syncope. Patients are likely tachycardic, tachypneic, hypoxemic on room air, and may have a low-grade fever.


• Chronic: Can mimic acute symptoms or be totally asymptomatic.


• Pulmonary Infarction Signs: Pleuritic pain, hemoptysis, and an effusion.


• High-Risk Red Flags: Signs of hypotension (systolic blood pressure < 90 mmHg for over 15 minutes), requirement of vasopressors, or signs of shock → activate PERT team immediately.


• Crucial Mimics: Think broadly; consider pneumonia, ACS, pneumothorax, heart failure exacerbation, and aortic dissection.

Workup & Diagnostics

• History/Scoring: Ask about prior clots, recent surgeries, hospitalizations, travel. Use Wells/PERC criteria to assess pretest probability.


• Labs:
  
  
  
  • D-dimer: A good test to rule out PE in a patient with low probability. If suspicion is high, proceed directly to imaging.
  
  
  • Troponin/BNP: Act as RV stress gauges. Elevated levels are associated with increased risk of a complicated clinical course (25-40%).
  
  
  • Lactate: Helpful in identifying patients in possible cardiogenic shock.
  
  
  • EKG: Most common finding is sinus tachycardia. Classic RV strain patterns (S₁Q₃T₃, T-wave changes/inversions) are nonspecific.
  
  
  
  


• Imaging:
  
  
  
  • CXR: Usually normal, but quick and essential to rule out other causes.
  
  
  • CTPA: The usual standard and gold standard for stable patients. High sensitivity (> 95%) and can detect RV enlargement/strain.
  
  
  • V/Q Scan: Option for patients with contraindications to contrast (e.g., severe contrast allergies).
  
  
  • POCUS (Point-of-Care Ultrasound): Useful adjunct for unstable patients.
    
    
    
    • Bedside Echo: Can show signs of RV strain (enlarged RV, McConnell sign).
    
    
    • Lower Extremity Ultrasound: Can identify a DVT in proximal leg veins.
    
    
    
    
  
  
  
  

Treatment & Management

• Resuscitation (Reviving the RV):
  
  
  
  • Oxygenation: Give supplementally as needed (nasal cannula, non-rebreather, high flow).
  
  
  • Intubation: Avoid if possible; positive pressure ventilation can worsen RV dysfunction.
  
  
  • Fluids: Be judicious; even the smallest amount can worsen RV overload.
  
  
  • Vasopressors: Norepinephrine is preferred as first-line for hypotension/shock.
  
  
  
  


• Anticoagulation (Start Immediately):
  
  
  
  • Initial choice is UFH or LMWH (Lovenox).
  
  
  • Lovenox is preferred for quicker time to therapeutic range, but is contraindicated in renal dysfunction, older age, or need for emergent procedures.
  
  
  • DOACs can be considered for stable, low-risk patients as an outpatient.
  
  
  
  

Escalation for High-Risk PE

• Systemic Thrombolytics: Consider for very sick patients with shock/cardiac arrest (e.g., Alteplase 100 mg over two hours or a bolus in cardiac arrest). High risk of intracranial hemorrhage; weigh risks versus benefits.


• PERT Activation: Engage multidisciplinary teams (usually including ICU, CT surgery, and interventional radiology).


• Interventions: Consult specialists for catheter-directed thrombolysis or suction embolectomy. Surgical embolectomy can also be considered.


• Bridge to Care: Activate the ECMO team early for unstable patients to buy valuable time.

Prognosis & Disposition

• Mortality: Low risk < 1%; intermediate 3-15%; high risk 25-65%.


• Complications: 3-4% of patients develop Chronic Thromboembolic Pulmonary Hypertension (CTEPH). Others may have long-term RV dysfunction and chronic shortness of breath.


• Recurrence: ∼ 30% chance in the next few weeks to months, if not treated correctly.


• Disposition:
  
  
  
  • ICU: All high-risk and some intermediate-high risk patients.
  
  
  • Regular Floor: Intermediate-low risk patients.
  
  
  • Outpatient Discharge: Low-risk patients can be sent home on anticoagulation. Use PSI or HESTIA scores to risk stratify suitability, typically starting a DOAC.
  
  
  
  


• Shared Decision-Making: Critical to ensure care is safe and consistent with the patient’s wishes.

Show Notes

Show Notes