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ALTEs and BRUEs

Ilene Claudius, MD and Rob Orman, MD
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14:05
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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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08:35

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EM:RAP 2016 October Written Summary 754 KB - PDF

ALTE is out and BRUE is in! A low risk child who has had a brief resolved unexplained event may be a candidate for discharge home after a focused ED evaluation.

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Tanner B. -

The idea that we can send a recently cyanotic infant home is ludicrous. Practically speaking, I see it being nearly impossible to properly screen out a low risk patient in a busy practice and then convince anxious parents that their formerly blue baby is not going to up and die. Furthermore, even if we are following guidelines and there is nothing that could have been done to prevent a bad outcome, this sounds like a recipe for getting an emotionally-charged sympathetic jury settlement against you in the setting out a bad outcome.

ilene c. -

I certainly don't think that any of us should be sending home infants that we are genuinely worried about, and apologize if I made anyone feel that they need to go against their gut. But creating and utilizing low-risk criteria to define a group that can be safely discharged most of the time is the same thing we do with chest pain, head trauma, neck trauma, pediatric fever and a host of other conditions. I'm not sure why we would not do the same H&P and risk stratification on an ALTE patient as we would on everyone else in a busy ED. I hope most of us are not scanning or admitting every single minor head injury. I hope we're not admitting every person with chest pain for fear of litigation. ALTE is no different, and no more time-intensive. In fact, typically, I do a quick H&P, park them on a monitor for an hour, and the family is sufficiently reassured that they ask to go home. The research is there that the well-appearing kids with no other reason for concern really don't have an increased risk of a bad outcome. And now there are guidelines to support you and serve as a guide if you want to send them home. To your specific point, if a reasonable parent tells me their kid was deeply cyanotic for 5 minutes, of course I'm not sending them home, nor is that what the guidelines say. But for the majority of ALTE patients who "might have stopped breathing for a few seconds" and "might have been a bit pale or blue and possibly felt a bit floppy but might have been sleepy"- this is a great opportunity to feel supported if you you choose not to do an extensive work-up or admit.

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Say Hello to BRUE Full episode audio for MD edition 217:39 min - 303 MB - M4AEM:RAP 2016 October German Edition Deutsche 115:41 min - 159 MB - MP3EM:RAP 2016 October Canadian Edition Canadian 10:10 min - 14 MB - MP3EMRAP 2016 October Résumé en Francais Français 35:33 min - 49 MB - MP3EM:RAP 2016 October Aussie Edition Australian 31:48 min - 44 MB - MP3EM:RAP 2016 October Spanish Edition Español 94:36 min - 130 MB - MP3EM:RAP 2016 October Board Review Answers 187 KB - PDFEM:RAP 2016 October Board Review Questions 292 KB - PDFEM:RAP 2016 October MP3s 257 MB - ZIPEM:RAP 2016 October Written Summary 754 KB - PDF

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