Rosen & Barkin's 5-Minute Emergency Medicine Consult (66 page)

DIAGNOSIS

Apnea may be current, historical, or impending.

• Duration of apnea
  
• State:
  
  • Asleep, awake, crying
    
  • Relationship to feeds and position (supine, prone)
    
• Respiratory effort:
  
  • None, shallow breathing, increased work of breathing, struggling to breathe, choking
    
• Presence and location of any color change
  
• Position of eyes
  
• Description of movements and muscle tone
  
• Interventions done by the caregiver
  
• Antecedent symptoms such as fever or cough
  
• Antecedent trauma
  
• Past medical history, including prematurity, cardiopulmonary, GI, or neurologic conditions
  
• Any past history of ALTEs in this patient or family members
  

• Vital signs with temperature
  
• Growth parameters:
  
  • Weight pattern
    
  • OFC (head circumference) pattern
    
• Pulse oximetry
  
• Exam of airway and lungs:
  
  • Assess impending apnea
    
  • Stridor or other evidence of upper airway obstruction
    
  • Fast or slow respirations
    
  • Use of accessory muscles
    
  • Adventitial lung sounds
    
• Exam of heart:
  
  • Irregular rhythm
    
  • Murmur
    
  • Evidence of CHF
    
• Neurologic exam:
  
  • Assess mental status
    
  • Assess for trauma, seizure, or toxidrome
    
  • Muscle tone and reflexes
    
  • Funduscopic exam
    

• Complete history and physical exam
  
• The historical factors and exam will direct the diagnostic evaluation and treatment
  
• Check/clear out upper airway as appropriate.
  
• Remove or suction any obstruction as appropriate
  
• Ensure proper head positioning with special consideration for occult trauma
  

Perform as appropriate for presentation:

• Dextrostix
  
• CBC
  
• Urinalysis
  
• CSF studies
  
• Blood, urine, and CSF cultures
  
• Electrolytes (including calcium)
  
• BUN, creatinine
  
• Blood gas
  
• RSV and respiratory viral studies
  
• Pertussis and chlamydia tests
  
• Consider toxicologic screen (including toxic alcohols and acetaminophen)
  
• Consider LFTs and ammonia
  

Perform as appropriate for presentation:

• CXR
  
• Head CT or MRI
  
• ECG
  
• UGI or swallowing study
  
• Polysomnography in follow-up in patient with suspected central or obstructive sleep apnea
  
• EEG in follow-up
  
• 0 Bone survey and other studies as indicated
  

• Multiple etiologies as previously noted
  
• Special considerations:
  
  • Breath-holding spells:
    
    • Reflexive cessation of respiratory effort during expiration
      
    • Cyanotic and pallid types
      
    • Paroxysmal event occurring in 0.1–5% of healthy children 6 mo–6 yr of age
      
  • Periodic breathing may be seen in neonates:
    
    • 3 or more respiratory pauses lasting >3 sec with <20 sec of respiration between pauses
      
    • May be normal event
      

TREATMENT

• Respiratory support as indicated
  
  • High-flow oxygen if breathing resumes
    
  • Check/clear out upper airway
    
  • Bag-mask ventilation
    
  • Endotracheal intubation if continued apnea
    
• IV access, cardiac monitoring
  
• Look for signs of an underlying cause:
  
  • Medications
    
  • Document a basic neurologic exam:
    
    • GCS
      
    • Pupils
      
    • Extremity movements
      
  • Gross signs of trauma
    
  • Talk with family/pre-hospital personnel for information
    

• Establish unresponsiveness
  
• Check/clear out upper airway
  
• Remove or suction any obstruction
  
• Ensure proper head positioning
  

• If currently apneic, ventilate with the bag-valve-mask device and high-flow oxygen
  
• Endotracheal intubation is required if apnea persists
  
• Resuscitation medications and antibiotics as indicated
  
• Support and counseling if breath holding suspected
  

• Antibiotic doses in ED
  
  • Ceftriaxone: 50 mg/kg IV
    
  • Vancomycin: 15 mg/kg IV
    
  • Neonates:
    
    • Ampicillin: 50 mg/kg IV
      
    • Gentamicin: 2.5 mg/kg IV
      
• Dextrose: 2–4 mL/kg D
  ₂₅
  W IV or 5-10 mL/kg D
  ₁₀
  W IV
  
  • Neonates: 1 mo 2–4 mL/kg D
    ₁₀
    W IV
    
• Naloxone: 0.01–0.1 mg/kg IV/IM/SC/ET
  
  • Caution: May precipitate withdrawal symptoms in patients with chronic opiate use
    

FOLLOW-UP

• Patients who were or may become apneic should be admitted to an inpatient unit for appropriate monitoring. Those with persistent abnormal vital signs need intensive care monitoring.
  
• Variables that identify most children requiring admission include those with an obvious need for admission including abnormal vital signs or a medical history, or >1 apparent ALTE event in 24 hr.
  
• Recommend referral for pediatric evaluation and follow-up as indicated. Interventions may include further studies (i.e., EEG), antireflux medications or caffeine, and home monitoring.
  

In patients without true apnea who are low risk and have no abnormalities noted during the period of observation and evaluation, discharge may be considered, assuming that parents are compliant and comfortable with their child and follow-up and support are definitively established.

Primary care physician and subspecialist, reflecting suspected etiology

• Consider occult sepsis, especially in a neonate
  
• Consider occult trauma
  

• Brand AD, Altman RL, Purtill K, et al. Yield of diagnostic testing in infants who have had an apparent life-threatening event.
  Pediatrics.
  2005;115:885–893.
  
• Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted?
  Pediatric
  s. 2007;119(4):679–683.
  
• De Piero A, Teach SJ, Chamberlain JM. ED evaluation of infants after an apparent life-threatening event.
  Am J Emerg Med
  . 2004;22(2):83–86.
  
• Kahn A; European Society for the Study and Prevention of Infant Death. Recommended clinical evaluation of infants with an apparent life-threatening event. Consensus document of the European Society for the Study and Prevention of Infant Death, 2003.
  Eur J Pediatr
  . 2004;163(2):108–115.
  
• Kaji AH, Claudius I, Santillanes G, et al. Apparent life-threatening event: Multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital.
  Ann Emerg Med.
  2013;61:379–387.
  
• McGovern MC, Smith MB. Causes of apparent life threatening events in infants: A systematic review.
  Arch Dis Child
  . 2004;89(11):1043–1048.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Sudden Infant Death Syndrome
  
• Neonatal Sepsis
  

CODES

• 327.23 Obstructive sleep apnea (adult)(pediatric)
  
• 770.81 Primary apnea of newborn
  
• 786.03 Apnea