Case of the Quarter: BRUE in an 8-week old Infant

This quarter the Montgomery County Hospital District EMS (MCHD) brings you a case that can be very anxiety-provoking for EMS providers. A potential pediatric cardiac arrest that, much to our relief, is awake and normal appearing on our arrival. Now that the initial adrenalin rush settles, EMS is responsible for assessing the potential serial killers provoking this patient’s initial presentation.

Brief resolved unexplained event (BRUE) is a descriptive term used for these types of presentations in infants less than one-year-old who are at high risk for serious underlying conditions that provoked the event.

Staffed by ~250 paramedics and supported by twelve regional first responder organizations, Montgomery County Hospital District (MCHD) EMS is a publicly funded 9-1-1 provider for Montgomery County, Texas, covering 1,100 square miles just north of Houston. MCHD answers 80,000+ calls per year. This article will follow one of the MCHD crews responding to a call for a potential pediatric cardiac arrest and how they sorted through the differential diagnosis for BRUE.

The Call

8-week-old male, unresponsive and gray in color. No further information.

En route, the crew prepares for a potential critical/cardiac arrest pediatric patient. Differentials, along with treatment options for each, are discussed by the crew.

Additionally, Handtevy ^TM (our clinical support app) is utilized for preparation and to allow for cognitive offloading during care. The medic unit also requests fire department assets and a district chief to be dispatched due to call note details suggesting significant potential for a critical patient.

Differential Diagnosis

Cardiac arrest, respiratory illness/compromise, seizure, toxins, trauma, infection, endocrine (hypoglycemia), congenital cardiac abnormality.

Arrives on Scene

As the medic unit pulls up to the house, it is noted that the patient’s grandmother is carrying the patient out toward the ambulance, accompanied by first responders. Initial clinical impressions are favorable, with the crew noting that our patient is awake and tracking the caregivers.

Additional History

The caregiver stated the patient was lying on the floor playing with a toy when he went limp and unresponsive. She then noted that the patient’s skin began to turn ashen gray. During this period of unresponsiveness, there was no report of seizure activity, and the caregiver denied any previous trauma or potential exposure to medicines/toxins.

Patient medical history was an unremarkable full-term infant without preceding illness and no previous episodes like this.

Exam

Vital signs: Pulse 140, RR 40, CR<2sec, Sat 100% RA.

General appearance: Mildly distressed crying

HEENT: No head trauma noted, fontanelles are soft and flat, pupils equal and reactive

Chest: Clear to auscultation, no retractions or increased work of breathing noted

CV: Heart exam regular without murmur

Abdomen: Soft non-tender

GU: Normal appearing male GU exam with wet diaper noted

Skin: Warm and dry

Neurologic: Awake, tracking appropriately and moving all extremities

Vitals, EKG, BGL, and temperature are all obtained and noted to be within normal limits.

Overall, the patient looks healthy and has a normal clinical exam post BRUE event. After the initial assessment, the caregiver consoled the patient, who settled immediately.

EMS Approach to BRUE Patient

These are unexplained events, as in our case, the crew considered a broad differential of the potential serial killers for BRUE and assessed for each with a focused history and physical examination. This event resolves, and the child returns to normal baseline.

A BRUE has no clear answer as to why the event occurred and cannot be attributed to other secondary diagnoses such as seizures, toxic ingestion, trauma, infection, endocrine issue, etc. These are very high-risk patients, and we should do everything we can to transport them to the appropriate facility.

Clinical Features and Pediatric Pearls

Watch for these telltale signs.

• Child < 1-year-old
• Event lasting <1 minute
• Has one or more of the following:
  • Central cyanosis or pallor
  • Absent decreased or irregular breathing
  • Change in tone
  • Alterations in consciousness
  • Resolves and the child returns to baseline

Here are some best-practice approaches:

• Undress patients. If you can’t see, you can’t diagnose.
• Resuscitate in place for pediatric medical cardiac arrest; clinical outcome data fully supports working critical pediatric cases in place rather than a scoop and run strategy.
• Critical pediatric cases are stressful and rare for every clinician. Use your available resources to cognitively unload these tasks from your providers.
• Don’t forget the basics (pediatric assessment triangle, high-quality CPR, early airway assessment, and circulatory support).

Clinical Course and Outcome

This child was transported without incident to a local pediatric facility for evaluation and had an uneventful course. In this case, the teaching points are not focused on resuscitation skills or outcomes but on clinical assessment and risk management.

This case had a benign clinical outcome, yet 5% of these patients will have a significant underlying pathology as the cause for their event. Therefore, any BRUE refusal of transport represents a high-risk refusal.

SIDEBAR

Take-home Points

• Prepare prior to arrival
• Undress all these patients to allow yourself the best physical assessment possible
• Remember your pediatric pearls and age-appropriate vital signs
• Utilize your resources and allow for cognitive offloading when applicable
• Do everything you can to transport these patients, even if the caregiver initially wants to refuse

SIDEBAR 2

Pediatric Assessment Triangle: A Diagnostic Foundation

Appearance: Tone, interactiveness, consolability, look/gaze, speech

Work of breathing: Work of breathing, positioning, retractions, nasal flaring, apnea/gasping

Circulation: Pallor, mottling, cyanosis

ABOUT THE AUTHORS

Clayton Smith, LP, is captain and field training officer for Montgomery County Hospital District EMS.

Robert Dickson, MD, is EMS medical director at Montgomery County Hospital District EMS and faculty at HCA Houston Healthcare in Kingwood, Texas.

James Seek, LP, is division chief of Montgomery County Hospital District EMS’s clinical department.

Casey Patrick, MD, is medical director for Harris County ESD 11 Mobile Healthcare and assistant medical director for the Montgomery County Hospital District EMS.