www.emtldr.com

TL;DR - Simple BRUEs can be discharged with safety netting. Complex BRUEs are admitted for observation and may require bloods

JMS Edu Spiel:
“Brief resolved unexplained episode. Baby went unresponsive for no reason. Then back to normal quickly.”
“We will need to make sure bub is ok, and I will be doing some rather specific investigations. Blood pressure, oxygen levels, heart rate, ECG and blood sugar for a start. I will also be examining bub for some specific things. If everything checks out, then we could safely say there is very low risk of anything sinister happening.”
“These episodes are usually caused by a heightened airway reflex when feeding or having upper airway secretions.”
“Document the event in as much detail as possible.”

Step 1: Is it actually a BRUE?
baby is < 12 months old.
sudden onset. Quick return to baseline.
Had one of the following:
– cyanosis/pallor
– absent, decreased, or irregular breathing.
– change in tone (hypertonia or hypotonia)
– altered level of responsiveness

Step 2: Are there any high risk criteria?
age < 60 days
not premature: born >32/40, with corrected gestational age > 45 weeks
no CPR by trained professional
first event (ie. Not recurrent)
event lasted > 1 minute
neonatal death in the family or first degree relative? SIDS? Including late miscarraiges or stillbirths?
unexpected death under 40yo.

Step 3: Check it is not explainable by any medical conditions
Airway:
– No noisy breathing, congenital issues (laryngomalacia), suspicion of inhaled FB

Breathing:
– Saturating well on room air
– No grunting, rib retractions, wheeze, tachypnoea, nasal flaring.

Circulation:
– Normal ECG, with normal QT, no sx brugadas or WPW.
– Normal blood pressure.

Infection
– No tense fontanelle. Normal limb movements. Equal pupils. Moving neck freely.
– Chest clear
– No rash.
– ENT exam unremarkable (throat / ears)

Metabolic/Endocrine
– BSL normal
– Hypokalaemia/Hypocalcaemia: No U waves on ECG. No tetany or hyperreflexia.

No NAI:
– Social history
– TEN4FACES – Torso, Ear, Neck <4yo. Frenulum. Angle of jaw. Cheek. Eyelid. Sclera at any age.

No growth issues / Failure to thrive: Meeting targets on growth chart.

If any flags are positive, discuss with paeds if an indication and further investigation (bloods / cultures / imaging) are required. Otherwise, proceed with discharge checklist below

Check in with mother / Post Natal Depression Screen: Laugh? Enjoyment? Self blame? Anxious? Scared? Unhappy? Miserable?
Printed Letter to GP for review in 1-2 days. (Is this the start of pertussis or other illness?)
AAFP Handout provided.