Clinical solution: Baby not breathing

You are asked to respond to a park for an infant in respiratory arrest; did you get the diagnosis right?


While parents may experience a lot of anxiety about small changes in how their newborns look and act, EMS providers should be aware that these seemingly minor changes may be significant signs of underlying medical conditions.

Apparent life threatening event

An apparent life threatening event (ALTE) is one which is concerning enough to the patient’s caregiver that they perceive that a medical emergency has occurred. ALTE is not a diagnosis so much as a collection of symptoms generally including a combination of apnea, color change, weak or limp limbs and choking or gagging.[1] The caregiver or calling party will often be concerned that the patient is dead.

The term ALTE was defined in 1986 by a workgroup of the National Institutes of Health. At the same time the panel recommended against continuing to use historical terms like "near-miss SIDS" as research did not show any link between ALTE occurrences and Sudden Infant Death Syndrome.

ALTE cases are generally seen in patients younger than one year with the majority occurring in those less than 10 weeks of age. Males are more likely to experience an ALTE than females.[2]

Since ALTE is a presentation rather than a diagnosis, these cases should be seen as a possible indicator of an underlying disease process. Prehospital providers are not well equipped to diagnose the underlying cause of ALTE and these patients should be transported for further evaluation.

Approximately 50 percent of ALTE patients are ultimately diagnosed with a condition that explains the concerning presentation. Most commonly these causes are categorized as gastrointestinal, neurologic, respiratory, cardiac or metabolic and might include seizure, infection, sepsis, arrhythmia and GERD.[2]

Prehospital findings in ALTE

Since symptoms associated with ALTE are often short-lived, patients may present normally to EMS. In cases which last longer or when EMS arrives during the event, patients may present with decreased responsiveness, flaccid or weak limbs, cyanosis, difficulty breathing or apnea and gagging or choking.

During the questioning of the parent or caregiver it is particularly important to build a timeline of the event and any behaviors or conditions leading up to it. Patients should be evaluated completely and a full set of vital signs obtained. In addition to a hands-on assessment obtain a blood glucose reading and a temperature (if these tools are available).

Given the broad range of symptom presentation during an ALTE it is possible for such an event to appear as a post-ictal period or even as an absence-type seizure. Differentiating between an ALTE and a seizure relies heavily on a thorough history and assessment of the patient. Since these patient are young and the scope of underlying medical conditions encompassed by ALTE is so broad the whole medical history is important and potentially useful. Keep in mind that a seizure itself may be the cause of the ALTE in the first place.

Prehospital treatment of ALTE

Prehospital treatment for ALTE is largely supportive and focuses on airway patency and quality of breathing. As such, positioning for best breathing, airway adjuncts or supplemental oxygen may be indicated.

Recognized life-threatening conditions like abnormal heart rhythms should be treated in a manner consistent with local protocols. Above all, encourage transport of the patient to the hospital. While an ALTE does not have a definitive link to SIDS, some causes of ALTE symptoms may be serious if left untreated. Some EMS systems have specific destination choices for ALTE patients. Refer to your local protocols or medical director for more guidance.

Treatment for the baby choking while feeding

With Kate’s mother unsure about whether or not to have her transported based on your partner’s dismissive attitude, you realize that Kate is presenting with ALTE symptoms. You confer privately with your partner and remind her about the ALTE training during your last protocol update. You partner agrees and suggests to Jennifer that her daughter should be evaluated at the emergency department to determine what caused her to choke and become blue around the lips.

During your transport to the local pediatric ED, your partner monitors Kate watching specifically for any signs of hypoxia. Kate’s pulse oximetry reading drops briefly into the 70’s accompanied by an increase in work of breathing, but rebounds quickly after application of blow-by oxygen. Your transport completes without any further issues.

References

  1. Fuchs, S., & Pante, M. D. (Eds.). (2014). Sudden Infant Death Syndrome and Death of a Child. In Pediatric Education for Prehospital Professionals (pp. 247–260). Burlington, MA: Jones & Bartlett Learning.
  2. Hall, K., & Zalman, B. (2005). Evaluation and Management of Apparent Life-Threatening Events in Children. American Family Physician71(12), 2301–2308. Retrieved from http://www.aafp.org/afp/2005/0615/p2301.html

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