CLIPP case 25. 2 month-old with ALTE

Question 1

2 month-old boy presents to ED after mom found him to be not breathing or moving with cyanosis. He is now pink and breathing without distress. While in the ED, he has a minute-long tonic-clonic seizure. Afterward, his exam shows hypothermia, tachycardia, bradypnea, hypertension, and abnormal neurological exam (poor suck, tense full fontanelle, intermittent crying, decreased tone, and inability to fix and follow visually).

Answer 1

• Closed head injury
• CT: subdural hematoma
• Ophtho: bilateral retinal hemorrhages
• *Shaken baby syndrome**
• DDx: Meningitis, encephalitis, GERD, cardiac arrhythmia, respiratory infection

Question 2

Shaken baby syndrome

Answer 2

Extreme rotational acceleration force to brain causes bridging vessels to tear, and diffuse axonal injury.
*Symptoms: Constant crying, stiffness, excessive sleeping, difficulty to arouse, decreased appetite, Seizures, Dilated pupils, Retinal hemorrhages (outside the newborn period are pathognomonic for shaken baby syndrome and found in 65–90% of victims; but lack of does NOT rule out)
*Outcomes: Risk of intellectual disability, developmental delays, motor delay or deficit, vision problems (including blindness), and
seizures

Question 3

Infant apnea

Answer 3

Cessation of inspiratory gas flow for 20 seconds, or shorter if accompanied by bradycardia (< 100), cyanosis, or pallor

Question 4

Apparent life-threatening event (ALTE)

Answer 4

*Not a diagnosis, but a description of
an event by caregiver: apnea, color change, change in tone, maybe choking or gagging; maybe impression infant has died. Recovery occurs only after stimulation or resuscitation.
*Causes:
-CNS (seizure, breath-holding spell in 6mo-6yo, increased ICP)
-Cardiac (arrhythmia, Tetralogy, ductal-dependent CHD)
-Pulm infection (RSV, pertussis)
-GI (GERD, TEF)
-Systemic (sepsis, IEM, intoxication, botulism, CO)

Question 5

Physical exam in ALTE

Answer 5

• Tachycardia: Deterioration in cardiovascular status and may be related to sepsis or increased intracranial pressure (ICP)
• Respiratory rate: Bradypnea suggests CNS depression rather than sepsis or a respiratory infection, which generally present with tachypnea
• HTN: Response to pain, compensated shock, or increased ICP

Question 6

Normal neurological exam in 2 month-old

Answer 6

• Can fix and follow easily with his eyes
• Smiles to voices
• Beginning to coo
• Strong suck
• Lies flexed at hips with good tone and moves all four extremities
• When prone, can raise head and move it from side to side
• Lacks good head control when held upright and cannot roll over

Question 7

Closed head injury

Answer 7

• Apnea, seizure, and altered neurological status
• Subdural hematomas result from trauma, either accidental or non-accidental. Infants who have experienced violent shaking. Newborn with vacuum extraction deliveries.
• NOT seen from cardiopulmonary resuscitation or seizures and do NOT occur from short falls (<4 ft).

Question 8

Meningitis

Answer 8

• Increased ICP and maybe apnea.

* Irritable, do not eat well, vomit, and fever >38.2, inconsolable and lethargic

Question 9

GERD

Answer 9

• May cause emesis, gagging, and aspiration pneumonia. Seldom presents as apnea without associated symptoms. Maybe irritable
• Normal vital signs
• Normal neurological findings

Question 10

Cardiac arrhythmia

Answer 10

• May cause apnea

* Would NOT lead to persistent alteration of mental status

Question 11

Respiratory infection

Answer 11

• Maybe apnea; other symptoms tachypnea, fever, decreased feeding, and change in activity
• Infants may not cough or wheeze initially

Question 12

Studies in suspected closed head injury

Answer 12

• Coagulation studies to r/o bleeding disorde
• Skeletal survey: Old or new fractures. Fractures or injuries inconsistent with reported mechanism or the developmental abilities of the child. Multiple fractures or injuries at different stages of healing. Fracture of femur or tibia in non-walking child. Posterior rib fractures (shaken baby due to squeezing of the thorax). Skull fracture in an infantis also very suspicious for abuse.
• CT: To confirm subdural hematomas. Repeat if clinical deterioration. Maybe MRI for confirmation when stable.

Question 13

Initial emergency management of head trauma in order

Answer 13

1. CAB -> resuscitation
2. Vitals
3. IV access, rapid response team
4. Head CT
5. Admit to critical care unit
6. Consult neurosurgery/neurology