FIGURE 14.1 Approach to the diagnosis and management of apnea Has a Significant Apneic Episode Occurred? The key to answering the two questions is invariably in the history ( Table 14.5 ) A clear initial history from a firsthand caregiver without the predictable influence of repeated questions is vital This may not be a simple task, considering the caregiver’s recent stressful experience The following details should be included: (i) where the event took place; (ii) how long the event lasted; (iii) whether the infant was awake or asleep; (iv) whether there was an associated color change and, if so, to what colors and in what order; (v) description of associated movements, posture, or changes in tone; (vi) what resuscitative efforts were made and the infant’s response to them; (vii) when the infant was last fed; (viii) how quickly the infant returned to baseline behavior The responses to these questions may provide the physician with clues to the diagnosis As an example, an 8month-old infant who was interrupted in a favorite activity, began to cry, turned red and blue, and finally had several seconds of tonic–clonic motor activity likely had a breath-holding spell In contrast, a history of 40 minutes of cyanosis and apnea in a now well-appearing child may be unreliable Other recent events that should be documented include symptoms of other illnesses, such as changes in behavior, activity, and appetite, as well as recent trauma and immunizations TABLE 14.4 COMMON LIFE-THREATENING CONDITIONS THAT CAUSE APNEA Pneumonia Sepsis/meningitis Hypoglycemia Seizures Intracranial hypertension Shock Ingestion (e.g., analgesics, sedatives, muscle relaxants) TABLE 14.5 HISTORICAL FEATURES OF APNEA History Significant apnea Duration of event Greater than 20 sec or of any duration associated with pallor, cyanosis, and/or bradycardia Either, but apnea during sleep is more worrisome Pallor or cyanosis Seizure activity Hypotonia, hypertonia “He/she looked dead” Color change or hypotonia requiring cardiopulmonary resuscitation to improve If shortly after feeding, consider gastroesophageal reflux Association with sleep, trauma Was child asleep or awake? Color change Associated movements, posture, or change in tone Resuscitative efforts and response Interval since last feeding Where event occurred In many cases, the description of the event may be concerning, although the child appears well In this situation, hospitalization for further workup, as outlined next, is warranted A typical case might be the previously well 5-weekold child who was noted by the parents to be apneic during a nap The infant was described as limp and blue and “looked like he was dead.” There was no response to tactile or verbal stimulation for to 10 seconds, but after 15 to 20 seconds of mouth-to-mouth breathing, the child coughed, gagged, and began to breathe His color improved over the next 30 seconds, and the parents rushed him to the emergency department (ED) Although the baby now looks entirely normal, he may be at grave risk for experiencing another episode of apnea The medical history also may provide important information regarding infants at risk for significant or recurrent apnea The physician should ask specifically about previous similar episodes Information about prenatal and perinatal events, including gestational age, birth weight, labor and delivery issues, maternal health and medication exposures, and nursery course, is helpful A family history with specific reference to seizures, infant deaths, and serious illnesses in young family members also should be included Information regarding medications, including those available over the counter, and poisons available in the household may be important in treating an older child Finally, obtaining a detailed social history may provide information that is pertinent to the care of the child Is There an Underlying Cause? A careful physical examination identifies many treatable acute illnesses that can cause apnea One clue to serious systemic disease is abnormal body temperature, including fever or hypothermia Tachypnea may suggest either a respiratory or a metabolic problem Signs of shock should prompt consideration of potential underlying etiology, including sepsis or hypovolemia from occult trauma Evaluation of the nervous system should include notation of mental status, palpation of the fontanelles, and funduscopic examination Dysmorphic features might suggest an underlying congenital abnormality Bruising may be indicative of nonaccidental trauma However, an entirely normal physical examination provides no reassurance that the described event was clinically insignificant and will not recur For the child with a diagnosis of BRUE and considered to be lower risk ( Table 14.2 ), it is recommended that minimal testing be done Engaging caregivers and utilizing a family-centered approach can help guide management, disposition, and follow-up Resources such as cardiopulmonary resuscitation (CPR) training classes can be provided Further testing should be guided by the history and physical examination A 12-lead EKG looking for dysrhythmias may be ordered Laboratory testing is not routinely performed, but may be indicated for specific clinical concerns Pertussis testing might be considered when there is an appropriate history or possible exposure For other potential diagnoses, tests to consider in the ED include a measurement of blood glucose and serum electrolytes Any indication that the infant could have a serious infection should be pursued with cultures of blood, urine, and cerebrospinal fluid Urine and blood for toxicologic analysis should be obtained from patients who may have been exposed to toxic substances or medications Noninvasive pulse oximetry is adequate to identify hypoxemia, and significant metabolic acidosis will be identified through analysis of serum electrolytes The arterial or venous blood gas examination does not serve as a screening test for a serious event and should only be obtained on the basis of specific indications Radiologic studies (such as of the lateral neck, chest, abdomen, or neuroimaging) should be performed as indicated by the history and physical examination The tasks of the emergency physician faced with a young patient who has had an apneic episode are to identify whether he or she should be hospitalized and to treat underlying conditions If a careful history and physical examination suggest ... began to breathe His color improved over the next 30 seconds, and the parents rushed him to the emergency department (ED) Although the baby now looks entirely normal, he may be at grave risk for... neuroimaging) should be performed as indicated by the history and physical examination The tasks of the emergency physician faced with a young patient who has had an apneic episode are to identify whether