Brief Resolved Unexplained EventsWe have previously explored some issues with one of my “favorite” topics: Apparent Life Threatening Events (See ALTE and Never Trust a Neonate).  Recently, it has been recommended that the term “Apparent Life Threatening Event / ALTE” be removed from our medical lexicons.  Since we like to always stay in style and remain “hip and with it” (said in the voice of Dr. Evil), let’s review what the cool kids will be referring to in the future: Brief Resolved Unexplained Event / BRUE.


BRUE: What’s in a name?

  • We have known that the definition of an ALTE is imprecise at best.
    • This leads to challenges in studying the entity as a whole.
    • This also leads to many challenges with its evaluation and management.
    • “Life Threatening” also seems to generate confusion when the family is then told “everything is ok.”
  • Brief Resolved Unexplained Events” is the term now recommended to be used.
    • It aims to be more precise (at least it has age limits).
    • It highlights the reassuring qualities of the “typical” episode: Brief and Resolved.
    • The clinical practice guideline also defines “Lower Risk” patients.


BRUE: What is it?

  • BRUE describes an event that:
    • Occurs in a child younger than 1 year of age,
    • Lasts less than 1 minute (typically 20-30 seconds),
    • Has one or more of the following:
      • Central Cyanosis or Pallor 
        • Discoloration of face, gums and/or trunk.
        • Not acrocyanosis or only peri-oral cyanosis
        • Not rubor / redness
      • Absent, Decreased, or Irregular breathing
      • Marked change in tone (hypertonia or hypotonia)
      • Altered level of responsiveness
    • Resolves and patient returns to baseline, and
    • Has a reassuring history, physical exam, and vital signs during ED evaluation.
  • BRUE is used only when another condition cannot be discerned as the etiology of the event.
    • BRUE is still a constellation of symptoms that, in the end, may be attributed to a more specific diagnosis, but if you can be more specific at the outset, then do not label as BRUE.
      • For example, if a child has bronchiolitis and had an apneic event, that is not a BRUE… it is apnea associated with bronchiolitis.
      • Additionally, if the child a choking event, this is not a BRUE either. Maybe it is a T-E fistula…
    • A good goal is to attempt to use the H+P to determine a more precise Ddx rather than BRUE.


BRUE: Low Risk?

  • There are characteristics of patients at Lower Risk for having a serious underlying condition.
  • Lower Risk criteria:
    • Older than 60 days
    • Gestational Age 32 weeks or greater and a Postconceptional Age of 45 weeks or greater.
    • First BRUE (no previous BRUE ever and not occurring in clusters)
    • Not requiring CPR by a trained medical provider
    • NO concerning historic features 
      • See Guideline’s Table 2 for long list of features to consider [Tieder, 2016]
      • Some features not to overlook:
        • History concerning for potential Abuse.
        • Family history of sudden death in first degree relatives.
        • Social and Environmental issues
          • House mold problems (yes… mold is listed as a concerning feature)
          • Previous Child Protective Services or Law Enforcement involvement
          • Current level of concern/anxiety of family
    • NO concerning physical examination findings
      • Obviously, these children need a thorough physical exam… use your super sleuth skills.
      • Don’t overlook skin and genital exam.
  • If the patient does not meet Lower Risk criteria, then she/he is High Risk by default!


BRUE: What to do?

  • This is similar to what we would have done for ALTE.
  • There is a nice diagram in the Guideline’s… [Tieder, 2016]
  • But I’m simple so…
  • Medical Stabilization! 
    • Don’t forget, little neonates can be tricky and deceptive. Check capillary refill!
    • Check a glucose early! (I say this mostly so I don’t forget!)
  • History and Physical
    • The foundation upon which we build all medical decisions
    • Abnormal vital signs? H+P consistent with a specific diagnosis? – NOT a BRUE.
    • H+P meets BRUE criteria? No other explanation? – It’s a BRUE! (yeah)
      • Even if BRUE, consider the broad Ddx that exists
      • Try to narrow down the most likely culprits to help guide evaluation and work-up.
        • Cardiac vs Pulmonary
        • Neuro vs GI
        • Zebras vs Horses
  • Risk Stratify BRUE
    • This is simple… does the patient fit Lower Risk criteria?
      • Yes! = Lower Risk
      • No! = High Risk
    • Realize that Lower Risk does not equate to “No Risk.”
  • Disposition
    • High Risk
      • Hospitalize.
      • Base initial evaluation upon your assessment of most likely culprits on DDx.
        • Neonate doing weird things? –> LP and start antibiotics
        • “Funny” story that changes? –> Head CT and evaluate for NAT
      • We know that indiscriminate, broad work-ups are not useful.
    • Lower Risk
      • Avoid:
        • Indiscriminate labs and imaging studies – not helpful in this group either.
        • Empirically prescription of GI meds (ex, acid suppression medications) -unless you are diagnosing the episode was GER… in which case it is not a BRUE.
        • Admission solely for CardioPulmonary monitoring.
      • Do:
        • It is reasonable to obtain 12 Lead ECG.
        • Some advocate for pertussis testing.
        • Monitor the child in the ED and perform serial exams [Tieder, 2016]
          • 1-4 hours seems “reasonable” – no solid evidence
          • Establish stability of vital signs and exam.
          • May witness another event that assists in the diagnosis.
        • Educate family
          • Discuss BRUE.
          • Discuss CPR training for families.
          • Engage in shared decision making.
        • If, and only if, the stars align and the child can be discharged safely and the family is comfortable, ensure ability to be re-evaluated within the next 12-24 hours.


BRUE: What’s new?

Admittedly, this is my humble opinion (feel free to gently disagree with me… my feelings are fragile).

  • Essentially, I do not see this change in terminology as a huge alteration in my current practice.
    • I like the term BRUE as it accentuates the Brief and Resolved nature, but fear that that may also diminish provider’s vigilance.
    • “BRUE” should not equate to no concern, even though it does offer a pathway to actually discharge some.
    • Remember, being vigilant most often only requires a thorough H+P.
  • First and foremost: NEVER TRUST A NEONATE!
    • Similar to what we worried about with ALTE, BRUE in a neonate is concerning for badness!
    • Neonates are, by definition, High Risk kids in BRUE criteria.
  • Use your super sleuth skills for the history and exam – Is this a BRUE or something else that is Brewing (get it?).
  • Don’t order a million tests. Direct initial evaluation toward what your super sleuth skills have determined to be the most likely etiology of the event.
  • What’s new is the fact that there is now a guideline that supports the potential discharge of a LOWER RISK patient who has had a BRUE.
    • This does not mean all lower risk kids get to go home.
    • Part of the lower risk characteristics is the family’s perspective of the event.  It may be counterproductive to argue with a family that their CPR was not necessary and the kid is safe at home. (Yes, CPR provided by untrained personnel (ex, family) would still qualify as being Lower Risk potentially).
    • Often, the story and exam evolves… many times before your eyes… use observation in the ED in cases where you are unsure.


FOR ANOTHER PERSPECTIVE, See Dr. May’s post on St. Emlyns.



Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, Katz ES, Krilov LR, Merritt JL 2nd, Norlin C, Percelay J, Sapién RE, Shiffman RN, Smith MB; SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. 2016 May;137(5). PMID: 27244835. [PubMed] [Read by QxMD]

Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, Katz ES, Krilov LR, Merritt JL 2nd, Norlin C, Percelay J, Sapién RE, Shiffman RN, Smith MB; SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016 May;137(5). PMID: 27244836. [PubMed] [Read by QxMD]

The post BRUE appeared first on Pediatric EM Morsels.

Towards the humanized and integrative ICU. By Federico Carini

In the last Congress of Argentinean Society of Intensive Care Medicine (SATI) held in Salta, there was a gale of news.

A difference from previous years, news came not only from classical areas of intensive care such as shock, acute distress respiratory syndrome or sepsis, but we saw the appearance of humanizing intensive care on the scene and the increasingly more finished idea that today more than ever "primum non nocere" should prevail.

From the time of Ibsen, Danish anesthesiologist who in full epidemic of polio in the 50's first proposed the use of positive pressure ventilation and teamworked for the treatment of these patients (at that time, the birth of the modern ICU), critical care has come a long way.

The most of the patients survive to the ICU but, How do they do? In which state do they come back to their homes? How do they return to their lives?

And even though many of the consequences of the critical illness are inevitable, many others are the product of customs and usages coined at the time, but without any evidence.

What is the risk for a child visiting his father?. What about a grandfather to his grandson?. The lights at night in the entire unit, what is the advantage for us?. For the treatment of serious illnesses, could be sedation many times deleterious?.

We had the honor to have among our guests to Gabi Heras from Spain, fervent and motivating leader of the IC-HU Project. Also Thomas Strøm, a Danish physician who comes preaching non-sedation from long ago, and with much evidence in favor! Dr. Jukka Takala, from Finland, was also devoted to this issue, making clear that no sedation certainly isn't for everyone and always, but is key for a comprehensive approach and the use of tools and appropriate goals. Another visitor of honor was Nathan Brummel, from the team of Dr. Wesley Ely at Vanderbilt, who stressed the importance of including family in the who stressed the importance of including the family in the process of care, in addition to the fundamental work of early rehabilitation and long-term follow-up.

In the Hospital Italiano de Buenos Aires we have a family-centered care ICU and undoubtedly has meant a positive change in our way of working and relationship with patients and their loved.

As Thomas Strøm, the barriers of space and time should not be insurmountable. The key message is that any external program that will attempt to insert as is on a different system will have no real chance of success.

The multidisciplinary work, the training of leaders of opinion, the positive reinforcements and the constant evaluation of results are fundamental at the time of implementing the change.

There we go in Argentina and we join this movement clearly unstoppable.

Dr. Federico Carini
Intensive Care physician (SATI / UBA)
Care Coordinator UTIA - HIBA

FOAMed Resource Series Part II: Ultrasound

Author: Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC) // Edited by: Alex Koyfman, MD (@EMHighAK)

This is Part II of the FOAMed Resource Series. Part I evaluated the FOAMed world of the ECG, which can be found here: Today’s post will evaluate Ultrasound (US) resources. As EM has grown, so has US. This tool is now often considered an extension of the physical exam, providing key clinical data at the bedside. A great deal of resident curriculum is geared towards US use in the ED.

The following resources were chosen based on useful education pearls, validity of content, impact on clinical practice, and clear citation of references and authors. Similar to Part I in this series, this list is not all encompassing, but serves as an overview of several top education US resources. If you have found other great resources, please mention them in the comments below!


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The Ultrasound Podcast by Dr. Matt Dawson, Dr. Mike Mallin, and Dr. Mike Stone originally sought to fill a void, as at the time of this podcast introduction few US resources were available. Today, this resource has given the EM community so much more. From amazing, free podcasts with videos to a great app, this resource provides top-of-the-line ultrasound education. Also look for the free books “Intro to Bedside Ultrasound: Volume 1 and 2” at or iBooks, as well as the app One Minute Ultrasound for iPhone and Android.


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This US guide was originally published online by Dr. Beatrice Hoffmann and the ACEP Emergency US section. It serves as a comprehensive reference with still images and videos that educates those of all training levels. The explanations are second-to-none, with a variety of topics including primary EM scanning topics (FAST, aorta, cardiac, gall bladder, renal, DVT), critical care, small parts (ENT, testicular, ocular), and procedures (vascular access, pericardiocentesis, US guided nerve blocks, and many others). The videos have complete explanations, and the still images possess a roll-over function that explains specific anatomical areas of interest.


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LIFTL makes the FOAMed list again, providing a full database page with posts, critical care based ultrasound posts, clinical cases with US, and a library with over 40 videos demonstrating key US findings. This is a great reference to use while on shift or if the provider has a specific question in mind.


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Ultrasound Village is an online site containing several great features including US modules, lectures, worksheets, quizzes, and references. It also has an image library categorized by system with normal anatomy and pathology. The site provides high-quality education, produced by physicians passionate about education and medical ultrasound.


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This resource from Dr. Jacob Avila and Dr. Ben Smith provides a basic how-to video for specific US exams, though videos do not delve into subtle findings or much of the research behind the exam. A link on each video page demonstrates abnormal and normal findings. This resource also provides US reference values for many specific US exams. The creators do have a linked blog to the site ( that evaluates updates in scanning technique and new US exams, as well as the literature behind scans.


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ICU Sonography is a resource brought to you by Dr. Kishore Pichamuthu and Dr. George John, based on US use for the medical ICU. This resource contains tutorials with tremendous explanations and anatomical images, with videos. The echocardiogram and volume assessment sections are particularly thorough.


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This resource comes from the Sinai EM US division. It provides information for medical students, residents, fellows, and attendings on point-of-care US. The site has great tutorials on separate scans that are constantly being updated. One of the best features is a breakdown of the current machines on the market and how to actually use them in the ED.


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SonoSpot is truly one of the most comprehensive sites on this list. This resource contains tutorials on standard US examinations, as well as US of the appendix, airway, procedural, pelvic, and pleural examinations. Cases are provided based on anatomy and chief complaint. Best of all, each post contains links to primary literature, making this resource important for academic centers and those with desire for the evidence behind scanning.


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SonoWorld is a complete resource for learners of all levels. It contains full lectures, cases, tutorials, literature, and CME. If wanting to use this site in its full glory, registration is needed (which is free). The blog portion is updated daily with articles from around the world for US enthusiasts.


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This site from South Carolina is a great resource geared for all learners, but targeting residents, PA’s, nurses, and attending physicians. It provides full lectures, US cases, US still images, and videos on scanning. It contains an entire section of US literature, as well as pediatric centered scanning. If you’re interested in testing your knowledge, you can take three separate tests.


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Last, but not least, this blog by Dr. Ben Smith and Dr. Jacob Avila (yes, the same creators of provides posts with the mission “learn bedside ultrasound, one week at a time,” with weekly posts based on cases. Each post contains a patient case with high-quality US images, followed by an explanation and case resolution based on the most recent literature.

Thanks for reading, and comment below on other great resources. Stay tuned for our next post on Pediatric EM FOAMed!

The post FOAMed Resource Series Part II: Ultrasound appeared first on emdocs.

Apparent Life Threatening Events in Babies – Trouble BRUEing

St.Emlyn's - Meducation in Virchester #FOAMed

Whenever I start to think about teaching on a paediatric subject, I feel like I should open with a reminder that being a parent is HARD. It’s REALLY HARD. Especially for first-time parents with newborn babies, lives for whom they are...
Read more

The post Apparent Life Threatening Events in Babies – Trouble BRUEing appeared first on St.Emlyn's.

Apparent Life Threatening Events in Babies – Trouble BRUEing

St.Emlyn's - Meducation in Virchester #FOAMed

Whenever I start to think about teaching on a paediatric subject, I feel like I should open with a reminder that being a parent is HARD. It’s REALLY HARD. Especially for first-time parents with newborn babies, lives for whom they are...
Read more

The post Apparent Life Threatening Events in Babies – Trouble BRUEing appeared first on St.Emlyn's.