Month: June 2016

Brief Resolved Unexplained Events (BRUE)

3 Categories: High Risk BRUE. Low Risk BRUE. Not a BRUE.

Step 1: Is This a BRUE?

  • Brief
    • <60 seconds
  • Resolved
    • Exam and vitals back to baseline in the ED
  • Unexplained
    • No symptoms other than event itself
  • Event
    • Concerning change in any of the following…
      • Tone
      • Color
      • Breathing
      • Mental status

Step 2: Is This Low Risk BRUE?

  • Five low risk criteria
    • Age >2 months
    • Born at >32 weeks gestational age
    • First and only episode
    • No CPR by medical providers
    • No “Red Flags”

Step 3: Do They Have Red Flags?

  • For abuse
    • History of SIDS/BRUE in sibling
    • Mental illness at home
    • Drug use at home
  • For dysrhythmia
    • Family history of sudden unexplained death
  • For infection
    • Fevers
    • Unimmunized
    • Sick contacts
    • Rash

Step 4: Examine for Non-Accidental Trauma

  • Bulging fontanelle
  • Petechia
  • Torn frenulum
  • Blood

Step 5: Place Patient Into One of Three Categories

  • NOT a BRUE
    • Treat as you normally would
  • HIGH risk BRUE
    • Admit
  • LOW risk BRUE
    • Discharge without testing
    • May consider EKG and pertussis

Additional Reading

  • Brief Resolved Unexplained Events (AAP)

ATLS

Airway/C-spine. Breathing. Circulation. Disability. Exposure. Secondary Survey.

Airway and C-Spine

  • General airway principles
    • “If they can’t speak, they can’t control their airway”
    • “If GCS is <8, intubate”
      • In the real world, it’s a clinical judgement call
  • General c-spine principles
    • Clear c-spine with NEXUS/Canadian rules
    • Otherwise stabilize spine and place in cervical collar

Breathing

  • If patient has tachypnea, hypoxemia, or respiratory distress
    • Give O2
    • Examine for tension pneumothorax
      • Deviated trachea
      • Asymmetric breath sounds
        • If concerned perform needle decompression
        • THEN
        • Tube thoracostomy

Circulation

  • If patient has tachycardia, hypotension, or obvious blood loss
  • Stop the bleed
  • Emergent transfusion
  • Consider early OR if unstable
    • In the real world, CT is frequently obtained pre-op regardless of stability

Disability

  • Pupils
  • GCS
  • If concerned for head injury
    • Obtain CT head without contrast

Exposure

  • Fully undress the patient
  • Warm blankets

Secondary Survey

  • Visualize everything
  • Palpate everything
  • Bedside chest/pelvic x-ray and FAST scan

Common Labs

  • Type and screen
  • CBC
  • Electrolytes
  • Urinalysis
  • EKG
  • Blood alcohol level
  • Lactic acid (if concerned for shock)

Common Imaging

  • CT head without contrast
  • CT maxillofacial without contrast
  • CT cervical spine without contrast
  • CTA neck
  • CT abdomen/pelvis WITH contrast
  • Retrograde urethrogram
  • Additional x-rays

Common Treatments

  • Blood products
  • Tetanus immunization
  • Analgesics

Additional Reading

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