Transient Cyanotic Episode

Question 1

A 3 month old presents to ED following an episode of going blue at home. The infants SP02 is 98% on arrival to ED.

Answer 1

Impression
Given the episode of ‘blue’ which likely represents cyanosis, but now normalised SP02, I am concerned of a transient cyanotic episode (or BRUE - brief resolved unexplained episode), there are a wide range of differentials to consider and exclude in this patient

DDx
- cardiac: congenital heart disease, arrhythmia, prolonged QT
- SEPSIS SEPSIS SEPSIS
- Respiratory: inhaled FB, infective (pneumonia, pertussis), laryngospasm
- Neuro: Seizure, head injury
- GIT: gastro, intussusception, etc
- NAI: shaken baby syndrome, other trauma
BRUE = diagnosis of exclusion

Goals
- thorough Hx/Ex/Ix to determine underlying aetiology
- appropriate definitive and supportive management

Question 2

Transient cyanotic episode - Assessment

Answer 2

Assessment
- conduct A to E assessment to ensure haemodynamic stability before continuing with Hx/Ex/Ix

Question 3

Transient cyanotic episode - History

Answer 3

History
- PC: description of the event (before, during, after); duration, setting, position,
Differentials;
- resp: infective sx, instant choking, preceding viral illness, WOB, sick contacts
- NAI: SCAN protocol if suspicious, additional survey for further injuries
- cardiac: cyanosis at birth, abnormalities on antenatal screening US, sweaty, syncope, SOB
- CNS: tone, jerky movements, incontinence, post-ictal

Risk factors
- Age <60
- Pre-term birth
- Episode > 1min
- Concerning features on exam
- More than one episode
- Not back to baseline
- No CPR given at hospital

Paeds history
- Development, blue book assessment (growth parameters),
- vaccinations
- pregnancy, birth, any complications

Question 4

Transient cyanotic episode - Examination

Answer 4

Examination
- general appearance + vitals
- biometrics for growth charts
- cardioresp: crackles, consolidation, murmurs
- neuro: tone, focal neuro
- GIT: focal tenderness
- systems review for trauma

Question 5

Transient cyanotic episode - Investigations

Answer 5

Investigations
- stratify into low vs high risk BRUE if nothing found on Hx/Ex
consider Ix including;
- Bedside: ECG
- Bloods: FBC, UEC, BSL, nasopharyngeal swab and PCR,
- Imaging: CXR, Echo, etc

Question 6

Transient cyanotic episode - Management

Answer 6

Management
Depends on any underlying pathology noted on assessment, or, if diagnosis of exclusion BRUE is noted, then manage according to

Low risk BRUE
- managed in community
- parent reassurance, education, and safety netting
- no association between BRUE and SIDS

High risk BRUE
- admission for further monitoring and observation, ?role for telemetry and ongoing vitals monitoring, further investigation
- involvement of senior paediatrics for management and assessment

Other supportive
- CPR training for families
- regular follow-up with GP and regular review