He just turned blue OSCE by Michael

 
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

Susan / David Dower has come to your ED with their 3-month-old son Jake. They report an episode where he appeared to stop breathing and turned blue. He has now returned to normal and his examination and observations are normal.

Instructions for the candidate

You are the consultant on. You are to take a history and describe ongoing management.

Domains being examined

  • Medical Expertise
  • Communication
  • Health Advocacy
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

You are the parent of Jake, who is your first and only child. You had just finished feeding Jake and put him into bed. You were still in the room putting away clothes when you heard him cough, and then he appeared to stop breathing and turned a blue-ish colour. You picked him up and rushed to phone the ambulance. He was floppy and not responsive. In a short while (maybe less than a minute - you were still on the phone with the ambulance), he started breathing again and returned to normal colour. Since then he has returned to normal.

He has been well recently. He had his immunisations 2 weeks earlier. He was born at 39 weeks via NVD with no ante- or post-partum complications. He did not require nursery or special attention at birth. You were discharged on day 2. He has had no significant illnesses prior. He is formula-fed having 6-7 60-80mL bottles per day. He is having normal wet nappies and bowel movements. He is thriving and reaching his developmental milestones. He is immunised to date. There is no significant family history.

You are obviously quite concerned:
- 'What happened? Why did this happen?'
- 'Will this happen again?'
- 'How do I prevent this happening?'
- 'What do I do if it happens again?'
- 'Ís this because of his immunisations?'
- 'Ís this a sign of something dangerous?'

If the candidate suggests you go home, you become quite upset and worried it will happen again. You are content with admission for a period of observation.

For the examiner

None.

Domains Assessment Objectives

Medical Expertise
Assessment, risk and management of Apparent Life-Thretening Events (ALTEs)

Communication
Clear and relevant discussion

Health Advocacy
Infant wellbeing and prevention of SIDS

Other Assessment Notes

1. History *Event - circumstances, location, how noted - activity, breathing, colour, movement/tone, cough/vomit, duration *Interventions - none, gentle vs vigorous stimulation, blowing on face - mouth-to-mouth, CPR by professional *Recent illness - recent fever, weight loss, rash, irritability, sick contacts *PHx - antenatal, birth - feeding - development - prior admissions, accidents *FHx - congenital, arrhythmias, SIDS - smoking exposure in home High risk if: - <28/7 - significant prematurity - significant PHx - clinically unwell - recurrent events - severe/prolonged episode Consider NAI if: - age >6/12 - previous apnoea, cyanosis, ALTE in care of same person - previous unexplained or unexpected death of child, simultaneous twin death in family or in care of same person - blood in infant's nose/mouth with ALTE 2. Management - detailed physical exam - consider CBE, EUC, BSL, NPA for viruses/pertussis, ECG for QT - admission for observation Bonus - offer to discuss with partner


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Comments:

Hey team, better to use the term "brief reversible unexplained event" rather than ALTE if it meet the strict criteria 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 - Central or obstructive or mixed apnea - Not periodic breathing or breath holding spell. - 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. Re ongoing management for the exam (my approach) - after thorough history and examination meets above criteria for "low risk" - do BSL (especially if difficult feeding etc) - observe ~4 hours (ideally in short stay) -> keeps sats on, at least 3 sets of eyes (e.g. 2 nurses and 1 doc or 2 docs and 1 nurse) - at least one feed, - consider a sleep-wake cycle (especially if presents after 6pm) - i.e. admit overnight - consider ECG - DONT routinely do bloods, CXR, NPA, pertussis - but use clinical acumen based on a detailed history and exam. Any thoughts? Flow diagram: http://foamcast.org/tag/brue/ AAP reference: http://pediatrics.aappublications.org/content/137/5/e20160590 RCH (old ALTE guidelines) - http://www.rch.org.au/clinicalguide/guideline_index/Apparent_Life_Threatening_Event_ALTE/

Luke Jeremijenko at 15:11 12 Mar 2017