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How High-Risk is a High-Risk BRUE?

August 24, 2021

Written by Seth Walsh-Blackmore

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Presence of AAP high-risk BRUE criteria do not accurately predict the presence of a serious underlying diagnosis. Abnormal medical history, history of similar event, event duration >1 minute, and altered responsiveness increased the odds of a serious underlying diagnosis.

Why does this matter?
The absence of high-risk criteria is an effective risk stratification tool to reduce unnecessary workup and admission in BRUE. However, does the presence of these criteria predict outcomes that warrant more than education and discharge, and if not, what does?

Trouble BRUEing?
This was a multicenter retrospective cohort of 2,036 children who met criteria for BRUE (formally ALTE) at ED presentation via a heroic chart review of 4,446 patients identified through ICD-10 codes. Primary endpoint was the diagnosis of a serious condition explaining the index ED visit, which occurred in 82 (4%) cases, with 37 occurring after ED discharge. AAP high-risk criteria (see MDCalc here) were used as covariates for multivariate regression. While the absence of AAP high risk criteria had a robust NPV (97%) for underlying serious condition, presence of criteria did not have a strong PPV (4%). Abnormal medical history (OR 7.3, 95%CI 2.4-21.8), history of similar event (OR 4.1, 95%CI 1.3-12.8), event duration > 1 min (OR 3.6, 95%CI 1.2-10.3), and altered responsiveness (OR 3.6, 95%CI 1.3-10) were associated with increased odds of a serious underlying condition.

This study supports AAP recommendations that in the absence of high-risk criteria further workup can be deferred. However, the decision to pursue admission or further workup should be in the greater context of the patient’s history rather than BRUE screening criteria alone, as their presence is not predictive of a serious underlying diagnosis. Seizure disorder and abusive head trauma were the serious conditions most frequently missed in those discharged from the ED with BRUE, and it may be prudent to focus additional resources towards these conditions and, of course, document these have been considered.

Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study. Pediatrics. 2021 Jun 24;e2020036095. doi: 10.1542/peds.2020-036095. Online ahead of print.

Edited by Aaron Lacy

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