12-phase flow (12)

1. 1FRAME
   Confirm BRUE definition: infant <1 yr + sudden brief (<1 min) resolved episode + ≥1 of cyanosis-pallor / breathing change / tone change / altered responsiveness + no explanation after history-exam (AAP 2016 Tieder PMID 27244835)
   inputs: age_days, event_duration_seconds, event_features_cyanosis_pallor, event_features_breathing_change, event_features_tone_change, event_features_altered_responsiveness
   advance: BRUE definition confirmed; episode resolved at presentation; no alternative diagnosis from history-exam
2. 2ENTRY
   Caregiver-reported cyanotic / pallid / breathing / tone / responsiveness event in infant <1 yr; now well-appearing (AAP 2016 Tieder)
   inputs: age_days
   advance: Entry trigger captured + infant currently well
3. 3CONTEXT
   Birth history (GA, perinatal complications, NICU stay), feeding history (GERD symptoms, choking with feeds), family history (sudden unexplained death, channelopathy, metabolic disease), social history (caregiver stress, prior CPS involvement), prior similar events, vaccination status, sleep environment, current medications, exposure to medications-toxins (AAP 2016 Tieder)
   inputs: gestational_age_weeks, postconceptional_age_weeks, concerning_history_features, concerning_exam_features, spo2, hr, rr
   advance: Complete history + exam documented
4. 4RED_FLAGS
   Fever in infant <60 d → route to peds.febrile-infant.core.v1; persistent hypoxemia or hemodynamic instability or seizure activity → resuscitate + admit + full workup; bruising / retinal hemorrhages / abnormal neuro exam → child abuse pathway (AAP 2016 Tieder)
   inputs: temperature, concerning_exam_features
   advance: Red flags screened; any positive → bypass to higher-risk workup + admit
5. 5INITIAL_WORKUP
   Lower-risk: NO routine labs / imaging / EEG / CXR / echo; ECG may be obtained per AAP 2016 weak recommendation; pertussis PCR may be obtained if <4 mo; brief monitored observation (1-4 h continuous pulse-ox); CPR teaching for caregivers (AAP 2016 Tieder). Higher-risk: tailored workup based on clinical concern (AAP 2016 Tieder)
   inputs: ecg_12_lead, pertussis_pcr_if_under_4mo
   actions: workup.brue_lower_risk_observation, workup.brue_higher_risk_tailored
   advance: Initial workup completed per risk tier
6. 6BRANCHING_WORKUP
   Higher-risk subtype-specific workup: (1) sepsis if febrile or ill-appearing → blood/urine/CSF cultures per peds.febrile-infant.core.v1; (2) seizure → EEG + neuro consult; (3) cardiac → echo if structural CHD suspected from ECG/exam; (4) GERD → pediatric GI consult, trial of management; (5) child abuse → skeletal survey + ophthalmology retinal exam + social work + CPS notification; (6) inborn errors of metabolism → ammonia, lactate, glucose, acylcarnitine profile, urine organic acids, plasma amino acids if recurrent / family history; (7) pertussis → PCR if <4 mo or unvaccinated; (8) apnea of prematurity → if <44 wk PMA, consider as different entity (AAP 2016 Tieder)
   inputs: concerning_history_features, concerning_exam_features
   actions: workup.pediatric_fever, workup.brue_cardiac_evaluation, workup.brue_seizure_evaluation, workup.brue_abuse_evaluation, workup.brue_metabolic_evaluation
   advance: Subtype workup launched as clinically indicated
7. 7DIFFERENTIAL
   BRUE (idiopathic — most common) vs sepsis vs seizure vs GERD with apnea vs congenital heart disease (long-QT, WPW, hypertrophic cardiomyopathy, anomalous coronary, ductal-dependent lesion) vs metabolic / inborn error vs child abuse (abusive head trauma, suffocation) vs pertussis vs apnea of prematurity (if <44 wk PMA) vs breath-holding spell (typically >6 mo with trigger) vs vasovagal-equivalent vs medication / toxin exposure (AAP 2016 Tieder)
   advance: Differential narrowed; idiopathic BRUE is diagnosis of exclusion after risk-stratified evaluation
8. 8RISK_STRATIFICATION
   Apply AAP 2016 lower-risk criteria (ALL must be met): age >60 d AND GA ≥32 wk AND PMA ≥45 wk AND first event AND duration <60 s AND no CPR by trained provider AND no concerning history-exam features → lower-risk BRUE. Any criterion failing → higher-risk BRUE. Calculator: calc.brue_risk_stratification (deferred to future SCAFFOLDED+ pass)
   inputs: age_days, gestational_age_weeks, postconceptional_age_weeks, event_duration_seconds, first_event_vs_recurrent, trained_cpr_required, concerning_history_features, concerning_exam_features
   advance: Risk tier (lower-risk vs higher-risk) assigned
9. 9TREATMENT
   Lower-risk BRUE — NO routine medications; supportive observation; caregiver CPR teaching; reassurance; shared decision-making about brief admission for monitoring vs discharge with close follow-up (AAP 2016 Tieder). Higher-risk — etiology-specific treatment: empiric antibiotics if sepsis suspected (route to peds.febrile-infant.core.v1), antiepileptics if seizure confirmed (route to peds.status_epilepticus.v1 if recurrent), GERD management (lifestyle + acid suppression per peds GI), cardiac management (route to peds cardiology), metabolic management (route to peds metabolism). Treat the underlying cause, not the BRUE itself (AAP 2016 Tieder)
   advance: Treatment plan documented per risk tier + suspected etiology
10. 10DISPOSITION
    Lower-risk BRUE: shared decision-making with caregivers — option A) brief observation (1-4 h continuous pulse-ox) + discharge with close (24 h) PCP follow-up + CPR teaching + return precautions; option B) brief admission for cardiorespiratory monitoring if caregiver anxiety high or social-risk concerns (AAP 2016 Tieder). Higher-risk BRUE: admit for monitored observation + targeted workup; PICU if respiratory failure, seizure activity, or hemodynamic instability (AAP 2016 Tieder)
    advance: Disposition documented per risk tier + caregiver preference
11. 11MONITORING
    Lower-risk: continuous pulse-ox during brief observation; vitals q1h; recheck before discharge. Higher-risk: continuous cardiorespiratory monitoring + apnea alarm; vitals q4h; serial neuro exam if seizure suspected; EEG monitoring if epileptiform activity captured (AAP 2016 Tieder)
    advance: Monitoring orders documented
12. 12FOLLOWUP
    Lower-risk: PCP follow-up within 24 h (telephone + in-person at 24-72 h); reinforce CPR teaching; review return precautions (any new event, color change, breathing concern, feeding difficulty, lethargy → ED); discuss safe sleep (back-to-sleep, room-sharing not bed-sharing, smoke-free home) and breastfeeding promotion (AAP 2016 Tieder; AAP 2022 Moon safe sleep). Higher-risk: outpatient pediatric subspecialist follow-up based on workup findings (cardiology, neurology, GI, metabolism, child abuse / CPS); developmental surveillance (AAP 2016 Tieder)
    advance: Follow-up plan + return precautions + safe sleep + CPR teaching documented