SUID Sudden Unexpected Infant Death Training for EMS and Fire Rescue

1. SUIDSudden Unexpected Infant Death Training forEMS and Fire Rescue Presented by: Major Connie Shingledecker Manatee County Sheriff’s Office & Dr. Barbara Wolf District 5 Medical Examiner

3. FSS 383.3362 • Requires first responders (law enforcement, fire rescue and EMS) to receive training specific to Sudden Unexpected Infant Death (SUID) cases in accordance with the CDC’s training. • This presentation will provide insight into the problem of sleep related infant death in Florida, the new investigative protocol being used by law enforcement at these death scenes, and how EMS & Fire Rescue response affects the law enforcement investigation.

4. Objectives: • To understand the problem of sleep related infant death in Florida • To understand the goal of FSS 383.3362 in regards to first responders • To understand the role of first responders at infant death scenes as it relates to the Centers for Disease Control SUID initiative • How EMS & Fire Rescue response affects the law enforcement investigation

5. “Florida: We Have a Problem”

6. Nationwide: Infant Deaths • According to the CDC, nearly 4,500 babies die each year from Sudden Unexpected Infant Death • The sudden unexpected death of a baby up to one year of age • From 2010-2012 in Florida three years of data: 603 babies died under the heading of SUID

7. SIDS vs. SUID What’s the difference?

8. SIDS and SUID • SIDS and SUID are different • SUID: Sudden Unexpected Infant Death • Sometimes known as SUDI (Sudden Unexpected Death in Infancy) • SUID is the umbrella term that SIDS falls under • Accidental sleep related deaths fall under SUID explained category

9. Sleep Related Deaths • Most SUIDs occur during sleep or in sleep environment = Sleep-related deaths • Suffocation, overlay deaths, strangulation, entrapment, wedging • Undetermined/ill-defined/unknown • Sleep related deaths: 100% PREVENTABLE • SIDS: can only REDUCE the RISK

10. What is SIDS? Sudden Infant Death Syndrome (SIDS) is the sudden death of an infant younger than 1 year of age that remains unexplained after a thorough case investigation, including: Performance of a complete autopsy Examination of the death scene Review of the infant’s and family’s clinical histories

11. SIDS Vs Suffocation • SIDS is one of several causes of SUID • SIDS, unlike the other SUID causes, is a diagnosis of exclusion. • SIDS is a diagnosis that should be given only after all other causes of SUID have been ruled out through a careful scene investigation, an autopsy, and a review of medical history. “Death scene investigation is often the only way to make a distinction between SIDS and suffocation as a cause of death” (Hanzlick 2001).

12. Some causes of deaths that occur suddenly and unexpectedly during infancy SIDS Neglect or homicide Accidental suffocation SUID Unknown Hypothermia/ Hyperthermia Poisoning Metabolic disorders

13. SUID Unexplained Explained SIDS Undetermined Known Diagnosis Accidental Suffocation & Strangulation Trauma Poisoning Drowning

14. SIDS is NOT… Preventable, but the risk can be reduced Caused by vomiting and/or choking Caused by DPT vaccine or other immunizations Contagious The result of child abuse or neglect The cause of every unexpected infant death

15. Understanding the Risk Factors Stomach sleeping during naps and at night Propping infants on their side during sleep Soft sleep surfaces and loose bedding Bed sharing with an adult or with other children Overheating during sleep Maternal smoking during pregnancy and smoke in the infant’s environment Risk exists from birth up to one year of age with highest incidence between 2-6 months of age

16. Sleep-Related Deaths • Are 100 percent preventable! • Falls under SUID • Types: • Suffocation • Wedging • Entrapment • Strangulation

17. Sleep Related Deaths • Bumper pads • Should be removed from crib • Suffocation hazard • Breathable ones available

18. Obstruction of Nose or Mouth • The obstruction of the external airway passages of the nose and/or mouth by an object. • Smothering

19. Smothering • The impedance of oxygen supply by obstruction of nose or mouth.

20. Re-Breathing • The inhalation of expired CO2 and other gases recovered from porous sleeping surfaces. • The inspired CO2 inhibits CO2 receptors in the brainstem.

21. Sharing Sleeping Surface • When any two or more adults, children or pets sleep on the same surface.

22. Bed Sharing with Adults • Infants should be placed on a separate sleeping surface • Can be brought to bed for nursing or comforting • Returned to bassinet or crib in room

23. SIDS Risk Reduction/Safe Sleep Recommendations • Baby should sleep on the back for each and every sleep. • Baby should sleep alone in their own separate sleep space: crib, bassinet, pack-n-play. • No bedsharing with adults or other children. • Firm mattress with tight fitting crib sheet. • No toys, pillows, loose bedding in the crib.

24. SIDS Risk Reduction/Safe Sleep Recommendations 6. No bumper pads! 7. No exposure to tobacco smoke. 8. Offer a pacifier each and every sleep. 9. Room sharing with caregiver, no bed sharing. 10. Do not allow baby to overheat with sleep: one layer of clothing; overhead fan use recommended.

25. SIDS Risk Reduction/Safe Sleep Recommendations 11. Educate all caregivers about safe sleep! Not just parents. EVERYONE! 12. Avoid products that say they prevent SIDS. 13. Encourage breastfeeding.

26. First to Arrive on Scene of Infant Death • Neighbors • EMS/EMT • Fire Rescue personnel

27. Good Samaritan • An individual, without a previous relationship, who voluntarily provides emergency medical care. • These individuals are not legally liable for their actions.

28. EMS Emergency Medical Services-Systems A community’s established policies, procedures and departments responsible for providing emergency medical care. A community’s established policies, procedures and departments responsible for providing emergency medical care.

29. EMT Response to SUID From the“National Sudden Infant Death Resource Center” • EMT has three major roles in responding to a sudden, unexpected infant death: • Providing immediate emergency medical care to the baby • Observing, assessing, and documenting the scene • Offering support and consolation to parents/caregivers.

30. Observing, Assessing, and Documenting the Scene “National Sudden Infant Death Resource Center” • The ME/coroner likely will not be at the death scene. • ME will rely on documentation from the EMS team and law enforcement to help determine cause of death. • Law Enforcement may conduct the formal investigation, the first responder team’s information about the scene is often invaluable.

31. Observing, Assessing, and Documenting the Scene “National Sudden Infant Death Resource Center” • EMS/Fire Rescue personnel should expect that they will need to prepare a report for the ME on what they saw and heard at the scene. • This report is a legal document. Parents, other family members, and the child death review team also may review the report. • The report should be objective, accurate, and complete and should follow local protocol.

32. EMS/Fire Rescue Collecting Information“National Sudden Infant Death Resource Center” • At the scene, ask questions about the circumstance of the death and the baby’s health history, obtain key information, including current medication, and circumstances at the time of death. Open-ended, precise questions are most effective, for example:

33. Collecting Information“National Sudden Infant Death Resource Center” • Can you tell me what happened? • Where was the baby? • Who found the infant? • What did you do when you found the baby? • Has the infant been moved? • What time was the infant last seen alive? • How did the infant seem that day? • Had the infant recently been sick?

34. Resuscitative Efforts • Document all resuscitative efforts by caregivers, relatives, neighbors, etc. • Fire Rescue/EMS should document their resuscitative efforts in their run sheets. • The M.E. is usually responsible for obtaining EMS/Fire Rescue run sheets and E.R. medical records to document artifact on body due to their resuscitative efforts.

35. When & Why EMS/FIRE Rescue Should Not Remove the Body • When Livor, Rigor and Algormortis indicate obvious death • Creates two scenes that law enforcement must maintain and respond to • Family will need to respond back to the scene for a doll re-enactment • Scene can be altered prior to us responding

36. Time of Death • Always an estimate • Narrowest window is when body is examined as soon after death as possible • May depend on observations at the scene by law enforcement or EMS

37. Time of Death • Particularly difficult to evaluate in children • Children, particularly infants, have greater surface area/body mass ratios and therefore their bodies lose heat more rapidly. • Infants have widely varying body configurations and therefore there are no standardized tables for the parameters used to estimate time of death.

38. EARLY POSTMORTEM INTERVAL • Livor mortis (lividity) • Rigor mortis (stiffening of body muscles) • Algor mortis(body temperature)

39. Lividity • The pooling and settling of blood within the body due to gravity. • Can sometimes provide indicators of time of death and position of body. • If the body has been moved, the blood remains pooled around the white pressure points where weight of body was resting. • A body that has been moved after death can signal foul play but not usually in infant/child death cases.

40. FACTORS AFFECTING THE PROGRESSION OF RIGOR MORTIS • Ambient temperature and microenvironment • Clothing, bedding • Body habitus (under, avg., or over weight) • Body temperature at death • Infection • Drugs • Prior physical activity

41. Ways to determine a person is dead; • Not breathing • Body temperature • Skin pallor • Fingernails may be pale • Eyes milky or cloudy • Rigor mortis • Lividity • Obvious signs of trauma • Analyze information and evidence that might indicate possible cause of death • Use agency policy

42. What Can EMS Do If They Do Not Remove Body • Attend to the family. • Make observations about the Rigor, Livor, and Algormortis. • Try not to move the infant as this can cause shifting of lividity patterns. • Do not run out to the EMS coach with the infant if it is obviously deceased. • Allow EMS to enter and assess the infant.

43. First Responding LEO • Provide first aid if warranted • Observe infant, check for obvious trauma • Make note of lividity pattern and assess body temperature (warm, cool, cold) • Determine actual incident scene (crib or bed) • Observe scene condition and document • Temperature, odors, substance abuse, TV or computer on and what is on • Do not alter scene (turn on air, open windows, turn off fans, etc.)

44. Law Enforcement First Responder cont’d • Secure scene (location of death and body of deceased must be protected) • Make note of: initial statements made, of activities of individuals, who called 911 and from what phone, overall scene, of unusual things at the scene and with individuals • Scenes may have evidence of substance use, people may be under the influence (these should be documented and addressed by Law Enforcement

45. Assess Infant’s Body • Examine infant’s body and note appearance of marks or injury • Assess Rigor Mortis – rigidity of muscles after death, evident in smaller muscles sooner than in larger muscles • Assess Livor Mortis – settling of the blood due to gravity, can change if body is moved • Assess Algor Mortis – Cooling of the body after death. Document by touch, or external thermometer if available.

46. Unusual Marks • Unusual marks on an infant that died while co-sleeping in bed with mother • Appear to be post-mortem • What the scene told us • How an old case where the baby had similar marks and scene photos helped solve the mystery

47. Scene Investigation • Exact location where infant was placed to sleep. • Observe the condition of the sleep environment. • Note the sleep environment to include: • Purge or hemorrhagic fluid • Clutter • Animals • Insects • People (include height and weight)

48. Unique Death Cases • Pacifier Duct Taped in Baby’s mouth • Sticky residue around the baby’s mouth area • Drug addicted parent co-sleeping with infant • Bottle propping • Baby aspirated the formula • Not a substitute for a crib • Swings • Car Seats • Carriers

49. Suspicious Circumstances • placement position issues • found position issues • questionable witness accounts • suspicion of inflicted injury or poisoning

50. Found Position Issues • Caregivers may be unwilling or unable to provide detailed information on body position • The body may have been moved