SUIDSudden Unexpected Infant

Death Training for

EMS and Fire Rescue

Presented by:Major Connie Shingledecker

Manatee County Sheriff’s Office&

Dr. Barbara WolfDistrict 5 Medical Examiner

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.

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

“Florida: We Have a Problem”

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

SIDS vs. SUID

What’s the difference?

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

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

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

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).

Some causes of deaths that occur suddenly and unexpectedly during infancy

Neglect

or homicide

Hypothermia/Hyperthermia

Metabolic disorders

Poisoning

Unknown

Accidental suffocation

SIDS

SUID

SUID

Unexplained

SIDS

Undetermined

Explained

Accidental Suffocation & Strangulation

Known Diagnosis

TraumaPoisoningDrowning

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

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

Sleep-Related Deaths

• Are 100 percent preventable!

• Falls under SUID• Types:

– Suffocation– Wedging– Entrapment– Strangulation

Sleep Related Deaths

• Bumper pads• Should be removed

from crib• Suffocation hazard• Breathable ones

available

Obstruction of Nose or Mouth

• The obstruction of the external airway passages of the nose and/or mouth by an object.

• Smothering

Smothering

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

Re-Breathing

• The inhalation of expired CO2 and other gases recovered from porous sleeping surfaces.

• The inspired CO2 inhibits CO2 receptors in the brainstem.

Sharing Sleeping Surface

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

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

SIDS Risk Reduction/Safe Sleep Recommendations

1. Baby should sleep on the back for each and every sleep.

2. Baby should sleep alone in their own separate sleep space: crib, bassinet, pack-n-play.

3. No bedsharing with adults or other children.

4. Firm mattress with tight fitting crib sheet.

5. No toys, pillows, loose bedding in the crib.

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.

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.

First to Arrive on Scene of Infant Death

• Neighbors

• EMS/EMT

• Fire Rescue personnel

• An individual, without a previous relationship, who voluntarily provides emergency medical care.

• These individuals are not legally liable for their actions.

Good Samaritan

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.

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.

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.

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.

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:

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?

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.

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

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

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.

Time of Death

EARLY POSTMORTEM INTERVAL

Livor mortis (lividity)Rigor mortis (stiffening of body muscles)Algor mortis (body temperature)

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.

FACTORS AFFECTING THE PROGRESSION OF RIGOR

MORTISAmbient temperature and microenvironment

• Clothing, beddingBody habitus (under, avg., or over weight)Body temperature at death

• Infection• Drugs• Prior physical activity

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

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.

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.)

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

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.

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

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)

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

a. placement position issues

b. found position issues

c. questionable witness accounts

d. suspicion of inflicted injury or poisoning

Suspicious Circumstances

• Caregivers may be unwilling or unable to provide detailed information on body position

• The body may have been moved

Found Position Issues

Duty to Report; Prohibited Acts FSS 406.12

• It is the duty of any person in the district where a death occurs…who becomes aware of the death of any person occurring under the circumstances described in s. 406.11 to report such death and circumstances forthwith to the district medical examiner... Any person who, without order from the medical examiner, willfully touches, removes, or disturbs the body… with the intent to alter the evidence or circumstances surrounding the death, shall be guilty of a misdemeanor of the first degree.

Questionable Witness Accounts

• A story concerning the events of an event or injury given by a witness that constantly changes is suspicious.

Suspicions of Inflicted Injury or Poisonings

• Major injuries may not be visible

• Poisons go undetected without scene knowledge

• The death inconsistent with the story given

welfare/safety issues of other children in environment

concerns of domestic violence concerns of drug/alcohol abuse history of problems with

caregivers previous deaths in family concerns from caregivers concerns from other

investigations/witnesses

Other Alerts to the Pathologist

Unsafe Sleep Warning Ignored

• CPI Worker observed baby on couch when responding to a DV case

• CPI warned parents and had them sign an agreement not to put baby in that position or co-sleep with her

• Within two months the baby would be dead from a co-sleeping incident; parents ignored the warning of the CPS worker.

Physical Evidence and Gathered Information

• inconsistencies between scene and verbal description of events

• inconsistencies between observed injury and explanation of injury

• note changes in “story” based on investigator’s suggestions

• note explanation of events that defy logic and common sense

Duty to Report; Prohibited Acts FSS 406.12

• It is the duty of any person in the district where a death occurs…who becomes aware of the death of any person occurring under the circumstances described in s. 406.11 to report such death and circumstances forthwith to the district medical examiner... Any person who, without order from the medical examiner, willfully touches, removes, or disturbs the body… with the intent to alter the evidence or circumstances surrounding the death, shall be guilty of a misdemeanor of the first degree.

Data Collection & Reporting Tools

• Goal of infant death scene investigation• Gather information about circumstances

surrounding the death so M.E. can use it to:– Interpret autopsy findings– Determine cause of death– Establish the manner of death

• Have consistency by use of SUIDI Form

SUIDI Form

• Recent contacts, activities and behaviors– Go back over the last 72 hours– Describe signs and symptoms– Describe any recent injuries or falls– Changes in caregivers

• Placed – Exact location, position of head, etc.

• Last known alive – location, position, etc.• Found – exact location, position of head,

etc.

Additional Forms: EMS• Document medications administered• List actions performed by EMS and duration • Document EMS outcomes• Document observed behavior / statements• Document evidence of illegal activity• Document environmental hazards present• Document concerns about scene, comments,

people, previous family contacts by EMS• May have to conduct EMS interviews at a later

time and location

Day Care Scene

• Notify Law Enforcement immediately so we can determine:

• Number of care providers for number of children present at time of death.

• Level of care – exposure to other sick children

• Activity by and for the infant the entire time baby was there.

• Document observable concerns by photo and report

Doll Re-enactment Scene Recreation

• Goal – to depict accurately the sleep environment into which the infant was placed.

• Must be performed by the placer, the person that last saw the infant alive and finder.

• Explain importance• Show the doll to the family member/caregiver• Describe procedure – photographs, video

Scenario # 1• 12 day old B.M.• Co-sleeping in a twin bed with

mother and father.• Supine position is not protective

when co-sleeping.• Video is also helpful tool for

improving your investigation technique.

Scenario #2

• 4 month old W/F• Co-sleeping with mother and grandmother

in full size bed• After 0200 feeding placed back in bed• Mom awoke at 0830 to find baby

deceased• Apparent lividity along back • Not transported

Scenario #3

• The child’s mother said she put the baby down on her back in her crib for a nap before she herself took a nap. (Mom on methadone)

• The child’s father arrived home at 1640 found infant deceased lying face down in a laundry basket next to the bed.

• The infant was cold to the touch and had lavidity consistent with being on her stomach at the time of death.

• Child not transported.

Scenario #3 continued

• Mom gave four separate versions, after confronting her inconsistencies she told the truth that baby was co-sleeping.

• Both refused to submit to Drug Urinalysis test for CPS and denied consent to search the residence to collect evidence.

• Obtained signed warrants for the residence and to collect a blood sample from mom.

• There has been a history with CPS and they have been informed about the dangers of co-sleeping and signed a form would not co-sleep.

Summary• Aware of SUID issues• Aware of importance in NOT transporting

obviously deceased infants• Aware of communicating unusual or

suspicious circumstances to L.E.• Aware of L.E.’s investigative responsibility

under the CDC SUIDI initiative

Florida First Responders:Safe Sleep Initiative Firefighters and EMS

Presented by:Florida Department of Children and Families

In partnership with

Florida Department of HealthFort Lauderdale Fire Rescue

Healthy Mothers, Healthy Babies Coalition of Broward

What Can You Do?

Safe Sleep Environment Check

• When the opportunity arises during a call

ask to see where is the baby sleeping• Is there a crib? bassinet? Pack-n-play?• Is the sleep area free from: pillows, toys,

stuffed animals, loose bedding, bumper pads?

• Should be nothing but a firm mattress with a tight fitting crib sheet in the crib

Position of Baby• If you directly observe the baby sleeping,

what position is the baby in?• Baby should be on their back for each and

every sleep; • As babies get older and are able to roll

from stomach to back and back to stomach, instruct the caregiver to always start baby off on their back;

• they do not have to continually reposition the baby on back when they are able to roll.

Now What?

• Actually demonstrate to caregiver the safe sleep environment, by physically removing all unsafe materials from the crib

• Take off bumper pads• For families with no crib, bassinet or pack-

n-play, refer to community agencies for assistance in obtaining a crib

• Give the family safe sleep educational materials

ABCs of Safe Sleep

• Alone: baby should be alone in their crib or safe sleep space

• Back: baby should always be on their back

• Crib: baby should always sleep in their crib

Summary

• You as a first responder are on the front line in our battle against infant mortality

• Environment check, education, referrals• You can make a difference! You can save

a baby’s life through preventative efforts!• Remember, it is all about the babies!

www.MyFLFamilies.com/safesleep