“Undetermined” Infant Deaths and - Texas Injury … · “Undetermined” Infant Deaths and the Importance of Comprehensive Scene Investigation Reade A. Quinton, M.D. Southwestern

“Undetermined” Infant Deaths and the Importance of Comprehensive Scene

Investigation

Reade A. Quinton, M.D.

Southwestern Institute of Forensic Science

Dallas, TX

The Forensic (Medicolegal) Autopsy

• External Examination

• Internal Examination

• Toxicology

• Ancillary studies

• Scene Investigation

• Medical record review

Limitations of the autopsy

• Good at structural defects:

– Coronary artery disease, etc.

– Injuries (gunshot wounds, sharp force, blunt force)

• Weak at functional defects:

– Arrhythmias

– Electrolyte disorders

– Seizures

• “Snapshot” versus “evolution”

– Acute and chronic disease

– Recent and remote injury

The “Negative” or “Undetermined” Autopsy

• No significant findings

• Unexplainable positive findings

• Inadequate (scene) information

• Scientific imprecision

“SIDS”

•Age > 1 month and < 1 year

•After a complete autopsy and investigation, no cause of death can be found

•Essentially an undetermined cause of death (but often considered “natural”)

Characteristics of SIDS

•Occurs suddenly without warning, often

during periods of sleep

•Cause unknown after thorough

investigation

– Not due to suffocation, aspiration, abuse or

neglect

•Peak incidence at 2 to 4 months of age

“SIDS”

•The SIDS rate began significantly

dropping in the mid 1990’s

–“Back to sleep”

–Reclassification

•Better scene investigation

•Better autopsies

•New disease entities

Mortality rates due to SIDS, U.S., 1980-2003

53

130

0

20

40

60

80

100

120

140

160

180

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

Year

Rate

per

100

,000

liv

e b

irth

s

Possible Stressors

• Disease of uncertain significance

• Injury of uncertain significance

• Bed sharing or unsafe sleep surface

• Prone face-down position

• Drugs detected

• Change in sleep position/location/surface

• Over-wrapping/excessive blanketing

• Regular smoking in environment

“Gray Zone” issues may arise because of findings at the scene or autopsy.

Breakdown of Cases after Autopsy

• Known specific cause of death

• SIDS-Like, no stressors

Gray • SIDS-Like with stressor(s) Zone

Cases

• Not SIDS, but cause unknown

• Inadequate investigation

Death Certification Examples

A. Respiratory Distress Syndrome

Due to, or as a consequence of:

B. Prematurity


C. Placental Abruption (maternal)

OTHER SIGNIFICANT CONDITIONS: Conditions contributing to death but not resulting in the underlying cause of death in Part I

Manner of Death

Natural

How Injury Occurred

“Classic” SIDS

History:

• 4 month infant is found supine in crib

•

• Complete investigation of the scene, circumstances and

medical history

• Autopsy, toxicological and metabolic testing fails to

identify a cause of death or potential external causes

A. Consistent with the definition of

Sudden Infant Death Syndrome Due to, or as a consequence of:

B.


C.


Manner of Death

Undetermined

How Injury Occurred

Undetermined whether external causes were involved

Or…

A. Consistent with

Sudden Infant Death Syndrome


B.


C.


Manner of Death

Undetermined

How Injury Occurred


A. Sudden Infant Death Syndrome


B.


C.


Manner of Death

Undetermined

How Injury Occurred


If you want to affirm that you think its natural Or… causes and you use the term “SIDS”…

A. Sudden Infant Death Syndrome


B.


C.


Manner of Death

Natural

How Injury Occurred

If you want to affirm that you think its natural Or… causes but don’t like the term “SIDS”

A. Sudden Unexplained Infant Death


B.


C.


Manner of Death

Natural

How Injury Occurred

Or…



B.


C.


Manner of Death

Undetermined

How Injury Occurred


Or…

A. Sudden death during infancy:

no identifiable cause Due to, or as a consequence of:

B.


C.


Manner of Death

Undetermined

How Injury Occurred


Gray Zone Case

History: • 3 month infant is found supine in an adult bed that it was

sharing with mother and 3 year old sibling.

• Mother does not report waking up on top of the infant or seeing the sibling on top.

• Complete investigation of the scene, circumstances and medical history, along with autopsy and metabolic testing, fails to identify a cause of death.


while cosleeping (bed-sharing) Due to, or as a consequence of:

B.


C.


Manner of Death

Undetermined

How Injury Occurred:

Sleeping in an adult bed with an adult and older sibling

Not SIDS, but Undetermined

History: • 4 month infant with 2 days of fever becomes lethargic.

• In the ER, he is conscious but then loses consciousness

and dies several hours later.

• Complete investigation, workup, and autopsy fails to

demonstrate a cause of death.

The Dilemma…

• It’s not “SIDS”

• It’s not “Unclassified”

(investigation was adequate)

• There is no identified cause (a cause is not specifiable)

• Investigation was complete

A. Undetermined


B.


C.


Manner of Death

Undetermined

How Injury Occurred

Undetermined whether external causes were involved.

Cause of death undetermined after complete investigation

SUID Investigations

•A SUID investigation is the gold standard for infant death investigation

•All child death investigations should include: –Scene investigation

–Witness interviews • Doll Reenactment

–Full autopsy

SUIDI “Top 25”

• Information considered vital by the forensic pathologist (pre-autopsy)

•Reflects structure of SUIDI reporting form

•Standardizes crucial national SUIDI data

SUIDI Top 25

• General case information

• Asphyxia concerns

• Sleep surface sharing

• Sleep condition changes

• Hyperthermia/hypothermia

• Environmental hazards

• Unsafe sleeping conditions

• Diet

• Recent hospitalizations

• Previous diagnoses

• Acute life-threatening events

• Medical care without diagnoses

• Recent falls/injuries

• Religious/cultural remedies

• Natural causes other than SIDS

• Prior sibling deaths

• Prior interactions with police or social services

• Request of tissue/organ donation

• Objection to autopsy

• Resuscitation efforts

• Trauma, poisoning, intoxication

• Suspicious circumstances

• Other alerts

• Description of circumstances

• Pathologist information

Case Information

• Investigator’s name

• Agency

• Phone

• Date/Time investigated • Case number

• Decedent’s name

• DOB

• Date/Time pronounced

Sleep conditions

•Asphyxia: Failure of the body’s cell to receive sufficient oxygen –Overlaying

–Wedging

–Choking

–Mouth/nose obstruction

–Re-breathing

–Neck compression

–Immersion

•Doll reenactment is extremely important!

Sleep conditions (cont.)

• Sharing Sleep surfaces:

– Bed sharing

– Co-sleeping

• Change in sleep conditions – Position change

– Location change

– Surface change

Sleep conditions (cont.)

• Unsafe sleep conditions: – Soft or lumpy surface

– Concave

– Broken, worn, torn

– Stained or wet

– Mattress/frame mismatch

Environment

• Hypo- or Hyperthermia – excessive wrapping

– excessive blanketing

– excessive clothing

– hot environment

– cold environment

Environment (cont.)

•Other environmental hazards: –CO and other noxious gases

–Chemicals and sprays

–Electricity

–Cigarettes

–Illegal drug exposure

–Ligature

Infant History

• Diet

– Introduction of new foods

– Food Allergies

– Food inappropriate for age

• Recent Hospitalization

• Previous diagnoses

– Asthma

– Diabetes

– Cystic Fibrosis

– Failure to Thrive

• Acute life-threatening event (ALTE)

Acute Life Threatening Event (ALTE)

•An episode that is frightening to the

observer and is characterized by some

combination of apnea, color change,

marked change in muscle tone, choking or

gagging.

Willinger M, James C and Catz C. Defining the Sudden Infant Death

Syndrome. Pediatr Pathol. 1991; 11:677-684

Infant History (cont.)

• Medical Care without Diagnosis – Misdiagnosis

– Munchausen’s by Proxy

– Lack of parental follow-up

• Death due to natural causes other than SIDS – Congenital anomalies

– Chromosomal abnormalities

– Prematurity

• Recent fall or other injury

• Religious or cultural remedies

Family Information

• Prior sibling deaths

• Encounters with police or CPS

• Request for tissue or organ donation

• Objection to autopsy

External Scene Examination

• Pre-terminal resuscitative

treatment

• Death due to trauma,

poisoning or intoxication

Investigator Insight

• Overview of Investigation

• Suspicious circumstances or behavior

• Other alerts to the pathologist

• Physical evidence and gathered info

• Pathologist Information

Doll Reenactment

•Accurately depict the sleep environment of the

decedent:

–How was the infant last placed

–How was the infant found

Introduction of the Doll

•Explain the doll’s purpose

•Handle the doll with respect (but not as a real

infant)

•Demonstrate articulation of the head and

extremities

Procedure

• Involve the placer and finder (may be the same person)

• Provide brief explanation of the procedure

• Encourage them to ask questions

Procedure

•Emphasize accurate

recreation:

–Infant body position

–Bed-sharing scenario

–Bedding/blankets

–Toys/animals

– Positional supports

(wedges)

Uncooperative Witnesses

•Refused reenactment x2

•Ask them to verbally describe as accurately as possible

•Photograph scene, sleep environment

•Document refusal in report.

Remember:

•Refusal is not a “suspicious behavior”

•Cooperation does not necessarily indicate

truthfulness

SUID - Asphyxial Deaths

•Asphyxia: Lack of oxygen to the brain –Airway obstruction

–Blood flow obstruction

•Types –Overlay

–Wedging

–Suffocation

–Re-breathing

–Choking

–Drowning

• It is possible for ALL of these cases to have negative autopsies!

Overlying

• The compression of a person by another occupant’s weight while sharing a sleeping

surface

• Generally the child is

sleeping with the parents

• Inquire to see if parents

are obese

• Inquire as to alcohol or

drug usage

Wedging

•The mechanical

asphyxia of a

person by their

own weight

compressed

between two hard

surfaces.

Choking

•Asphyxia caused by

obstruction within the

air passages.

•May have negative

autopsy if foreign

object was removed.

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.

Neck Compression

•The external

compression of the

neck by an object

through an unusual

position.

Drowning

• Often lack significant findings at autopsy

• Pulmonary edema

– Foam in airway

– “water in the lungs”

• Sphenoid sinuses?

Conclusions

•Some cases can be determined by autopsy

alone.

•Many cases are determined by a combination of

scene investigation and autopsy.

•Some cases are determined by the scene, with

negative autopsy findings.

•Some cases are undetermined despite scene

and autopsy information.

Resource

• http://www.cdc.gov/sids/TrainingMaterial.htm

http://www.cdc.gov/sids/TrainingMaterial.htm

Documents

“Undetermined” Infant Deaths and - Texas Injury … · “Undetermined” Infant Deaths and the Importance of Comprehensive Scene Investigation Reade A. Quinton, M.D. Southwestern