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What is the most common cause of death between 1-18 years?
What is the current definition of Sudden Infant Death Syndrome (SIDS)?
Death of an infant less than one year of age (usually between 1-6 months, peak at 3 months) with a death scene investigation reveals no evidence of potential unnatural death. A thorough postmortem exam also fails to give an adequate cause of death. Review of infant's and mother's medical history reveals no history of disease sufficient to cause death. SIDS is a diagnosis of EXCLUSION.
What five criteria must be investigated at the scene of a potential SIDS death, even if the infant has been removed from the scene? (Hint: PTSWD)
- Position of Infant
- Sleeping structure and associated items
- Witness interviews
- Develop a timeline
What are 5 "red-flags" from a SIDS scene investigation? (Hint: PAADI)
- Plastic bags of sheets near the infant
- Abundant fluffy bedding or stuffed animals
- Areas of possible wedging
- Damaged cribs
- Ill-fitting mattresses
What are 4 qualities involving a usual history regarding a SIDS death?
- Usually found in crib or other sleeping structure
- Apparently died quietly during sleep
- Many have a history of upper respiratory tract symptoms
- More common in winter months
What are three typical autopsy findings of a SIDS death? (The three Ps)
- Pulmonary congestion and edema (froth from mouth, nose, and in airway)
- Petechiae of epicardium, pleural surfaces of lungs, and thymus (80-85% will have intrathoracic petechiae)
- Possible terminal aspiration of gastric contents
What are some of the major autopsy artifacts surrounding a SIDS death?
- Cooling of subcutaneous adipose tissue leaves SKIN CREASES of neck
- MONGOLIAN SPOTS
- mucosal DRYING OF LIPS
- FONTANEL DEPRESSION
- Resuscitation attempts
- Livor mortis may resemble bruising
What are Mongolian spots?
An autopsy artifact of a SIDS death in which darker pigmented areas appear on the buttocks and lower back of the infant.
What are the 8 risk factors mentioned that increase the risk of SIDS?
- Low birth weight
- premature birth
- male sex
- black race
- maternal smoking
- lack of breast feeding
- bed sharing, sleeping on couches
- face down sleeping position
What is the cause of SIDS?
The cause is still unknown, but the manner is presumed natural.
What is infanticide (neo-naticide)?
Deliberate killing of a newborn
Who is usually the perpetrator in an infanticide? What are usually the two causes of death?
The perpetrator is usually the mother; the cause of death is usually either asphyxia or the effects of abandonment (exposure for example)
How do you determine a stillbirth?
A death within the uterus often shows maceration (decomposition within the uterus - skin slippage, fluid filled blisters, hemoglobin-stained fluid collects in thoracic and abdominal cavities).
What are the signs of a live birth?
- Food in stomach
- Air in lungs (could be complicated by attempted resuscitation; air filled lungs should float in water)
- Air in digestive tract
In regards to child abuse, what constitutes an acute impulsive act?
A child presents with an acute injury with no or minimal evidence of chronic abuse; usually the child has annoyed an adult who reacts by kicking, punching, or throwing the child.
In regards to child abuse, what constitutes chronic battering?
Multiple bruises and abrasions of different ages; may occur in combination with an acute impulsive act
There are two discrepancies that may help judge an inflicted injury on a child versus one that was accidental. The diagnosis requires an inappropriate historical explanation for the injury sustained. What do these discrepancies involve?
- discrepancy in age of the injury
- discrepancy in severity or appearance of injury
There's a lot to look for when conducting an external examination on an abused child. Trying to sum them up best that I can, I came up with DA SCOOPS. Ready? Go.
- Document weight, height, head circumference
- Acute or healing injuries
- State of nutrition (weight, thickness of abdominal fat)
- Cleanliness of clothing, diapers, body
- Oral mucosa inside the lips, frenulum and buccal mucosa
- Old or healing scars from injuries of various ages
- Patterned injuries
What are some typical pattern injuries involved in a case of child abuse?
- Parallel rows of narrow bruises - belt
- loop shapes - electric cord
- small round burns or scars - cigarette burns
- lacerations inside lips/torn frenulum - blow over the mouth
________________ injuries are the most common cause of death in hospitalized abused children.
Special procedures of a suspected child abuse internal exam involve examining the _________ for acute fractures of a healed fracture (callus formation ) and posterior incisions to reveal underlying ____________.
Why is the body of an abused child retained for a second examination after 24 hours?
After blood has drained from the vessels, any that is trapped in the subcutaneous tissue as a contusion may become more visible a day after the autopsy examination.
Posterior incisions are made to reveal underlying contusions in internal examination of an abused child. Where are these made?
- Back and extremities
- Posterior neck dissection
Skull ___________ and __________ hematomas usually require moderate to severe mechanical force
How are brain contusions in infants different than those in adults? And why is this?
Brain contusions in infants manifest as a tear of the brain substance rather than a wedge-shaped hemorrhage as in adults. An infants immature brain is not completely myelinated.
A(n) _________________ hematoma may occur without a skull fracture due to the pliability and flexibility of the infant skull.
___________________ injuries rarely display significant injury to the skin.
An abdominal injury results when the duodenum and/or pancreas is crushed between the ______ wall and ________ _________.
abdominal, lumbar spine
Lacerations of the ________, ________, and small ______ mesentery indicate an abdominal injury.
Spleen, liver, bowel.
Grabbing the extremities, shaking, and twisting may result in _________ fractures, ___________ fractures, or elevation of the ___________ with subperiosteal hemorrhage.
spiral, metaphyseal (tearing of the ends of the bones), periosteum
Any rib fracture in a child less than _______ years of age is considered evidence of child abuse unless there is a history of severe trauma (such as a car accident)
- NOTE: CPR will not fracture the ribs of infants and young children.
The mechanism of injury in Shaking Baby Syndrom is due to what?
acceleration-deceleration of the brain.
How long does most shaking in Shaking Baby Syndrome last?
20-30 seconds or less
What is the cause of death in Shaking Baby Syndrome?
Diffuse axonal injury (damage and tearing of individual nerves)
What are other injuries/so-called markers of the amount of energy applied to the head in Shaking Baby Syndrome? (Hint: there are 3)
- Subarachnoid hemorrhage
- Subdural hemorrhage
- Retinal/optic nerve hemorrhages
Why are infants more susceptible to injury when shaken? (FILL W)
- Flat skull base as compared to adults
- Incomplete myelination of white matter of the brain
- Large head with respect to torso
- Larger subarachnoid space
- Weak, underdeveloped neck musculature
In diffuse axonal injury, injured axons start to swell within _____ hours after injury while retraction bulbs from interrupted axonal cytoplasmic flow and disconnected neurons form after _____ to _____ hours
two; 18-24 hours.
NOTE: Survival for a period after injury is necessary to see these changes develop.
Osteogenesis imperfecta is one condition that may look like child abuse, but is actually a rare genetic disorder of connective tissue. What are some of the characteristics of this disease?
the child has fractures and bruising, hypermobility of joints, and blue sclerae (the white part) of the eye.
What X-linked disorder of copper metabolism results in short, sparse, poorly pigmented hair, and makes bones more brittle and susceptible to fracture?
Menkes' kinky hair syndrome
Neglect is defined as homicide by _________.
Is neglect more or less common than physical abuse?
What are the two categories of lethal neglect?
- An infant who has not been given enough food/water
- Older infant, toddler, child who has been inadequately supervised or not provided with adequate medical care.
Children dying of neglect usually (do/do not) have other signs of physical abuse.
In child neglect cases, evidence of starvation and dehydration can be discovered at autopsy by finding these six things: (most are rather obvious)
- Skin Tenting
- Loose, wrinkled and redundant skin
- prominent ribs
- sunken fontanels and globes of eyes
- body weight less than 5 percentile for age
- no or minimal intestinal contents
Immune system depression results from malnutrition. What are 3 common infections that can result?
- Skin infection
- Urinary tract infections
NOTE: the immediate cause of death may be the infection, but the underlying (proximate) cause of death is neglect.
What is the definition of Munchausen Syndrome by Proxy?
a form of child abuse in which a parent or guardian fabricates or induces an illness in a child
Children subject to Munchausen Syndrome by Proxy (are/are not) killed by an impulsive act.
What 4 qualities are characteristic of Muncahusen Syndrome by Proxy? (EUEO)
- Eagerness for invasive procedures
- Unusual familiaritywith medical jargonand disease
- Excessive familiarity with medical staff
- Often involved in health care themselves