SUID
Sudden Unexpected Infant
Death Training
for
EMS and Fire Rescue
Presented by:
Major Connie Shingledecker
Manatee County Sheriff’s Office
&
Dr. Barbara Wolf
District 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
SIDS
Neglect
Accidental
suffocation
or homicide
SUID
Hypothermia/
Hyperthermia
Metabolic
disorders
Unknown
Poisoning
SUID
Unexplained
Explained
Known
Diagnosis
Accidental
Suffocation &
Strangulation
Trauma
Poisoning
Drowning
SIDS
Undetermined
SIDS is NOT…
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–
–
–
–
–
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
Good Samaritan
• An individual, without a
previous relationship,
who voluntarily provides
emergency medical
care.
• These individuals are
not legally liable for
their actions.
EMS Emergency Medical ServicesSystems
AAcommunity’s
established
policies,
community’s
established
policies,
procedures
and
departments
procedures
and
departments
responsible for providing emergency
responsible for providing emergency
medical care.
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. Openended, 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

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.
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
MORTIS
Ambient temperature and microenvironment
• Clothing, bedding
Body habitus (under, avg., or over weight)
Body temperature at death
• Infection
• Drugs
• Prior physical activity
Ways to determine a person is dead;
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•
•
•
•
•
•
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
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
Suspicious Circumstances
placement
position issues
b. found position
issues
c. questionable
witness
accounts
d. suspicion of
inflicted injury or
poisoning
a.
Found Position Issues
• Caregivers may be unwilling or unable
to provide detailed information on body
position
• The body may have been moved
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
Other Alerts to the
Pathologist







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
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
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•
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•
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•
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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 Health
Fort 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 packn-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