Emma O. Lew

Do Resuscitation-Related Injuries Kill Infants and Children?

Occasionally, individuals accused of inflicting fatal injuries on infants and young children will claim some variant of the “CPR defense,” that is, they attribute the cause of injuries found at autopsy to their “untrained” resuscitative efforts. A 10-year (1994–2003) historical fixed cohort study of all pediatric forensic autopsies at the Miami-Dade County Medical Examiner Department was undertaken. To be eligible for inclusion in the study, children had to have died of atraumatic causes, with or without resuscitative efforts (Natraumatic = 546). Of these, 382 had a history of cardiopulmonary resuscitation (CPR; average age of 4.17 years); 248 had CPR provided by trained individuals only; 133 had CPR provided by both trained and untrained individuals; 1 had CPR provided by untrained individuals only. There was no overlap between these 3 distinct groups. Twenty-two findings potentially attributable to CPR were identified in 19:15 cases of orofacial injuries compatible with attempted endotracheal intubation; 4 cases with focal pulmonary parenchymal hemorrhage; 1 case with prominent anterior mediastinal emphysema; and 2 cases with anterior chest abrasions. There were no significant hollow or solid thoracoabdominal organ injuries. There were no rib fractures. The estimated relative risk of injury subsequent to resuscitation was not statistically different between the subset of decedents whose resuscitative attempts were made by trained individuals only, and the subset who received CPR from both trained and untrained individuals. In the single case of CPR application by an untrained individual only, no injuries resulted. The remaining 164 children dying from nontraumatic causes and who did not undergo resuscitative efforts served as a control group; no injuries were identified. This study indicates that in the pediatric population, injuries secondary to resuscitative efforts are infrequent or rare, pathophysiologically inconsequential, and predominantly orofacial in location. In our population, CPR did not result in any rib fractures or significant visceral injuries. Participation of nonmedical or untrained individuals in resuscitation did not increase the likelihood of injury.

Shaken Infants Die of Neck Trauma, Not of Brain Trauma

Objective review of the vital statistics of sudden unexplained infant death indicates a failure of what was, initially, a public health success. Early categorization of sudden unexplained infant deaths as SIDS was a tremendously productive stimulus for wide-ranging, high profile research. It provided a very important proverbial flag around which to rally. Over time, however, many death investigators recognized the major shortcomings of the use of SIDS: 1) its inconsistent use among forensic pathologists wreaks havoc with vital statistics and 2) it masks the fundamental truth for any consumer of death certificate information (in-

What is a Complete Autopsy

Postmortem examinations have taken place over the past several thousand years. Despite this, the definition of a “complete” autopsy remains nebulus and the subject of controversy. Although ‘minimal autopsy practice standards’ have been published by professional bodies globally, recognition of, and adherence to those standards remains sporadic. An underlying refutation that ‘autopsies can never be complete’ – the reductio ad absurdum fallacy – has influenced many forensic pathologists’ opinions about autopsy. More pragmatic pathologists attempt to balance the financial and workload burdens of autopsies with the principles of adequacy and accuracy. Some medical examiners cite “statutory duty” as the force guiding the nature and completeness of their work, and as such, external examinations, partial autopsies and other limited variants are substituted for complete autopsies. Although it is impossible to perform every conceivable test in any one autopsy, an evidence-based approach guided by three forensic autopsy goals – statutory duty, the creation of a minimal dataset for societal and governmental inquiry, and maintenance of practitioner competency – ensure the completeness of any one postmortem examination.

Homicide by Unspecified Means

The fundamental function of all North American systems of death investigation is to determine cause and manner of death. Modern teaching emphasizes the need to consider all investigative aspects including careful evaluation of the scene and circumstances, history, physical examination of the body, and ancillary laboratory studies, prior to death certification. This integrative approach to forensic pathology differs from an autopsy-focused practice whose function is to produce “anatomic” cause of death statements.Some individuals die under suspicious circumstances and, despite thorough autopsy, have no anatomic cause of death. In Miami-Dade County, when the preponderance of evidence and investigative data suggest homicide despite the absence of an identifiable cause of death, “homicide by unspecified means” has been used as a summative cause of death statement. The records of the Miami-Dade County Medical Examiner Department were searched for this diagnosis, identifying 18 such cases between 1990 and 2004. The characteristics of these cases are discussed. Guidelines for the use of this diagnostic label are provided.

Routine Metabolic Testing is Not Warranted in Unexpected Infant Death Investigations

Inborn errors of metabolism (IEM) only rarely cause sudden unexpected infant death. Yet, postmortem metabolic screening is often ordered reflexively during infant death investigations, even in the absence of historical, clinical or autopsy findings suggestive of IEM. This retrospective descriptive study examines the impact of metabolic screening of infants who die suddenly in a medical examiners jurisdiction. The study population included 135 cases, one of which was certified as death due to IEM with historical and pathologic findings suggestive of IEM and an abnormal postmortem screening study, one which was certified as death due to IEM with historical and pathologic findings suggestive of IEM and a negative postmortem screening study, and one which was certified as undetermined with pathologic features of IEM and a negative postmortem screening study, but also with features suggestive of accidental asphyxia. Nine cases had abnormal postmortem screens that were deemed to represent false positives. During the entire nine-year study of these 135 cases, the utilization of screening tests in cases without historical or autopsy features of IEM did not detect any unsuspected cases. IEM may rarely cause unexpected infant death, and it can be suggested by historical and autopsy findings. Thus, within the appropriate investigative and autopsy context, judicious use of metabolic screening tests is warranted. Caution is advised when interpreting negative screening studies with suggestive historical and/or autopsy findings as the success of testing decreases with increasing postmortem interval.

An Approach to the Classification of Apparent Asphyxial Infant Deaths

Recent evidence indicates that with thorough, high quality death investigations and autopsies, forensic pathologists have recognized that many unexpected infant deaths are, in fact, asphyxial in nature. With this recognition has come a commensurate decrease in, and in some cases, abolition of, the label “sudden infant death syndrome” (SIDS). Current controversies often pertain to how and why some infant deaths are determined to be asphyxial in nature and whether or not apparent asphyxial circumstances are risk factors for SIDS, or rather, harbingers of asphyxial deaths. In an effort to sidestep these controversies, some forensic pathologists elected to instead use the noncommittal label “sudden unexpected infant death” (SUID), leading to the unfortunate consequence of SUID – like SIDS – gaining notoriety as an actual disease that could be diagnosed, studied, and ultimately cured. Although it is not possible to provide death certification guidance for every conceivable type of unexpected infant death, we recognize and propose a simple classification system for overarching themes that cover the vast majority of cases where infants die suddenly and unexpectedly.

Morbid Obesity is Not a Risk Factor for the Development of Clinically Significant Coronary Artery Atherosclerosis

Morbid obesity represents a significant health problem to a large and growing segment of the industrialized world. The cardiovascular complications are numerous and include systemic and pulmonary hypertension, obesity cardiomyopathy, heart failure, left ventricular dilatation and hypertrophy, arrhythmias, and sudden cardiac death. Morbidly obese (MO) individuals who die suddenly and unexpectedly may not have significant coronary artery atherosclerosis or acutely lethal natural diseases at autopsy. In this way, forensic pathologists may be challenged to understand the mechanism of sudden death when the major anatomic finding is often limited to cardiomegaly with or without chamber dilatation and wall thickening. The death investigation files for a large metropolitan medical examiner department were the source of data in this case-control retrospective study. A total of 3863 cases met inclusion criteria. The following data were obtained: sex, age, cause of death, manner of death, weight in pounds, height in inches, body mass index, heart weight in grams, and coronary artery atherosclerosis (CAA) severity. A population of MO decedents (N = 1290) was identified, and sex- and age-matched case controls of non-obese decedents (N = 2573) were selected. The degree of CAA was recorded for all major vascular territories in both MO decedents and control cases, and there was no statistically significant difference in CAA between decedents in the MO group and the control group. These data illustrate that obesity is not a significant independent risk factor for CAA.

Skull Base Fractures are Markers of Severe Forces in the First Two Years of Life

While experience indicates that basilar skull fractures are an uncommon injury in the first two years of life, an evidential basis for this observation is lacking in the forensic pathology literature. The aim of this study was to determine the incidence and forensic significance of basilar skull fractures in the first two years of life. This retrospective analysis reviewed pediatric deaths over a 17-year period in a large metropolitan medical examiner jurisdiction and included the deaths of infants and children under 24 months of age. All cases had a cause of death statement of “blunt head trauma”, “blunt head and neck trauma” or “blunt trauma”. Sixty-three cases were found, 23 of which had basilar skull fractures. The most common circumstance with basilar skull fracture was pedestrian versus motor vehicle accidents (57%), followed by inflicted injury (30%), and vehicle accidents in which the child was an occupant (13%). As such, basilar skull fractures are uncommon injuries that are the end result of the application of significant forces to the head. The discovery of a basilar skull fracture without an appropriate history of the accidental application of severe forces should cause those tasked with the investigation of child injuries and death to carefully consider inflicted head trauma.

Lethal Neurotoxicity Induced by Endosulfan Ingestion

Endosulfan is a highly toxic agricultural pesticide that has been banned in many countries due to its significant neurotoxicity and environmental persistence. Accidental or intentional ingestion by humans induces severe neurological symptoms, which frequently culminate in coma or death. Forensic evaluation of suspected endosulfan toxicity cases can be challenging, given that endosulfan residue may not be detectable in the blood or tissues at the time of death. As such, evaluation of the case history in the context of the reported literature becomes extremely important. Although acute endosulfan toxicity in adults has been well documented, pediatric cases are rare within the literature. Here we present the case of a toddler who accidentally ingested an unknown quantity of endosulfan from an unmarked water bottle on his family farm. The child developed rapid-onset neurological symptoms, including vomiting and seizures, followed by coma. Despite medical intervention, the child was eventually pronounced brain dead and taken off life support. Autopsy revealed massive cerebral edema and its sequelae (sutural diastasis, pituitary necrosis, and dural venous thromboses), and pulmonary thromboemboli. Endosulfan was detected in the bottle from which the child drank. As endosulfan was not detectable in postmortem blood, the cause of death was certified based upon the totality of available information including history, consistency of the case history with the clinical presentation, and the autopsy findings.

Injuries of the Upper Cervical Spinal Column are Markers of Severe Forces in the First Two Years of Life

Cervical spinal column injuries occur uncommonly in infants and young toddlers, and rarely in the upper cervical spine. Any injury, when discovered at forensic autopsy, must be interpreted within the context of a complete case investigation, and available science. When severe upper cervical spinal column injury is detected, such as atlanto-occipital dislocation (AOD), atlanto-axial dislocation (AAD) or spinal cord transection, forensic pathologists commonly regard such trauma as a marker of significant forces. This retrospective study evaluated 60 cases of accidental and homicidal deaths occurring in the first 24 months of life and investigated by a large metropolitan medical examiner jurisdiction. All cases with AOD, AAD or spinal cord transection occurred under documented accidental circumstances, and all of those cases involved severe forces, including being struck by or run over by a car. While such high cervical spinal column pathology is not unusual when an infant or young toddler is struck by or run over by a motor vehicle, or other accidental circumstance involving severe forces, this discovery in a case of apparent natural death or death following alleged short fall or other commonplace activity of daily living should be considered highly suspect.