Investigation of Child A Team Based Approach -...
Transcript of Investigation of Child A Team Based Approach -...
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Investigation of Child Fatalities: A Team Based
Approach
Antoinette L. Laskey, MD, MPH, MBA
Professor of Pediatrics
Objectives
• Recognize leading causes of preventable deaths inchildren
• Describe a multidisciplinary approach to childfatality (or near‐fatality) investigations
Causes of Death in Infants (28 days to 11 months)1. SIDS
2. Congenital anomalies
3. Unintentional injuries
4. Diseases of the circulatory system
5. Gastritis
6. Homicide
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Most Common Causes of Preventable Death in InfantsManner of Death: Accident
• Asphyxiation
• Fire
• Traffic
• Exposure (overheating)
• Drowning
Most Common Causes of Preventable Death in InfantsManner of Death: Homicide
• Abusive head trauma
• Physical abuse (smothering, beating, strangling)
• Drowning/poisoning
• Neglect resulting in death
Most Common Causes of Preventable Death in InfantsManner of Death: Underdetermined
• SUID
• SIDS
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Terminology
• SUIDI: Sudden Unexpected Infant DeathInvestigation
• SUID: Sudden Unexpected Infant Death
• SIDS: Sudden Infant Death Syndrome
• SUID ≠ SIDS
• Co‐sleeping: sharing a room with a baby
• Bed‐sharing: sharing a sleep surface with a baby
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Unsafe Sleep Deaths
Can be due to • Wedging
• Overlay
• Smothering
• Rebreathing/overheating
Determining the Cause and Manner• SIDS/SUID is a diagnosis that cannot be mademedically without key scene information
• This means DOCTORS cannot determine if this is the cause of death in the hospital or at autopsy without having other data!
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SUIDI Team Players
Death Investigators• Law enforcement• Deputy coroners• Child Protection workers
• Pathologist
Witnesses and family• Placer• Last Known Alive• Finder
The Top 25
• National panel of forensic pathologists developed the Top 25
• Includes information that has to be collected by non‐medical investigators
• Includes information that has to be collected as soon as possible to the precipitating events
Death Scenes
• If an infant dies at the scene, the investigators areinvolved immediately and know what to do
If an infant makes it to the hospital, the death scene • May be in multiple locations
• May not be properly investigated due to delays inactivation of the system
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Fatal Physical Abuse
Fatal Physical Abuse
Leading cause: Abusive head trauma
Second leading cause: Abusive abdominal trauma
May also be due to
• Poisoning
• Smothering/strangulation
• Weapons
• Burns
• Severe physical assault
• Drowning
Fatal Physical Abuse
• General scene information• Location of rooms and furniture
• Upkeep and condition of premises
• Any medications or potential poisons
• Presence of food (and access to food)
• Evidence related to event• Clothing
• Water (examples: tub, sink, water on floor)
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Abusive Head Trauma
• Leading cause of inflicted trauma death <4 years
• Studies in international populations show shaking is more common than medically recognized
• >80% of head trauma deaths <2y are due to abuse
Victims
• Children less than 2 years of age• Highest risk between 6 weeks and 4 months
• Older children can be shaken hard enough to causeinjury
Risk Factors for Infants
• Normal infants cry for 2‐3 hours per day
• Research has shown 20‐30% of infants exceed this,sometimes substantially
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Triggers
• “I didn’t want to choke him, but I wanted him tostop crying. I picked him up and I shook him; I threw him on the bed and he bounced…”
• “He was crying; it drove me crazy, I shook him…maybe 10 times and threw him on the sofa.”
Triggers
• “I had fits of anger. She would cry; sometimes, when she did that, I’d shake her…I got worked upand twisted her arm; I was slapping her hard for more than 2 months.”
• “I shook her so she’d be quiet, it lasted maybe 5 minutes; I was exasperated; I shook her up anddown…I was shaking her hard; I was crying just likeshe was and I was worked up.”
Intracranial Injury
• Shaken Baby Syndrome (SBS)
• Abusive Head Trauma (AHT)• Inflicted Traumatic Brain Injury (iTBI)
• Shaken Impact Syndrome (SIS)
• Whiplash Shaken Baby Syndrome• Non‐Accidental Head Trauma (NAT)
• Blunt force trauma to the head
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Physical Vulnerabilities
• Big heads relative to body size• Child’s head is 10‐15% of total body weight
• Adult’s head is 2‐3% of total body weight
• Weak neck muscles
• Larger relative space between the brain and theinside of the skull
• Less developed brains than adults
Shaking and Impact
• There often is an impact• Baby can be thrown down
• Baby can be slammed into a stationary object
• We may not be able to tell there was an impact externally
• There is impact within the skull
Retinal Hemorrhages
• Not found in all cases
• 85% of fatalities
• Doesn’t predict severity
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Retinal Hemorrhages
• Not all retinal hemorrhages are the same• Single layer are non‐specific
• Posterior pole are non‐specific
• Retinoschisis is specific for abuse
• Multi‐layer to the periphery are specific
Rib Fractures
• Most often posterior
• Acute may not be seen on initial x‐ray
• 10‐14 days for callus formation
• Squeezing mechanism
• Rarely bruising associated
Metaphyseal Fractures
• Only in patients <15m
• Difficult to see if images not collimated on the joint
• Due to forceful separation of the metaphysis from the shaft
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Other Injuries
• May be no external injuries seen
Key Point
If a child presents with • Vomiting
• Lethargy
• New onset seizure
• Irritability
You must conduct a complete• History
• Physical exam
Trauma History
Ask
• Length of fall
• Landing surface
• Position baby landed
• Response of baby after trauma
• Response of caregiver after trauma
• Symptoms noted by any witness
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Exam
Examine all of the skin • Document bruises, petechiae
Examine the mouth
• Document the labial and lingular frenula• Torn frenula are rare in non‐mobile infants
Key Point
You should consider
• Head CT or MRI
• Skeletal survey
• Blood counts
• Liver function
• Coagulations studies
• Dilated fundoscopic exam
Imaging
• Skeletal survey should be done according to theACR Guidelines (Google: ACR Skeletal Survey)
• Repeat the skeletal survey in 2 weeks to look for healing rib fractures (may leave off repeat skull, pelvis and spine films)
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Key Point
• Abusive head trauma that is missed due to subtle initial presentation may result in further injury or death if returned to the caregiver who caused theinjury
Outcomes
• Approximately 1/3 of patients will die
• 1/3 have serious, life long morbidity
• 1/3 that look “normal” at discharge almost always have some level of behavioral, developmental or learning impairment manifest as they get older
Cases
• 6mo found not breathing in crib by boyfriend ofmom
• Claims fed normally then put down, checked on her 15 minutes later and found not breathing
• At hospital, found to have massive skull fracture, devastating brain injury, bruising and swelling over back of head
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Cases
• 4m infant, reportedly laid on couch while mom’s boyfriend fixed her bottle in kitchen
• Returned to find baby being “shaken” like a toy by puppy
• Grabbed baby from puppy’s jaws and drove tohospital
• Baby had bleeding on the brain (subduralhemorrhage) and in the eyes
Second only to AHT
• 2nd leading cause of child abuse fatalities
• 40% fatality rate
Victims
Tend to be older than abusive head trauma victims
Triggers are slightly different• Discipline issues
• Toilet training issues
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Types of Injuries
Most common injuries:• Transected or perforated duodenum
• Fractured or contused pancreas• Traumatic pancreatitis
• Liver contusion or fracture• Disseminated intravascular coagulation (DIC)
• Traumatic hepatitis
• Splenic rupture
Types of Injuries
Types of Injuries
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Mechanism of Injury
• Kicks to the abdomen
• Punches to the abdomen
• “Jack‐knifing”—being thrown against an object andbending in half
• Body slams
Difficulty in Identifying Injury
If non‐offending caregiver isn’t present for the event, they may not be able to recognize the serious internal injury
• Symptoms are non‐specific• Vomiting
• Crying
• Abdominal pain
• Anorexia
Difficulty in Timing the Injury
Symptoms may slowly progress• Peritonitis
• Bleeding
• Infection
Symptoms may rapidly progress• Bleeding
• Shock
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Key Point
• When considering the possibility of abdominaltrauma, consider concurrent injuries
• Skeletal survey, even in slightly older children (up to 36 months)
• Head injuries, especially in infants
• Cutaneous injuries: document all bruises
Key Point
Lab studies • Liver function tests: AST or ALT >80 indicate the possibility of a forensically relevant injury, even if it is not a clinically relevant injury
• Blood counts: consider risk of anemia and hypovolemiaas well as infection
Confusing Cases
Older children can have serious internal injuries from traumas like
• Seat belts
• Bicycle handlebars
• Being run over by a car
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Confusing Cases
The key to understanding these cases is the history• History from the victim or witnesses if possible
• History from caregivers about symptoms
Poisoning
Poisoning
Increasing number of deaths nationally due to poisoning in children
Leading drugs• Methadone
• Fentanyl patches
• Methamphetamine
• Illicit drugs (all kinds)
• Over the counter cough and cold medications
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Poisoning
• Cases frequently look like “SIDS” at autopsy, only discovered to be poisoning after tox screen comes back
• Better to assume possibility of poisoning from theoutset
Scene Considerations
• Evidence of illegal drug use or production
• Evidence of large quantities of prescription drugs
• Evidence of methadone
• Medications left out as if being currently used
Case
• 3mo infant found unresponsive face up in crib
• Sleep environment dangerous—pillows, blankets, stuffed animals
• None of these apparently near child on discoverythough
• Mom reports baby woke normally at 3AM, fedwithout difficulty and then went back to sleep
• Mom work at 11AM and realized baby hadn’t woken up around 8AM as usual
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Case
• On entering the room, mom reports she “knewsomething was wrong” and ran to bedside
• Baby was cold to the touch and not breathing
• EMS finds infant in crib as mom described, fixedlividity posteriorly
• Documents “probable SIDS” and transports tohospital
• ED documents no injuries on exam, non‐viable infant
Case
• ED discharge diagnosis (and initial report to LE)“probably SIDS”
• Autopsy next day reveals no external or internal injuries, no clear evidence of suffocation
• Preliminary autopsy report is “undetermined/undetermined”
• Toxicology is sent
Case
• 4 weeks later, official toxicology report is received:• Oxycodone
• Methadone
• Scene investigation…• Mom has subsequently moved, unable to be located
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Drug Endangered Children
• Remember—if you find drugs or paraphernalia inthe child’s home—they are drug endangered
• Parents who use are unable to effectively and safely parent
• Increased risk for children of all ages for physicalabuse, sexual abuse and neglect
• Increased risk of accidental ingestion
• Increased risk of being intentionally given drugs
Drug Endangered Children
• Children generally should not be drug tested unless they are exhibiting symptoms
• A negative drug test (including hair) does not meanthe child was not endangered or exposed
Drug Endangered Children
• Children DO need a medical evaluation by a primary care physician, preferably who knows them
• They need to be screened for growth, development, immunizations, unmet healthcare needs AND develop a continuity relationship
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Drowning
Drowning
• 10 people die each day from drowning• 2 of these will be <14y old
• 2nd leading cause of death for children
1‐14y old
• For every child who drowns, 4 receive care for near‐drowning events
• Increasing number of autistic victims
• Survivors can have substantial neurological injuries
Drowning
Inside• Buckets
• Tubs
• Toilets
• Sinks
Outside• Pools/hot tubs
• Decorative fish ponds
• Natural bodies of water
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Scene Investigation
Evidence of submersion• Wet clothes
• Wet surfaces
• Water where the submersion reportedly took place
Evidence of barriers • Locks on doors, fences
• Dog doors
• Barriers and ladders
Scene Investigation and Interview
• Evidence of supervision• Quality of supervision: Eyes on? Ears on? Arm’s length?
• Distractors
• Impairments
• Hand offs
Drowning
• It may not be possible to sort out an intentionalfrom an unintentional
• A tragic “accident” may have been preventable with appropriate supervision
• Consider: Was it neglect?
• Are other children at risk due to inadequate supervision+/‐ hazards in the environment
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Summary
• Infants and children don’t die from the same things as adults
• Scene investigation and interviews must be broadfrom the beginning to not miss important clues
• Detailed histories of time courses and allsurrounding events are crucial
Summary
• Medical information can be confusing—finding someone who can be an interpreter is helpful
• Find out who is your closest child abuse pediatrician ormedical resource
• Talk with the medical examiner
• Talk to the child’s primary care physician
The Team Approach
Identifying fatal (or near fatal) child abuse is dependent on a multidisciplinary approach
• Medical professionals have critically necessaryinformation that investigators need
• Often, the diagnosis cannot be made with only medical information
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The Team Approach
Medical providers should share • The history they have from the caregivers
• The medical information in terms that a non‐medical professional can understand
• Whether the injuries are consistent with the statedhistory
• Suspected timing based on the medical information• Remember: this answer may be “We don’t know”
The Team Approach
Investigators can provide the medical team• Scene information
• Scene photos
• Witness statements
• Caregiver statements
The Team Approach
When a child dies, more than one medical provider may be able to help the investigators
• First responders• Radiologists
• Surgeons
• Primary care physicians
• Forensic pathologists
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The Team Approach
• Working together as a team helps a child tell their story
Summary
• Prevention is always the goal• We can’t turn back the clock on a death that has alreadyoccurred
• We may be able to prevent a future death—in thisfamily or another one in the community