Rosen & Barkin's 5-Minute Emergency Medicine Consult (685 page)

• SIDS is a diagnosis of exclusion, so requires an evaluation to identify primary and/or contributing conditions.
  
• Thorough investigation of the death scene:
  
  • Conditions surrounding sleeping space (temperature, surface, bedding, bed sharing)
    
  • Position in which infant was sleeping
    
  • Interview of parents, family members, and caregivers
    
  • Exam of potentially relevant items from the death scene
    
  • Maintain sensitivity toward family as investigation may be difficult for them.
    
• Review infant and family histories:
  
  • Prenatal, perinatal, and postnatal infant medical history
    
  • Family medical and social histories, particularly mother
    
• Impact of investigation on family:
  
  • Family is very vulnerable during the investigation
    
  • May help them through the grieving process.
    

• Selective studies reflecting nature of episode and patient condition
  
• Arterial/venous blood gas
  
• Blood culture and other sepsis workup as indicated
  
• CBC
  
• ECG
  
• Include family member to evaluate for familial dysrhythmias such as prolonged QT syndrome
  
• EEG
  
• Electrolytes including calcium, magnesium and phosphorous. Liver function tests
  
• Toxicology screen
  
• UA and culture
  

• Chest radiograph to assess cardiopulmonary status
  
• Skeletal survey to evaluate for child abuse (may be performed by pathologist)
  
• Head CT if child survives to assess intracranial pathology
  
• Consider upper GI to evaluate for GER
  

• Autopsy:
  
  • Most states require an autopsy for potential SIDS cases
    
  • Important that postmortem exam be performed as SIDS is a diagnosis of exclusion
    
  • Involves microscopic exam of vital organs through tissue samples as well as gross exam
    
  • Some postmortem findings in SIDS cases that might establish alternative cause of death:
    
    • Congenital cardiomyopathies
      
    • Cardiac rhabdomyomas
      
    • Tuberous sclerosis
      
    • Rare genetic/metabolic diseases
      
    • Viral myocarditis
      
    • Intracranial arteriovenous malformations
      

• Cardiovascular:
  
  • Anomalous coronary artery
    
  • Aortic stenosis
    
  • Cardiomyopathy
    
  • Dysrhythmia
    
  • Myocarditis
    
• Respiratory:
  
  • Aspiration
    
  • Suffocation
    
• Infection:
  
  • Botulism
    
  • Bronchiolitis/respiratory syncytial virus
    
  • Encephalitis
    
  • Meningitis
    
  • Pertussis
    
  • Sepsis
    
• CNS:
  
  • Arteriovenous malformation
    
  • Central hypoventilation
    
  • Neuromuscular disorders
    
  • Seizures
    
  • Tuberous sclerosis
    
• GI:
  
  • GER
    
  • Diarrhea
    
  • Pancreatitis
    
  • Volvulus
    
• Endocrine/metabolic:
  
  • Carnitine deficiency
    
  • Congenital adrenal hyperplasia
    
  • Glycogen storage disease
    
  • Long- or medium-chain acyl-coenzyme A deficiency
    
  • Urea cycle defect
    
• Systemic:
  
  • Child abuse
    
  • Dehydration
    
  • Intentional poisoning
    
  • Hyperthermia
    

TREATMENT

• Initiate resuscitation at the scene; transport infant to ED and continue protocols en route.
  
• On very rare occasion and under medical direction, resuscitations have been aborted and the infant is pronounced at the scene; consideration must be given to the emotional, social, and clinical circumstances.
  

• Resuscitation procedures supplemented by support for the family
  
• Evaluate setting; determine if suspicion of abuse
  

• Assess and support ABCs (bedside).
  
• Administer appropriate medications per protocols by endotracheal tube if IV access unobtainable (atropine, epinephrine, lidocaine, and naloxone).
  
• Monitor vital signs: BP, heart rate, respirations, and oxygen saturation continuously.
  
• Conduct a thorough physical exam; look for unintentional as well as intentional traumas.
  
• Assess the scene, family members, and other caretakers.
  

• Resuscitate patient per established protocols continuing efforts initiated by pre-hospital personnel:
  
  • Health care providers are encouraged to offer family members the opportunity to be present during resuscitation.
    
• If resuscitation unsuccessful and no obvious diagnosis found, parents should not be told that SIDS is the cause of death:
  
  • In speaking with the parents, SIDS may be included among the possible causes of death.
    
  • A diagnosis cannot be made until completion of an autopsy, investigation of circumstances and death scene, and exploration of the medical histories of the infant and family.
    
• Family support:
  
  • If resuscitation unsuccessful, attention should then focus on the family; if resuscitation ongoing, communication and support of family is essential.
    
  • All family members and caregivers are affected; they experience grief, guilt, failure, and inadequacy.
    
  • Some parents want to spend quiet time holding their infants after an unsuccessful resuscitation.
    
  • Family is defined variably among different cultures; ED personnel should attempt to be sensitive to cultural needs and expectations of the family.
    
  • Family should be offered support in the ED and supplied with resources of support for beyond the day of the infant’s death; local, state, and national SIDS Foundation resources should be made available.
    
  • Support may be obtained from Sudden Infant Death Syndrome Alliance/First Candle, 1314 Bedford Avenue, Suite 210, Baltimore, MD 21208 (800-221-7437) or local SIDS support organization.
    
  • The child’s PCP should be involved in the follow-up and support of the family.
    
• Emergency personnel support:
  
  • ED debriefing should be conducted for all staff who were involved in the infant’s care, including EMS personnel; it is important to allow people to express their feelings and freely process the event in a supportive environment.
    

FOLLOW-UP

• Observe all infants who have ALTE for evaluation and monitoring after initial resuscitation and stabilization.
  
• Most high-risk infants have 1 of the following variables: Obvious need for admission, significant medical history, and >1 ALTE in 24 hr.
  

Patients are generally admitted for observation and monitoring for documented episodes and support of family.

• All surviving infants should have a pediatric consultation.
  
• Families will need support.
  

Infants with SIDS or ALTE should be resuscitated appropriately. Autopsies are essential for diagnosis and should be considered mandatory. Use available resources including social workers and chaplains as support for the family is crucial.

• Carroll-Pankhurst C, Mortimer EA Jr. Sudden infant death syndrome, bed sharing, parental weight, and age at death.
  Pediatrics
  . 2001;108:1239–1240.
  
• Fu LY, Colson ER, Corwin MJ, et al. Infant sleep location: Associated material and infant characteristics with sudden infant death syndrome prevention recommendations.
  J Pediatr
  . 2008;153:503–508.
  
• Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis.
  Pediatrics
  . 2005;116:e716–e723.
  
• Kaji AH, Claudius I, Santillanes G, et al. Apparent life-threatening event: Multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital.
  Ann Emerg Med.
  2013;61:379–387.
  
• Krous HF, Beckwith JB, Byard RW, et al. Sudden infant death syndrome and unclassified sudden infant deaths: A definitional and diagnostic approach.
  Pediatrics
  . 2004;114:234–238.
  
• Paris CA, Remler R, Daling JR. Risk factors for sudden infant death syndrome: Changes associated with sleep position recommendations.
  J Pediatr
  . 2001;139:771–777.
  
• Task Force on Sudden Infant Death Syndrome, Moon RY. SIDS and other sleep-related infant deaths: Expansion of recommendations for a safe infant sleeping environment.
  Pediatrics
  . 2011;128:e1341–e1367.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Abuse, Child
  
• Apnea, Pediatric
  
• Resuscitation, Neonatal; Resuscitation, Pediatric
  

CODES