01Approach to the Critical Patient/attcp51

Immediate resuscitation priorities

›Unresponsive infant in ED

›Initiate pediatric BLS immediately

›2025 AHA/AAP PALS guidelines

›Compression-to-ventilation ratio 15:2 (two-rescuer)

›Call for resuscitation team and equipment

›Pediatric code cart at bedside

›Defibrillator/AED available

›Airway control

›Bag-mask ventilation with 100% oxygen

›Endotracheal intubation if prolonged resuscitation

›Rhythm and cardiac assessment

›Cardiac monitor and 12-lead ECG as soon as feasible

›VF/pVT: defibrillation 2 J/kg first shock

›Asystole/PEA: CPR and epinephrine

›Epinephrine IV/IO 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL solution)

›Repeat every 3–5 minutes

›IO access preferred if IV not immediately available

›Reversible causes — 4 Hs and 4 Ts

›Hypoxia, Hypovolemia, Hypothermia, Hypo/Hyperkalemia

›Tension pneumothorax, Tamponade, Toxins, Thrombosis

›Time-sensitive pronouncement and investigation triggers

›If unsuccessful resuscitation, notify medical examiner/coroner

›Do not remove IV/IO lines or tubes

›Preserve evidence for death scene investigation

›Safe sleep environment details from EMS/caregivers

›Sleep position, surface, bedding, co-sleeping

›Last seen alive time and circumstances

02History/hx72

Sleep environment and event circumstances

›Sleep position and surface

›Prone sleep position — strongest modifiable risk factor

›Back to Sleep campaign reduced SIDS rate by 39%

›Side position also elevated risk versus supine

›Sleep surface type

›Adult mattress, sofa, armchair — increased risk

›Firm, flat, separate sleep surface recommended

›Bedding and environment

›Loose blankets, pillows, bumpers, stuffed animals

›Overheating and overbundling

›Co-sleeping and bed sharing

›Bed sharing with adult caregiver

›Risk ≥2× baseline; higher if caregiver smokes or intoxicated

›Risk highest in first 12 weeks of life

›Sofa and armchair sharing

›Significantly elevated suffocation risk

›History from all present caregivers

Prenatal and birth history

›Prenatal exposures

›Tobacco exposure — strongest modifiable prenatal risk factor

›Dose-dependent increased SIDS risk

›Postnatal secondhand smoke also increases risk

›Alcohol, marijuana, and opioid use during pregnancy

›Each independently associated with SIDS

›Combined exposure compounds risk

›Prenatal care adequacy

›No prenatal care OR 1.7

03Physical Exam/exam56

Initial assessment of unresponsive infant

›Responsiveness and tone

›Response to stimulation

›Completely unresponsive — initiate CPR

›Minimal response — airway and breathing priority

›Muscle tone

›Flaccidity — neurologic or terminal

›Abnormal posturing

›Airway and breathing

›Airway patency

›Nasal and oropharyngeal obstruction

›Position and positioning maneuver response

›Spontaneous respiratory effort

›Agonal versus absent breathing

›Chest rise with ventilation

›Circulation

›Pulse check

›Brachial pulse in infants

›Central versus peripheral pulse quality

›Skin perfusion

›Mottling, pallor, cyanosis

›Capillary refill time

Trauma and abuse screen

›Skin and soft tissue

›Bruising in pre-mobile infant

›Any bruising is a red flag in non-mobile infant

›Pattern, distribution, and aging of bruises

›Petechiae

04Differential Diagnosis/ddx69

Life-threatening causes within SUID

›Non-accidental trauma

›Intentional suffocation

›No external marks in many cases

›ICD-10 T71 — asphyxiation

›Abusive head trauma

›Retinal hemorrhages, subdural hematoma

›ICD-10 T74.4 — shaken baby syndrome

›Cardiac channelopathies

›Long QT syndrome

›~5–10% of SUID attributable to channelopathies

›ICD-10 I45.81

›Brugada syndrome

›Right bundle branch pattern and ST elevation V1-V3

›Genetic testing of surviving family members

›Catecholaminergic polymorphic ventricular tachycardia

›Exercise or emotion-triggered VT

›Family history of syncope or sudden death

›Inborn errors of metabolism

›MCAD deficiency

›~1% of SUID

›Fasting intolerance, hypoketotic hypoglycemia

›Fatty acid oxidation disorders

›Carnitine deficiency

›Organic acidemias

Accidental and environmental causes

›Accidental suffocation and asphyxia

›Soft bedding overlay

05Laboratory Tests/lt69

Emergency metabolic and toxicology panel

›Point-of-care glucose

›Critical hypoglycemia threshold <2.6 mmol/l

›Inborn error of metabolism screen trigger

›Fasting hypoketotic hypoglycemia pattern

›Repeat after resuscitation

›Stress hyperglycemia common

›Persistent hypoglycemia requires metabolic workup

›Electrolytes and renal function

›Sodium, potassium, chloride, bicarbonate

›Hyperkalemia in prolonged downtime

›Metabolic acidosis severity

›Creatinine and BUN

›Organ injury marker

›Prerenal versus intrinsic

›Ammonia

›Elevated in urea cycle defects and organic acidemias

›>100 mcmol/l — urgent metabolic consultation

›Sample on ice, immediate processing

›Lactate

›Elevated in metabolic disorders, sepsis, hypoperfusion

›>2 mmol/l — significant organ hypoperfusion

›Repeat after resuscitation to trend

Toxicology screen

›Urine toxicology

›Opioids, benzodiazepines, stimulants, cannabinoids

›Collect before administration of medications

›Immunoassay has cross-reactivity limitations

06Diagnostic Tests/dt89

Scoring Systems

›BRUE risk stratification criteria (AAP 2016)

›Lower-risk BRUE criteria — all must be met

›Age >60 days

›Gestational age ≥32 weeks and corrected age ≥45 weeks

›First BRUE, no recurrence

›No CPR by trained medical provider required

›No concerning history or physical exam features

›Higher-risk BRUE criteria — any one present

›Age ≤60 days

›Preterm birth or low corrected gestational age

›Recurrent event or CPR by trained provider required

›Concerning features on history or exam

›SUID triple risk model (pathophysiologic framework)

›Intrinsically vulnerable infant

›Prematurity, genetic predisposition, brainstem immaturity

›Serotonin receptor deficiency in medullary raphé

›Critical developmental period

›Peak incidence 2–4 months of age

›Rapid autonomic and arousal system maturation

›Exogenous stressor

›Prone position, overheating, co-sleeping, infection

›Convergence of all three required in model

›SIDS risk score (Polavarapu 2022)

›Variables include sleep position, smoking, bed sharing, prematurity

›Not validated for clinical use in ED

›Research tool for epidemiologic risk stratification

MRI

›Postmortem MRI utility

›Structural brain assessment

›Subdural hematoma — abusive head trauma

›Cortical contusions, diffuse axonal injury

›ICD-10 S06.4 — epidural hemorrhage

›Posterior fossa anatomy

›Brainstem hypoplasia or dysplasia

›Chiari malformation

›Brainstem and medullary assessment

›Raphé nuclei abnormalities in SIDS research context

›Not routine clinical MRI — research/forensic autopsy

›Clinical MRI indications in surviving infant (BRUE)

›Brain MRI for suspected NAT

›Subdural, subarachnoid, or epidural collections

›Shear injury on diffusion-weighted imaging

›Brain MRI for neurologic cause of BRUE

›Malformations of cortical development

›Vascular anomalies

CT

›Head CT in ED evaluation

›Indication: suspected abusive head trauma

›Sensitivity ~90% for acute subdural hematoma

›Skull fractures — accidental versus non-accidental pattern

›Head CT first-line if neurologic concern in BRUE

›Fast acquisition in uncooperative infant

›Follow with MRI for more detail

›Limitations

›Radiation exposure — ALARA principle

›May miss isodense subacute subdural

›Skeletal survey components

›Standard views — skull, spine, chest, abdomen, extremities

›Posterior rib fractures highly specific for NAT (specificity >95%)

›Metaphyseal corner fractures — classic bucket-handle fractures

›Repeat skeletal survey at 2 weeks

›Subperiosteal new bone formation becomes visible

›Detection sensitivity increases at follow-up

›Chest CT

›Pulmonary hemorrhage assessment

›Diffuse alveolar hemorrhage pattern

›Rare cause of SUID

›Mediastinal assessment

›Thymic enlargement — normal variant in infants

›Not a SIDS risk factor despite historical claim

Ultrasound

›Cardiac ultrasound in resuscitation

›Point-of-care echo during cardiac arrest

›Cardiac motion assessment for resuscitation guidance

›Pericardial effusion/tamponade identification

›Structural cardiac assessment

›Septal defects, outflow obstruction

›Systolic function estimation

›Formal echocardiography indications

›Murmur identified on exam

›Structural congenital heart disease

›Function assessment — cardiomyopathy

›Family history of channelopathy or cardiomyopathy

›Hypertrophic cardiomyopathy screening

›Dilated cardiomyopathy

›Abdominal and FAST ultrasound

›Hepatic or splenic injury in NAT

›Free fluid in peritoneum

›Organ laceration

›Renal assessment

›Adrenal hemorrhage

›Rare in NAT but described

07Disposition/dispo46

Pronouncement and medical examiner pathway

›Infant found deceased

›Pronouncement of death by physician

›Document time of pronouncement

›Notify attending and senior physician

›Mandatory medical examiner/coroner notification

›Required by law in all jurisdictions for unexpected infant death

›Do not remove IV/IO lines or ETT without ME authorization

›Death scene investigation coordination

›Law enforcement or ME investigator

›EMS provides initial scene information

›Family notification and support

›Private room for family

›Social work consultation immediately

›Chaplaincy or spiritual care as requested

›Allow family time with infant

›After ME authorization and documentation

›Photographs and keepsakes offered per protocol

›Grief resources at discharge

›First Candle, Share Pregnancy and Infant Loss Support

›Local bereavement services

BRUE disposition criteria

›Lower-risk BRUE

›Brief observation 1–4 hours acceptable

›No mandatory admission per AAP 2016 guideline

›Repeat BRUE during observation — reassess risk

›Discharge with safety netting

›Safe sleep counseling mandatory before discharge

08Treatment/t97

Resuscitation and cardiac arrest management

›Pediatric BLS sequence (2025 AHA/AAP PALS)

›Compressions

›Rate 100–120 per minute

›Depth one-third AP chest diameter (~4 cm infant)

›Two-finger or two-thumb encircling technique

›Ventilation

›2 breaths after every 15 compressions (two-rescuer)

›1 breath every 3–5 seconds if advanced airway in place

›Minimize interruptions

›Pulse check <10 seconds

›Switch compressors every 2 minutes

›Advanced cardiac life support

›Epinephrine

›0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL solution)

›Repeat every 3–5 minutes

›Higher dose 0.1 mg/kg if no response — not routinely recommended

›Vascular access

›IO access — tibial tuberosity, distal femur

›Intraosseous preferred over peripheral delay

›Defibrillation for shockable rhythms

›First shock 2 J/kg

›Second shock 4 J/kg

›Subsequent shocks 4–10 J/kg (max 10 J/kg or adult dose)

›Airway management

›Bag-mask ventilation first-line

›Appropriate mask size — covers nose and mouth

›Chest rise confirmation

›Endotracheal intubation

›Uncuffed ETT preferred in infants under 1 year

›ETT size: (age/4) + 3.5 for term newborn ~3.5 mm

›Supraglottic airway as rescue

›Laryngeal mask airway — size 1 for neonates, 1.5 for infants

›Bridge to definitive airway

BRUE management (lower-risk)

›Observation and monitoring

›Continuous pulse oximetry for observation period

›Duration 1–4 hours after event

›Cardiorespiratory monitor

›No routine laboratory testing for lower-risk BRUE

›AAP 2016 guideline recommendation

›Targeted testing if exam findings suggest etiology

›Recommended interventions for lower-risk BRUE

›Pertussis testing if vaccination status incomplete or community exposure

›Nasopharyngeal PCR

›Azithromycin 10 mg/kg once daily x5 days if confirmed

›12-lead ECG

›Screen for long QT — QTc >460 ms in infants

›Brugada pattern

›Not recommended for lower-risk BRUE

›Home apnea monitor — does not prevent SIDS

›AAP Level A recommendation against routine use

›Not evidence-based for SIDS prevention

›Routine chest X-ray, blood gas, glucose, CBC in lower-risk

›Unless specific indication from history or exam

Safe sleep counseling (SIDS prevention)

›AAP 2022 safe sleep recommendations (Level A)

›Sleep position

›Supine for every sleep until age 12 months

›Tummy time supervised while awake to prevent plagiocephaly

›Sleep surface

›Firm, flat, non-inclined surface in own sleep space

›Approved crib, bassinet, or portable play yard

›Sleep environment

›Own separate sleep space in caregiver's room for first 6 months ideally 12 months

›No soft bedding, bumpers, pillows, or toys

›Protective factors counseling

›Breastfeeding encouragement

›Any breastfeeding reduces SIDS risk

›Protective effect dose-dependent

›Pacifier use at sleep onset

›Protective after breastfeeding established

›Cochrane 2017 — protective for SIDS (Level B)

›Room temperature

›Avoid overheating — comfortable room temperature

›Light clothing sleep sack preferred over loose blankets

›Modifiable risk factor elimination

›Tobacco smoke elimination from household

›Prenatal and postnatal smoke exposure — dose-dependent risk

›Refer all household smokers to cessation program

›No alcohol or sedating substances before co-sleeping

›Avoid co-sleeping if <3 months or preterm

›Safe sleep surface preparation if bed sharing unavoidable

›Immunization schedule adherence

›Routine vaccination protective against SIDS (Level A)

›No increased SIDS risk from vaccines

Family bereavement care after SIDS death

›Immediate support

›Social work consultation within 1 hour

›Grief counseling pathway initiated

›Practical support — who is with family, transport

›Follow-up appointment within 1–2 weeks

›Surviving siblings evaluation

›Autopsy and investigation results review

›Ongoing care

›Monitor for complicated grief, depression, PTSD

›Refer to mental health professionals

›Peer support groups — First Candle, The Compassionate Friends

›Future pregnancy counseling

›Slightly increased risk in subsequent siblings

›Safe sleep practices reinforced for all future infants

09Special Populations/sp72

Pregnancy

›Prenatal SIDS risk reduction

›Tobacco cessation during pregnancy

›Strongest modifiable prenatal risk factor

›NRT patches safe in pregnancy — benefit outweighs risk

›Alcohol and substance avoidance

›Alcohol, marijuana, opioids all independently increase SIDS risk

›Medication-assisted treatment for opioid use disorder is preferred over untreated use

›Adequate prenatal care

›No prenatal care OR 1.7 for SIDS

›Address barriers to care access

›Maternal conditions affecting infant risk

›Young maternal age <25 years

›Increased SIDS risk independent of other factors

›Enhanced counseling and follow-up

›Mental health conditions

›Depression may affect adherence to safe sleep practices

›Integrated care model

›Interpregnancy interval

›Short interval (<12 months) associated with increased risk

›Contraceptive counseling postpartum

›Postpartum safe sleep education

›Hospital-based education before discharge

›Written and verbal information on safe sleep

›Demonstration of safe sleep environment

›Hospital sleep environment modeling

›Infants should room-in supine in approved bassinets

›Avoid swaddled prone positioning in hospital

10Background/b95

Epidemiology

›Incidence and prevalence

›US annual SUID deaths ~3,500

›SIDS accounts for ~41% of all SUID

›Approximately 1,400 SIDS deaths annually in the US

›Rate decline following Back to Sleep campaign (1994)

›SIDS rate declined by approximately 39% since campaign launch

›Plateau in decline since 2000 despite continued promotion

›Global variation

›Higher rates in indigenous and socioeconomically disadvantaged populations

›African American and Native American infants — 2–3x national average SIDS rate

›Demographic patterns

›Age distribution

›Peak 2–4 months

›90% before 6 months; rare before 1 month

›Sex

›Male predominance — OR 1.7

›Seasonal variation

›Higher incidence in winter months

›Possibly related to respiratory infections and overheating

›Mortality and morbidity

›SIDS is leading cause of post-neonatal infant mortality in US

›Post-neonatal period: 28 days to 1 year

›Significant family and community impact

›Total SUID mortality includes SIDS + suffocation + undetermined

›Suffocation rates rising as SIDS rates fall — possible diagnostic shift

›Coding inconsistency across jurisdictions

Pathophysiology

›Triple risk model

›Vulnerable infant

›Intrinsic brainstem serotonin system deficiency

›Serotonin (5-HT) deficiency in medullary raphé and arcuate nucleus

›Impaired autonomic and arousal responses to hypoxia and hypercapnia

›Critical developmental period

›2–4 months — rapid maturation of cardiorespiratory control

›Autonomic nervous system instability

›Transitioning sleep-wake architecture

›Exogenous stressor

›Prone position — impaired arousal, rebreathing of CO2

›Soft bedding — CO2 accumulation and airway obstruction

›Overheating — blunted arousal response

›Serotonin hypothesis

›Brainstem serotonin deficiency — most evidence-based neurobiological model

›Kinney and Thach, NEJM 2009 — key review

›5-HT1A receptor deficit in medullary raphé

›Role of serotonin in autonomic responses

›Impaired response to CO2 accumulation

›Failure of autoresuscitation during hypoxic apnea

›Supportive findings

›Auditory brainstem response abnormalities in SIDS cases (Maylott 2024)

›Newborn metabolic patterning differences (Oltman JAMA Pediatr 2024)

›Cardiac genetic mechanisms

›Channelopathies in 5–10% of SUID

›SCN5A mutations — long QT type 3 and Brugada

›KCNQ1, KCNH2 mutations — long QT types 1 and 2

›Post-mortem whole-exome sequencing findings

›Neubauer et al. EJHG 2017 — cardiovascular and metabolic variants

›Tester et al. JACC 2018 — cardiac genetic predisposition

›Arousal deficit hypothesis

›Impaired arousal from sleep during hypoxia

›Prone position blunts arousal threshold

›CO2 rebreathing from soft bedding

›Preterm infants — augmented arousal instability

›Horne et al. Sleep Medicine Reviews 2024

›Immature pontine and medullary circuitry

Therapeutic Considerations

›Prevention — no pharmacologic treatment exists for SIDS

›Safe sleep environment is the only proven intervention

›AAP 2022 updated safe sleep guidelines

›Public health campaigns — Back to Sleep, Safe to Sleep

›Home apnea monitors are not recommended for SIDS prevention

›AAP Level A recommendation against routine use

›Do not prevent SIDS and may provide false reassurance

›Evidence base for protective interventions

›Supine sleep position — Level A (strongest evidence)

›39% reduction in SIDS rate following recommendation

›Moon, Carlin, Hand. Pediatrics 2022

›Breastfeeding — Level A

›Any breastfeeding protective; exclusive breastfeeding optimal

›Duration-dependent protective effect

›Pacifier use at sleep onset — Level B

›Cochrane 2017 systematic review

›Offer after breastfeeding established

›Routine immunization — Level A

›Vaccines do not cause SIDS; vaccination is protective

›Avoidance of soft bedding and inclined surfaces — Level A

›Firm, flat surface required

›No bumpers, loose blankets, or pillows

›Emerging and investigational areas

›Newborn metabolic screening for SIDS risk markers

›Oltman et al. JAMA Pediatrics 2024 — metabolic patterning differences

›Not yet clinical practice

›Genetic screening of surviving family members

›Channelopathy panel for first-degree relatives

›Informed by 2021 AAP and 2026 AHA/AAP PALS guidelines

›Serotonin system biomarkers

›Research in postmortem brainstem tissue

›Future antemortem biomarker identification — investigational

11Patient Discharge Instructions/pdi55

copy discharge instructions

›Safe sleep instructions for your baby

›Always place baby on their back to sleep

›Every sleep — naps and nighttime

›Until baby is 12 months old

›Use a firm, flat sleep surface

›Approved crib, bassinet, or play yard

›No adult beds, sofas, armchairs, or inclined surfaces

›Keep the sleep area clear

›No loose blankets, pillows, bumpers, or stuffed animals

›Use a fitted sheet only on the mattress

›Your baby should sleep in your room but not in your bed

›Ideally for the first 6 months — up to 12 months is best

›Use a separate bassinet or crib next to your bed

›Protective habits to reduce risk

›Breastfeed if you are able

›Any amount of breastfeeding helps protect against SIDS

›Talk to your nurse or lactation consultant for support

›Offer a pacifier at sleep time

›Wait until breastfeeding is well established (3–4 weeks)

›Do not force it if baby refuses

›Keep smoke out of your home and car

›No smoking near baby — before and after birth

›Ask household members who smoke to do so outside

›Do not let baby get too hot during sleep

›Dress baby in one more layer than you would wear

›Sleep sacks are safer than blankets

›Keep baby's vaccinations up to date

12References/r36

Guidelines and key sources

›AAP 2022 Safe Sleep Guideline

›Moon RY, Carlin RF, Hand I. Sleep-Related Infant Deaths: Updated 2022 Recommendations. Pediatrics 2022

›Primary evidence base for all safe sleep recommendations

›Supine sleep, firm surface, room sharing, breastfeeding

›AAP 2016 BRUE Guideline

›Tieder JS et al. Brief Resolved Unexplained Events (Formerly ALTEs). Pediatrics 2016

›Defines BRUE, replaces ALTE terminology

›Lower-risk and higher-risk stratification criteria

›AHA/AAP PALS 2025 Guidelines

›Lasa JJ et al. Part 8: Pediatric Advanced Life Support. Pediatrics 2026

›CPR compression depth, rate, drug dosing

›IO access, defibrillation energy recommendations

Landmark studies and reviews

›Kinney HC, Thach BT. The Sudden Infant Death Syndrome. NEJM 2009

›Brainstem serotonin deficiency model

›Triple risk convergence framework

›Medullary raphé and arcuate nucleus pathology

›Carlin RF, Moon RY. Risk Factors, Protective Factors, and Current Recommendations. JAMA Pediatrics 2017

›Comprehensive risk factor review

›Quantified odds ratios for modifiable and nonmodifiable risk

›Evidence levels for protective interventions

›Tester DJ et al. Cardiac Genetic Predisposition in SIDS. JACC 2018

›Channelopathy genetics in SUID cohort

›Prevalence of pathogenic cardiac gene variants

›Post-mortem genetic testing rationale

›Oltman SP et al. Early Newborn Metabolic Patterning and SIDS. JAMA Pediatrics 2024

›Newborn metabolic differences in infants who later died of SIDS

Evidence & Review