A case of fatal hyperthermia in a child – Biomedical realities

Auxiliary heating. © Wikipedia

This is the story of a 14 month old baby died after being placed in a stroller inside an empty room near a space heater. The boy was almost naked, wearing only diapers. He had been placed in this room, without furniture, along with another 4-year-old boy. Both were in a mobile home in poor condition. The youngest child died.

This fatal case of pediatric hyperthermia occurred during the winter months in the southeastern United States. It was published in May 2022 in Journal of Forensic SciencesAmerican Journal of Forensic Medicine.

Rectal temperature of 42.2 ° C

It all started when the local authorities were notified in the middle of the morning by the emergency services. When help arrived, the two children were no longer unconscious in the room where they had been placed, but in the entrance courtyard. Both have been taken to the local hospital. The 14-month-old baby will succumb. Before his transport to the hospital, his rectal temperature was 42.2 ° C.

Investigators immediately noticed that the room where the children slept was extremely hot. The heat is already off. The temperature in the room is measured several times, approximately 45 minutes after the help has arrived. The thermometer shows 31.8 ° C. Carbon monoxide (CO) poisoning is excluded, as the CO content is zero during the analysis performed by the firefighters.

At the start of the investigation, the children’s caregivers said they both normally played for five minutes before calling 911, the emergency number. One of the adults had noticed that the children were behaving strangely and asked for an ambulance to be sent. When help arrived, the children were unconscious.

The autopsy of the young victim revealed discrete signs of bleeding on the surface of the heart (petechiae along the epicardium, made of the pericardium in direct contact with this organ), suggesting a lesion in hyperthermia, defined by a body temperature above 40 ° C .

Therefore, a question arises: how long did the two children stay in an overheated room before being confronted with fatal hyperthermia for one of them? Lee Bushong, an expert from the Florida State Department of Justice in Tallahassee, will be contacted by the authorities to conduct a series of experiments with the aim of answering this question. He is the first author of the article published in Journal of Forensic Sciences. The simulations are performed using the same 1500 W heater located in the same place where it was at the tragedy. The temperature at the start of the experiment is 20.5 ° C. Eventually it rises to 41 ° C.

The room is a bedroom measuring 3.48m by 2.84m, with a ceiling height of 2.26m. Two thermometers were used. One sensor was installed where the children slept, the other near the opposite wall, 2.74 m from the first sensor. However, two unknowns remain: It is not known with certainty whether the deceased child was placed in a room while it was at room temperature, or whether the temperature was already high. It is also not known what the body temperature of this child was when he was placed in the room.

Two thermal models were used for these experiments, whose data were collected over a period of 16 hours. According to the first model, the children’s temperature began to rise dangerously after 2 hours and 45 minutes. This would have happened when the room temperature rose above 36 ° C. The second simulation is based on the assumption that the children would have been placed in an already overheated room. She concludes that it only took 45 minutes for the children’s core temperature to rise above that in the bedroom and about an hour longer before their body temperature reached 39 ° C.

It’s only estimate, the authors point out. In this drama, in fact, we will never know for sure how long the children were in the room, or how long they were exposed to the heat. In the experiments performed, one parameter could not be controlled, namely the relative humidity. Furthermore, the experiments apparently did not integrate the possible effects of the two children’s breathing.

In summary, taking into account the environmental factors, the data collected during the experiments and the traces collected by the investigators, it was possible to establish that the deceased child had been exposed to a significant heat source during “a period of between 45 minutes and 2 hours and 45 minutes before his core temperature reached a dangerous level, leading to his death from hyperthermia”, we can read in the article. And the authors add that according to them it is “It is unlikely that the deceased child was playing as indicated by the one who had custody of him”.

At the end of their experiments, the authors conclude that this case corresponds to one “Child homicide due to exposure to extreme indoor environmental conditions combining negligence and hyperthermia”.

Children left alone in a car in the sun

Most pediatric cases of hyperthermia usually occur when a child is left in the cabin of a car on a hot day, or when he sleeps wrapped in an electric blanket or wearing a large layer of clothing.

A US study, published in 2020 in the journal Pediatric emergency care, shows that in about 16% of cases the child had been left alone in the vehicle by persons who were fully aware of it. Litigation was initiated in more than 58% of the cases.

Children who succumb to heatstroke are often found dead the next morning. Case reported in Journal of Forensic Sciences is unusual in that there has never been a case of fatal hyperthermia in a child without clothes for an entire night.

Failure of thermoregulation

Thermoregulation is a complex body temperature control system. The human body is actually able to maintain a stable temperature thanks to the center of thermoregulation, which is located in the anterior hypothalamus. This balances excessive heat production through cooling mechanisms such as vasodilation and sweating. The purpose of thermoregulation is to keep the core temperature within limits that are compatible with service life.

Four physiological mechanisms ensure the dissipation of body heat: radiation (diffusion of electromagnetic waves in the infrared spectrum), convection (transfer of heat to moving air or water), conduction (transfer of heat to an object directly in contact with the skin, e.g. as an ice pack or cold soil), and evaporation (every gram of sweat that evaporates on the surface of the skin allows you to lose about 0, 59 Kcal of heat). It has been shown that in children aged 52 days to 2 years, the body temperature can reach between 39.9 ° C and 41.3 ° C when exposed to a temperature above 37 ° C for a period of 4 to 7 hours.

Hyperthermia manifests itself in a state of confusion and / or loss of consciousness. The skin is warm and dry. Hyperthermia can lead to failure of the heart, kidneys, liver, central nervous system.

Heat stroke

Heat stroke is a life-threatening variant of hyperthermia. It is characterized by a rapid rise in core temperature above 40 ° C and is associated with neurological disorders that can develop into multi-organ failure (many organs malfunction) and death.

A classic example of heat stroke is hyperthermia, which occurs when a child is left in a car in direct sunlight. When the core temperature exceeds 41 ° C, vital functions are compromised. Multiple organ failure syndrome is the consequence of a complex interaction between the toxic effect of heat on cells (responsible for tissue damage), a generalized inflammatory response and bleeding.

At the autopsy of heat stroke victims, there are usually no specific signs of hyperthermia. On the other hand, some lesions are suggestive, such as small hemorrhagic skin spots (petechiae) on the skin, thymus, spleen, visceral pleura (which encloses the lungs), and epicardium (in contact with the heart muscle). Disseminated intravascular coagulation (several small blood clots inside the vascular system), cerebral and pulmonary edema can be observed.

Mark Gozlan (Follow me on TwhitesFacebook, LinkedInand on my new blog ‘Diabetes in all states’, devoted to the thousand and one facets of diabetes. Already 16 tickets)

To know more:

Bushong LC, Diao Z. Fatal Pediatric Hyperthermia: A Forensic Review. J Forensic Sci. May 2022; 67: 1092-1107. doi: 10.1111 / 1556-4029.14989

Hammett DL, KennedyTM, Selbst SM, et al. Pediatric heat stroke deaths caused by left in motor vehicles. Pediatrician Emerg Care. December 1, 2021; 37 (12): e1560-e1565. doi: 10.1097 / PEC.0000000000002115

Alunni V, Crenesse D, Piercecchi-Marti MD, et al. Fatal heat stroke in a child trapped in a confined space. J Forensic Medicine Med. 2015 Aug; 34: 139-44. doi: 10.1016 / j.jflm.2015.05.011

Grundstein AJ, Duzinski SV, Dolinak D, et al. Evaluation of infants’ core temperature response in a hot car using a heat balance model. Forensic Sci Med Pathol. 2015 Mar; 11 (1): 13-9. doi: 10.1007 / s12024-014-9619-7

Zhou Y, Li L, Liu L, et al. Heatstroke caused deaths of electric blankets: case report and review of the literature. Am J Forensic Med Pathol. 2006 Dec; 27 (4): 324-7. doi: 10.1097 / 01.paf.0000233567.51784.31

Krous HF, Nadeau JM, et al. Environmental Hyperthermic Infant and Early Childhood Death: Circumstances, Pathological Changes, and Mode of Death. Am J Forensic Med Pathol. 2001 Dec; 22 (4): 374-82. doi: 10.1097 / 00000433-200112000-00008

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McLaren C, Null J, Quinn J. Heat stress from closed vehicles: moderate ambient temperatures cause significant temperature rise in closed vehicles. Pediatrics. 2005 Jul; 116 (1): e109-12. doi: 10.1542 / peds.2004-2368

Zhu BL, Ishida K, Fujita MQ, Maeda H. Infant death probably due to strenuous self-heating in bed: an autopsy case on suspicion of child abuse. Nihon Hoigaku Zasshi. 1998 Apr; 52 (2): 153-6. PMID: 9711068

Surpure JS. Heat-related illness and the car. Ann Emerg Med. 1982 May; 11 (5): 263-5. doi: 10.1016 / s0196-0644 (82) 80097-8. doi: 10.1016 / S0196-0644 (82) 80097-8

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On the Internet:

Heat stroke in children (UpToDate, updated: 28 January 2022)

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