Heart

Sepsis leads to depressed myocardial function. This situation is attributable to a number of mechanisms, including hemodynamic alterations, development of myocardial ischemia, changes in coronary vascular tone and myocardial contraction rate, and release of myocardial depressant factor. Macroscopically, subepicardial hemorrhages, unevenly distributed and ranging from tiny little spots to more confluent hemorrhagic zones, are a frequent finding in sepsis due to DIC or other clotting...

Artificial or Man Made Radioisotopes

An interesting approach was suggested within the concluding remarks of Knight and Lauder's publication.68 It was considered that the measurement of man-man (artificial) isotopes might provide information of value. Unlike the methods that depend upon chemical changes, radioisotopes are less affected by changes within the physical environment to which bones have lain exposed. Many of these isotopes are also known to accumulate within the calcified matrix of bones. Exposure of the population to...

Skeletal Musculature

The skeletal musculature is a rare site for septicopyemic abscess formations (Figure 3.37), a fact ascribable to the inherent resistance of the skeletal musculature to infectious agents. In a series of autopsied cases of staphylococcus sepsis, abscesses in skeletal muscle were found in fewer than 1 of cases.109 Skeletal muscle fiber alterations, such as the appearance of longitudinal striation, loss of cross-striation with homogenization of fibers, and the finding of a segmental and...

Death Investigation and Forensic Nursing in the United States and Canada

Nurses have served as field death investigators for Canadian medical examiners since the 1970s, when nurses in Alberta began receiving training. This trend moved across the Canadian provinces into the United States. In fact, the theoretical model of forensic nursing evolved from the role of the police surgeon (forensic medical examiner) in the United Kingdom and other European countries, as no such posts existed within the United States or Canada. Historically in the United States, a gap had...

Pathologic Features of Sepsis General Approach

The majority of pathoanatomic textbooks and manuals devote little, if any, attention to pathomorphologic organ alterations in sepsis. The likely explanation is the fact that the clinical pathologist hardly ever is in the position to set up a primary diagnosis of sepsis postmortem. A thorough microscopic examination and toxicologic analysis are necessary to rule out concomitant diseases and or intoxications, respectively, that may have contributed to fatal outcome in a given case. Apart from...

Postmortem versus Antemortem Burns

Traditionally the presence of a red rim to a burn has been regarded as evidence of vital reaction. However, a red flare is frequently seen around postmortem burns, so this distinction cannot be considered reliable.11'70'72 Blisters usually are part of ante-mortem burns but can also form after death, where they tend to be pale, yellow, and lack a red base.11 The content of protein and chlorides is said to differ in the fluids of antemortem versus postmortem burns.72 Histologic examination for...

Conventional Mechanisms Handcuffs Batons and Neck Holds

Most injuries caused by handcuffs are the result of forceful application, overtightening of the ratchet mechanism, or continued resistance by the offender after the handcuffs have been applied. More pronounced injuries may result if the handcuffs are used to forcefully drag the offender after the handcuffs have been applied (Figure 7.5). Fig. 7.5. Bruising and abrasion caused by dragging of offender after application of handcuffs. Fig. 7.5. Bruising and abrasion caused by dragging of offender...

General Assessment of Burns

Clinically, burns are assessed primarily according to the percentage of the body surface involved and the depth of the burns. The former is principally of use in predicting the likelihood of systemic complications and death (see later). The latter Fig. 9.1. Estimating the surface area of the body burned (rule of nines). determines how the wound will heal and whether skin grafting likely will be necessary. The extent of burns in adults is determined by the rule of nines910 (Figure 9.1). In...

Forensic Pathologic and Medicolegal Problems Arising in the Postmortem Elucidation of Infection Related Deaths

In the clinicopathologic field with regard to fatalities occurring in-hospital, in at least in a relevant proportion of cases there often is acceptable evidence of an underlying infectious condition in a deceased prior to death, based upon the medical history and results of diagnostic procedures preceding death. Furthermore, there usually is good interdisciplinary communication between the physicians who cared for the deceased and the clinical pathologist performing the autopsy. The latter can...

Vaccines

In recent years, particularly in the United States, vaccinations, specifically the diphtheria, tetanus, and pertussis (DTP) combined vaccination, have been postulated as a mimic of shaken baby syndrome. An autoimmune mechanism for cerebral injury has been speculated but, unlike pathology that may occur with rabies vaccination, no such mechanism has been demonstrated or proved with the DTP vaccine.129 A combined vaccine that has been reported to have a causal relationship with idiopathic...

Gastrointestinal Tract

Subserous petechial hemorrhages, erosions, and acute ulcers visible with the naked eye at autopsy are the most common (nonspecific) shock lesions in the gastrointestinal tract. These gastrointestinal shock lesions have been reported to occur more often in patients dying of septic shock than in shock situations of cardiogenic or hypovolemic origin.108 Septic enterocolitis refers to necrotic and ulcerous changes of the gastrointestinal mucosa in sepsis (Figure 3.30) as a result of DIC.99 Although...

Birth Related Hemorrhages

In the neonatal period, conjunctival and retinal hemorrhages (and some intracranial hemorrhages) can be the result of nonaccidental injuries (violent shaking, direct trauma) or birth trauma, and careful consideration should be given to this differential diagnosis. Birth-related conjunctival hemorrhages may be documented in delivery or neonatal medical notes charts, or they may be seen on family photographs of a newborn child. Note, however, that their absence may be the result of sampling...

Radiocarbon UC and Radiocarbon Dating in Forensic Practice

Radiocarbon is the naturally occurring radioisotope of carbon that decays through the beta emission of an electron to form stable nitrogen (Table 8.2). Radiocarbon is rapidly oxidized within the atmosphere to form 14CO2, which enters the oceans via atmospheric exchange forming dissolved carbonates and into plants and phytoplankton through photosynthesis. Hence radiocarbon can enter animals via the progression of the isotope through the subsequent food chains, where it is incorporated into...

Schizophrenia and Neuroleptic Drugs

An association with excited delirium is but one manifestation of the increased mortality associated with schizophrenia. Patients with this often devastating disorder suffer an increased incidence of natural disease, particularly cardiovascular disorders, as well as deaths by unnatural means (including suicide and accidents).4142 However, attention has increasingly focused upon abnormalities of cardiac rhythm, particularly prolongation of the QT interval. Several antipsychotic agents...

Adrenal Gland

One of the most characteristic morphologic findings in sepsis-related deaths is unilateral or bilateral bleeding in the adrenal cortex. Bleeding may vary in size from tiny focal hemorrhages visible at microscopy (Figure 3.28) to total hemorrhagic infarction (adrenal apoplexy) easily detectable at gross examination. In my experience, adrenal hemorrhages are, in addition to acute splenitis, the most frequent finding in sepsis-related fatalities. Bilateral adrenal hemorrhage (Figure 3.29) in...

References

Necropsy techniques in ophthalmic pathology. ACP Best Practice No. 164. J Clin Pathol 2001 54 417-425. 2. Underwood JCE. Autopsies and clinical audit. In Cotton DWK, Cross SS, editors. The hospital autopsy. Oxford Butterworth-Heinemann, 1993 163-172. 3. The autopsy and audit. Report of the Joint Working Party of The Royal College of Pathologists, The Royal College of Physicians of London and The Royal College of Surgeons of England. London The Royal College of...

Lens Displacement and Traumatic Cataract

The lens may be displaced as a result of blunt trauma, producing dislocation (completely displaced lens) or subluxation (partial displacement, although part of the lens remains attached to the zonules (suspensory ligaments). Note that lens displacement also may occur in homocysteinuria and Marfan syndrome, in the absence of significant trauma. A cataract is present when the lens becomes opaque, and in extreme cases the lens may appear totally white. In acute traumatic cataract the opacity of...

Congenital Heart Disease

Despite technical advances, neurologic complications of open heart surgery are estimated to occur in up to 24 of cases.111 The association between SDH and congenital heart disease CHD in infants is related to surgery and the postoperative period rather than a complication of untreated CHD. Humphreys et al.112 drew attention to intracranial hemorrhage occurring in children following open heart surgery for CHD, most frequently valve or congenital cyanotic heart operations. In their series of 16...

Excited Delirium

Variously referred to over the years as lethal catatonia, acute exhaustive mania described by Lewis Bell in 1849 , delirious mania, and agitated delirium, excited delirium is now the commonly accepted name for a relatively stereotypical constellation of psychomotor signs associated with high mortality.34 The cause may be related to an underlying psychiatric illness or ingestion of stimulant drugs such as methamphetamine or cocaine. However, when associated with cocaine the levels detected tend...

Blunt Chest Trauma

Blunt injury to the chest, particularly if there is compression in the anteroposterior direction, can cause direct injury to the heart. The degree of injury can vary from minor myocardial contusion to complete disruption of one or both ventricles. The range and nature of possible injury was originally described by Parmley et al.19 in 1958, and this still provides the benchmark for classification. In addition, it has been postulated that there is a condition of myocardial concussion that can...

Connective Tissue Disease

Two connective tissue diseases have been reported to present with SDH in childhood Ehlers-Danlos syndrome EDS and osteogenesis imperfecta OI . Ehlers-Danlos syndrome is a heterogeneous group of inheritable connective tissue disorders characterized by skin laxity, joint hypermobility, and tissue fragility. There are six types classified according to their signs and symptoms. The vascular type type IV has an associated shortened life expectancy because of rupture of vessels and organs. A single...

Perinatal Hypoxia

Perinatal hypoxia has been considered a risk factor for SDH during birth. However, in a paper on risk factors for intracranial hemorrhage in full-term infants, Jhawar et al.35 draw attention to the earlier publication of Wigglesworth and highlight that this relationship should be considered with caution because the hemorrhage may be secondary to birth trauma, which in turn may precipitate a respiratory crisis and hence the hypoxic event, rather than vice versa, that is, the hypoxic event having...

Vascular Disease Malformations and Flow Abnormalities

Subdural hematomas may occur in children as a presenting symptom of vascular disease or vascular malformations. Kawasaki disease is a multisystem disorder characterized by vasculitis of small and medium arteries. Neurologic complications, including meningoencephalitis, monocyte-predominant pleocytosis in the CSF, facial nerve palsy, seizures, hemiplegia, and sensorineural hearing loss have been reported to occur in 1.1 to 3.7 of affected children.103105 Two papers detailing seven cases of SDH...

Autopsy Bacteriology

Determining the species and strain of a pathogenetic germ can be of evidential value in reaching etiopathogenetic conclusions about a causal relationship among portal of entry, infection, and fatal outcome. Therefore, the pathologist may have to decide on the value of obtaining samples for postmortem microbiologic investigations at autopsy. Although the diagnostic value of postmortem microbiology for the diagnosis of antemortem infection has been discussed controversially for decades, the...

Skin Subdural Hematoma

Putrefactive Bullae Postmortem

Circumscribed bleedings of the skin are a clinically well-known manifestation of DIC during the course of sepsis and are still apparent postmortem on the outer body surface Figure 3.33 . Sometimes these bleedings appear in a discreet petechial pattern, occasionally taking the shape of extensive, confluent hemorrhages. Metastatic spread of septic microemboli may lead to circumscribed cutaneous bleedings in distinct locations Figures 3.34 and 3.35 and must be differentiated from DIC-related skin...

Liver

Pyemic Abscess

The highly complex pathophysiology of the liver in shock is determined by a variety of overlapping inflammatory reactions. At gross inspection, the liver in shock is enlarged, showing a tense Glisson capsule and rounded edges. The weight of the liver in sepsis often is increased because of accumulation of leukocytes and interstitial edema. In septic shock complicated by DIC, spotty hemorrhages are a frequent feature on cut sections. Despite the high incidence of cholecystitis, appendicitis, and...