Your role in death investigations.
Caring for a patient continues even after he dies. Here are some guidelines for when to report an unusual or suspicious death to the authorities and how to handle the patient's body to protect evidence.
Adult↗
Biomedical subjects
G J Davis
Publications and source records attributed to G J Davis.
An atypical shotgun entrance wound caused by a sabot slug. All is not as it seems.
An 18-year-old woman was killed by a single gunshot wound to the head during a high-speed chase on a rural two-lane road. At autopsy, the entrance wound of the calvarium first appeared to be a tangential "keyhole" defect. Upon internal examination, the wound was determined to have been caused by a shotgun sabot slug that had yawed approximately 90 degrees during its flight. The unusual characteristics of the wound and the ammunition are discussed.
Adolescent↗
Medium-chain acylcoenzyme-A dehydrogenase deficiency. Not just another Reye syndrome.
The medium-chain acylcoenzyme-A dehydrogenase enzyme (MCAD) is involved in the initial stages of breakdown of medium-chain-length fatty acids in mitochondria. A deficiency of this enzyme can become symptomatic during a catabolic state and may resemble Reye syndrome. We report the case of a 17-month-old white girl whose 1-day history of vomiting and agitation followed by generalized unresponsiveness caused her to be brought to a local emergency department. She died after resuscitative efforts failed, and an autopsy revealed severe cerebral edema, marked hepatic steatosis, and steatosis of the renal tubule epithelia. Electron microscopy of the liver showed cytoplasmic lipid spherules and mitochondria with dense matrices, changes similar to Reye syndrome; however, postmortem examination of the decedent's blood revealed elevated medium-chain-length acylcarnitines diagnostic of an MCAD deficiency. Although uncommon, a deficiency of this enzyme should be considered in apparent Reye syndrome victims.
Acyl-CoA Dehydrogenase↗
Storage, surgery, outcome, and complications of corneal and conjunctival grafts.
Corneal transplantation is still limited by a shortage of donor material, but the type of storage medium used once a cornea has been acquired is probably irrelevant to graft outcome. Vancomycin HCl shows promise as a supplement to gentamicin sulfate in storage media. New methods of HLA typing using donor ocular tissue have largely helped to overcome the problems associated with typing of cadaveric blood, but the value of HLA typing in improving corneal graft survival is now in doubt. Alternative regimens of immunosuppression are being tested in animal models, but there is still no consensus on the best ways to use existing agents such as corticosteroids. Rejection remains the most common cause of unsuccessful corneal grafting in large cohorts, but glaucoma and astigmatism also limit postoperative graft function. Limbal stem cell grafts are promising for the management of many ocular surface diseases and conjunctival limbal autografts for pterygia may be the most successful surgical method for preventing recurrence.
Anti-Bacterial Agents↗
Body packing with a twist. Death of a salesman.
Reported cases of death due to oral ingestion of lidocaine are rare. We report the case of a known cocaine dealer who died after swallowing a small packet of white powder, thought to be cocaine, during a relatively routine arrest. The authors describe how the deceased differed from the usual "body packer" and alert the forensic community to be wary of what may first appear to be another "garden-variety" cocaine death.
Adult↗
Dirty diving. Sudden death of a SCUBA diver in a water treatment facility.
We report a case of a sudden death in a SCUBA diver working at a water treatment facility. The victim, an employee of the facility with a specialty in electronics, was a sport diver not qualified in commercial diving. While attempting to clean sludge from a blocked drain 25 ft under water, the diver was suddenly pinned against the drain valve when the sludge plug was broken up. We review the mechanics of the incident and the actual cause of death, asphyxia, as opposed to drowning. We believe this to be the first reported case of traumatic (pressure) asphyxia in a SCUBA diver.
Adult↗
Thoracic empyema due to Streptococcus intermedius.
With improved laboratory identification procedures, Streptococcus milleri (intermedius) is becoming recognized as an important human pathogen with the potential to form abscesses in a wide range of organs. The occurrence of a rapidly progressive and toxic empyema due to this organism in an otherwise healthy young adult without a predisposing lower respiratory tract infection allows us to examine the possibility that this microbe may be a significant but frequently unrecognized cause of adult empyema.
Adult↗
Cerebral tissue pulmonary embolization due to head trauma: a case report with immunohistochemical confirmation.
Pulmonary embolization of cerebral tissue as the result of severe head trauma is an uncommon, if not rare, phenomenon, and few cases have been reported in the literature. The authors discuss the case of a 51-year-old male who died six days after suffering extensive head trauma in a motor vehicle collision. At autopsy, white-gray emboli were found in several subsegmental pulmonary arteries. The results of histologic examination with the hematoxylineosin stain gave the impression that the emboli were necrotic cerebral tissue; however, routine special stains for neural tissue produced inconclusive results. Immunohistochemical staining of the emboli with monoclonal mouse anti-human neurofilament protein (Dako Corp., Carpinteria, California) confirmed the cerebral nature of the emboli. To the authors' knowledge, this is the first reported case of pulmonary embolization of cerebral tissue confirmed by immunohistochemistry.
Accidents, Traffic↗
Auscultatory mean blood pressure.
This study examined the relationship between direct mean arterial blood pressure and cuff pressure for the maximum acoustic index calculated from the Korotkoff sounds in the dog. The acoustic index was computed by summing the squares of amplitudes in each Korotkoff sound complex, thereby providing a measure of acoustic energy content. Mean arterial pressure was compared with cuff pressure for the maximum acoustic index. Ten mongrel dogs were fitted with appropriately sized blood-pressure cuffs containing a microphone mounted inside the bladder and positioned over the brachial artery. The Korotkoff sounds, cuff pressure, and direct arterial pressure were recorded over a range of mean arterial pressures (23 to 155 mm Hg), achieved by manipulating the depth of anesthesia with halothane. It was found that cuff pressure at the maximum acoustic index overestimated mean arterial blood pressure by a mean of 14% (range, -8 to +30%).
Acoustics↗
In the shadow of the Baron: sudden death due to Munchausen syndrome.
The authors describe a woman who died suddenly in an emergency department restroom after self-injection of corn starch in an attempt to gain admission to the hospital. At autopsy, multiple pulmonary vascular corn starch granulomata were identified, as well as pulmonary arteries filled with brewer's yeast. Retrospective evaluation of the patient's medical history showed multiple signs of Munchausen Syndrome. The authors suggest that the case illustrates the importance of scene investigation and review of the medical history by emergency department personnel and the forensic pathologist.
Adult↗
Age-related differences in erythropoietic response to recombinant human erythropoietin: comparison in adult and infant rhesus monkeys.
Human recombinant erythropoietin (r-HuEPO) was given i.v. to rhesus monkeys to compare its safety, erythropoietic effects, and pharmacokinetics in healthy adult and infant animals. Eighteen adult and 18 infant (9- to 15-d-old) monkeys were divided into three groups each of six animals. One group was given 250 U/kg twice weekly, another was given 100 U/kg twice weekly, and a control group was given the drug vehicle for 6 wk. All animals were healthy throughout this period, and for 10 wk after that. Administration of r-HuEPO at these dosages did not produce any changes in leukocytes, platelets, urea nitrogen, bilirubin, creatinine, alkaline phosphatase, alanine amino transferase, gamma-glutamyl transferase, and blood pressure in either age group. At 6 wk, both adult treatment groups had statistically significant increases in Hb concentration. The same dosages that produced these increases in Hb concentration in adults produced no changes in Hb concentration in infant monkeys. Despite active erythropoiesis, as determined by reticulocytosis and increased total body Hb, Hb concentration decreased similarly in the infant treatment and control groups. Pharmacokinetic profiles were obtained at 5 wk of dosing. One h after administration, both doses of r-HuEPO produced significantly lower serum r-HuEPO concentration in the infant monkeys compared with the adults. These differences appeared to be due to a larger volume of distribution of r-HuEPO in the infant monkeys. The t1/2 of r-HuEPO in circulation was the same in both age groups.
Age Factors↗
Fetal death due to nonlethal maternal carbon monoxide poisoning.
Fetal death due to acute carbon monoxide poisoning is rarely reported in the medical literature. Of the eight cases found in literature review, only one documented the fetal carboxyhemoglobin concentration. This paper reports a fetal death due to accidental nonlethal maternal carbon monoxide intoxication in which both maternal and fetal carboxyhemoglobin concentrations were obtained. The corrected carboxyhemoglobin concentration was 61% at the time of death in utero, while the maternal carboxyhemoglobin was measured at 7% after one hour of supplemental oxygen. The authors review the mechanisms of fetal death and emphasize the different carbon monoxide kinetics in the fetal circulation.
Adult↗
Death associated with abuse of a "designer drug".
A case of death is reported in a 26-year-old male previously thought to be healthy. At autopsy, the anterior descending branch of the left coronary artery was markedly atherosclerotic with a superimposed thrombus. Toxicologic analysis revealed 3,4 methylene dioxyamphetamine (MDA) in the blood at a concentration of 0.08 mg per deciliter. The authors draw attention to the reappearance of designer drugs in Kentucky and to the need for awareness of these deadly substance.
3,4-Methylenedioxyamphetamine↗
Nonfracture-associated fatal fat embolism in a case of child abuse.
Fatal fat embolism is usually thought of as a sequel to long-bone fracture, although cases secondary to soft tissue injury and atraumatic conditions have been infrequently reported. In this case of a two-year-old child-abuse victim who sustained multiple blunt traumatic injuries without skeletal fractures, pulmonary and systemic (brain and kidney) fat emboli were identified. At autopsy, all thoracic and abdominal viscera were intact; cranial contents exhibited only diffuse symmetrical petechial hemorrhages of the white matter. Because of the severe and widespread nature of soft tissue hemorrhage, and the absence of a grossly discernible cause of death, fat embolism was suspected. Using a combination of frozen section with oil red O staining and formalin-fixed osmium stained tissues, the immediate cause of death was determined to be diffuse fat embolism. Review of the literature reveals a pathophysiologic basis for fat embolism in the absence of fracture, both as a consequence of an acute increase in local pressure at the site of trauma and an alteration of the emulsification of blood lipids during shock. In light of these findings, we present this case to remind the forensic science community to consider fat embolism as the cause of death in cases of blunt-force injury without fracture.
Cause of Death↗
Toxicologic evaluation of ofloxacin.
Results of studies conducted to characterize local, systemic, reproductive, and mutagenic effects indicate that ofloxacin is well tolerated within reasonable multiples of the intended clinical dose. Quinolone-associated arthropathic effects characterized by blister, erosion, and increased synovial fluid occurred in rats and dogs and appeared to be both age- and dose-related. Maternal toxicity and embryotoxicity were noted, but there was no teratogenicity in rats or rabbits. There was no impairment of fertility, and no adverse effects on late fetal development, labor, delivery, lactation, neonatal viability, or growth of offspring occurred. Target-organ studies revealed no evidence of ocular toxicity in rats, nephrotoxicity in rabbits, or antigenicity or ototoxicity in guinea pigs. Overall, the toxicologic evaluation of ofloxacin has shown this compound to be a drug with a low toxicologic potential.
Abnormalities, Drug-Induced↗
Sudden death due to fibromuscular dysplasia of the sinoatrial nodal artery.
A case of sudden death is reported in a previously healthy 28-year-old female. No gross abnormalities of the heart or other organ systems were identified at autopsy. Routine microscopic sections of heart were unremarkable; however, sections of the cardiac conduction system revealed marked fibromuscular dysplasia of the sinoatrial node artery. The authors suggest that pathologists and clinicians index of suspicion be high when confronted with the enigma of sudden death in a patient with no apparent anatomic or toxicologic cause of death.
Adult↗
Acute myocardial infarction following cocaine abuse in a young woman with normal coronary arteries.
Explore the source record for details and available documents.
Adult↗