MMSC230 Forensic Pathology

11/6

Ancient Times:

• humans have used substances for various purposes, including medicinal, religious, and recreational, for thousands of years. Evidence suggests that opium was used as early as 5000 BCE, and alcohol production dates back to at least 7000 BCE

The Middle Ages:

• while some substances were used in moderation, excessive use and drunkenness were condemned by religious authorities

Renaissance and Enlightenment:

• increased trade and exploration led to the introduction of new substances, such as tobacco and coffee, to Europe. The use of opium and alcohol became more widespread

19th Century:

• the development of new technologies, such as the hypodermic needle, led to increased use of injectable drugs like morphine and heroin. These substances were often used for medicinal purpose,s but also had a high potential for abuse and addiction

20th Century:

• The 20th century saw the rise of recreational use

Late 20th and 21st Century:

• drug abuse remains a significant global problem, with the opioid crisis being a major public health concern. The use of prescription drugs for non-medical purposes has also become a growing issue

Throughout history, drug abuse has been viewed in different ways

• from a moral failing to a medical condition. Today, it is widely recognized as a complex disease that affects both the brain and behavior

• Drug Overdose

• Drug overdose is the leading cause of accidental death in the US

  • 52,404 lethal drug overdoses in 2015

  • 20,101 overdose deaths related to prescription painkillers

  • 12,990 overdose deaths related to heroin in 2015

    • Fivefold increase from 2002-2014

      

• Ways of Administration:

• Smoking (pot)

• Huffing (inhaling volatile) gasoline, toluene

• Snorting

• Ingesting

• Injecting: veins, under skin

• Tolerance:

• Always repeated use of a drug, no longer acts the same way it initially did

  • Takes higher amounts to produce same effect

• Dependence

• Neurons only function normally when drug is present physiological withdrawal will occur

• Not sunonymous with addiction, however, usually accompanies it

  • Ex: patient with cancer taking morphine

• Cocaine

• White powder (hydrochloride salt)

• Originates from coca leaves

  • Peru, Bolivia, Columbia

• Crack: salt processed with baking soda and heated to remove salt

  • Not water soluble, comes in rock crystales

    • Cheaper

  • Heated, then vapor is inhaled

• Tears made from coca leaves can combat altitude sickness

• Snorted: high lasts 15-30 min

• Smoking: rapid intense effect, high lasts 5-10 min

• Causes euphoria, reduced fatigue, mental alertness, loss of appetite or need to sleep

• Acts through reward center in midbrain

• Main metabolites BZE can be found in urine up to a week, up to 3 weeks with high doses

  • Varies with concomitant use of other drugs

• Different state, different rules. Not all drug deaths can be viewed as accidental or natural.

• Toxidrome causes elevated blood pressure, heart attack, hyperthermia, increased heart rate, dilated pupils, chest pain, stroke, seizures, headaches, abdominal pain

• One of the few drugs with cardiotoxicity 

  • Vasospasm and myocardial infarction

• Can cause delirium, jump from height, aggressive, associated with sudden death when taken to custody

• Often used with alcohol: cocaethylene is found in blood, increased risk of sudden cardiac death

• “Cut” with adulterants leading to acute and chronic pulmonary toxicity - “crack lung”

  • Baking soda

  • Talcum powder

  • Lactose sugar

  • Levamisole

• Increased weight and more profits

• Abusers can develop tolerance

• National survey on drug use and health reports 1.5 million cocaine users

• Decline in recent years due to increased price

• Pregnancy: prematurity and growth retardation, decreased IQ, ADHD

• No FDA-approved medication to treat addiction

PCP

• Angel dust

• Developed in the 1950s and used as a dissociative anesthetic

  • Discontinued in the 60s due to dysphoria and hallucinations

  • In 1979, all legal manufacturing was terminated

• Crystalline powder, tablets, capsules

• Creates a feeling of detachment, hallucinations, slurred speech, acute anxiety, hostility, paranoia

• Very dangerous and addictive

Cannabis

• Comes from the hemp plant Cannabis sativa

• Smoked dried leaves, flowers, stems, seeds

• 10% of users become dependent

• Can cause shallow breathing, dizziness, dry mouth, dilated pupils, depression, and anxiety

• Causes relaxation, detachment from reality

• Most commonly abused drug

• Affects short-term memory, ability to focus and learn, and coordination

• HR increased 2x times

• Active component delta-9 tetrahydrocannabinol (THC)

• 1 in 3 people in the US have tried at least once

• Big changes have recently occurred in the legislature of several states

• Allowed for sale in stores or for medicinal use

• Medicinal synthetic cannabinoids:

  • Marinol for nausea associated with chemotherapy, increased appetite in AIDS pt

• Medical marijuana is currently approved for a myriad of conditions

  • Cancer, glaucoma, HIV, chronic pain, nausea, cachexia, muscle spasm

• November 2016: 28 states and the District of Columbia legalized cannabis for personal use

• Rules vary by state

• 2012: Colorado and Washington states legalized to use older than 21

• 2014: Oregon, Alaska, Washington, DC

• 2016: California, Maine, Nevada, Massachusetts

• In stark contrast to the legalization happening at the state level, it is still a Schedule I drug and federally illegal.

  • Cultivation and distribution are felonies

  • Possession misdemeanor

K-2

• “Spice”

• Herbal mixtures have, similar effect to marijuana

• Synthetic or designer cannabinoid compounds

• Common use in teenagers

• Agitation, hallucinations, elevated BP, vomiting

• Extreme addictive potential 

• Illegal to sell, buy, or possess the main chemicals in these drugs

Benzodiazepines

• Anti-anxiety agents attach to the GABA receptor

  • Withdrawal can be fatal

    • Seizures

• Often abused with opiates, potentiate their effect

• Valium-diazepam

  • Often prescribed as muscle relaxer

• Xanax - alprazolam

• Ativan - lorazepam

• Serax - oxazepam

• Opium

• Extracted from poppy plant (growth cycle 120 days)

  • Needs warm climate with lower humidity

    • Central Asia, South America

• Produced when poppy flower dies in 10-12 day period

  • Extremely labor intensive

• Chemical structure can be altered to produce many opiates 

• Sleep inducing, was used in medicine for centuries

• 16th century laudanum use as painkiller

• 1806- German biologist isolated active ingredient morphine named after “god of dreams”

• 1953 - used as painkiller after introduction of hypodermic syringe

Heroin

• Derived from morphine alkaloid found in opium, 2-3x times more potent

• Highly addictive, creates rush

• Schedule 1

• White powder with bitter taste

• Mostly sold as white or brown powder

• Cut with other drugs or adulterants

  • Sugar, starch, quinine, strychnine

• First produced in 1874 as diacetylmorphine

• 1897 Bayer Pharmaceuticals created drug combining aspirin and heroin; used as effective treatment for asthma, tuberculosis and morphine addiction

• Heroin was restricted to prescription-only use in the U.S. in 1914 and banned in 1924

• Chemical addiction can develop with one dose

• High risk of OD

• Actual strength never known

• Can be smoked, snorted, ingested, injected, suppository 

• Inhalation: smoking cigarette which is dipped in liquid heroin: “chasing the dragon”

• IV use produces quick rush: flushing of skin, dry mouth, wakeful and drowsy state, respiratory depression, decreased BP, pinpoint pupils, nausea, convulsion, coma

• Quickly metabolizes to morphine, which binds to opioid receptors in brain

• 6-MEM metabolite detected in urine and vitreous fluid

• IV users inject into veins in their neck, arms, hands/feet

  • Often use shared, contaminated needles

    • Risk of HIV, HCV, bacterial and fungal infections

• Skin poppers, inject the drug under the skin, not into a vein

  • Risk of abscesses, endocarditis 

Heroin Resurgence

• Painkillers became more regulated, more stricter regulations on prescribing

• People who were legally prescribed opioids (Vicodin, oxycodone) for pain got addicted but have no more access to drugs, and turned to heroin as a substitute 

• Methadone

• Can be prescribed for chronic pain patients or for former heroin addicts

  • Methadone clinics

• High street abuse potential

• A longer half-life does not create a quick high

• Fentanyl/Heroin Epidemic

• In 2014 increased amount of OD

• Testing did not detect 6-MEM or morphine, or traces

  • Fentanyl was detected in the majority of cases

• National alert about fentanyl:

  • OD is at an alarming rate, representing a significant threat to public health and safety

  • 100 times more potent than morphine and 50 times more potent than heroin

  • The danger is that the drug users do not know what they are buying:

    • Heroin, heroin laced with fentanyl, cocaine, and fentanyl or fentanyl alone

Fentanyl

• Looks like heroin

• Powerful synthetic painkiller, used frequently in the ICU settings (IV), anesthesia (IV), chronic pain (lollipop, patch)

• Very fast acting

• Schedule II drug

• Illegal sale from Mexico and China

Bath salts

• Designer drugs of abuse

• The name has nothing to do with a hygiene product

• CNS stimulators, the main component MDPV

• Similar to cathinone

  • Alcaloid found in the khat plant and methamphetamine

• 2011 DEA emergency scheduling to control MDPV and all other chemicals in BS

• President Obama in 2012 signed law ban on all chemicals found in BS, placed in Schedule I

• Ban the production of any chemicals mimicking BS

• Before these rulings, they were easily accessible in convenience stores, gas stations, internet

• Packaged in plastic or foil 200-500 grams

  • $20 a package

Inhalants

• Volatile substances that are inhaled to produce mind-altering effects

• Solvents: paint thinners and removers, gasoline, glue

• Aerosols: spray paints

• Gases: ether, nitrous oxide

• Nitrites: isobutyl nitrite 

• Methamphetamine

• Stimulant, used during WWIII

• Increases dopamine in brain

• Clinically similar to amphetamine

• Comes in clear crystal chunks or shiny blue white rocks “ice”

• Smoked through small glass pipe but can be snorted and injected

Crystal meth

• Can be made from over counter medications

  • Psuedoephedrine

• Meth mouth, intense itching, weight loss, hallucination, paranoia

• Prescribed Stimulants

• Chemically similar to methamphetamine

  • Adderall

  • Ritalin

  • Concerta

• Enhance ability to concentrate, memorize, and increase attention and motivation

• Alcohol Abuse

• More than 85,000 deaths a year in the US are directly attributed to alcohol use

• Annual economic cost of alcohol use is estimated to be over $250 billion

• Roughly 1 in 10 deaths among working age adults results from excessive drinking

• In year 2000, 40% of all traffic fatalities were due to alcohol

• One of the drugs that can be fatal if you go cold turkey

• Leads to liver cirrhosis

• Causes hypertension, dilated cardiomyopathy

• Increases risk of malignancies 

  • Esophageal, throat, mouth

• Withdrawal cna be fatal

  • Seizures

• Chronic use leads to cognitive impairment

  • Wernicke’s encephalopathy

    • A neurological disorder caused by a severe deficiency of thiamine (vitamin B1)

• Often coexists with other substance abuse, depression, mental health

  • Lifetime rate of suicide attempts among frequent alcohol users in the US was 7% 

    • US general adult population rate of 1%

• Drug Scene Investigation

• Check for pills, crack pipes, glassine bags, powdery substances, pill bottles, syringes, cooker spoons, razor blades

• A lot of times the scene is “sterile”

• If prescription bottles are found document amount prescribed, used and remained

• Name of doctor, dates

• If missing: used, stolen, sold

• Drug Mules

• Be aware about practice of smuggling drugs: body packers of mules (massive overdose and death if drugs rupture in body)

• External Exam

• Look for injection sites: fresh or scarred track marks

• Check unusual places between toenails or fingernails

• Foam in the nares or the mouth

• Pill fragments in stomach contents

• Lung and brain swelling

• Microscopic finding

• In lungs can see crystalline material

Suicide

• Is the third leading cause of death for ages 15-24

• ⅔ of people who commit suicide are depressed at the time of death

• Adolescent female 16-19 years old are 6x more likely to experience depression if they abuse ethanol

• Drug abuse is strongly associated with prevalence of depression

Depression among physicians

• Rates of depression is higher in medical students and residents 15-30% than general population

• The lifetime prevalence of depression among physicians is 13% in men and 20% in women

CDC statistics

• 2012 suicide 10th leading cause of death in USA roughly 40,000 death reported

• From 2000 to 2012 ther ehas been a 21% increase

• Mortality and Morbidity weekly report, 2016

• Study analyzed 12,312 suicides

  • 77% males, 22.8% females

  • 84% aged 16-64

  • Highest rate age 45-54, 22.7%

  • Lowest age 16-24, 11.6%

  • By occupation:

    • Protective services (law enforcement, firefighters)

    • Legal

    • Healthcare

• Conditions associated with suicide

• Mental illness

• Depression

• Alcohol and drug abuse

  • 30-50% of alcoholics suffer from clinical depression

• Terminal illness

• Postpartum depression

• Mental illness and suicide

• Bipolar disorder

• Major depression

• Schizophrenia

• PTSD

• 90% of all individuals who completed suicide meet criteria for 1 or more psychiatric conditions

Archive International

• Study of medical conditions and risk of suicide in elderly in Ontario 1992-2000

• Rates are hgih among elderly

• Increases with male sex, advanced age, alcohol and substance abuse, mood disorders

• Specific med conditions:

  • CPOD, CHF, depression, severe pain

• Firearm, hanging, self-poisoning

• Suicide Rates:

• Second leading cause of death for teens and young adults, ages 10-34

• 13.6% of adults 18-25 had serious thoughts of suicide in the past year (2023)

• Stressors in the Elderly

chronic health problems, the death of loved ones, social isolation and loneliness, and financial worries. Other significant stressors involve major life changes like retirement or moving, the loss of independence, and caregiving responsibilities for a spouse or family member. 

• Retirement

• Loss of loved ones

• Social isolation

• Disability

• Negative Impacts of Social Media:

• Cyberbullying: online harassment, threats, and humiltion can have a devastating impact on a teen’s mental health. Cyberbullying can be relenltess and inescapable, leading to feelings of isolation and despair

• Social comparison and insecurity: social media often presents idealized versions of people’s lives, leading to feelings of inadequacy 

• Social isolation and reduced face to face interaction

• Sleep disruption

• Key Considerations

• Vulnerability

• Context matters

• Positive aspects

• Suicide in Veterans

• US veterans with substance abuse have higher risk of suicide

• Study look at 4 million veterans

• Substance abuse affect 8% of males and 3% of females

• Every day 20 US veterans die by suicide 

• Self-Inflicted Injuries

• Manifest in different ways

  • Stabbing and cutting

  • Firearms and explosives

  • Jumping from height

  • Jumping into water

  • Burning

  • Suffocation

  • Hanging 

  • Electrocution

  • Railroad injuries

  • Poisoning

• Hanging

• Self-suspension by rope, scarf, shoelaces, bedsheets, etc.

• Often not full suspension

• Ligature mark is present

• Usually does not completely encircle the neck

• Mark is abraded, dried

• Upward direction

• Petechiae in eyes are rare

• Knife Wounds

• In suicide, favor certain locations

  • Throat, wrists, chest

• Multiple

  • Superficial trial cuts

• Usually incised

• Gunshot wound

• Men > women

• Weapon found at the scene

• Soot around the wound

• Location: temple, neck, mouth, chest

• Suicide by Submersion

• Common with both genders

• Depend on availability of water: river, lake, even bathtub

• May be associated with drug OD and occasionally accidental

• Jumping from heights

• Very important to know circumstances to determine motivation

• Aortic rupture

• Splenic laceration

• Pelvic fractures

• Spinal injuries

• Asphyxiation

• Lack of oxygen

• Plastic bag suffocation

• Can be homicide, accident (little kids) and suicidal

• Rapid

• Leaves no physical signs

• Carbon Monoxide Poisoning

• Odorless, tasteless, colorless gas formed by hydrocarbon combustion

• Binds to hemoglobin causing impaired oxygen transportation

  • Organ ischemia

  • Metabolic derangements

• Fire smoke inhalation is most common

• Color of skin, muscle and blood is cherry pink

• Blood levels > 20%, often reaching 80%

• The elderly and pregnant are more sensitive to lower levels

• Putting head in gas oven was a common way to commit suicide in the past

  • Replacement of coal gas to natural gas

• Motor vehicle exhaust gases

• In small spaces lethal level of CO can build up fast

• History and scene investigation is important

Ethylene Glycol

• Common household agent, antifreeze

• Lethal in excess of 100 ml (soda can 345 ml)

• Coma and death within first day

• Causes kidney injury and metabolic derangement

  • Refractory crystals of calcium oxalate form in kidney’s tubules

Cyanide Poisoning

• Blocks ATP use in the cell during aerobic metabolism

• Most common reason is industrial societies is victims of domestic fire

  • Is liberated in combustion of carbon and nitrogen

    • Plastics, household items, rubber, polyurethane

  • Reported that significant levels of cyanide are present in up to 35% of all fire victims

  • Acute poisoning usually suicidal

  • Fatal dose is small

  • Almond smell can be detected

  • Tissue can be bright pink

  • Diagnosis is made via blood CN concentrations

Which of the following drugs was originally used in the 1950s and 60s as a dissociative anesthetic but was discontinued due to addiction and severe side effects?

• PCP

The five drug schedules: The Controlled Substances Act outlines five schedules for drugs:

• Schedule I: High abuse potential and no accepted medical use, such as heroin.

• Schedule II: High abuse potential with severe dependence risk, but have accepted medical uses under restrictions. Examples include fentanyl and oxycodone.

• Schedule III: Moderate to low dependence potential and accepted medical use, like ketamine.

• Schedule IV: Low abuse potential and dependence risk, with accepted medical use, including drugs like Valium.

• Schedule V: Lower abuse potential than Schedule IV, accepted medical use, and limited narcotic content, such as certain cough preparations. 

Asphyxia

• Greek origin, meaning breathlessness

• Lack of O2 in the blood → failure of cells to utilize O2 → failure of the body of eliminate CO2

• Terminal asphyxia is the end point of life for virtually all causes of death

  • Ex: GSW, MI, ruptured aneurysm 

    

Smothering

• Mechanical obstruction or occlusion of external airways (nose and mouth)

  • Homicide - pillow over face, gag over nose or mouth

  • Smothering agents - fabric, sheet, pillow, hand

Strangulation

• Mechanical pressure on the neck

  • Airway occlusion

  • Occlusion of neck veins

  • Compression of carotid arteries

  • Baroreceptor (pressure receptor) and vagal (parasympathetic) reflexes

• Hands, ligature, arm-locks, garrote

• Frequently accompanies sexual assaults

  • Women > Men

• Few physical findings:

  • Petechial hemorrhages

    • Sclera, conjunctivae, eyelids

  • Blood in nares and ears

  • Visceral congestion

  • Injury to deep structures of the neck

  • Occulsion of neck veins

    • Congestion, cyanosis and petechiae above the line of constriction

    • External jugular vein needs 2kg pressure to block blood return from head

• Petechial hemorrhages

• Rupture of small venules due to a rise in venous pressure

• Less pressure for jugular veins (superficial)

• More pressure for carotid arteries (deeper)

• Neither specific or sensitive

  • Can be seen in CPR, different body positions, and severe retching

Neck dissection

• Specialized examination in strangulation cases

• All organs are removed, including the brain

• Layer by layer dissection of strap muscles

• Thyroid gland examination

• Hyoid bone

  • Fractured or contused soft tissue around it

• Thyroid cartilage

Suffocation

• Reduction of oxygen in inhaled air

• Most common replacement of oxygen by other gases (CO2 in grain silo, nitrogen in ship tanks, industrial metal chambers, refineries)

• Plastic bag over head common suicide method

Traumatic asphyxia

• Restriction of respiratory movements and preventing inspiration:

  • Burial in the earth after the collapse of the excavation

  • Pinned under overturned vehicle

  • Crushing in crowd

• Autopsy findings

  • Marked congestion and cyanosis in chest wall

  • Bleeding from ears and nose

Positional asphyxia

• Person’s position leads to mechanical obstruction of respiration 

• Common in infants, patients with cerebral palsy or under influence of drugs or alcohol

• Usually accidental

  • Co-sleeping

  • Baby bjorns

  • Crib bumpers

  • Stuck in between mattress and wall/bed frame

Hanging

• This was covered in previous suicide lecture

• Judicial hanging, unlike suicide, the mechanism of death is fracture/dislocation of cervical vertebrae C1/C2 or C2/C3

  • Death is immediate due to compression of the brain stem and respiratory collapse

 Choking

• Blockage of trachea (windpipe) due to foreign bodies or acute inflammations

  • Foreign bodies

    • Marbles/toys

    • Dentures

    • Food

      • Common offenders, grapes, grapefruit, steak, hot dog

  • Acute inflammation

    • Anaphylaxis

      • Insects, medications, peanut butter

• Those at rick include infants, elderly, mentall ill, or under influence of drugs or ethanol

• Cafe coronary syndrome

Choking games

• Popular in teenagers

• Game of choking each other or yourself and then removing pressure from neck

• Gained popularity via social media

  • Experiencing “high” without taking drugs

  • Numerous death reported, real statistics unknown

• Autoerotic asphyxiation

• Usually young adult males

• Intentionally induced hypoxia (low oxygen) to enhance orgasm

• Planned escape mechanism with elaborate knots and contraptions

• Scene examination is crucial

• Can observe cross dressing, pornography, bondage, webcams, no suicide notes

• MOD Accidental

•  Fire Related deaths

• Most common cause of death is inhalation of noxious gases rather than thermal injuries

• Rapid oxidation of material in chemical process of combustion, releasing heat, light and various reaction products

• Flame is the visible portion of the fire

• Flames consist of CO2, water vapor, oxygen, and nitrogen

• National fire protection association data

• U.S. fire departments responded to an estimated average of 358,300 home structure fires per year during 2010-2014

• Home fires caused an annual average of

  • 2,560 civilian fire deaths, or 93% of all civilian structure fire deaths

  • 12,720 civilian fire injuries, 87% of all civilian structure fire injuries

  • $6.7 billion in direct damage, or 69% of total direct damage in structure fires

• Heat Injuries

• First degree

  • Erythema and blistering

• Second degree

  • Destruction of full thickness of skin

• Third degree

  • Destruction of deeper tissue

• 30-50% body surface involvement is not compatible with survival

• Moist thermal injury (scalds) due to hot liquid

  • Water, oil, steam

• Dry heat

  • Radiant heat, sunlight, articial sunlamps, hot gas

• Fire Related Deaths

• CO forms from incomplete combustion of hydrocarbons during fire and is inhaled if someone is alive in fire

• CO binds to hemoglobin molecule with affinity 200-250 times more than oxygen

• COHb is formed which impairs release of oxygen to tissues

• Normal level is less 6% in chronic smokers levels can be 10-15%

• Younger or sick are affected by lower level of COHb and can cause death with minimal exposure

• Hydrogen cyanide also can be released during fire

• Used in production of acrylic fibers, synthetic rubber and plastics

• Increased frequency of cyanide posioning in house fires

• Can act independently or together with carbon monoxide

• Thermal Injuries

• Total body surface burned is estimated using rule of 9’s

  • Help guide fluid resuscitation and/or transfer to specialized ICU Burn Unit

• Those who survive initial effect of burns can die later from complications

  • Infection due to breach of skin barrier

  • Multi-organ failure

  • Shock

• Fire-related deaths always need in-depth investigation

• Can be accidental or homicide

• Scene investigation is performed by Fire Marshall office and police

• Investigation is crucial for determination of MOD

• Important factors in both the criminal investigation and physical examination

  • How, where and when the fire started

  • Use of accelerant

  • Equipment malfunctioning

  • Medical history of victim(s)

  • Evidence of any other injuries 

• Determining COD is crucial in investigation

• Homicide: other significant injuries found or accelerant used

  • Postmortem burning

  • Victims set on fire to destroy evidence

• Accidental

  • Lit cigarettes, portable heaters, cookers, kids playing with matches or lighters, candles

  • Postmortem burning

    • Ex: victim or motor vehicle accident with blunt force trauma then car catches fire

• Suicide

  • Self-immolation as sacrifice

• Mass fatalities

  • First responders

  • Wild fires

• X-ray needed to look for bullets or metal objects

• Clothing must be saved in sealed metal cans

• Proper identification needed

• Blood is collected for CO determination

• Medical, social and psychiatric history needs to be obtained 

• Evidence that may help determine cause of death in Thermal Injuries

• Soot in airways

  • Victim was breathing

• Determination of carbonxyhemoglobin in blood

  • Victim was breathing noxious gases of combustion

• Cherry red discoloration of tissue and blood

• Need to determine what actually caused death in Thermal Injuries

• Burns

• Smoke and soot inhalation

• Natural disease

• Injury

• Drugs

• Combination of factors

• Thermal Injuries - Artifacts

• Artifacts: important not to confuse with real trauma

  • Puglistic posturing (resembles stance of bozer) due to heat effect on muscle

  • Splitting of skin with exposure of underlying tissue resembling incised wounds

  • Epidural hemorrhage

  • Thermal fractures

• Early decomposition changes and thermal induced skin slippage is seen

• Hyperthermia

• Humans need to maintain body temp within narrow range

• Hypothalamus regulates heat loss and gain

• High temp can be fatal

• More dangerous in young, elderly and sick

• High-related death

  • Direct effects

  • Indirect effects

    • Worsening of underlying medical condition

• Body temp above 105 F (40.5 C)

• Heat stroke is severe form

• Mild form

  • Heat cramps and heat exhaustion

• Exercising/manual labor in heat

• Diabetes mellitus

• Obesity

• Dementia

• Certain medication (tricyclic antidepressants)

• Coronary artery disease

• Alcoholism

• No specific finding on autopsy

• Most important to document condition at scene

  • Working a/c or not

  • Electricity on/off

  • Temp inside and outside (heat advisory)

  • Fans on/off

  • Medical history

  • Availability of drinking water

• Infants and young children left inside the cars

  • Reduced capacity for sweating as a means of heat loss

  • Higher metabolic rate

• Death can be ruled as accidental or homicide

• Hypothermia

• Core temperature below 95F (35C)

• Death due to exposure to cold

• The temperature does ont have to be below 0C

• Very important to know if wet clothing, drugs, alcohol or meications invovled, age, other medical conditions

• If taken to the hospital, must document core body temp prior to re-warming

• Physiological response:

  • Vasoconstriction

  • Increased cellular metabolism (to produce heat)

  • Shivering

• Can occur on land or water-immersion hypothermia

  • Water much more rapid

• Scene investigation crucial

  • Was there a heater or electricity?

  • Document temperature inside and outside

  • Clothing and body temperature

• Paradoxical undressing due to cerebral vasoconstriction leading to confusion, causing sensation of hot flash

  • Terminal burrowing

    • Victims found in cupboards

    • Surrounded by furniture

• Wishnevsky ulcers: small gastric mucosal hemorrhages

• Electrocution

• Passage of electric current through the body

• Mostly accidental

• Need to consider current, voltage, resistance and time

• Body must be incorporated into electric circuit

• Current enters at one point (usually hand) and leaves at exit point usually to the earth

• Scene investigation is most important, death is often not observed 

  • From direct contact to live parts or indirect contact

• Point of contact burns or electric marks

• May absent when in bath

• Passage of current heats issue fluids and produces steam, blister form

• Extent of injury or death depends on resistance, duration of contact, surface area of contact, and pathway of the current through the body

• Most common passage of current through heart, but it will always take the path of least resistance

  • Dry skin - 1 million ohms

  • Wet skin - 1200 ohms

• If hand to head, the current goes through brain

  • Brain steam death and immediate death

• If hand to leg, the current goes through heart

  • Ventricular arrhythmias, death within seconds

• If hand to hand, the current goes through chest wall

  • Diaphragmatic paralysis and traumatic asphyxia

    • Requires contact for minutes for death to occur

• Electric Chair

• Wood chair, metal electrodes strapped to scalp and leg, with moist sponge over the head

• Brought to light as a more humane method of capital punishment by Albert Southwick, a dentist from Buffalo, in 1880s

• First use in 1890

• Last use in 2013, Richard Gleason in VA

Drowning

• Hypoexmia leading to irreversible cerebral anoxia due to submersion in liquid

  • Natural bodies of water, they do not have to be deep

  • Pools, bath tub

• Can occur while swimming, fishing, boat, ship, ferry malfunction, walking on ice, taking shower, etc.

• Can be accidental, suicidal or homicide

• Postmortem examination shows non specific findings

• Frothy fluid mouth and nostrils

• Lung edema

• Fluid in stomach

• Hemorrhages in petrous temporal bones

• Body Found in Water

• Need to consider the following scenarios:

  • Died from natural disease and fell into water

  • Died from natural disease while in the water

  • Died from injury and thrown/found in water

    • Homicide, GSW, stabbing, strangled

    • Diving into shallow pool, C1 fracture/dislocation

  • Died from injury while in water

  • Died from drowning

• Mechanical Trauma

• Occurs when the force applied to skin or bone exceeds the mechanical or tensile strength of the tissue

  • Can result from sharp or blunt forces

• Blunt Force Trauma

• Factors in determining the severity, extent, and appearance of blunt force injuries 

  • Amount of force delivered to the body

  • Time over which the force is delivered

  • Area of body struck

  • The amount of surface area of the body struck

  • Nature of weapon or device used to deliver force

• Categories of Injuries

• Four categories:

  • Abrasions

    • Injury to the skin, in which there is removal of the superficial epithelial layer of the skin (epidermis) by friction against a rough surface or destruction of the same layer by compression

    • Three types:

      • Scrape of brush abrasion

        • leaves denuded surface; “road rash”; “raspberry from sliding”

      • Impact abrasion

        • Force directed perpendicular to the surface, crushing it; over bony prominences 

      • Patterned abrasion

        • Version of impact; imprint of object or intervening material

  • Contusions

    • Area of hemorrhage into soft tissue due to rupture of blood vessels caused by blunt trauma (synonym: bruise)

      • Can be present only in the skin, but may also be seen in internal organs as well

      • Factors influencing the size of the contusion: age, sex, condition, and health of the individual, site, and tissue struck

      • Skin contusions are not good indicators of the severity of underlying organ injuries

    • Contusions: Aging

      • Rough estimate

        • Color changes from blue-red to dark purple to green to yellow to brown

        • “The change of color may be used as a guide for aging the injury.”

      • Current data: aging bruises are fraught with difficulty 

  • Lacerations

    • A tear in the tissue caused by either a shearing or crushing force

    • Characteristics:

      • Tend to be irregular with abraded and/or contused edges

      • It occurs over bony prominences, where skin is fixed and can only be stretched and torn

      • Incomplete separation of skin components (nerve, blood vessels) leads to “bridging” within the wound and differentiates a laceration from an incised wound

      • Undermining of skin on one side can help determine the direction from which the force was delivered (avulsions)

  • Fractures of the skeletal system

    • It occurs when a force acts on a long bone

    • It can be caused by direct or indirect application of force

      • Direct force fractures: penetrating, focal, or crush

      • Indirect force fractures: traction, angulation, rotational, vertical compression, angulation, compression and angulation, rotation, and compression

        

• Bite Marks

• Actual injury rare

• Patterened abrasion with underlying hemorrhages

• Often sexual in nature

• Can be compared with the suspect’s dentition

• Internal Organ Injuries

• Ribs: pathologic, iatrogenic, direct localized violence and indirect violence

• Heart: Commotio Cordis

• Aorta: lacerations of the thoracic aorta occur distal to the origin of the left subclavian artery; ascending lacerations from increased pressure

• Solid abdominal organs: parenchymal lacerations

• Urinary bladder: rupture

• Sharp Force Wounds

• Wounds caused by pointed and sharp-edged devices

• Categories: 

  • Stab wounds: depth of wound exceeds length in the skin

  • Incised wounds: length of wound exceeds depth

  • Chop wounds

  • therapeutic/diagnostic wounds

• Stab Wounds

• The length of the wound in the skin can be less than, equal to, or greater than the  width of the knife

• The depth of the stab wound can be less than, equal to, or greater than the  length of the knife

• Appearance of wound depends on nature of blade and knife; direction of force; movement of blade in wound; movement of victim; and state of the skin

  

• Incised Wounds

• Wounds produced by sharp-edged devices, wherein the length is greater than the depth

• Characteristics:

  • Clean cut, straight edges free of abrasion or contusion

  • No bridging of soft tissue in the wound

  • Usually not fatal; seen more in suicides than homicides

• Chop Wounds

• Wounds produced by heavy devices with a cutting edge, e.g., axes, machete

  • An incised wound with a long groove or a comminuted fracture of the underlying bone suggests a chop wound

  • Can have characteristics of incised wounds and lacerations

Defensive Wounds

• Special consideration for these wounds

• Usually along the palms of hands, the back of the forearms, and arms, and on the ulnar aspect of the forearm

  • Sustained trying to ward off the attacker

Venous Air Embolism

• Penetrating wound of the neck or upper chest

• Neurosurgical procedures

• Central venous catheter placement

• Vaginal air insufflation (especially if the woman is pregnant)

• Dental procedures

Therapeutic/Diagnostic Wounds

Created in the condition of medical care, e.g., surgical incisions, surgical stabs for placement of tubes and drains