Autopsy Final Exam

1. Ages 1-4

2. 80% male

3. Inexperienced swimmer

4. Seizure disorder

5. Environmental (slippery ground, very cold water)

6. Ethanol

Discuss the risk factors which contribute to an increased incidence of drowning (6)

cutis anserina

spasm of erector pili muscles that can be a sign of immersion in drowning deaths

1. cutis anserina (spasm of erector pili muscles)

2. washerwoman hands

3. white or hemorrhagic edema fluid present in the nostrils, mouth, airways

4. large, bulky hyperinflated lungs, completely occupying the pleural cavities

   1. brick-red, large edema fluid, white hemorrhagic foam in trachea, subpleural hemorrhages (paltauf’s spots)

5. water in stomach

6. conjunctival hemorrhage (drowning = asphyxia)

7. dilation of right ventricle

8. nonspecific brain swelling

9. hemorrhage of mastoid bones or petrous portion of temporal bone

10. condition of body: floating head down, butt up; animal activity could be present

11. dry drowning = lungs do not exhibit heavy, boggy, edematous appearance seen in drowning cases - laryngeal spasms ??

List the expected gross findings associated with drowning.

survival of 24 hours or more post immersion

define what constitutes a near drowning

1. pneumonia

2. pulmonary edema

3. diffuse alveolar damage/acute respiratory distress (hyaline membranes)

4. sepsis

5. DIC (disseminated intravascular coagulation)

6. brain death due to hypoxic encephalopathy (transtentorial herniation)

discuss the most common causes of death in near drownings

1. natural: cardiac, respiratory, metabolic, neurologic, unlikely at MEO unless sudden or unknown medical condition

2. accidental: drowning, asphyxia, MVA, firearms, fire/burn deaths/ electrocution

differentiate injuries from accidental and natural deaths in children as discussed in lecture

1. TEN4FACES

   1. Torso

   2. Ears

   3. Neck

   4. Bruising anywhere on a child 4 months or younger

   5. Frenulum

   6. Auricular area

   7. Cheek

   8. Eyelids

   9. Scleral hemorrhage

2. Contusions, abrasions

3. Radiographic: fractures along growth plate of long bones, periosteum shearing, spiral/transverse fractures, head trauma, rib fractures

4. Head injuries: subdural, arachnoid hemorrhages

5. Abdominal: liver lacerations

6. Neglect: appears skeletal, subcu fat has tacky, sticky feeling, empty bowel, sunken eyes and soft globes

   1. Parent claims child a “poor eater”

describe injuries seen in battered child syndrome

1. Battered child syndrome = repeated and deliberate physical abuse

2. Impulse homicides = acute injury/minimal evidence of chronic abuse; symmetric, well-demarcated, patterns; typically a child “annoys” adult and child is punished

   1. Scalding burns, cigarette burns

   2. Accidental will be more irregular, on anterior portion of body, splash marks

3. Gentle = asphyxia, smothering

   1. external/internal findings absent

   2.  Can’t diagnose from autopsy alone - scene and toxicology report very important

   3. SIDS vs. smothering

      1. Usually not considered homicide unless multiple children have died

differentiate between the different types of homicides in children

soot in airways, ischemia or hemorrhagic necrosis in globus pallidus and perivascular foci of demyelination in deep white matter

autopsy findings from CM poisoning?

renal failure, shock, ARDs, pneumonia, pulmonary embolism

autopsy findings from delayed death after CM poisoning

1. Charred body

2. Pugilistic attitude = flexion of upper extremities

3. Complete absence of fingers, toes, portions of extremities

4. Heat fractures and no ST hemorrhage

5. Heat epidural = blood boiling out of venous sinuses; chocolate or brown in color, spongy or crumbly; frontal/temporal/parietal areas of brain

6. Black carbonaceous matter in upper and lower airway indicates if decedent was alive prior to the fire

autopsy findings from death due to burn injury

1. Cherry red lividity = accumulation of oxyhemoglobin in tissues due to under utilization - not specific!

2. Death not immediate = hemorrhagic pancreatitis, erosions/focal hemorrhages of GI mucosa, pneumonia, acute tubular necrosis in kidneys, myocardial fiber necrosis

3. paradoxical undressing (terminal hallucinations)

autopsy findings for death from hypothermia

1. Impairment of the driver

2. Human factors: speed, recklessness, falling asleep

3. Environmental factors: slick pavement, icy roads, construction, fog

Analyze the causes of common motor vehicle accident injuries according to lecture

1. Driver = rectangular or linear abrasion/contusion angling downwards from left neck or shoulder toward anterior midline of chest

2. Passenger = angle downwards from right neck or shoulder area

3. Lap belt may produce horizontal linear contusion or abrasion of the abdomen

Contrast the injuries that occur to passengers with and without using seatbelts, according to lecture.

1. No restraints = can be thrown from the vehicle

   1. Full ejection = numerous injuries result when victim lands on firm surface

      1. Could be crushed or trapped beneath vehicle = traumatic asphyxia

   2. Partial ejection = body may be crushed or amputated

Argue the utility of vehicular restraint devices according to lecture

epidural hematoma

• laceration of the middle meningeal artery

• breaking of temporal bone

• bleeding between dura and skull

subarachnoid hematoma

• rupture of AVM or aneurysm, head injury

• bleeding within the subarachnoid space

subdural hematoma

• typically from trauma

• tearing of the bridging veins, between brain and dura

coup

brain injury at the site of impact

countercoup

• brain injury opposite the site of impact

• larger

  • common in MVA

1. number

2. location

3. distribution

4. presence of satellite injuries

5. characteristics: length, shape, orientation, appearance of margins, marginal or adjacent abrasion, depth and structures injured, direction of wound track

6. clothing defects

List the important factors to document for stab wound injuries (6)

• circular defect with marginal abrasion

• inverted margins

• soot and stippling

entrance wounds

• irregular defect whose edges can be re-approximated

• stellate, beveled, slit, crescent

• everted margins

• no marginal abrasion, but can be shored (collar of abrasion)

exit wound

entry wound

exit wound

• congestive and heavy lungs

• little food in GI tract

• distended and full bladder

• sedation

• foam cone

• drug users: track marks, skin popping

• cocaine = MI with no other risk factors

list potential autopsy findings in overdoses cases as discussed in lecture. ​

scratch

• abrasion caused by sharp object passed across the skin

• heaping of surface layers in front of the object leaves clean area at the start and tags at the end

• e.g. fingernails, thorn, pin

graze

abrasion that occurs when there is movement between the skin and some rough surface (e.g. road rage)

impact abrasion

abrasion with more force and less duration

pressure abrasion

abrasion caused by crushing of superficial layers of skin; associated with bruise of surrounding area; force less, duration more

patterned abrasion

post mortem insect bites can mimic

contusion

bruises due to rupture of vessels, usually capillaries; no loss of continuity of skin

pulmonary contusion

caused by extreme chest trauma; excess fluid interferes with gas exchange leading to hypoxia (e.g. explosions, traffic accidents, falls, sport injuries, falls)

basilar skull fracture

battle’s sign behind ear and raccoon/panda eyes indicate?

laceration

irregular edges, hair bulbs crushed, less hemorrhage, wound bridging, varying depth

split laceration

occurs by crushing of the skin between two hard objects

stretch laceration

common in high velocity intraoral GSW

avulsion

degloving accidents

tearing laceration

ripping of skin and tissue from impact by or against object

compound

fracture in which bone protrudes through skin

incised wound

• clean, cut edges, well-defined, free from contusions

• spindle-shaped

• lots of hemorrhage from clean cut vessels

• deeper at the beginning and more shallow at the end (“tailing”)

defensive wound

• grasping surfaces of hands - flap wound created

• ulnar border of forearm

• dorsum or plantar surface of hand

• lower limbs - sexual assault

stab wound

• depth > length

• width of wound < width of weapon - stretching of skin

• clean cut edges

• punctures around concealed parts of the body (axilla, vagina, rectum, nostrils)

1. abrasion

2. contusion

3. laceration

4. fracture

4 types of blunt force trauma

1. removing the tension caused by the elastic fibers in the skin is necessary to evaluate the true shape

2. isolating the area by cutting it from the surrounding skin and subcutis or with transparent tape

describe the procedure necessary to evaluate the true shape of a stab wound

contact gunshot wound

• circular and smaller

• stellate over scalp

• burning /blackening of immediate wound edges

• soot within tissues

• muzzle mark

• inverted wound margins

• back spatter = blood sucked up into the barrel of the weapon

close range gunshot wound

• almost always circular

• inverted edges

• collar of abrasion

• burning effects

• tattooing/stippling

medium/distant range gunshot wound

• from less than 0.5 meters to several kilometers away

• abrasion collar around entry wound

• wound is inverted

• ring of dirt or grease ring

• bullet striking sideways – may produce rectangular lacerated wound 

tangential gunshot wound

tears with skin tag formation

short range shotgun wound

• 6 inches – 6 feet

• soot soiling vanishes after 1 foot

• tattooing

• single wound

• rat hole injury

• separate wad injury as an abrasion or bruise

distant range shotgun wound

• >6 feet

• no soot

• number of separate pellet holes increase progressively around main wound

• wad often takes lower trajectory

• 6-10 meters, central hole may shrink to nothing

1. suffocation

2. strangulation

3. chemical asphyxia

three types of asphyxial deaths

smothering

suffocation due to mechanical obstruction of the nose and mouth

choking

suffocation due to obstruction of airway; no petechiae

mechanical suffocation

• pressure on chest and abdomen making it impossible to breath; most accidents

• face and neck are deep purple from congestion; petechiae of conjunctiva and sclera, confluent scleral hemorrhage

strangulation

1. occlusion of BV in neck secondary to external pressure

2. mechanism of death = cerebral hypoxia secondary to obstruction of vessels bringing oxygenated blood to the brain

3. NOT due to compression of the trachea

4. cyanosis, petechial hemorrhages of conjunctiva, sclera and periorbital skin

hanging

1. type of strangulation

2. usually pale face, protruding tongue and dried out mucus drips from nose with no petechiae depending on the degree 

3. tardieu spots on heart and pooling of blood in the LE and forearms

4. furrow in neck

5. may see sclera or conjunctival hemorrhage/strap muscle hemorrhage/hyoid bone or thyroid cartilage fracture but not always

ligature strangulation

• pressure on neck applied by object tightened by force other than body weight

• most commonly associated with rape

• death due to occlusion of carotid arteries with cerebral hypoxia

• blood gets to head but can’t drain = congested face, numerous petechiae of sclera and conjunctiva, periorbital and face skin too

manual strangulation

1. strangulation from hand, forearm or another limb; occludes vessels on neck

2. congestion of face, petechial hemorrhages, fingernail marks, hemorrhage in the strap muscles, hyoid fracture, abrasions/contusions on neck

3. can’t say antemortem if no significant hemorrhage around hyoid/thyroid

chemical asphyxia

• gases that prevent utilization of oxygen at the cellular level

• carbon monoxide most common

• helium, hydrogen cyanide, hydrogen sulfide

cyanide poisoning

• bitter almond scent

• tox - 200 mg lethal

• internal organs = bright pink

• damage, blood-stainined stomach lining

hydrogen sulfide

• green discoloration of brain

• exposure by proximity to waste water treatment facilities, landfills and farms with manure storage

• supine, naked, spread, legs

• bite marks and bruising - breasts, inner thighs

  • double swab method for bites! (wet then dry swab)

• trauma to vagina/anus

  • contusions in posterior 5-7 o’clock

• semen deposits - UV light (don’t need sperm to prove)

• common COD - strangulation, BFT, stabbing

• swabs of mouth, rectum, and vagina

• fingernails

describe potential autopsy findings in a sexual assault/rape case as presented in lecture.

objectivity - based on facts and not personal opinions or other influences

internalize the importance of upholding professional ethical standards when arriving at a manner of death, as discussed in class

contact

what distance?

contact

what distance?

contact

what distance?

close range

what distance?

close range

what distance?

medium range

what distance?

medium range

what distance?

tangential

what distance?

contact

what distance?

near contact

short range

what distance?

1. return organs to body and suture

2. family makes arrangements with the funeral home 

3. funeral home contacts the hospital or ME to schedule pick up

   1. state laws vary on who can pick up and transport (funeral home directors vs. private contractors)

4. ALWAYS maintain chain of custody

   1. security must be involved

   2. verify ID on the remains and personal belongings with the transport

   3. release authorization form

5. usually handled by appropriately trained staff

6. documentation:

   1. document deceased with the local county recorder

   2. death registration form

   3. burial permit form

OUTLINE THE PROCEDURE FOR RELEASING A BODY AFTER AN AUTOPSY IS COMPLETE

1. Final anatomic diagnosis = concise summary of anatomic diagnosis

   1. Gross + histological examination

   2. Most serious to least serious to include cause and mechanism of death

2. Clinical summary = brief synopsis of all hx gathered

   1. Pertinent clinical issues and pathologic findings relating to the FAD

3. Grossing findings = external and internal findings; include photographs and radiographs; NO DX OR INTERPRETATION

4. Microscopic findings

5. Additional findings = tox, micro, molecular or chromosomal studies

6. Clinicopathological summary = “final note” that sums up the entire case and states the COD

DESCRIBE THE COMPONENTS OF AN AUTOPSY REPORT (6)

1. Staff can provide QA for the hospital by thoroughly reviewing medical history

2. Autopsy can provide QC by providing definitive dx and comparing clinical to autopsy findings - any notable variations must be documented

   1. Unexpected pathologies are not uncommon, but could mean life vs. death!

DESCRIBE THE ROLE AUTOPSIES CAN PLAY IN HOSPITAL QUALITY MANAGEMENT

1. Training (initial and continuing)

2. Turnaround time - respect among health care professionals

   1. PADs in 2 days, FADs in 60 days

3. Improving rates - fully staffed and well-trained team

4. Regional autopsy centers - create centralized area for data collection as well as training

IDENTIFY WAYS TO MAINTAIN QUALITY IMPROVEMENT IN AUTOPSY PRACTICE (4)

1. National Association of Medical Examiners (NAME) = primary accredidation body for ME and coroners

2. American Board of Medicolegal Death Investigators (ABMDI) = individual certificates of death investigators and medicolegal investigations

3. ANSI National Accreditation Board (ANAB) = international standard; crime labs, law enforcement agencies, ME offices

IDENTIFY ACCREDITING BODIES FOR AUTOPSY PRACTICE (3)

1. Autopsied generally not covered by medicare, medicaid, or most insurances

2. Private, non-forensic can cost a family 5000

3. Forensic autopsies - government service (taxes) and not charged to families

   1. Drug overdose costs taxpayers ~2600

   2. Shooting victims ~6000

4. Medicare payments are bundled into overall service payments for hospital autopsies

5. Hospitals receive full payment, whether or not an autopsy is performed

   1. ~$1200-$1300

   2. Not seen as cost effective or necessary

ARGUE THE DIFFICULTIES THAT EXIST WHEN IT COMES TO AUTOPSY BILLING

1. determine:

   1. gestational age

   2. time of death

   3. underlying abnormalities

   4. COD

2. evaluate:

   1. pregnancy

   2. obstetric care

3. assess diagnostic and therapeutic procedures, treatment courses

4. generate data

5. research

6. medical teaching

7. legal evidence gathering

8. provide genetic info for future pregnancies:

   1. cytogenetic analysis

   2. SNP microarray/LOH

discuss the purposes of performing a perinatal or infant autopsy (8)

1. body weight

2. body length (crown to heel and crown to rump)

3. head circumference (occipital-frontal)

4. chest circumference (nipple line)

5. nipple separation

6. arm span (3rd digits)

7. xiphoid → pubis

8. xiphoid → umbilicus

9. abdominal circumference (umbilicus)

10. umbilical cord stump (LxD, # of vessels)

11. penis length

12. hand length, bilateral

13. foot length, bilateral (most reliable)

list the body measurements taken during the external examination of perinatal autopsy (13)?

1. interpupillary distance

2. inner canthal

3. outer canthal

4. interalar distance (width of nose)

5. philtrum (nose to upper lip)

6. upper lip thickness

7. lower lip thickness

8. mouth commissure

9. palpebral fissure, bilateral

10. pupils, bilateral

11. external ear helix (2), bilateral

12. fontanelles in 2D (easier after skin reflection if possible)

list the face/head measurements taken during the external examination of perinatal autopsy (12)

1. May or may not have access

2. Causes of pregnancy loss in the second trimester are different from early pregnancy losses

3. Obstetric care/treatment and labor/delivery

4. How could the mother’s health affect the child?

   1. Diabetes

   2. Environmental factors - smoking, drinking

5. Family history and genetics that could impact the child

defend the significance of reviewing the mother’s medical chart prior to performing an infant autopsy.

1. Requires consent if:

   1. Gestational age is greater than 20 weeks

   2. Body weight is greater than 500 grams

   3. Less than 20 weeks usually surg path

2. Talking to family for consent and disposition of body before performing the autopsy

3. Consent ONLY following death

   1. Mother and father have equal rights - need agreement

   2. Ability to accept/decline, choose limitations:

      1. “Minimize disfigurement”

      2. External only

      3. Certain organs only

      4. Research only

      5. No extremities or head

      6. May or may not want to know the sex

      7. No photos

      8. All tissue returned with body

examine the unique importance of verifying consent with perinatal specimens

1. Assessment of anomalies/malformations vs. medical disease

2. Letulle method almost always - important to preserve anatomic relationships

defend the significance of an extensive external examination.

maceration

degenerative changes in fetal tissue when retained in utero

icteric sclera

iris coloboma

missing iris portion of eye

moebius sequence

paralysis of facial nerves, unable to form facial expressions

cloverleaf deformity

enlarged anterior fontanelle, other cranial sutures fused, hydrocephalus, macrocephaly

nuchal cord

umbilical cord around neck

cystic hygroma

lymphatic obstruction leading to fluid accumulation

cleft palate

high arch

macrognathia

abnormally large jaws

clinodactyly

abnormal curvature of 5th digit associated with down syndrome

amniotic band syndrome

osteogenesis imperfecta

1. abnormally formed bones due to insufficiency or absent type I collagen production; most severe form is lethal

   1. short, bent limbs

   2. multiple fractures

   3. short, beaded ribs

   4. reduction or absence of cranial vault ossification

   5. blue sclera