Testing an Age-old Adage: Can Autopsy Findings be of Assistance in Differentiating Opioid Versus Cardiac Deaths?

Given the common occurrence of both opioid and cardiovascular deaths, and the concomitant use of opioids in those with cardiac disease, the present study was undertaken to see whether the old adage of using the triad of cerebral and pulmonary edema and bladder fullness to suggest an opioid death could be used to differentiate deaths due to opioid toxicity from deaths due to cardiac disease. Brain weight, lung weight, and bladder fullness were compared among opioid-related deaths, cardiac deaths, and a control population. It was found that opioid-related deaths were more likely to have heavy lungs, a heavy brain, and a full bladder, while cardiac-related deaths had smaller volumes of urine in the bladder and heavier hearts. In conjunction with a thorough investigation, these findings may be useful to forensic pathologists when determining whether a death is opioid-related, especially in the setting of concomitant cardiac disease.

A 25-Year Review of Pediatric Suicides: Distinguishing Features and Risk Factors.

Childhood and adolescent suicides have been increasing worldwide in recent years, and the investigation of such deaths is often complex. Forensic pathologists frequently find themselves having to opine as to the manner of death in these difficult cases. The present study was undertaken to identify distinguishing features in childhood and adolescent suicides to assist in the investigation and prevention of these deaths. A 25-year review of pediatric suicides in a metropolitan area was performed, which showed a steady increase in pediatric suicides over time. Male pediatric suicides were more common than female, with both having an average age of 15 years. Gunshots wounds and hanging were the most common methodologies seen, with drug toxicity being more common in females and gunshot wounds more common in males. Approximately 20% of decedents had a psychiatric history, 25% had a previous history of a suicide attempt or ideation, and 24% had a history of drug use. Only a minority of decedents made their intentions known prior to the suicidal act (16%) or left a note of intent (16%). In 62% of cases, a temporal, precipitating event could be identified, of which conflict with a significant other (boyfriend or girlfriend) was the most common. No specific trends over time were identified. While these features may assist forensic pathologists in assessing a possible suicidal death in the pediatric age group, medicolegal death investigators must approach these deaths as they would any violent death in an attempt to accurately determine the manner of death regardless of the societal and familial implications of such a determination.

Organ Weight Reference Ranges for Ages 0 to 12 Years.

Abnormal organ weights often serve as an indicator of underlying disease or other pathological process making assessment of organ weight a critical part of the autopsy examination and interpretation. Unfortunately, normal organ weights for children are often based on studies done in the 1930s and 1960s. Thus, the present study was designed to accurately assess organ weights in children to establish reference ranges for use in autopsy examinations. A total of 1759 traumatic deaths in children aged 0 to 12 years were reviewed. Analysis revealed that body length was the best predictor for organ weight. Reference ranges were established and stratified by both age and body length.

Can Intoxication Status Be Used as a Prediction Tool for Manner of Death?: A Comparison of the Intoxication Status in Violent Suicides and Homicides.

Determining the manner of death in medicolegal death investigations can be difficult. The investigator relies on many facets of death investigation, including the circumstances of death and autopsy examination. A study was designed to analyze whether the intoxication status of the decedent could be used as another tool in death investigations. The intoxication status of violent (nonoverdose or poisoning) suicides and homicides was retrospectively reviewed and compared. A total of 625 deaths were identified, including 366 suicides and 259 homicides. Age, sex, cause of death, and intoxication status, including the specific drugs present, were analyzed. Gunshot wounds were the most common cause of death in both groups, with hanging being the second most common cause in suicides and sharp force injuries in homicides. Analysis found that although the overall intoxication status for suicides versus homicides did not differ significantly, certain drugs were more prevalent in one group over the other. Specifically, illicit drugs, that is, heroin, cocaine, and methamphetamine, were more likely to be present in homicides, whereas antidepressants or antipsychotics, benzodiazepines, and zolpidem were more common in suicides.

Postmortem Propofol Levels: A Case of Residual Detection Long After Administration.

Propofol has gained notoriety in recent years because of its involvement in high-profile deaths and has increasingly become a drug of misuse and abuse particularly by health care personnel with easy access to it. In addition, propofol has also been used for more nefarious purposes such as murder and suicide. These, coupled with the drug's routine use for both major and minor medical procedures, provide ample opportunities for it to be implicated as a cause of death or contributing factor. In such instances, forensic investigators may be faced with the task of not only detecting the presence of propofol on postmortem toxicology screening, but also determining if it was indeed responsible for the decedent's demise. While propofol has a high volume of distribution, it is thought to equilibrate and be eliminated rapidly and not show significant tissue accumulation. However, this article presents a case illustrating that propofol can accumulate in the tissues and may be found up to a week after administration. This capacity to accumulate implies that postmortem detection does not necessarily confirm administration near the time of death, and further investigation needs to be undertaken to determine the timeline of events in order to rule out other factors, such as recent medical interventions, before attributing the cause of death to the presence of the drug.

Head Trauma and Alcohol: A Lethal Combination.

There has been much recent attention regarding "concussions" and the role they may play in death. As most medical professionals are aware, concussions exist on a spectrum ranging from minimal or no loss of consciousness with no residual sequelae to diffuse axonal injury and sudden death. The location on the spectrum depends not only on the nature of the impact or blow but also on the state of the individual impacted. Three previous reports have illustrated 7 deaths due to blunt force head trauma with acute ethanol intoxication (postconcussive apnea). The present report describes 6 additional deaths, five of which were witnessed. The report discusses the pathophysiology of postconcussive apnea and concludes that the head trauma results in a concussion, which when combined with the ethanol, results in prolonged apnea by disruption of the cardiorespiratory centers leading to death. In addition, it is concluded that individuals dying from postconcussive apnea become immediately unresponsive after the head trauma, demonstrate no significant anatomic abnormalities at autopsy, and have blood ethanol concentrations ranging from 0.168 to 0.33 g/dL (mean, 0.258 g/dL; median, 0.24 g/dL).

Deaths in Custody: A 25-Year Review of Jail Deaths in Bexar County, Texas.

Although deaths in custody are an expected occurrence, they are often subjected to increased scrutiny and raise many questions as to circumstances surrounding the death as well as the cause and manner of death. It is usually the responsibility of the medical examiner to answer these questions. Relatively few studies have reviewed the causes and manners of death that occur while in custody and even fewer specific to jail populations. This study reviews the cause and manner of death of persons in custody in an urban county from 1985 to 2010. A retrospective review of death investigations, including death certificates and autopsy reports, was conducted on all deaths that occurred in custody during the period. The age and sex of the decedent as well as the place of death were also recorded. Most deaths were attributed to natural disease followed by suicide, and most deaths occurred either in the emergency department or in the hospital. Regarding the cause of death, cardiovascular disease followed by suicide by hanging accounted for the most number of deaths (25% and 20% of all deaths, respectively). It is recommended that all deaths in custody be reported to the medical examiner and that a thorough death investigation be conducted to properly define and document the cause and manner of death. This is particularly important given the increased scrutiny to which deaths in custody are often subjected.

Normal Organ Weights in Women: Part I-The Heart.

Cardiac enlargement is a well-known independent risk factor for sudden cardiac death, though the definition of what constitutes cardiac enlargement is not universally established. A previous study was undertaken to establish a normal range for male hearts to address this issue; the present study was designed to address the issue and to determine normal cardiac weights in adult human females. A prospective study was undertaken of healthy females dying from sudden, traumatic deaths aged 18 to 35 years. Cases were excluded if: there was a history of medical illness, including illicit drug use; prolonged medical treatment was performed; there was a prolonged period between the time of injury and death; body length and weight could not be accurately assessed; if there was significant cardiac injury; or if any illness or intoxication was identified after gross, microscopic, and toxicologic analysis, including evidence of systemic disease. A total of 102 cases met criteria for inclusion in the study during the approximately 10-year period of data collection from 2004 to 2014. The decedents had an average age of 24.4 years and ranged in length from 141 to 182 cm (56.4 to 72.8 in.) with an average length of 160 cm (64 in.). The weight ranged from 35.9 to 152 kg (79 to 334 lbs) with an average weight of 65.3 kg (143 lbs). The majority of the decedents (86%) died from either ballistic or blunt force (including craniocerebral) injuries. Overall, the heart weights ranged from 156 to 422 g with an average of 245 g and a standard deviation of 52 g. Regression analysis was performed to assess the relationship between heart weight and body weight, body length, and body mass index, respectively, and found insufficient associations to enable predictability. The authors, therefore, propose establishing a normal range for heart weight in women of 148 to 296 g.

Normal Organ Weights in Women: Part II-The Brain, Lungs, Liver, Spleen, and Kidneys.

Organomegaly can be a sign of disease and pathology, although standard tables defining organomegaly have yet to be established and universally accepted. This study was designed to address the issue and to determine a normal weight for the major organs in adult human females. A prospective study was undertaken of healthy females who had sudden, traumatic deaths at age 18 to 35 years. Cases were excluded if there was a history of medical illness including illicit drug use, prolonged medical treatment was performed, there was a prolonged period between the time of injury and death, body length and weight could not be accurately assessed, or if any illness or intoxication was identified after gross and microscopic analysis including evidence of systemic disease. Individual organs were excluded if there was significant injury to the organ that could have affected the weight. A total of 102 cases met criteria for inclusion in the study during the approximately 10-year period of data collection from 2004 to 2014. The decedents had an average age of 24.4 years and ranged in length from 141 to 182 cm (56.4-72.8 inches) with an average length of 160 cm (64 inches). The weight ranged from 35.9 to 152 kg (79-334 lb) with an average weight of 65.3 kg (143 lb). The majority of the decedents (86%) died of either ballistic or blunt force (including craniocerebral) injuries. The mean brain weight was 1233 g (range, 1000-1618 g); liver mean weight, 1288 g (range, 775-2395 g); spleen mean weight, 115 g (range, 51-275 g); right lung mean weight, 340 g (range, 142-835 g); left lung mean, 299 g (range, 108-736 g); right kidney mean weight, 108 g (range, 67-261 g); and the left kidney mean weight, 116 g (range, 55-274 g). Regression analysis was performed and showed that there were insufficient associations between organ weight and body length, body weight, and body mass index to allow for predictability. The authors therefore propose establishing a reference range for organ weights in women, much like those in use for other laboratory tests. Reference ranges (95% inclusion) are proposed: brain, 1033 to 1404 g; liver, 603 to 1767 g; spleen, less than 230 g; right lung, 101 to 589 g; left lung, 105 to 515 g; right kidney, 38 to 174 g; and left kidney, 35 to 192 g.

Homicide or suicide? Gunshot wound interpretation: a Bayesian approach.

Many studies have been published examining various features of fatal gunshot wounds such as type of firearm, range of fire, number of shots, and wound location as a way of determining between homicidal and suicidal deaths. Pathologists frequently have to give evidence in court, and may have their opinion about probable manner of death challenged or be questioned about how sure they can be. In the literature, the features are always discussed in isolation, but in practice, the pathologist has to consider such details in combination. Using pooled data from a systematic review to obtain large data sets, this study shows how Bayesian analysis can be applied to consideration of combined features and can thus provide a quantified degree of confidence to support the pathologist's opinion through the use of likelihood ratios. Case examples are provided to illustrate the impact of different features.

Synovial fluid: an alternative toxicologic specimen?

Although blood is the most commonly used specimen in forensic toxicology, it is not always available. In those cases, alternative samples are sought on which to perform toxicology testing. The current study assessed the usefulness of synovial fluid for postmortem cocaine and opiate/opioid testing. One hundred four cases were sampled, with 98 cases being tested representing 24 negative controls and 74 cases positive for cocaine, benzoylecgonine, morphine, 6-monoacetylmorphine, hydrocodone, and/or oxycodone. Synovium demonstrated excellent correlation and predictability when compared with blood, although it was not as sensitive for 6-monoacetylmorphine as either vitreous or urine. The authors recommend further study to assess the usefulness of synovial fluid in postmortem toxicology to include the evaluation of its utilize for more drugs and the development of further assays to use its potential even in limited quantities.

Peripheral postmortem redistribution of morphine.

It is known that postmortem drug concentrations can vary depending on the sampling site and that, in general, central sites have higher drug concentrations than do peripheral sites. It has also been suggested that clamping the femoral vessel before drawing the sample may eliminate possible contribution from central sites. Morphine is a commonly prescribed and commonly encountered opiate medication that is often found in postmortem examinations, both as a cause of death and also as an incidental finding. It is important to understand the degree of postmortem redistribution of morphine to peripheral sites and whether clamping the femoral vessel can eliminate postmortem redistribution of morphine to ensure the correct interpretation of postmortem morphine concentrations. Morphine drug concentrations were evaluated in clamped and unclamped femoral vein blood samples at 3 different times before autopsy, and no significant change in either the clamped or the unclamped femoral vein morphine concentration was seen over time. Furthermore, no significant difference was found between the clamped and unclamped blood concentrations at any period. Therefore, it can be concluded that for morphine, unclamped femoral blood samples do not show significant redistribution from central sites within the first 24 hours after death in bodies kept refrigerated at 4°C.

Morphine concentrations in skeletal muscle.

Skeletal muscle constitutes a large percentage of the total body volume, making it a potentially widely available specimen for drug quantitation when blood is not available for toxicological testing. Morphine is a commonly encountered opiate in postmortem toxicology known to have stable blood concentrations in peripheral vessels. Morphine concentrations were measured in both femoral blood and skeletal muscle to assess the stability and predictability of skeletal muscle concentrations as compared with femoral concentrations. Analysis showed skeletal muscle was a sensitive matrix for the detection of morphine; however, there is significant disparity between the skeletal muscle and blood concentrations with a lack of predictability. The authors conclude that thigh skeletal muscle may be used for qualitative identification of morphine; however, interpretation of quantitative results should not be made as there does not seem to be a clear correlation between femoral blood and skeletal muscle concentrations for morphine.

Handgun wounds: a review of range and location as pertaining to manner of death.

Citizens of the United States own more firearms than those in any other country, and the majority of the firearms owned are handguns. Given such prevalence, surprisingly few studies have been published describing the characteristics of deaths due to handguns. To address this gap, nonaccidental handgun deaths examined at the Bexar County Medical Examiner's Office between 2000 and 2010 were reviewed. A total of 1450 cases were identified, including 797 suicides and 653 homicides. Age, range of fire, location of wound, and manner of death were analyzed. The average age of suicide victims (46.7 years) was found to be greater than that of homicides (34.3 years). Suicidal wounds tended to be contact wounds to the head; abdominal, extremity, back, and multiple wound locations were more common in homicides as were distant and intermediate wounds. Handgun wounds to the forehead, side of head, submental, and intraoral locations were significantly more common in suicide, whereas those to the face, apex of the head, and back of the head were more common in homicides. Where possible, likelihood ratios were calculated to determine relative likelihood of suicide or homicide for specific wound locations and ranges. While each death should be analyzed based on its unique circumstances and not solely its statistical probability, these data may help inform the pathologist's conclusions.

Gunshot wounds: a review of firearm type, range, and location as pertaining to manner of death.

Many studies have examined the characteristics of gunshot wounds by manner of death; however, no published study has directly compared these characteristics for the different types of firearms. This study was designed to address that deficiency. Existing data sets of nonaccidental deaths by handguns, shotguns, and rifles were reviewed. The victim data were analyzed by age and sex of the victims, wound location, range of fire, manner of death, and type of firearm. Handguns were the most common firearm used in both suicides and homicides, followed by rifles and then shotguns. For both homicides and suicides, there were significant differences between the firearm types for age of victims, range of fire, and wound locations. Possible reasons for those differences are discussed. It is concluded that information about the type of firearm is crucial to have when examining the nature of a firearm injury and determining the manner of death.

Should postmortem subclavian blood be considered a peripheral or central sample?

The phenomenon of postmortem redistribution has long been described, but the processes driving it have not, as yet, been fully elucidated. Peripheral blood samples are currently used, when available, in an effort to minimize the effects of postmortem redistribution on drug concentrations, but what sources of blood are peripheral sources? A study was undertaken to determine if postmortem subclavian (SC) blood should be considered a peripheral or central blood sample. Twenty-eight cases were identified in which drugs were quantified in at least 2 of the following blood sources: femoral (F), SC, and heart (H); the concentrations found in each source were compared. Twenty different drugs were analyzed including 6 antidepressants, 6 opioid medications and metabolites, 3 benzodiazepines, 2 antihistamines, 2 sedative hypnotics, and 1 muscle relaxant. Analysis found that SC blood concentrations reflect neither F nor H blood concentrations, with the exception of the benzodiazepines where SC blood concentrations closely mirrored H blood concentrations. Overall, SC blood drug concentrations tended to be 1.3 times greater than F blood and 0.77 times less than H blood. Therefore, it is recommended that the exact source of the blood, rather than simply "peripheral" or "central," be notated on toxicology results to ensure appropriate interpretation.

Deaths due to sharp force injuries in Bexar County, Texas, with respect to manner of death.

In the United States, there is a paucity of studies examining sharp force injuries (SFIs), defined as an injury inflicted by cutting or stabbing with a sharp instrument. Few studies exist that discriminate between the injury patterns of suicidal or homicidal deaths incurred by SFI. In this retrospective study, all deaths secondary to SFI were evaluated at the Bexar County Medical Examiner's Office from January 1988 through May 2010. Exclusion criteria were deaths occurring more than 24 hours after injury and wounds obscured by healing or extensive medical intervention. The following data were analyzed: age of decedent, sex, wound location, number of wounds, type of SFI (stab vs incised), visceral organ or vascular injury, concomitant injuries, and manner of death. Defensive injuries in homicides and hesitation marks in suicides were also recorded. A total of 418 deaths met inclusion criteria: 349 homicides, 54 suicides, 12 accidents, and 2 where the manner of death could not be determined.The average age of homicide victims was 35 years, whereas that of suicide victims was 47 years. Gender was not significantly different between the homicide and suicide groups. Homicide victims incurred a greater number of wounds per case compared with suicides, 5.3 versus 4.1, respectively, and had a greater number of stab wounds, 3.3 per case compared with 0.7 per case, respectively. Incisional wounds were statistically greater in suicides, with an average number of 3.3 per case compared with 2.1 in homicides.Injuries to the head, chest, and back were more common in homicides when compared with suicides, whereas injuries to the abdomen and extremities were more frequent in suicides. Comparison of major visceral and vascular damage between homicides and suicides revealed statistically greater injury to the heart, lungs, and thoracic vessels in homicides, but there was a greater frequency of injury to the vasculature of the extremities in suicides. The presence of additional (non-SFI) injuries was more common in homicides than in suicides. Hesitation marks/tentative wounds occurred in 35% of suicides, whereas defensive injuries occurred in 31% of homicides. This epidemiological study can assist the forensic pathologist in determining the most probable manner of death from SFI but does not substitute for a thorough examination of the circumstances of death and a meticulous autopsy.

The atypical entrance wound: differential diagnosis and discussion of an unusual cause.

The appearance of gunshot entrance wounds on the body depends upon many factors including, the type of firearm, the type of ammunition, the location of the wound on the body, and the circumstances of how a wound was sustained. Atypical gunshot entrance wounds are usually created when the bullet is destabilized prior to entering the body and consequently does not enter the body nose first but sideways or at an angle. The most common causes of an atypical entrance wound are bullet ricochet and interaction with an intermediate target. A case is presented in which the decedent sustained a gunshot wound with an atypical entrance. The cause of the atypical nature of the wound was determined to be increased yaw due to bullet instability caused by the condition of the firearm used, not a ricochet or intermediate target. The case emphasizes the importance of collaborative investigation between the different forensic agencies in gunshot cases.