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).

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.

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.

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.

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.

Normal organ weights in men: part I-the heart.

It has been shown that cardiac enlargement, whether hypertrophic or dilated, is an independent risk factor for sudden cardiac death, although the definition of what constitutes cardiac enlargement is not universally established. This study was designed to address this issue and to determine normal cardiac weights in adult men. A prospective study was undertaken of healthy men 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; there was significant cardiac injury; or any illness or intoxication was identified after gross and microscopic analysis, including evidence of systemic disease. A total of 232 cases met the criteria for inclusion in the study during the approximately 6-year period of data collection from 2005 to 2011. The decedents had an average age of 23.9 years and ranged in length from 146 to 193 cm with an average length of 173 cm. Their weights ranged from 48.5 to 153 kg with an average weight of 76.4 kg. Most decedents (87%) died of either ballistic or blunt force (including craniocerebral) injuries. Overall, their heart weights ranged from 188 to 575 g with an average of 331 g and an SD of 56.7 g. Regression analysis was performed to assess the relationship between heart weight and body weight, body length, and body mass index and found insufficient associations to enable predictability. The authors, therefore, propose establishing a reference range for heart weight in men, much like those in use for other laboratory tests including hemoglobin, hematocrit, or glucose. A reference range (95% inclusion) of 233 to 383 g for the adult male human heart is proposed.

Normal organ weights in men: part II-the brain, lungs, liver, spleen, and kidneys.

Organomegaly can be a sign of disease and pathologic abnormality, 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 males. A prospective study of healthy men aged 18 to 35 years who died of sudden, traumatic deaths was undertaken. Cases were excluded if there was a history of medical illness including illicit drug use, if prolonged medical treatment was performed, if there was a prolonged period between the time of injury and death, if 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, which could have affected the weight. A total of 232 cases met criteria for inclusion in the study during the approximately 6-year period of data collection from 2005 to 2011. The decedents had a mean age of 23.9 years and ranged in length from 146 to 193 cm, with a mean length of 173 cm. The weight ranged from 48.5 to 153 kg, with a mean weight of 76.4 kg. Most decedents (87%) died of either ballistic or blunt force (including craniocerebral) injuries. The mean weight of the brain was 1407 g (range, 1070-1767 g), that of the liver was 1561 g (range, 838-2584 g), that of the spleen was 139 g (range, 43-344 g), that of the right lung was 445 g (range, 185-967 g), that of the left lung was 395 g (range, 186-885 g), that of the right kidney was 129 g (range, 79-223 g), and that of the left kidney was 137 g (range, 74-235 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 men, much like those in use for other laboratory tests including hemoglobin, hematocrit, or glucose. The following reference ranges (95% inclusion) are proposed: brain, 1179-1621 g; liver, 968-1860 g; spleen, 28-226 g; right lung, 155-720 g; left lung, 112-675 g; right kidney, 81-160 g; and left kidney, 83-176 g.

Trends in firearm usage in homicides and suicides in Bexar County Texas from 1982 to 2004.

Numerous studies and epidemiological reports have been published which analyze firearm deaths by the type of firearm, the majority of which focus on a small time span and categorize weapon types by handgun, rifle, or shotgun. Few studies have focused on the caliber of weapon or long term trends in weapon use. We designed a retrospective study to analyze firearm deaths occurring between 1982 and 2004, considering manner of death (homicide versus suicide), firearm type, and caliber of the weapon. We found that the homicides by firearm steadily declined during the study period, mirroring the overall homicide rate during this period, whereas suicide by firearm rate remained steady. Handguns were the most commonly used weapon for both homicides and suicides during the 22-year period examined. Overall, the .38/.357 and the .22 caliber were the most commonly used handguns. The rate of .357/.38 handgun usage in homicides declined sharply over the study period whereas the use of the 9mm rose steadily, overtaking the .38/.357 in the late 1990s. The use of small caliber handguns steadily decreased in both homicidal and suicidal shootings whereas the .380 and .45 caliber handguns steadily increased in both homicidal and suicidal shootings.

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

Given the prevalence of rimfire and centerfire rifle usage in both suicidal and homicidal cases, there is a paucity of articles in the literature that focus specifically on rifle wounds. Gunshot wounds, in general, have been extensively studied with articles focusing on the types of injuries, weapons used, wound locations and weapon range. We designed a study to examine the characteristics of rifle wounds, including both centerfire and rimfire rifles, especially pertaining to location and range of the wound. All deaths due to rifles examined at the Bexar County Medical Examiner's Office between 1988 and 2004 were reviewed. A total of 509 cases were identified, with 233 suicides and 266 homicides. We found that the average age of suicide victims (41.6 years) tended to be older than that of homicide victims (32.6 years). Suicides tended to be contact wounds to the head whereas homicides most often had multiple wound locations sustained from a distant range. The most common location to the head of suicidal wounds was intraoral whereas homicidal head wounds were more often to the temporoparietal region. We developed odds ratios for assessing the manner of death given a wound location or range; however, we caution that every case should be analyzed based upon it's unique circumstances and not solely its statistical probability.

The sensitivity of computed tomography (CT) scans in detecting trauma: are CT scans reliable enough for courtroom testimony?

BACKGROUND: Rapid and accurate recognition of traumatic injuries is extremely important in emergency room and surgical settings. Emergency departments depend on computed tomography (CT) scans to provide rapid, accurate injury assessment. We conducted an analysis of all traumatic deaths autopsied at the Bexar County Medical Examiner's Office in which perimortem medical imaging (CT scan) was performed to assess the reliability of the CT scan in detecting trauma with sufficient accuracy for courtroom testimony. METHODS: Cases were included in the study if an autopsy was conducted, a CT scan was performed within 24 hours before death, and there was no surgical intervention. Analysis was performed to assess the correlation between the autopsy and CT scan results. Sensitivity, specificity, positive predictive value, and negative predictive value were defined for the CT scan based on the autopsy results. RESULTS: The sensitivity of the CT scan ranged from 0% for cerebral lacerations, cervical vertebral body fractures, cardiac injury, and hollow viscus injury to 75% for liver injury. CONCLUSIONS: This study reveals that CT scans are an inadequate detection tool for forensic pathologists, where a definitive diagnosis is required, because they have a low level of accuracy in detecting traumatic injuries. CT scans may be adequate for clinicians in the emergency room setting, but are inadequate for courtroom testimony. If the evidence of trauma is based solely on CT scan reports, there is a high possibility of erroneous accusations, indictments, and convictions.

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

Shotguns are used in a considerable number of homicides and suicides, and while gunshot wounds are extensively reported in the literature, there is a paucity of shotgun deaths. To specifically study deaths by shotguns, all deaths due to shotguns examined at the Bexar County Medical Examiner's Office between 1988 and 2005 were reviewed. The cases were evaluated by age and sex of the victim, wound location, wound range, and manner of death. Three hundred eighty-seven cases were evaluated, composed of 343 males and 44 females, with 180 homicides, 203 suicides, 3 accidents, and 1 undetermined manner of death. Contact wounds were the most common range in suicides and the head was the most common location. For homicides, the most common range of fire was distant, and the most prevalent distributions of wounds were head, chest, and multiple wound locations. Statistical analysis showed significant differences between homicide and suicide wound locations and ranges, and then odds ratios were generated. Knowledge of the statistical distribution of shotgun wounds in a large series with respect to range of fire and wound location may be of assistance to the medical examiner in evaluating the circumstances of an individual case to arrive at a manner-of-death opinion.

Gunshot residue testing in suicides: Part II: Analysis by inductive coupled plasma-atomic emission spectrometry.

Several different methods can be employed to test for gunshot residue (GSR) on a decedent's hands, including scanning electron microscopy with energy dispersive x-ray (SEM/EDX) and inductive coupled plasma-atomic emission spectrometry (ICP-AES). In part I of this 2-part series, GSR results performed by SEM/EDX in undisputed cases of suicidal handgun wounds were studied. In part II, the same population was studied, deceased persons with undisputed suicidal handgun wounds, but GSR testing was performed using ICP-AES. A total of 102 cases were studied and analyzed for caliber of weapon, proximity of wound, and the results of the GSR testing. This study found that 50% of cases where the deceased was known to have fired a handgun immediately prior to death had positive GSR results by ICP/AES, which did not differ from the results of GSR testing by SEM/EDX. Since only 50% of cases where the person is known to have fired a weapon were positive for GSR by either method, this test should not be relied upon to determine whether someone has discharged a firearm and is not useful as a determining factor of whether or not a wound is self-inflicted or non-self-inflicted. While a positive GSR result may be of use, a negative result is not helpful in the medical examiner setting as a negative result indicates that either a person fired a weapon prior to death or a person did not fire a weapon prior to death.

Gunshot residue testing in suicides: Part I: Analysis by scanning electron microscopy with energy-dispersive X-ray.

Several different methods can be employed to test for gunshot residue (GSR) on a deceased person's hands, including scanning electron microscopy with energy-dispersive x-ray spectroscopy (SEM-EDX) and inductively coupled plasma-atomic emission spectrometry (ICP-AES). Each of these techniques has been extensively studied, especially on living individuals. The current studies (Part I and Part II) were designed to compare the use and utility of the different GSR testing techniques in a medical examiner setting. In Part I, the hands of deceased persons who died from undisputed suicidal handgun wounds were tested for GSR by SEM-EDX over a 4-year period. A total of 116 cases were studied and analyzed for caliber of weapon, proximity of wound, and results of GSR testing, including spatial deposition upon the hands. It was found that in only 50% of cases with a known self-inflicted gunshot wound was SEM-EDX positive for at least 1 specific particle for GSR. In 18% of the cases there was a discernible pattern (spatial distribution) of the particles on the hand such that the manner in which the weapon was held could be determined. Since only 50% of cases where the person is known to have fired a weapon immediately prior to death were positive for GSR by SEM-EDX, this test should not be relied upon to determine whether a deceased individual has discharged a firearm. Furthermore, in only 18% of cases was a discernible pattern present indicating how the firearm was held. The low sensitivity, along with the low percentage of cases with a discernible pattern, limits the usefulness of GSR test results by SEM-EDX in differentiating self-inflicted from non-self-inflicted wounds.

The reliability of immunoassay for determining the presence of opiates in the forensic setting.

Urine immunoassays are commonly used as a rapid screen for drugs of abuse in emergency room, hospital, clinic, and forensic settings. The authors were concerned whether or not a negative screen of the urine for opiates was of significance and indicative that analysis of blood for opiates was not necessary. Specifically, we wished to determine whether a negative test for opiates by immunoassay absolutely rules out an acute overdose, and if not, what percentage of cases with negative results have opiates in the blood. A retrospective analysis was performed using the toxicology results for cases ruled an acute narcotic overdose at the Bexar County Medical Examiner's Office between 1998 and 2003. One hundred eighty-three cases met the criteria for the study. A false-negative rate of approximately 15% was found using an immunoassay as compared with blood analysis for narcotics. The authors feel that while this rate may be acceptable in a clinical setting, it is unacceptable in a forensic setting.