Synergistic Effects of Forensic Medicine and Traumatology: Comparison of Clinical Diagnosis Autopsy Findings in Trauma-Related Deaths.

BACKGROUND: Trauma is the third leading cause of death worldwide after cardiovascular and oncologic diseases. Predominant causes of trauma-related death (TD) are severe traumatic brain injury (sTBI), hemorrhagic shock, and multiple organ failure. An analysis of TD is required in order to review the quality of trauma care and grasp how well the entire trauma network functions, especially for the most severely injured patients. Furthermore, autopsies not only reveal hidden injuries, but also verify clinical assumed causes of death. MATERIAL: During the study period of 3 years, a total of 517 trauma patients were admitted to our supraregional University Centre of Orthopaedics and Traumatology in Dresden. 13.7% (71/517) of the patients died after trauma, and in 25 cases (35.2%), a forensic autopsy was instructed by the federal prosecutor. The medical records, death certificates, and autopsy reports were retrospectively evaluated and the clinical findings matched to autopsy results. RESULTS: The observed mortality rates (13.7%) were 4.2% less than expected by the calculated RISC II probability of survival (mortality rate of 17.9%). The most frequent trauma victims were due to falls >3 m (n = 29), followed by traffic accidents (n = 28). The median ISS was 34, IQR 25, and the median New ISS (NISS) was 50, IQR 32. Locations of death were in emergency department (23.9%), ICU (73.2%), OR and ward (1.4%, respectively). Clinicians classified 47.9% of deaths due to sTBI (n = 34), followed by 9.9% thoracic trauma and multiple organ failure (n = 7), 8.4% multiple trauma (n = 6), and 2.8% hypoxia and exsanguination (n = 2). In 18.3%, cases were unspecific or other causes of death recorded on the death certificates. Evident differences with evident clinical consequences were ascertained in 4% (n = 1) and marginal clinical consequences in 24% (6/25). In 16% (4/25), marginal differences with minor forensic consequences were revealed. CONCLUSIONS: Even in a supraregional trauma center, specialized in multiple trauma management (4.2% survival benefit), room for improvement exists in more than a quarter of all casualties. This underlines the need for higher autopsy rates to uncover missed injuries and to understand the pathomechanism in each trauma fatality. This would also help to uncover potential insufficiencies in clinical routines with regard to diagnostics. The interdisciplinary cooperation of trauma surgeons and forensic pathologists can increase the quality of trauma patient care.

Complex fracture patterns in hanging associated with a fall from height.

In some rare cases of hanging, the so-called 'hangman's fracture' is observed. This occurs when a fall from height is associated with hanging, e.g. capital executions. We describe the case of an 81-year-old man who committed suicide by jumping off a bridge, with a rope wrapped around his neck. The combination of hanging and falling caused a series of bone fractures to the cervical spine and the hyoid bone, leading to dislocation of the vertebral column and multiple bone fragments, producing peculiar patterns. Computed tomography also identified a transverse full-thickness fracture of the dens, which is a rare event. This case highlights specific injuries associated with the combination of hanging and falling, and underlines the importance of a multidisciplinary approach in terms of radiological examination and complete autopsy.

More interdisciplinary research is needed in forensic medicine.

Forensic routine consists of more than just the classical legal medicine described in textbooks. It is often crucial to answer forensic questions that involve numerous interfaces with other medical disciplines. These interdisciplinary questions that arise in routine autopsy proceedures can also be addressed scientifically, despite decreasing autopsy numbers. Forensic medicine is not only able to generate epidemiologically relevant data, but can also contribute to the establishment of new treatment pathways based on forensic data ("preventive pathology"), at least for certain autopsy sub-populations. In particular, this applies to cases that present prior to hospitalization, particularly with regard to emergency medical and cardiological issues.

[Cooperation between emergency and forensic medicine - retrospective evaluation of pre-hospital emergency measures]. / Netzwerk Rechts- und Notfallmedizin - Retrospektive Evaluation präklinischer Notfallmaßnahmen.

Emergency medical research is subject to special conditions. Emergency patients e.g. are generally considered to be non-capable of giving consent. This results in sparse emergency medical data when compared to clinical observation studies under controlled conditions. After emergency medical treatment, deceased patients are not rarely subject to forensic investigation. The cooperation between emergency and forensic medicine has not only emergency medical training potential in individual cases, but also scientific innovation potential especially with respect to the retrospective evaluation of pre-hospital emergency measures. Such partnerships (like in Berlin at the Charité - Universitätsmedizin Berlin between the Institute of Legal Medicine and the Center for Musculoskeletal Surgery or in Hamburg between the Institute for Legal Medicine at the University Hospital and the Municipal Fire Brigade with the Emergency Medical Service) are yet exceptional in Germany.

Calcified myocardial necrosis in pediatric patients after cardiopulmonary resuscitation.

We report three autopsy cases of wide-spread myocardial necrosis with calcification in pediatric patients after temporary generalized hypoxia and initially successful cardiopulmonary resuscitation, but subsequent in-hospital death. Autopsy and histological workup in all three cases showed multiple circumscribed calcified and necrotic areas in progressive stages of organization within the myocardium. We conclude that these macro- and microscopic autopsy features appear to be related to reperfusion injuries in children as a consequence of hypoxic-ischemic changes occurring in the peri- and postresuscitation period.

Overall distribution of trauma-related deaths in Berlin 2010: advancement or stagnation of German trauma management?

BACKGROUND: Trauma is the leading cause of death among children, adolescents, and young adults. The latest data from the German Trauma Registry reveals a constant decrease in trauma mortality, indicating that 11.6 % of all trauma patients in 2010 died in hospital. Notably, trauma casualties dying before admission to hospital have not been systematically surveyed and analyzed in Germany. METHODS: We conducted a prospective observational study of all traumatic deaths in Berlin, recording demographic data, trauma mechanisms, and causes/localization and time of death after trauma. Inclusion criteria were all deaths following trauma from 1 January 2010 to 31 December 2010. RESULTS: A total of 440 trauma fatalities were included in this study, with a mortality rate of 13/100,000 inhabitants; 78.6 % were blunt injuries, and fall from a height >3 m (32.7 %) was the leading trauma mechanism. 32.5 % died immediately, 23.9 % died within 60 min, 7.7 % died within 1-4 h, 16.8 % died within 4-48 h, 11.1 % died <1 week later, and 8 % died >1 week after trauma. The predominant causes of death were polytrauma (45.7 %), sTBI (38 %), exsanguination (9.5 %), and thoracic trauma (3.2 %). Death occurred on-scene in 58.7 % of these cases, in the intensive care unit in 33.2 %, and in 2.7 % of the cases, in the emergency department, the operating room, and the ward, respectively. CONCLUSIONS: Polytrauma is the leading cause of death, followed by severe traumatic brain injury (sTBI). The temporal analysis of traumatic death indicates a shift from the classic "trimodal" distribution to a new "bimodal" distribution. Besides advances in road safety, prevention programs and improvement in trauma management-especially the pre-hospital phase-have the potential to significantly improve the survival rate after trauma.

Bowel wall hemorrhage after death by hanging.

We describe and discuss autopsy findings of bowel wall hemorrhage in a study population comprising cases of suicidal death by hanging. Intramural hemorrhages were seen in approximately 12% of the cases examined; no preexisting bowel diseases were found. In hanging deaths with a longer agonal phase, we opine that abdominal congestion during the hanging process provides a viable pathophysiological explanation for bowel wall hemorrhage. Though we are not dealing here with obligatory autopsy findings, the detection of bowel wall hemorrhage might be used as another sign of vital hanging after considering differential diagnostic aspects.

[The sick accused: forensic and emergency aspects in the courtroom]. / Der kranke Angeklagte: rechts- und notfallmedizinische Aspekte in der Hauptverhandlung.

Evaluation of the fitness of an accused person to participate in legal proceedings is a classic forensic activity. Before the trial, the forensic expert will already assess any preexisting somatic and psychological illnesses and give a written expert opinion describing the condition of the accused at the time of the examination and assessing whether he is fit to stand trial. Nevertheless, decompensation or aggravation of a disease may occur--especially in stress situations as they are to be expected for an accused in the courtroom--so that apart from the current evaluation of the state of health of the accused, emergency treatment may occasionally become necessary in the courtroom. The article tries to answer the question how the expert can meet this challenge.

Epidemiologic, Postmortem Computed Tomography-Morphologic and Biomechanical Analysis of the Effects of Non-Invasive External Pelvic Stabilizers in Genuine Unstable Pelvic Injuries.

Unstable pelvic injuries are rare (3-8% of all fractures) but are associated with a mortality of up to 30%. An effective way to treat venous and cancellous sources of bleeding prehospital is to reduce intrapelvic volume with external noninvasive pelvic stabilizers. Scientifically reliable data regarding pelvic volume reduction and applicable pressure are lacking. Epidemiologic data were collected, and multiple post-mortem CT scans and biomechanical measurements were performed on real, unstable pelvic injuries. Unstable pelvic injury was shown to be the leading source of bleeding in only 19%. All external non-invasive pelvic stabilizers achieved intrapelvic volume reduction; the T-POD® succeeded best on average (333 ± 234 cm3), but with higher average peak traction (110 N). The reduction results of the VBM® pneumatic pelvic sling consistently showed significantly better results at a pressure of 200 mmHg than at 100 mmHg at similar peak traction forces. All pelvic stabilizers exhibited the highest peak tensile force shortly after application. Unstable pelvic injuries must be considered as an indicator of serious concomitant injuries. Stabilization should be performed prehospital with specific pelvic stabilizers, such as the T-POD® or the VBM® pneumatic pelvic sling. We recommend adjusting the pressure recommendation of the VBM® pneumatic pelvic sling to 200 mmHg.

Discrepancies between clinical diagnosis and hospital autopsy: A comparative retrospective analysis of 1,112 cases.

AIMS: The aim of this study was to compare discrepancies between diagnosed and autopsied causes of death in 1,112 hospital autopsies and to determine the factors causing this discrepancies. METHODS: 1,112 hospital autopsies between 2010 and 2013 were retrospectively studied. Ante-mortem diagnoses were compared to causes of death as determined by autopsy. Clinical diagnoses were extracted from the autopsy request form, and post-mortem diagnoses were assessed from respective autopsy reports. Variables, such as sex, age, Body Mass Index, category of disease, duration of hospital stay and new-borns were studied in comparison to discrepancy. P-values were derived from the Mann-Whitney U test for the constant features and chi-2 test, p-values < 0,05 were considered significant. RESULTS: 73.9% (n = 822) patients showed no discrepancy between autopsy and clinical diagnosis. The duration of hospitalisation (6 vs. 9 days) and diseases of the cardiovascular system (61.7%) had a significant impact on discrepancies. CONCLUSION: Age, cardiovascular diseases and duration of hospital stay significantly affect discrepancies in ante- and post-mortem diagnoses.

[Fatal sodium chloride intoxication--case report and review of the literature]. / Tödliche Intoxikation mit Kochsalzlösung.

The authors describe the case of a 63-year-old, female nursing home inhabitant suffering from trisomy 21, who accidentally ingested the anti-epileptic medication of another nursing home inhabitant. After telephone instructions from a specialist in internal medicine, caregivers forced the woman to vomit by means of saline solution and digital manipulation. This caused not only substantial hypernatriaemia but also aspiration pneumonia, from which the woman died after short hospitalization. The potential toxicity by major electrolyte shifts in terms of hypernatriaemia following administration of sodium chloride solution is well known; this measure is medically contraindicated for the induction of vomiting. The mechanisms leading to death in this case are presented, differentiated and discussed against the background of the literature.

[Determination of death and post-mortem examination on the high seas]. / Todesfeststellung und Leichenschau auf hoher See.

Usually death has to be determined by a physician. Deaths on board of ocean-going vessels confront the crew with special challenges, as on the high seas--especially in the container and cargo ship business--often no physician will be available and death has to be determined by medical laymen such as the captain or the medical officer. To document the determination of death, a "Provisional Certificate of Death on the High Seas" is presented. Moreover, an algorithm "Provisional Post-Mortem Examination on the High Seas" is presented to document the results and the practical performance of the external post-mortem examination by medical laymen on a ship. With the help of concrete procedural instructions medical laymen on board of sea-going vessels are to be enabled to determine the death of a human being beyond doubt, to perform a preliminary external post-mortem examination and to store the corpse according to forensic requirements until the ship reaches a port and the body is delivered to the harbour physician.

[A case of survived compression of the thorax by kneeling on it--"burking"?]. / Ein Fall von überlebter Thoraxkompression durch Beknien--"Burking"?

The authors describe the case of a 27-year-old Vietnamese shoplifter who was caught by two shop detectives and suffered traumatic and mechanical asphyxia due to obstruction of the respiratory excursion and pressure against the neck. The man surprisingly survived the incident without any neurological damage, although the emergency doctor called to the scene diagnosed a score of 4 on the Glasgow Coma Scale. Whether the term "burking" applies to the described case depends on which of the various definitions in the literature is used.

[Post-mortem animal predation of the genital region caused by a half-breed dog]. / Postmortaler Genitalfrass durch einen Mischlingshund.

The authors describe and discuss the case of a 51-year-old man, who was lying mummified in his apartment. Beside the corpse, the well-fed half-breed dog of the deceased was found. Only the penis and testicles of the corpse were destroyed by post-mortem animal scavenging, whereas the face and the rest of the body were intact. There was plenty of dog food in the apartment. In contrast to wild animals, with domestic dogs hunger is the cause for post-mortem scavenging only in the minority of cases. It is rather a displacement activity. Frequently, the face and hands are destroyed by post-mortem animal predation, as these body regions are usually unclothed and thus easily accessible. Lesions in other localizations are seldom seen and injuries in the genital region are a rarity.