Artifactual injuries of the larynx produced by resuscitative intubation.

Over a period of 9 months we examined a series of 50 deaths due to natural and unnatural causes in which there had been endotracheal intubation and chest compression during resuscitation at the scene or in the emergency department shortly before death. In 37 of 50 cases (74%) there were airway injuries directly resulting from the intubation procedure which we documented using a standardized protocol and photography. Specific airway injuries, ranging from petechiae to contusions, included oral injury (28%), posterior pharyngeal injury (16%), epiglottic injury (22%), piriform recess injury (12%), laryngeal and tracheal mucosa injury (64%), strap muscle hemorrhage (14%), and cutaneous injury of the neck (4%). In addition, we recorded the presence of facial (6%) and conjunctival petechiae (21%) and attributed these changes to resuscitative chest compression. No cases had associated fractures of the hyoid or thyroid cartilage. Based on our findings, we conclude that resuscitative intubation can cause artifactual injury that may mimic inflicted injuries caused by neck compression, including strangulation and neck holds.

The epidemiology of thoracic aortic injuries in pedestrians.

BACKGROUND: Traumatic rupture of the thoracic aorta is recognized as a common cause of occupant death after rapid deceleration in motor vehicle collisions. The incidence of thoracic aorta rupture in pedestrian victims of vehicular collisions, however, is unknown. This study focuses on the epidemiology of injury to the thoracic aorta in pedestrian vehicular collisions. METHODS: We performed a retrospective analysis of all pedestrian fatalities and survivors of rupture of the thoracic aorta during a 6-year period at a regional Level I trauma center and medical examiner's office. RESULTS: There were 220 pedestrian fatalities during the study period. Laceration of the thoracic aorta was noted in 28 of the 220 pedestrian victims (12.7%). Two additional pedestrians survived laceration of the thoracic aorta, for a mortality of 94%. Hospital mortality was 66% (4 of 6). The comparative hospital mortality for patients with rupture of the thoracic aorta secondary to motor vehicle collision was 42%. CONCLUSION: The incidence of thoracic aortic injury in pedestrian fatalities of 12.7% is comparable with previous reports of motor vehicle collision fatalities. Because of the presence of increased associated injuries, pedestrians have a significantly higher mortality. Severely injured pedestrians are at a similar risk to motor vehicle occupants for a life-threatening injury of the thoracic aorta.

Analysis of circumstances and injuries in 217 pedestrian traffic fatalities.

We performed a retrospective analysis of 217 pedestrian traffic fatalities in Seattle, WA, U.S.A. that occurred over a six-year period using medical examiner records with essentially all of the deaths examined by autopsy. The annual pedestrian fatality rate for the county averaged 2.0/100,000 for all ages and both sexes, and the age-specific rate varied from 1.0/100,000 for the 22-34 year age group to 1.5/100,000 for children under seven years and 7.0/100,000 for ages 70 years and older. Males had a 50% higher rate than females. Fatal accidents were most common during December and January and during the evening hours. Wednesday had the greatest number of accidents leading to death, 79% higher than the Saturday weekend rate. Of those tested, 24% had ethanol in their blood. 66% of the fatal injuries occurred on city or residential streets, and 29% occurred on major thoroughfares. A single urban highway accounted for 12% of pedestrian fatalities and represented a particularly hazardous traffic environment. Fatal head injuries and severe chest injuries were present in 73% of cases; injuries involving multiple sites were present in 60%. There were few significant differences in the extent of injuries with respect to vehicle speed or type of vehicle. Head injuries were much less common in the oldest age group, probably because elderly pedestrians were more vulnerable to death from less severe trunk and extremity injuries. Severe chest injury was the most important predictor of death occurring at the scene.

Fatal head injuries in ground-level falls.

We analyzed 75 cases of fatal ground-level falls that were investigated by the King County Medical Examiner over a 48-month period, with autopsies performed on 87% of the deaths: 69% of the cases were men and 61% occurred in ages > or = 70 years; only 12% were aged < 50 years, with the youngest aged 28 years. Most of the falls occurred in or about the residence, and many individuals were known to have fallen onto hard surfaces. In 77% of cases there was significant pre-existing natural disease, mostly cardiovascular disease. Liver disease was more frequently a contributing factor in those aged < 50 years. Ethanol was present in 48% of those cases tested, more frequently present in men than in women. Basal skull fractures were present in 37% of cases, and acute subdural hematomas, the most common intracranial lesion, were present in 85%. We concluded that fatal ground-level falls were much more common in elderly persons, owing to a greater predisposition to falling, as well as intrinsic age-related changes, including a greater susceptibility to acute subdural hematoma.

Accidental firearm fatality involving a hand-crafted pen gun. Case report.

We report a case in which a homemade 0.25 caliber "pen gun" resulted in the accidental death of a man examining the weapon unaware of its lethal nature. The design of the weapon consisted of a spring-loaded firing mechanism contained in a housing resembling a writing pen. Thus, the weapon was similar to zip guns and tear gas pen guns but differed in its craftsmanship and primary purpose of firing conventional ammunition. Another notable feature of the case was an atypical entrance wound due to the 0.25 caliber Winchester AXP ammunition that the pen gun fired. With respect to the weapon and ammunition, this case represents an unusual firearm fatality reported to increase awareness and alert pathologists, as well as law enforcement personnel, to the existence of homemade weapons made to look like innocuous objects.

Trabecular bone volume and microdamage accumulation in the femoral heads of women with and without femoral neck fractures.

Repetitive loading causes fragility and microdamage accumulation in the skeleton, but it is not clear whether microcracks accumulate with age in the human skeleton, or whether older women with femoral neck fractures have more microdamage than older women without fracture. This study tested the hypotheses that: (1) microcracks accumulate in the femoral head with age; and (2) older women with femoral neck fractures have significantly more microcracks than similar aged women without fractures. Nonosteoarthritic femoral heads from 9 young (16-66 years) and 12 old (73-88 years) female cadavers and those from 7 females with femoral neck fractures (56-90 years) were dissected. Midfrontal slabs were block stained with 1% basic fuchsin and 150-microm-thick specimens were measured histomorphometrically. Percent trabecular bone area (TbxAr) significantly decreased in older and fractured subjects compared with young subjects (p < or = 0.05). Microcrack density (CrxDn) was significantly higher in women older than 70 years compared with those younger than 70 (p = 0.005; Spearman's r = 0.41, p = 0.032), but was not different between older women with and without fractures. Osteocyte lacunar density (OtxDn) was significantly less in old and fractured subjects compared with young subjects (p < or = 0.01), and inversely correlated to crack density (r = -0.49, p = 0.011). CrxDn was higher in women with low TbxAr (Spearman's r = -0.56; p = 0.004), and varied inversely with OtxDn (Spearman's r = -0.47; p = 0.014). This is consistent with the idea that cracks accumulate more rapidly in women with low bone density. It is also consistent with the idea that the osteocyte network detects microcracks, and signals for their repair.

Asphyxial suicides using plastic bags.

Fifty-three suicides using plastic bags were identified in a review of cases within the jurisdiction of the King County Medical Examiner's Office, Seattle, Washington from 1984 to 1993. We found that this method was used at a greater frequency by individuals older than 50 in comparison with other methods. The most commonly identified stressor leading to the suicide in this population was failing health. The use of this method as a means of "self deliverance," as advocated by the Hemlock Society, could be inferred in only a small minority of cases where terminal illnesses were identified. This method may be preferred by those older than 50 years because of the ready availability of plastic bags and the relative nonviolence of the death. Analysis of the autopsy findings showed no specific features for this method of suicide. In particular, petechiae, which are often considered a marker of asphyxia, were present in only a small minority of cases (3%). Furthermore, the scene investigation rarely revealed specific features, other than the plastic bag in place. Thus, if the plastic bag were removed after death, the cause and manner of death would be obscure.

Prone sleep position and the sudden infant death syndrome in King County, Washington: a case-control study.

OBJECTIVE: To determine whether the prone sleep position was associated with an increased risk of the sudden infant death syndrome (SIDS). STUDY DESIGN: Population-based case-control study. PARTICIPANTS: Case subjects were infants who died of SIDS in King County, Washington. Control subjects were randomly selected infants born in King County. Up to four control subjects were matched on date of birth to each case subject. METHODS: During the study period, November 1992 through October 1994, sleep-position data were collected on infants who died of SIDS by the King Count Medical Examiner's Office during their investigation of the deaths. Parents of infants chosen as control subjects were contacted by telephone, and sleep position information was obtained. Infants who usually slept on their abdomen were classified as sleeping prone; those who usually slept on the side or back were categorized as sleeping nonprone. The adjusted odds ratio for prone sleep position as a risk factor for SIDS was calculated with conditional logistic regression after control for race, birth weight, maternal age, maternal marital status, household income, and maternal cigarette smoking during pregnancy. RESULTS: Sleep position data were collected on 47 infants with SIDS (77% of eligible infants) and 142 matched control subjects; 57.4% of infants who died of SIDS usually slept prone versus 24.6% of control subjects (p < 0.00001). The unadjusted odds ratio for prone sleep position as a risk factor for SIDS was 4.69 (95% confidence interval: 2.17, 10.17). After control for potentially confounding variables, the adjusted odds ratio for prone sleep position was 3.12 (95% confidence interval: 1.08, 9.03). CONCLUSION: Prone sleep position was significantly associated with an increased risk of SIDS among a group of American infants.

Case report: distribution of methamphetamine in a massive fatal ingestion.

A subject who apparently swallowed a baggie containing "crank" (methamphetamine) while being arrested, was admitted to hospital and then experienced a massive overdose of the drug. The subject went through a seizure with associated fixed dilated pupils, and a depressed pulse and blood pressure. His cardiac and respiratory problems could not be stabilized, and he died. Methamphetamine levels in central and peripheral blood, liver, bile, vitreous, gastric and urine were determined. Blood levels of greater than 60 mg/L, were found together with even higher levels in the bile, urine and gastric. These levels are discussed in terms of other fatal, non-fatal and recreational methamphetamine use.

Unexpected amantadine intoxication in the death of a trauma patient.

We present a case of amantadine intoxication that developed unexpectedly in a hospitalized patient with craniocerebral trauma. The intoxication confused the clinical situation and contributed to the patient's deterioration and death. After excluding overdosage as the cause of the intoxication, we concluded that the excessive blood drug levels (39 mg/L) resulted from tubulointerstitial nephritis--induced renal failure. This case represents an example of an adverse drug reaction that resulted in an unusual drug intoxication and illustrates why toxicological analyses are important for investigation of deaths in hospitalized patients.

Comparison of contact shotgun wounds of the head produced by different gauge shotguns.

A series of 89 contact shotgun wounds of the head were evaluated to compare the extent of wounding produced by different gauge shotguns. Twelve gauge shotguns were the most common, accounting for 69% of the cases, followed by 20 gauge (18%), .410 caliber (10%), and 16 gauge (3%). The mouth was the most common entry site, used in 62% of cases. Comparison of contact intraoral shotgun wounds revealed statistically significant differences between 12 gauge and 20 gauge wounds. Whereas the extent of internal destruction was similar with both gauges, intraoral 12 gauge shotgun wounds caused bursting of the head with lacerations of the face, forehead, and scalp in 74% of cases, while only 9% of 20 gauge wounds produced a similar extent of external disruption. The external head remained fully intact in 55% of 20 gauge intraoral wounds. To account for the threshold effect for head bursting between 20 gauge and 12 gauge shotgun blasts, commercial shotshell and reloading data were analyzed. While there was considerable overlap between the two gauges, a common 12 gauge load would generate 50% more kinetic energy and 40% greater volume of gas than a common 20 gauge load. Comparison of shotgun blasts at entry sites outside of the mouth showed similar differences. Wounds from .410 shotguns were similar to those from 20 gauge weapons, and 16 gauge shotguns produced wounds intermediate between 20 and 12 gauge.

Experimental assessment of small intestinal submucosa as a bladder wall substitute.

OBJECTIVES: This study determined the feasibility of promoting urinary bladder regeneration with porcine-derived small intestinal submucosa (SIS). METHODS: Twenty-two Sprague-Dawley rats underwent partial cystectomy with immediate bladder augmentation with SIS. Bladders were harvested for histologic evaluation at 2, 4, 8, 12, 24, and 48 weeks. RESULTS: Histologically at 2 weeks, there was infiltration of the graft material with viable host cells consisting of fibroblasts, macrophages, and blood vessels covered by complete mucosal urothelium comprised of transitional cells. During the next 10 weeks, collagen formation and maturation were noted, and by the end of 12 weeks, the SIS graft was comprised of a mature collagen matrix admixed with thinly scattered disorganized smooth muscle bundles and covered by normal urothelium. At 48 weeks, all three layers of the normal bladder (urothelium, smooth muscle, and serosa) were present and were grossly and microscopically indistinguishable from the normal rat urinary bladder. CONCLUSIONS: This study further supports the concept of bladder regeneration and suggests that SIS may be a viable material for bladder augmentations.

Firearm suicides during confrontations with police.

We reviewed the case records of suicides in Marion County, Indiana (Indianapolis) and in surrounding counties from 1984 through 1992. Out of 1203 suicides, there were 14 in which armed, on-duty police officers were confronting, pursuing, or apprehending the subject of the death investigation. All subjects were male, and the peak age range was 30 to 34 years. The head, especially the right temple, was the usual site of the fatal wound. More than half of the incidents started as domestic disputes with a wife or girlfriend. Many of the others occurred when police officers pursued or arrested a suspect wanted for a previous felony. Ethanol was involved in less than half of the cases, and drugs were not a factor. In at least four cases, the presence of police was a factor that precipitated the suicide. The histories of the 14 cases demonstrate the potential for controversy and the challenges for forensic scientists investigating suicides during police confrontations.

Disinterment from paving materials: use of heavy equipment for exhumation and examination of bodies.

Common paving materials--concrete and asphalt--pose an unusual and complex barrier to disinterment and examination of human remains. Although not commonly encountered, these materials are seen with sufficient frequency to justify consideration of the procedures and equipment necessary for disinterment. Over a seven year period we have encountered paving materials seven times. In each of these cases, the material was slightly different in quality, and different tools--including heavy construction equipment--were necessary. Sometimes the paving material could be managed without heavy power tools, but occasionally specialized construction tools have proven very useful.

Subendocardial hemorrhages in forensic pathology autopsies.

In a review of 1,034 consecutive forensic autopsies, there were 43 cases that had a distinct zone of subendocardial hemorrhage in the septal wall of the left ventricle. Cases in which there was direct injury to the heart or cardiac resuscitation were not counted. Of the 43 cases, 26 (60%) died of head injuries. Other causes of death were drug or chemical intoxication (14%) and abdominal injuries (12%); miscellaneous causes accounted for 14%. The time between injury and death varied considerably; in 13 cases (30%), the interval was < 1 h. Drugs and/or alcohol were not factors in the appearance of subendocardial hemorrhage, unless the drug itself caused death. Among the drug- or chemical-related fatalities, there were four cases of cocaine overdose with subendocardial hemorrhages. The results of this study are consistent with the hypothesis that cardiac lesions secondary to noncardiac injuries, particularly head injuries, are mediated by hypersecretion of catecholamines. Previous studies have shown significant cardiac decompensation due to noncardiac injuries, and it is likely that the cardiac lesions are part of the mechanism of death. The secondary cardiac lesions are also important for heart transplantation; catecholamine-mediated cardiac damage following head injury or shock may adversely affect performance of the transplant in the recipient.

Hypospermatogenesis is the cause of infertility in the male weaver mutant mouse.

The pathologic phenotype of the testis in both prepuberal and postpuberal male weaver mutant mice was studied by light microscopy. Morphometric analysis of seminiferous tubules was carried out. Epididymal fluid was examined for the presence of spermatozoa. The seminiferous tubules of 21-day-old prepuberal weaver mutant mice lacked patent lumina and had more degenerated cells than control mice. Fifty-six day-old weaver mutants had many germinal epithelial cells located within the adluminal compartment that were in advanced stages of degeneration. Round spermatids were enlarged and multinucleated. Round spermatids and spermatocytes had sloughed into the lumen. Compared to control mice, elongated spermatids were seen less frequently. In older weaver mice, the degenerative process involved germ cells in both the adluminal and basal compartments. In 143- and 226- day-old weaver mutants, the Sertoli cells were atrophic. Diameters of seminiferous tubules in weaver mice were significantly reduced when compared to control mice. Sperm were either absent or very low in number in the epididymal fluid of postpuberal weaver mice. We conclude that spermatogenesis is abnormal in male weaver mutant mice. The testicular phenotype is characterized by a degenerative process that affects both germ cells and supporting cells.

Microcracks in articular calcified cartilage of human femoral heads.

The purpose of this work was to determine whether microcracks occur in calcified cartilage in vivo, and to use histological techniques to separate these from artifacts caused by processing. Six femoral heads without disease were split in the frontal plane. Sections from one slab were cut to 150 microns and stained with basic fuchsin. The other slab was stained en bloc, and sections were cut to 150 microns after staining. Sections were examined microscopically, and microcrack density was calculated. Data show that microcracks occur routinely in calcified cartilage from nondiseased femoral heads of aged humans, and that they can be separated from processing artifact. Their physiological significance is unknown, but it is possible that microcracks may trigger vascular invasion of subchondral bone and may play a role in the initiation and progression of osteoarthrosis.