Death due to electrocution in childhood and early adolescence.

OBJECTIVES: To delineate the clinicopathological features of fatal childhood electrocutions and to identify specific risk factors. METHODS: Coronial files in Adelaide (Australia) were searched from 1967 to 2001 and Medical Examiners' files in San Diego (USA) were searched from 1988 to 2001, for cases of deaths of children and adolescents younger than 16 years attributed to electrocution. RESULTS: Sixteen cases were identified aged between 10 months and 15 years (mean 8.0 years) with a male : female ratio of 5 : 3. Deaths were due to accidents occurring while playing with or near faulty electrical equipment at home or at school (n = 8), electrical equipment while in the bath (n = 2), damaged outdoor electrical equipment (n = 1), overhead wires (n = 1), and a high voltage electricity substation (n = 1). In addition, one death was due to suicide involving an electrical appliance placed in a bath, and two other deaths occurred in older children who were moving equipment under overhead wires. No homicides were identified. CONCLUSIONS: Childhood deaths due to electrocution are rare and are more likely to occur when children are playing around electrical wires or equipment, and often result from either faulty apparatus, or a lack of understanding of the potential dangers involved. The majority of deaths (11/16; 69%) occur in the home environment. In contrast to adult electrical deaths, high-voltage electrocutions, suicides and workplace deaths are uncommon. Strategies for eliminating childhood electrocution should concentrate on ensuring safe domestic environments with properly maintained electrical devices.

Neck extension and rotation in sudden infant death syndrome and other natural infant deaths.

It has been hypothesized that some cases of sudden infant death syndrome (SIDS) are a result of neck extension and/or rotation that causes vertebral artery (VA) compression and brain stem ischemia. There is a paucity of relevant literature on this topic. Therefore, our aim was to compare neck rotation and extension in SIDS and other natural infant deaths. Cases of SIDS and other natural infant deaths within the San Diego SIDS Research Project database were analyzed retrospectively with respect to neck and body position as reported by the trained, experienced scene investigators and/or the caretakers who discovered the infants. Information was used from 246 SIDS cases and 56 cases of other natural deaths. Simultaneous neck extension and rotation was not reported in either group. When data regarding neutral/flexed/extended position and rotation of the neck were combined, no significant differences were found between the two groups (P = 0.94); 40% of the SIDS cases and 41% of the other natural death cases were found with the neck either extended or rotated (odds ratio [OR] 0.97, [reference group = neck either neutral or flexed, and not rotated], 95% confidence interval [CI] 0.45, 2.11). There were also no significant differences between the groups when neck rotation and neck extension were analyzed independent of one another. Neck rotation among cases found in the prone position was common and was not significantly different between the two groups (49% of 146 SIDS cases, 58% of 24 other natural death cases, P = 0.38, OR 0.68, 95% CI 0.28, 1.62). Neck rotation among infants found in the supine position occurred one-third as often in the SIDS group (9% of 33 cases) as in the other natural death group (29% of 14 cases); however, the difference was not significant (P = 0.17; OR 0.25, 95% CI 0.05, 1.31). Although our analysis does not exclude VA compression and brain stem ischemia in some cases of SIDS, we found no evidence to affirm its importance. This study demonstrates the importance of meticulous scene descriptions, including neck position.

Intrathoracic petechiae in sudden infant death syndrome: relationship to face position when found.

Previous studies have not addressed the relationship of intrathoracic petechiae (IP) to the position of the face when a caretaker finds a victim of sudden infant death syndrome (SIDS). The aims of this retrospective study were to determine (1) the rate of the facedown position in SIDS (not to be confused with the prone body position), (2) if the facedown position occurred more frequently among SIDS victims with intrathoracic petechiae than those without petechiae, and (3) if the facedown position occurred more frequently among cases with more severe petechial hemorrhage of the thymus. We selected 199 SIDS cases from the San Diego SIDS Research Project database and grouped them as IP-present and IP-absent. Each case was analyzed with regard to the face position when found unresponsive or dead. Among these 199 cases, 37% were found face-down, which represents 51% of the 142 cases found prone. The two groups were similar with respect to age, sex, and rate of premature birth. Thirty-nine percent (39%) of the IP-present group and 9% of the IP-absent group were found in the facedown position (P = 0.057; 95% confidence interval for the difference = 0.3%, 40%). Cases were also grouped by severity of thymic petechiae and analyzed regarding face position. Neither age nor the facedown position was associated with greater severity of thymic petechiae. The wide confidence interval yielded by our analysis of IP limits our ability to clarify the precise pathophysiologic role of external oronasal obstruction in SIDS. While it remains possible that a subset of SIDS cases occur as a result of external obstruction, we are unable to generalize its importance. Internal airway obstruction and rebreathing with terminal gasping, both of which have been documented in sudden infant death, remain other possible scenarios leading to the production of IP.

Shared bathing and drowning in infants and young children.

OBJECTIVE: A study was undertaken to look at possible risks of shared bathing in early childhood. METHODS: Autopsy databases were searched at the Women's and Children's Hospital and State Coroner's Office, Adelaide, Australia, from January 1963 to December 1999, the Victorian Institute of Forensic Medicine, Melbourne, Australia, from January 1991 to December 1999, and the Children's Hospital-San Diego, San Diego, USA, from January 1990 to December 1999, for all cases registered as drowning in children aged 2 years and under who were in a bath with another child around the time of death. RESULTS: A total of 17 cases were found. The age range of the victims was 8-22 months (average=11.8 months), with a male to female ratio of 10:7. The surviving children (who were all siblings) were significantly older, with an age range of 19-48 months (average=30.4 months), and a male to female ratio of 12:5. (The survivors were on average 18.5 months older than the victims, range=11-32 months). In every case the children had been left unsupervised for variable periods of time. CONCLUSIONS: These cases represented a significant component -- between 22 and 58% -- of bath drownings in the 2 years and under age group. It would appear that shared bathing for young children and infants may only acceptable if adult supervision is constant, and that a young sibling is not an appropriate person to look after an infant or toddler in the bath. While the risk of leaving an infant in a filled bath may be exacerbated if an older child is also present, further population-based studies are required to examine this hypothesis.

Oronasal blood in sudden infant death.

Oronasal secretions are observed frequently in sudden infant death syndrome (SIDS), but overt blood is uncommonly reported. The literature on oronasal blood in sudden infant death is limited. The goal of this study was to determine the frequency of oronasal blood in sudden infant deaths and to examine possible causative factors. Oronasal blood was described in 28 (7%) of 406 cases of sudden infant death. Oronasal blood could not be attributed to cardiopulmonary resuscitation in 14 cases, including 10 (3%) of 300 cases of SIDS, 2 (14%) of 14 accidental suffocation cases, and 2 (15%) of 13 undetermined cases. Eight of the 10 infants in cases of sudden infant death were bedsharing: 5 with both parents, 2 between both parents. The infant in 1 SIDS case was from a family that had had three referrals to Child Protective Services. Oronasal blood not attributable to cardiopulmonary resuscitation occurs rarely in SIDS when the infant is sleeping supine in a safe environment. Bedsharing may place infants at risk of suffocation from overlaying. Oronasal blood observed before cardiopulmonary resuscitation is given is probably of oronasal skin or mucous membrane origin and may be a sign of accidental or inflicted suffocation. Sanguineous secretions that are mucoid or frothy are likely of remote origin, such as lung alveoli. The use of an otoscope to establish the origin of oronasal blood in cases of sudden infant death is recommended.

Environmental hyperthermic infant and early childhood death: circumstances, pathologic changes, and manner of death.

Infant and early childhood death caused by environmental hyperthermia (fatal heat stroke) is a rare event, typically occurring in vehicles or beds. The aims of this study were to describe the demographics, circumstances, pathology, and manner of death in infants and young children who died of environmental hyperthermia and to compare these cases with those reported in the literature. Scene investigation, autopsy reports, and the microscopic slides of cases from three jurisdictions were reviewed. The subjects in 10 identified cases ranged in age from 53 days to 9 years. Eight were discovered in vehicles and 2 in beds. When the authors' cases were grouped with reported cases, the profile of those in vehicles differed from those in beds. The former were older, were exposed to rapidly reached higher temperatures, and often had more severe skin damage. The latter were mostly infants and were exposed to lower environmental temperatures. Hepatocellular necrosis and disseminated intravascular coagulation were reported in victims who survived at least 6 hours after the hyperthermic exposure. The consistent postmortem finding among nearly all victims was intrathoracic petechiae, suggesting terminal gasping in an attempt at autoresuscitation before death. The manner of death was either accident or homicide. Recommendations for the scene investigation are made.

Specific dangers associated with infants sleeping on sofas.

AIM: A study was undertaken to examine specific circumstances that may lead to accidental asphyxial deaths in infants on sofas. METHODS: Coronial files in South Australia (Australia) from 1989 to 1998, and files at the Office of the Medical Examiner in San Diego County (USA) from 1991 to 1998 were searched for all cases of infant deaths occurring on sofas. RESULTS: A total of 10 cases with complete death scene descriptions were found. Four deaths were attributed to sudden infant death syndrome and six deaths to accidental asphyxia, of which four involved shared sleeping with an adult. Lethal circumstances involved infants being overlayed by an adult (n = 2), wedged between an adult and the back of a sofa (n = 1), sleeping with an intoxicated/sedated adult (n = 2), wedged between pillows and the back of a sofa (n = 1), and wedged into the back of a sofa (n = 1). CONCLUSIONS: Although shared sleeping of an adult with an infant on a sofa may result in accidental asphyxia, there is also the potential for wedging and accidental asphyxia of infants sleeping alone on a sofa. For this reason the use of sofas for both shared and solitary infant sleeping is discouraged.

Early adolescent suicide: a comparative study.

A study was undertaken of suicides in children and adolescents aged 16 years and under in South Australia, (Australia), and in San Diego County (USA) from January 1985 to December 1997. In South Australia there were 48 cases of youth suicide, representing 2% of the total number of 2251 suicides over that time. There were 34 males and 14 females (age range 13 to 16 years; mean = 15.3 years), with 22 hangings (46%), six gunshot wounds (13%), five train deaths (10%), four drug overdoses (8%), four jumping deaths (8%), three self immolations (6%), three carbon-monoxide inhalations (6%) and one electrocution (2%). In San Diego County there were 70 cases, representing 1.6% of the total number of 4492 suicides. There were 48 males and 22 females (age range 11 to 16 years; mean = 14.7 years), with 41 gunshot wounds (59%), 21 hangings (30%), six drug overdoses (9%), and two jumping deaths (3%). Preferred methods of suicide differed between the two areas, with significantly more gunshot suicides in San Diego compared to South Australia. The methods of suicide also differed in South Australia from older age groups, with more hangings, jumping deaths and self immolations, and fewer firearm and carbon monoxide inhalation deaths. Suicides in adolescents under the age of 17 years in both populations were, however, rare, with no demonstrable increase in numbers over the time of the study.

Successful organ donation in victims of child abuse.

Organ transplantation has become a valuable and accepted treatment for many patients with organ failure. A major limitation to transplantation is the shortage of organ donors. Due to lack of willingness by medical examiners to release child abuse cases for organ donation, child abuse victims are a greatly underutilized pool of potential donors. This paper presents a model to facilitate organ recovery in the child abuse victim. This protocol has been in consistent use in San Diego County since midyear 1991. In all cases of child abuse where the victim was brain dead and the family consented to organ donation, the medical examiner's office released the body for organ donation. Since institution of the model described in this paper, organ donation among child abuse victims has risen dramatically in San Diego County. If similar protocols are established at other pediatric centers, the disparity between supply and demand in pediatric organ donation will diminish.

Inflicted skeletal injury: a postmortem radiologic-histopathologic study in 31 infants.

OBJECTIVE: The objective of this postmortem study was to use high-detail skeletal surveys, specimen radiography, and histopathologic analysis to determine the number, distribution, and age of inflicted skeletal injuries in infants studied at the University of Massachusetts Medical Center from 1984 to 1994. MATERIALS AND METHODS: Thirty-one infants (average age, 3 months) who died with inflicted skeletal injuries were studied with high-detail skeletal surveys and specimen radiography and histopathologic analysis. The distribution and number of fractures was determined for each technique, and dating was performed on the basis of radiologic and histologic criteria. The skull fractures noted in 13 cases were excluded from the numerical analysis. RESULTS: The radiologic-histopathologic correlation revealed 165 fractures involving the ribs in 84 (51%), long bones in 72 (44%), bones of the hands and feet in 6 (4%), clavicles in 2 (1%), and spine in 1 (< 1%). Of the 72 long bone fractures, the metaphyses were involved in 64 (89%, or 39% of the total), and the shaft was involved in 8 (11%, or 5% of the total). One hundred sixteen fractures were healing, 36 were acute, and 13 were of indeterminate age. In all but two infants, at least one healing fracture was present. Of fractures diagnosed histopathologically, specimen radiography increased the yield of fractures noted on skeletal survey from 58% to 92%. CONCLUSION: Most infants who die with inflicted injury have fractures at multiple sites. Metaphyseal and rib fractures are much more common than long bone shaft injuries, the opposite of the pattern found in older children. Because most abused infants who die have evidence of healing fractures at the time of autopsy, aggressive radiologic efforts to identify these injuries in living as well as in decreased infants appear justified.

Use of autopsy results in the emergency department quality assurance plan.

Traditionally, the autopsy is viewed as the ultimate quality assurance indicator in clinical medicine, yet very few clinical departments actually incorporate autopsy results in their formal quality assurance plans. Consequently, to investigate how autopsy results can be included on our emergency department plan, the clinical and autopsy diagnoses of 244 patients were reviewed retrospectively and compared to identify conditions that were unapparent or misdiagnosed at the time of death. The study period was from January 1984 through June 1988. The average yearly ED census was 33,266. Differences between clinical and autopsy diagnoses were categorized as class 1, 2, 3, or 4 findings. Major unexpected findings (classes 1 and 2) were found in ten patients (4%); the most common missed diagnoses were aortic dissection 3 (1.2%) and pulmonary embolus 2 (0.8%). Minor unexpected findings (classes 3 and 4) were discovered in 14 patients (5.8%). The results clearly identify unexpected findings and point to the need for more aggressive evaluations of certain conditions. Systematic review of autopsy data as presented has led to meaningful changes and delivery of care to emergency patients. Autopsies are a vital source of outcome-based information that should be part of every ED's quality assurance and risk management plan.

Radiologic contributions to the investigation and prosecution of cases of fatal infant abuse.

In 1984 we started a two-year program in Worcester (Mass.) and Boston to provide additional radiologic data for the medical investigation of suspected fatal infant abuse. During that period the investigation of 12 cases of unexplained infant death included the review of complete radiographic skeletal surveys by a pediatric radiologist. Autopsies were supplemented with resection, high-detail radiography, and histologic study of all non-cranial sites of suspected osseous injury. Thirty-four bony injuries were noted, including 12 acute and 16 healing fractures of the long-bone metaphyses and posterior-rib arcs in patterns indicative of infant abuse. The investigations determined that there were eight cases of abuse, two accidental deaths, and two natural deaths (sudden infant death syndrome). At this writing, the radiologic and osseous histologic studies appear to have influenced the determination of the manner of death in six of the eight cases of abuse and the criminal prosecution in four of the five convictions. These findings suggest that a thorough postmortem radiologic evaluation followed by selected histologic studies can have an impact on the investigation and prosecution of cases of fatal infant abuse.

Factors affecting visualization of posterior rib fractures in abused infants.

Rib fractures frequently are encountered in abused infants and commonly occur in the posterior rib arcs. Fractures occurring near the costovertebral articulations are rarely identified radiographically in the acute phase, and callus formation usually is the first indication of injury. To assess the factors influencing the visibility of fractures near the costovertebral articulations in abused infants, 103 posterior rib fractures occurring in 16 abused infants were studied radiologically. The plain radiologic studies were correlated with the pathologic findings in 15 ribs from four patients. The limited visibility of fractures relates to (1) the frequent superimposition of the transverse process over the rib fracture site, (2) a fracture line that crosses at an obliquity to the radiographic beam, and (3) nondisplacement of rib fragments due to preservation of the posterior periosteum. Fresh fractures invisible on a frontal projection are clearly defined when the rib is viewed axially with postmortem radiography. These findings explain the reported superior sensitivity of radionuclide bone scans vs radiography in the identification of fresh posterior rib fractures. A knowledge of the factors influencing the visibility of these important injuries is useful in planning an appropriate diagnostic evaluation in cases of suspected infant abuse.

Fatal water intoxication, schizophrenia, and diuretic therapy for systemic hypertension.

Clinical and morphologic findings are described in a 37-year-old hypertensive man with chronic schizophrenia who had two well-documented episodes of water intoxication. The use of diuretics for control of systemic hypertension in the setting of chronic schizophrenia appears ill-advised.

The metaphyseal lesion in abused infants: a radiologic-histopathologic study.

The metaphyseal lesions in abused infants have highly distinctive radiologic characteristics. The so-called "bucket-handle" and "corner" fractures often form the basis for the diagnosis of abuse. However, despite the great familiarity with the radiologic appearances, no systematic histopathologic study of the metaphyseal lesions in abused infants has been carried out. An in-depth study of pre- and postmortem radiologic features combined with histologic analyses of the metaphyses from a group of four abused infants provides new insights into the nature of these peculiar lesions. The basic histologic alteration is a subepiphyseal planar series of microfractures through the most immature portion of metaphyseal bone. This fracture results in the isolation of a mineralized disc or portion of a disc that is identifiable radiographically. Depending upon the size of the injury, the degree of involvement of the periphery of the bone, and the radiographic projection, a bucket-handle lesion, corner fracture, or metaphyseal lucency will result. In some cases, the radiographs may be normal even though there is significant histologic alteration. Although cartilaginous injuries may play a role in infant abuse, none of the specimens examined in this study evidenced injury through the germinal layers of cartilage. On the basis of the findings described here, it is recommended that postmortem analysis of all radiographically suspicious metaphyses be carried out in cases of suspected infant homicide. If there are other clinical or pathologic indications to support abuse, a strong argument can be made for removal of radiologically normal but high-risk metaphyses. Instituting these procedures will require closer cooperation between the radiologist and the medical examiner, but the potential for reducing the number of infant homicides demands this enlightened approach.

Vitreous humor chemistry in deaths associated with rapid chilling and prolonged freshwater immersion.

Vitreous humor chemistry studies were performed on 13 air crash victims who had remained immersed in near-freezing fresh water for seven to eight days. Glucose concentrations were observed to be higher than those in a comparison group of autopsied cases with prolonged postmortem intervals, suggesting that rapid chilling inhibited glycolysis. Evidence of dilution of vitreous humor electrolytes was also noted. After correction for the apparent degree of dilution, the potassium concentrations were found to fall within a narrow range.

Congenital hypoplasia of portions of both right and left ventricular myocardial walls. Clinical and necropsy observations in two patients with parchment heart syndrome.

Clinical and morphologic findings are described in two patients with congenital hypoplasia of portions of both right and left ventricular free walls in the absence of associated coronary or valvular heart disease. One, a 61 year old man who had never had clinical evidence of cardiac dysfunction, died suddenly and unexpectedly. The second, a 55 year old woman, died of progressive, eventually intractable congestive heart failure of 29 months' duration. Although at least 22 necropsy patients have previously been reported to have "parchment-like" thinning of portions of the right ventricular free wall, only one patient has previously been described with such thinning of portions of both right and left ventricular free walls. The spectrum of right or right and left ventricular wall congenital hypoplasia is a broad one, with nearly half of described patients dying of congestive heart failure in the 1st year of life and the other half reaching adulthood with or without manifestations of cardiac dysfunction.