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.

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.

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.

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.

So-called accidental firearm fatalities in children and teenagers in Tennessee, 1961-1988.

Tennessee State medical examiner reports of firearm fatalities classified as accidents involving victims aged 19 year or less from 1961 through 1988, were reviewed to evaluate circumstantial and contributing factors. A total of 225 were analyzed. The peak age for victims was 17 years, and there were more than five times more male than female victims. In Shelby County (Memphis), the racial distribution of fatalities was approximately that of the general population. Playing with a gun was the most frequent circumstance. The person responsible for pulling the trigger was equally likely to be a friend, a family member, or the victim. Head or neck were injured in most cases. The urban mortality rate was nearly twice that of the rural rate. More than half of the deaths in urban counties occurred indoors and involved handguns, whereas in rural counties only a third were due to handguns and the location was more often outdoors. Deaths in rural counties showed a seasonal variation that corresponded with the hunting season; by contrast, a peak in early summer was noted in the urban deaths. Defective guns or guns unsafe in design caused several deaths. (Semiautomatic pistols, which can be fired after unloading the ammunition magazine, are conspicuous examples of guns unsafe in design.) An important observation of this study is that medical examiners vary considerably in their classification of accidental manner, particularly when children are involved. Furthermore, medical examiner reports need to include much more information than is currently recorded if they are to be useful in guiding public policy to reduce firearm injuries.

Cocaine and homicide in Memphis and Shelby county: an epidemic of violence.

In Memphis and the surrounding county, there were a record number of homicides (179) in 1986. During the same year, there was a marked increase in medical examiner cases where tests were positive for cocaine or its metabolites. Review of medical examiner and toxicology records from 1980 to 1986 found 87 cocaine related deaths; 46 of these were homicides. In 1986 alone, there were 53 cocaine related deaths, all manners, and 31 cocaine related homicides. In this year, 17.3% of the homicides were positive for cocaine or metabolite. The cocaine related homicides were similar to other homicides in terms of age, race, sex, blood ethanol concentration, and cause of death being due most often to firearms. In homicide cases in which an abuse drug was detected, cocaine accounted for the entire increase in 1986. Police records indicated that cocaine directly contributed to the homicide in 39% of the cases in which the drug was found. In other cases, we speculate that cocaine altered behavior may have contributed to the victim's being murdered either during the drug "high" or during the posteuphoric depression or withdrawal phase.

Evidentiary value of the contents of hollow-point bullets.

The fortuitous recovery of material trapped within the cavity of a hollow-point bullet at autopsy was demonstrated to be of evidentiary value. Analysis of this material, as well as that from hollow-point bullets from test-firings, showed that the contents, especially if in multiple layers, could be correlated with the series of intermediate targets perforated. In the case presented, this aided investigators in determining how many bullets actually struck the victim. Frequently displaced, especially if distortion of the hollow point has occurred, this tidbit of trace evidence is worth recovering and analyzing.

Asphyxiating laryngeal cyst.

Cysts of the larynx are uncommon lesions that on rare occasions may cause sudden death. We report herein the asphyxial death by an obstructing vocal cord cyst in a woman whose body was found in a setting that aroused suspicions of foul play. Features of this case and the autopsy findings are compared with a literature review of laryngeal cysts.