Suicidal wrist bites.

Wrist injuries are not uncommon in forensic routine and are usually found in the context of suicides or as a result of psychiatric illnesses, e.g., borderline disorders. Sharp objects (knives, broken glass, etc.) are usually used. In the case reported here, a paranoid-schizophrenic man not only injured himself with razor blades on both wrists, but he also inflicted extensive wrist bite injuries using his dental prosthesis. In addition to the severance of flexor tendons, venous vessels and the left radial artery were torn with subsequent blood loss. At the time of death, there was also acute exposure to methadone and opiates. Patients suffering from psychotic illnesses have an increased risk of committing spectacular or bizarre suicides.

Mechanical trauma in children and adolescents in Berlin.

Management of severe pediatric trauma remains challenging. Injury patterns vary according to patient age and trauma mechanism. This study analyzes trauma mechanisms in deceased pediatric patients. Fatal pediatric trauma cases aged 0-18 years who underwent forensic autopsy in the Federal State of Berlin, Germany, between 2008 until 2018 were enrolled in this retrospective study. Autopsy protocols were analyzed regarding demographic characteristics, trauma mechanisms, injury patterns, resuscitation measures, survival times as well as place, and cause of death. 71 patients (73% male) were included. Traffic accidents (40%) were the leading cause of trauma, followed by falls from height > 3 m (32%), railway accidents (13%), third party violence (11%) and other causes (4%). While children under 14 years of age died mostly due to traumatic brain injury (59%), polytrauma was the leading cause of death in patients > 14 years (55%). Other causes of death were hemorrhage (9%), thoracic trauma (1%) or other (10%). A suicidal background was proven in 24%. In the age group of > 14 years, 40% of all mortalities were suicides. Cardiopulmonary resuscitation was carried out in 39% of all patients. 42% of the patients died at the scene. Children between 0 and 14 years of age died most frequently from traumatic brain injury. In adolescents between 14 and 18 years of age, polytrauma was mostly the cause of death with a high coincidence of suicidal deaths. The frequency of fatal traffic accidents and suicides shows the need to improve accident and suicide prevention for children and adolescents.

Fatal injuries due to direct helicopter propeller strike.

During a helicopter exercise, due to the scarce visibility caused by the presence of snow, a collision between a landing helicopter and one already on the ground occurred. The 40-year-old pilot of the already landed aircraft was killed as a result of a direct propeller impact in the right side of the pilot's cockpit, while the co-pilot remained uninjured. At autopsy, the macroscopic characteristic findings in the form of cut injuries and amputations along the axis of the rotor blade impact as well as a 3D reconstruction through CT-Scan were analyzed and discussed for a thorough reconstruction of the injuries and the dynamics.

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.

Death scene investigation and autopsy proceedings in identifying the victims of the terror attack on the Breitscheidplatz in Berlin 19th December 2016.

We describe and discuss the forensic mission after the terrorist attack on the Breitscheidplatz in Berlin on 19th December 2016, focusing on co-operation with police authorities, and the injury patterns of the deceased. Even after massive blunt trauma, severe injury patterns are often unrecognizable by visual inspection of the body ("Casper's sign"), which could instill false security among rescuers or, as happened on the Breitscheidplatz, may lead to distress or even trauma in rescue personnel when obviously primarily uninjured patients die suddenly.

Cardiac Implantable Electronic Device Interrogation at Forensic Autopsy: An Underestimated Resource?

BACKGROUND: Postmortem interrogations of cardiac implantable electronic devices (CIEDs), recommended at autopsy in suspected cases of sudden cardiac death, are rarely performed, and data on systematic postmortem CIED analysis in the forensic pathology are missing. The aim of the study was to determine whether nonselective postmortem CIED interrogations and data analysis are useful to the forensic pathologist to determine the cause, mechanism, and time of death and to detect potential CIED-related safety issues. METHODS: From February 2012 to April 2017, all autopsy subjects in the department of forensic medicine at the University Hospital Charité who had a CIED underwent device removal and interrogation. Over the study period, 5368 autopsies were performed. One hundred fifty subjects had in total 151 CIEDs, including 109 pacemakers, 35 defibrillators, and 7 implantable loop recorders. RESULTS: In 40 cases (26.7%) time of death and in 51 cases (34.0%) cause of death could not be determined by forensic autopsy. Of these, CIED interrogation facilitated the determination of time of death in 70.0% of the cases and clarified the cause of death in 60.8%. Device concerns were identified in 9 cases (6.0%), including 3 hardware, 4 programming, and 2 algorithm issues. One CIED was submitted to the manufacturer for a detailed technical analysis. CONCLUSIONS: Our data demonstrate the necessity of systematic postmortem CIED interrogation in forensic medicine to determine the cause and timing of death more accurately. In addition, CIED analysis is an important tool to detect potential CIED-related safety issues.

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.

Frequency and intensity of pulmonary bone marrow and fat embolism due to manual or automated chest compressions during cardiopulmonary resuscitation.

Iatrogenic consequences of cardiopulmonary resuscitation (CPR) include sternal or rib fractures, pulmonary bone marrow embolisms (BME) and fat embolisms (FE). This report aimed to analyze the frequency and intensity of pulmonary BME and FE in fatal cases receiving final CPR efforts with the use of automated chest compression devices (ACCD) or manual chest compressions (mCC). The study cohort (all cardiac causes of death, no ante-mortem fractures) consisted of 15 cases for each group 'ACCD', 'mCC' and 'no CPR'. Lung tissue samples were retrieved and stained with hematoxylin eosin (n = 4 each) and Sudan III (n = 2 each). Evaluation was conducted microscopically for any existence of BME or FE, the frequency of BME-positive vessels, vessel size for BME and the graduation according to Falzi for FE. The data were compared statistically using non-parametric analyses. All groups were matched except for CPR duration (ACCD > mCC) but this time interval was linked to the existence of pulmonary BME (p = 0.031). Both entities occur in less than 25% of all cases following unsuccessful CPR. BME was only detectable in CPR cases, but was similar between ACCD and mCC cases for BME frequency (p = 0.666), BME intensity (p = 0.857) and the size of BME-affected pulmonary vessels (p = 0.075). If any, only mild pulmonary FE (grade I) was diagnosed without differences in the CPR method (p = 0.624). There was a significant correlation between existence of BME and FE (p = 0.043). Given the frequency, intensity and size of pulmonary BME and FE following CPR, these conditions may unlikely be considered as causative for death in case of initial survival but can be found in lower frequencies in autopsy histology.

Internal patterned injuries in trauma.

Patterned bruising of the internal organs is unusual. In these cases a cutaneous pattern of bruising is not observed but the underlying tissue may show unusual injuries that may even be recognizable as a tramline pattern. We report the suicide of a 23-year-old man by jumping off a bridge. At autopsy, an unusual finding was "tramline" bruising of the right liver lobe. The "blunt objects" that inflicted the bruising were determined to be the right ribs which were pushed against the liver capsule as a consequence of the extensive thoracic and vertebral trauma after a fall from a height with intermediate impact.

[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.

Implications of intracochlear decomposition gas formation in non-putrefied cadavers.

Introduction: Postmortem computed tomography (pmCT) prior to forensic autopsy has become increasingly important in recent decades, especially in forensic documentation of single injuries, injury patterns, and causes of death. Postmortem decomposition gas formation can also be detected in pmCT scans, which might affect cochlear implant research in postmortem human temporal bones (TBs). Material and methods: Fifty non-putrefied hanging fatalities within a 2-year period (January 2017 to December 2019) were included with 100 TBs. Each body underwent whole-body pmCT prior to forensic autopsy. PmCT scans were analyzed with respect to the presence of intracochlear gas despite the lack of putrefaction at autopsy by an experienced fellow neurotologist. Results: PmCT revealed gas formation in two individuals despite the lack of head trauma and putrefaction at postmortem examination and autopsy. Both individuals showed enclosed gas in the vestibule and the cochlea on both sides. Discussion: Intracochlear gas formation, most likely related to decomposition, may occur despite the lack of putrefaction at postmortem examination and autopsy and can be detected by pmCT. This finding seems to be rather rare in non-traumatic death cases but might affect cochlear pressure research in postmortem human TB.

Maternal and pregnancy-related death: causes and frequencies in an autopsy study population.

BACKGROUND: Maternal deaths during pregnancy, both from pregnancy-related or other causes, are rare in Western industrialized countries. In this study we report maternal and pregnancy-related deaths in a large autopsy population focusing on medical history, autopsy findings and histological examinations. MATERIALS AND METHODS: Medico-legal autopsy files (n = 11,270) from the Institute of Legal Medicine and Forensic Sciences, University Medical Centre Charité, University of Berlin, and the State Institute of Legal and Social Medicine, Berlin, from 2005 to 2010 were reviewed. All female cases between 15 and 49 years were checked for maternal and pregnancy-related death, and deaths of pregnant women from non-natural causes were also included. Fatalities that met the chosen criteria were classified as "direct gestational death," "indirect gestational death" or "non-gestational death." RESULTS: 13 female fatalities (0.12 %) met the chosen criteria (median age 28 years ± 6.87 SD). Eight (61.5 %) women died in-hospital, four (30.8 %) at home, and one woman died in public. Three cases (23.1 %) were "non-gestational deaths," and one case (7.7 %) remained unclear after autopsy and additional examinations. Of the remaining nine cases, six cases (46.5 %) were "direct gestational deaths," and two cases (15.4 %) were "indirect gestational deaths." One case (7.7 %) was not to be defined as "late maternal death," but the cause of death seemed to be directly related to previous gestation ["(very) late maternal death"]. CONCLUSION: Maternal deaths during pregnancy, both from pregnancy-related or other causes, remain an uncommon event in routine forensic autopsy practice. We report on the collection and analysis of maternal and pregnancy-related deaths in a large autopsy population, with particular attention to the phenomenology of pregnancy, pathophysiological changes in different organ systems and their detection, and the forensic autopsy assessment.

Emergency medicine techniques and the forensic autopsy.

Emergency medicine measures often have to be carried out under suboptimal conditions in emergency situations and require invasive patient treatment. In the case of a fatal outcome these measures have to be evaluated at autopsy, regarding indications, correct implementation and possible complications. As well, alongside the more familiar procedures--such as endotracheal intubation, insertion of chest drains, external cardiac massage and cannulation of central and peripheral veins--there are alternative techniques being increasingly applied, that include new tools for the management of hemorrhagic shock, drug delivery and alternative airway management devices. On the one hand, all of these measures are essential for the survival and appropriate treatment of the injured and/or sick patient, but on the other hand they can damage the patient and thus contain a significant risk of both medical and forensic relevance for the patient and the physician. In the following review we provide an overview of established, new and alternative techniques for emergency airway management, administration of drugs and management of hemorrhagic shock. The aim is to facilitate the understanding and autopsy evaluation of current emergency medicine techniques.

Circumstantial and toxicological features of deaths from self-administered intravenous anesthetic/narcotic agents.

For a better understanding of circumstantial and toxicological findings of fatalities resulting from self-administration of intravenous anesthetic/narcotic agents, medico-legal autopsy files of the State Institute of Legal and Social Medicine Berlin from 1998 to 2011 were reviewed retrospectively. Of a total of 15,300 autopsies, 9 cases of such deaths were identified, and all were health care professionals. Medical supplies for injection were found still on, or near, the body at the scene. Anesthetic/narcotic agents detected were classified into 3 categories, and administered solely or in combination. Propofol was the most common agent, being detected in 6 cases. In 2 out of 6 cases, propofol was detected substantially above therapeutic levels and was considered the cause of death. In the remaining 4 cases, propofol levels were within the therapeutic range, but propofol intoxication was considered as lethal due to it being administered by rapid continuous injection. In 5 cases, injection of opioid narcotics was fatal. Alongside the 2 propofol-detected cases, there was one case where a higher-than-therapeutic level of piritramide and a therapeutic level of alfentanil was identified. Despite suspected usage, remifentanil was not detected due to its rapid metabolism by elastases in one case, and sufentanil was undetectable due to putrefaction in another, but death was attributed to their potent respiratory depressant effects without respiratory assistance. Benzodiazepines were detected in 4 cases. All of them were used together with propofol or opioids, and contributed to death by inhibiting respiration. It is essential to consider means of administration as well as additive or synergistic effects of combined agents when interpreting toxicological results in such cases.

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.