The "empty heart" sign

Approximately 15% of victims of instantly lethal central nervous system trauma have an empty or nearly empty heart at autopsy. This article defines and discusses the "empty heart" sign.     

Repeat Coronary Artery Dissection in Pregnancy: A Case Report and Review of the Literature

Non‐atherosclerotic spontaneous coronary artery dissection (NA‐SCAD) is a rare cause of morbidity and mortality with a propensity for young, healthy, and often peripartum women. NA‐SCAD etiology is poorly understood, with possible hormonal and hereditary mechanisms. Current treatment strategies range from conservative management (often showing resolution on angiographic follow‐up) to invasive angiographic procedures. Rarely, NA‐SCAD has recurred in another coronary artery, ranging hours to years later. We report NA‐SCAD of the right coronary artery (RCA) in a 30‐year old, 3‐month postpartum female with an additional autopsy finding of remote myocardial infarction (MI) in the left anterior descending (LAD) coronary artery territory. The remote MI is consistent with prior NA‐SCAD of the LAD and, given the medical history, may have occurred in the peripartum period of the decedent first pregnancy 3 years earlier. As such, to the best of our knowledge, this may represent the first reported case of NA‐SCAD recurrence in a subsequent pregnancy.     

Child and adolescent suicide deaths in New Mexico, 1990-1994

The suicide death rate in New Mexico is consistently higher than the national rate. Among adolescents, suicide is the third leading cause of death nationally, but in New Mexico it is the second leading cause of death. This study describes the pattern of adolescent suicide deaths in New Mexico. We conducted a retrospective review of all medical examiner autopsies for adolescent suicides (ages 20 years and younger) in New Mexico from 1990-1994. Records were reviewed for demographics and possible contributing factors such as depression, previous attempts, and alcohol and drug use. We identified 184 suicide deaths among children and adolescents ages 9-20 years for an overall rate of 12.9 per 100,000. Our rates for ages 5-9 years (0.2), 10-14 years (3.8), and 15-19 years (22.3) are over twice the U. S. rates. Suicide deaths resulted primarily from firearms (67%), hanging (16%), poisoning (6%), inhalation (4%), and other methods (7%). Method varied by ethnicity (p = .01) and gender (p = .03); males and non-Hispanic Whites were overrepresented among firearm deaths. Firearm ownership was known in 60 (48%) of the firearm deaths. Of these, 53% of the firearms belonged to a family member, 25% to the decedent, and 22% to a friend. Over one-third of decedents (41%) experienced mental disorders, primarily depressed mood and clinical depression. Previous suicide attempts were noted for 15% of the decedents. Some 50% of the decedents had alcohol or drugs present at the time of death; among American Indians/Alaska Natives, 74% had drugs or alcohol present (p = .003). Targeted interventions are needed to reduce adolescent suicide in New Mexico. We suggest raising awareness about acute and chronic contributing factors to suicide; training physicians to look for behavioral manifestations of depression; and involving physicians, teachers, and youth activity leaders in efforts to limit firearm accessibility, such as advising parents to remove firearms from their households.     

Amended cause and manner of death certification: a six-year review of the New Mexico experience

Little is known about the amendment of death certificates (DCs) issued by medical examiners and coroners. This retrospective study examined why, how, and with what frequency cause and manner of death were amended on DCs issued by forensic pathologists over a 6-year period at the New Mexico Office of the Medical Investigator. Approximately 1% of DCs had either cause or manner of death amendments, with arteriosclerotic cardiovascular disease and intoxicants the most commonly amended and resulting causes of death, respectively. There was a significant association between manner of death and number of DCs amended (p<0.001). By percent, natural and suicide DCs were the most frequently amended. The way in which manner of death changed was significantly associated with the amount of time elapsed between DCs (p=0.04). Toxicology was the most common reason for DC amendment.     

Fatal bupivacaine intoxication following unusual erotic practices

A fatal drug overdose is described which involved unusual erotic practices. A 54-year-old male was discovered supine on the floor surrounded by sexual paraphernalia, syringes, and medications including three empty bottles of bupivacaine. Acute and chronic injection sites of the external genitalia with contusions, scarring, focal necrosis, and calcification were present at autopsy. Toxicology revealed femoral blood, heart blood, and vitreous bupivacaine concentrations of 3.8, 2.8 and 1.3 mg/L, respectively. The urine bupivacaine concentration was 11.4 mg/L. The cause of death was attributed to bupivacaine intoxication and the manner of death was accidental.     

Rifle wounds from high velocity, center-fire hunting ammunition.

Wounds inflicted by high velocity, center-fire rifles firing hunting ammunition are radically different from wounds caused by handguns or .22 rim-fire rifles. Injuries from pistol or .22 rim-fire bullets are confined to tissue and organs directly in the wound track. In contrast, high velocity rifle bullets can injure structures without actually contacting them. This is due to the temporary cavity produced by such missiles with the resultant shock waves having pressures of up to 200 atmospheres (20 MPa). Organs struck by such high velocity rifle bullets may undergo partial or complete disintegration. Hunting ammunition, as it passes through the body, tends to shed fragments of lead from its core, producing a characteristic snowstorm picture on X-ray. The maximum range at which powder tattooing of the skin occurs from center-fire rifles depends on the physical form of smokeless powder used as propellant. In a test with a 30-30 rifle, cartridges loaded with ball powder produced powder tattooing out to a range of 30 in. (76 cm), while similar cartridges, loaded with the traditional cylindrical powder, produced tattooing out to only 12 in. (30 cm) of range.     

Trends in Adult Suicides in New Mexico: Utilizing Data from the New Mexico Violent Death Reporting System*

Abstract: Although many suicide prevention programs focus on youth suicides, data indicate the vast majority of suicides occur among adults (18–64 years). In 2005 New Mexico joined the Centers for Disease Control and Prevention’s National Violent Death Reporting System, collecting data on suicides, homicides, and unintentional firearm fatalities to better inform state and national prevention programs. We utilized data collected by the New Mexico Violent Death Reporting System in its first 2 years of operation (2005 and 2006) in order to define the demographic patterns of adult suicides in the state and characterize risk factors. A total of 526 suicides occurred among adults during this time, with the majority being male (78.5%) and White non‐Hispanic (56.7%). The highest incidence was in adults between 45 and 54 years (28.1%). Firearms were the most commonly used mechanism, and “current depressed mood” the most commonly identified risk factor. High rates of adult suicide indicate the need for targeted prevention programs.     

Utilization of serum tryptase and immunoglobulin e assay in the postmortem diagnosis of anaphylaxis

The postmortem diagnosis of anaphylaxis is difficult. Serum concentrations of tryptase (a mast cell product released during anaphylaxis) have been used after death as an indicator of possible antemortem anaphylaxis. However, studies have indicated that tryptase may be elevated with increasing postmortem interval (PMI), or in nonanaphylactic deaths with significant atherosclerosis or chest trauma. Serum total IgE has been used by some to confirm anaphylaxis when tryptase is elevated. Serum levels of tryptase from 57 decedents with varying PMI, all dying of presumed nonanaphylactic causes, were determined. In cases with elevated levels (>11.4 ng/mL), an assay of total serum IgE was also performed. Both tryptase and IgE demonstrated significant elevations with increasing PMI. Decedents were categorized according to presence of cardiovascular disease, chest trauma, or both; many demonstrated elevation of 1 or both markers, without statistically significant differences between categories. Postulated mechanisms for nonanaphylactic elevations of these markers are reviewed. The possible utility of allergen-specific IgE or allergen panels is discussed.