Abdominal Stab Wounds with Tension Pneumopericardium Confirmed by Autopsy and Postmortem Computed Tomography

We present the first report of pneumopericardium observed by autopsy and on postmortem computed tomography (PMCT) images. The subject was a woman who died of self‐inflicted stab wounds to the abdomen. The PMCT scan revealed air in the pericardial sac, a “flattened heart” sign, and retroperitoneal hemorrhage. Medicolegal autopsy revealed two abdominal stab wounds near the xiphoid process that had cut the apical pericardium and adjacent diaphragm and liver. Examination of the open thorax confirmed that the pericardial sac was distended with air. The wound extended to the abdominal aorta, causing retroperitoneal hemorrhage. PMCT images showed that the pneumopericardial volume was 133 mL. We believe that cardiac tamponade occurred resulting from the tension pneumopericardium; however, the effects were mitigated by hypovolemia secondary to the retroperitoneal hemorrhage as well as obstructive shock. Therefore, the cause of death appears to have been low‐pressure cardiac tamponade.     

Myocardial lesions induced after trauma and treatment.

In order to clarify the effect of trauma and treatment as stresses on myocardia, we examined histological changes of myocardia in victims who received various kinds of traumata and treatments. We also undertook a histochemical study for calmodulin, which we found useful in the diagnosis of early ischemia. Those who died shortly after stab wounds, traffic accident or head injuries, showed mild cardiac lesions such as contraction bands or fragmentation and mild diffusion of calmodulin, a marker for necrosis. A case with hemorrhagic shock after a traffic accident, involving intense resuscitation for 2 h, showed severe cardiac lesions such as contraction bands, hydropic change and subendocardial hemorrhage along with severe diffusion of calmodulin. In most of the instant death cases after falls, severe contraction band necrosis and severe calmodulin diffusion were observed. Myocardia of victims, who died several days after head injuries or traffic accidents, generally demonstrated distinct diffusion of calmodulin as compared to the mild and non-specific lesions detected by hematoxylin-eosin (H&E) staining. In cases of long-term survival in a state of brain death, calmodulin staining was very low, which was not always associated with the severity of the lesions on H&E staining. In cases with intensive or extended treatment, it appeared to be difficult to determine the cause-effect relationship between trauma and cardiac lesions or to distinguish the lesions due to extrinsic factors from those of disease. In some cases, calmodulin intensely stained the areas with hydropic appearance or hypereosinophilia, which may be related to calcium overload.     

Study of 5-hydroxytryptamine (serotonin) in pericardial fluid in different causes of death (II.). Experimental study of 5-HT levels in two types of shocks (hemorrhagic and septic) in dogs

In the present work we studied the levels of 5-HT in the pericardial fluid of 160 cadavers according to cause of death; such as myocardial infarction, violent asphyxia, pulmonary embolism, infections, bronchopulmonary diseases, traumatic and hemorrhagic diseases in the CNS, and multiple traumatism. We did not find significant differences in the various causes of death. A complementary study of 20 dead dogs having suffered induced shock, either hemorrhagic or septic, was made. In both series we studied the serum levels of 5-HT and the following parameters: systolic and diastolic arterial pressures, central venous pressure, hematocrit value, pH value, total proteins, albumin, PO2, and PCO2. We found the significant correlation (r = 0.828, P less than 0.01) only between 5-HT serum levels and the systolic arterial pressure in the hemorrhagic shock.     

Cervical Arterial Injury After Strangulation—Different Types of Arterial Lesions

After strangulation, cervical arterial injuries (CAI) are uncommon. We report three unusual cases where strangulation induced immediate stroke. CAI were examined using brain CT scan and Doppler ultrasonography in the three cases and then by autopsy in one of the victims. One of the two victims who survived the attempted strangulation had a unilateral carotid dissection, whereas in the other victim, no arterial dissection or thrombosis was observed. As regards the deceased victim, the autopsy confirmed the bilateral dissection showed on CT scan and Doppler ultrasonic examination and revealed that both carotid arteries were dilated up to two times the normal diameter. Microscopic examination showed a major bilateral hemorrhagic dissection of the media with obliterating fibrous endarteritis lesions associated with inflammatory damage. CT scan with arteriography does not demonstrate all the different types of arterial injury, particularly atheromatous embolism, direct compression, or prolonged spasm. Thus, traditional autopsy remains an essential forensic tool after strangulation to show the type of CAI.     

Application of ultrasonography to postmortem examination. Diagnosis of pericardial tamponade

In postmortem examination, it is difficult to diagnose pericardial tamponade in a dead body from the findings of conventional external examination alone. However, ultrasonography is a common diagnostic tool for pericardial tamponade in clinical practice. We studied the postmortem diagnosis of pericardial tamponade at external examination level by applying an ultrasonographic device. The ultrasonographic findings were compared with the conventional autopsy findings. Among 455 cases of forensic autopsy in Hamburg and Tokyo conducted within 5 days after death, we successfully diagnosed 11 cases of pericardial tamponade by ultrasound imaging prior to autopsy, and failed to diagnose pericardial tamponade in only two cases. In addition, 79 cases of external examination conducted at the Tokyo Medicinal Examiner's Office were also examined with ultrasonography, and we diagnosed three cases of pericardial tamponade and five cases of pericardial effusion. The differences in ultrasonographic findings between tamponade and effusion were relatively clear. Although autopsy provides definitive evidence for the cause of death, sometimes autopsy cannot be performed due to some social factors. In such cases, conventional external examination alone cannot establish a cause of death by pericardial tamponade, and application of diagnostic imaging technique will be helpful. While CT and/or MRI may provide more detailed information than ultrasound imaging, these techniques require special equipment, room and specialist, and most of all involves high cost, which is perhaps the most important consideration in the present atmosphere of medical cost containment. On the other hand, the ultrasonographic devices we use are compact, and can be used directly at the scene of death. Postmortem application of ultrasonography may be a valuable adjunct in the work of medical examiners and forensic pathologists.     

Sudden death in hemodialysis patients

Hemodialysis patients may die suddenly and unexpectedly from a number of causes. These may be divided into those deaths due directly to and occurring during hemodialysis, those deaths occurring while the patient is not undergoing dialysis, and those deaths that may occur at any time. The first group includes brain herniation, air embolism, acute hemorrhage as a result of machine malfunction or fistula rupture, electrocution, cardiac arrhythmia caused by hypokalemia, complications of subclavian intravenous catheter insertion, third-degree heart block as a result of triglyceride emulsion, and disseminated intravascular coagulation (DIC) or hyperkalemia caused by overheated dialysate. The second group includes deaths due to pericardial tamponade because of effusion and suicidal causes of death (exsanguination, electrolyte imbalance as a result of excessive intake of salt, fluid, or potassium) as well as more conventional methods of suicide. The last category includes people dying of arteriosclerotic cardiovascular disease, hypertensive cardiovascular disease, and internal hemorrhage. Investigation of these deaths, including pertinent historical, laboratory, and autopsy data and investigation of dialysis equipment, is discussed.     

Case reports of suicide with an electric drill

In this report, three cases of suicide by an electric power drill are described. In the first case, a man aged 51 was found with four penetrating wounds of the head and chest. The second case involves a 56-year-old man who suffered a penetrating craniocerebral injury and the third case involves a 53-year-old man who suffered one head injury and two chest injuries. In the first two cases, the victims were found dead. In the third case, the victim survived his injuries for 28 hours. The case histories and the post-mortem examinations revealed no evidence of homicide.     

Evaluation of post-mortem ethanol concentrations in pericardial fluid and bone marrow aspirate

This study confirmed post-mortem ethanol concentrations in pericardial fluid and bone marrow aspirate in comparison with those in the blood in medicolegal autopsy cases (n = 140, within 48 h post-mortem). The specimens were examined by head-space gas chromatography/mass spectrometry. Ethanol concentrations in the pericardial fluid (y) were approximately equivalent to those in peripheral blood (x): y = 0.99x + 0.02, n = 44, r = 0.972. A high stomach ethanol concentration (>10 mg/ml) appeared to mildly affect the pericardial levels. There was no significant interference in drowning cases. Ethanol concentrations in bone marrow aspirates (y) also showed a good correlation with those in the peripheral blood (x): y = 0.77 x + 0.02, n = 20, r = 0.981. A dissociation was observed in cases of delayed death from hemorrhagic/traumatic shock and elderly victims. These findings suggest that pericardial fluid and bone marrow aspirate can be used as an alternative material when adequate blood specimens are not available.     

Death from thermal effects and burns

One hundred and fifteen unselected autopsy cases of death from thermal effects and/or fire between 1990 and 1999 were analyzed with regard to time of death, signs of vitality at the scene of the fire, the manner and cause of death, and the extent of soft tissue loss. The cases represented approximately 6% of all autopsy cases at the Institute of Legal Medicine responsible for a catchment area with approximately 700,000 inhabitants. In 23 victims suffering burn injuries, death occurred during initial medical care or clinical treatment. The causes of death were primary respiratory arrest due to smoke poisoning or delayed shock caused by thermal injuries to the skin. Death occurred at the scene of the fatal event in 85 cases: eight cases exhibited no thermal effects; the cause of death in one of these cases was polytrauma incurred in a leap from a height; in seven cases there was poisoning due to smoke inhalation. The remaining 77 cases were characterized by signs of intensive thermal and/or fire effects. Clear signs of vitality (carboxyhemoglobin (COHb) in blood, inhalation and/or swallowing of soot) were found in 84.7% of the victims dying at the site of the fatal event. Of the 13 victims showing no signs of vitality at the scene, a cause of death could be determined in only seven cases; death in the other six cases remains unexplained. Quantification of the soft tissue loss revealed a possible correlation with the temperature and time course of heat exposure.     

Time-related changes in cardiac ct images of rabbits died from four kinds of execution

Objective To explore the feasibility and appropriate parameters for estimating postmortem interval (PMI) through time-related CT imaging into dynamically monitoring the cardiac changes of rabbits died from four kinds of execution. Methods The experimental rabbits were executed with four disposals of air embolism, strangulation, drowning and hemorrhagic shock. The dead rabbits were observed of their hearts with CT scanning every 6 hours within 120h from the death moment, having the obtained time-different CT images and mean CT values examined. With the cardiac average CT values of rabbits died from discrepant execution, four relevant regression equations were established against the elapsing time (i.e. PMI). Results The CT images of post-death cardiac tissue of rabbits died from one of four executions did change regularly with the PMI elongating, showing consistent with the autopsy verification. The binomial regressive equations were established between the post-death cardiac average CT value and PMI from four executions, demonstrating statistically significant (P<0.05). Conclusion The postmortem cardiac CT imaging into PMI analysis, plus the relating regression equation, provides a new objective visual quantitative approach and reference for forensic medicine to infer the time of death. © 2021, Editorial Office of Forensic Science and Technology. All rights reserved.     

Nonfracture-associated fatal fat embolism in a case of child abuse

Fatal fat embolism is usually thought of as a sequel to long-bone fracture, although cases secondary to soft tissue injury and atraumatic conditions have been infrequently reported. In this case of a two-year-old child-abuse victim who sustained multiple blunt traumatic injuries without skeletal fractures, pulmonary and systemic (brain and kidney) fat emboli were identified. At autopsy, all thoracic and abdominal viscera were intact; cranial contents exhibited only diffuse symmetrical petechial hemorrhages of the white matter. Because of the severe and widespread nature of soft tissue hemorrhage, and the absence of a grossly discernible cause of death, fat embolism was suspected. Using a combination of frozen section with oil red O staining and formalin-fixed osmium stained tissues, the immediate cause of death was determined to be diffuse fat embolism. Review of the literature reveals a pathophysiologic basis for fat embolism in the absence of fracture, both as a consequence of an acute increase in local pressure at the site of trauma and an alteration of the emulsification of blood lipids during shock. In light of these findings, we present this case to remind the forensic science community to consider fat embolism as the cause of death in cases of blunt-force injury without fracture.     

Death due to attack from chow dog.

It is estimated that between one and four million persons per year are bitten by dogs in the United States. While most injuries associated with the bites are minor, serious sequelae, and even death, may occur. Most victims of fatal dog attacks are children < 1 year of age or elderly women. The most frequent cause of death is hemorrhage and shock from major vessel damage. A case is reported in which an elderly woman was attacked by her pet Chow dog. The victim received multiple superficial abrasions, contusions, and lacerations from the dog attack. A large perforation of the right external pudendal vein and three perforations of the left superficial femoral vein resulted in exsanguination and death. Fractures of the left 2nd through 4th ribs with underlying pulmonary contusion were also found.     

Prevalence of potential risk factors in victims of electrocution.

OBJECTIVE: To identify risk factors of fatal arrhythmia following electrical shock, by comparing the prevalence of transthoracic current, tetany, decreased skin resistance because of wet extremities, skin burns and heart disease in victims of electrocution with instant as opposed to delayed death. DESIGN: Retrospective case-control study, based on the charts from the coroner's office. RESULTS: A total of 124 deaths from electrocution occurred between 1987 and 1992. One victim presumably died from delayed arrhythmia and was excluded from the study. Twenty victims had decreased skin resistance because of wet extremities and five had tetany. Autopsy revealed coronary heart disease in 21 cases, and burns in 109; 10 did not have any skin lesion. There was no difference in risk factors between those who died instantly presumably from arrhythmia (n=114) and those who died later from other causes (n=9). CONCLUSION: No differences in risk factors were found between victims who died immediately from arrhythmia following electrical shock and those died later from other causes.     

法医病理检案工作中的人为现象

目的 研究法医病理检案工作中常见的人为现象及其造成法医学鉴定结论错误的原因。方法 收集13例法医病理复核鉴定案例,并对其进行回顾性分析。结果 胸外心脏按压所致肋骨骨折,胸、腹腔出血及肺动脉栓塞栓子破碎,误认为生前外伤或死因不明5例;胰腺死后变化(自溶和被膜下及间质出血),误认为急性出血坏死性胰腺炎4例;死后动物咬伤误认为生前损伤2例;腐败尸斑误认为皮下出血1例;死后颈部解剖不当造成颈部肌肉出血,影响死因分析1例。结论 法医病理检案工作中的人为现象,常导致法医学鉴定的结论错误。     

纤维连接蛋白在诊断心肌梗死的特异性研究

探讨纤维连接蛋白 (Fn)对心肌梗死死后诊断的特异性。应用免疫组织化学和图像分析技术 ,对正常心脏、心肌梗死及其它非梗死性因素 ,如心肌炎、窒息、电击死、出血性休克、心挫伤、有机磷中毒等 ,直接或间接引起心脏损害时心肌细胞内Fn的变化进行研究。结果发现 :Fn仅在心肌梗死与心肌炎病例出现阳性反应 ,其阳性反应面积同正常对照组存在显著性差异 ,在窒息、电击死、出血性休克、心挫伤、有机磷中毒等病例未见明显阳性反应。Fn作为心肌梗死死后诊断指标仅受心肌炎的影响 ,对诊断心肌梗死具有较好的特异性     

Delayed pericardial tamponade following a stab wound to a branch of the right coronary artery

A 45-year-old man was attacked with a knife and suffered multiple stab wounds to the chest and abdomen. After surgical treatment and hospitalization for 9 days he was discharged in a stable condition. The following day he was found dead in his apartment. The autopsy revealed a pericardial tamponade caused by acute bleeding from an injured branch of the right coronary artery. This case shows that life-threatening late complications in patients with penetrating cardiac wounds may occur despite an initially uneventful course.     

An Unplanned Complex Suicide by Multiple Blank Cartridge Gunshots and Cutting

Blank firing guns are readily accessible in most countries due to an absence of legal regulations. These weapons are capable of causing lethal injuries. We report a rare case of secondary (unplanned) complex suicide committed with a knife and blank cartridge pistol. A 59‐year‐old man was found dead with three superficial incisions in his neck and a gunshot wound to the chest. The external examination revealed an entrance wound in the left chest region consistent with contact shooting. The appearance of a muzzle imprint suggested two discharges. The autopsy showed a slightly hemorrhaged but otherwise intact pericardium, blood in the pericardial sac, and a channel‐like defect in the anterior wall of the left cardiac ventricle. The cause of death was attributed to cardiac tamponade. To the best of our knowledge, this is the first reported case of unplanned complex suicide involving an unmodified blank firing gun.     

Fatal traffic injuries among children and adolescents in three cities (capital Budapest, Vilnius, and Tallinn)

Motor vehicle accidental injuries are a frequent cause of death among young children and adolescents. The goal of this study was to compare patterns of injury between three capitals (Budapest, Vilnius, and Tallinn). Information on 190 fatal traffic accidents (69 pedestrians, 14 bicyclists, and 107 motor vehicle occupants) between 2002 and 2006 was collected from databases of medico-legal autopsies. The role of victims in accidents, the location of injuries, cause of death, survival period, and blood alcohol levels were evaluated. One-hundred and forty-one (74%) victims had a passive role in traffic as pedestrians, passengers in cars, or public transport. In victims who died at the scene, the rate of head injury was higher than in cases who received medical treatment (odds ratio = 2.58, CI = 1.2-5.55, p = 0.0127). These results underline the importance of postmortem studies to examine the pathomechanism of fatal traffic accidental injuries and to provide information for the prevention of road traffic accidents against children and adolescents.     

Fatal injuries caused by glass fragments. Case reports and autopsy findings

The authors report three cases of fatal domestic accidents by falling through glass doors. Multiple cuts and stabwounds in one of these cases primarily suggested a crime of violence. In contrast the bodies of the two other perished persons showed only unsignificant injuries. Causes of death were aerous embolism (1 case) and mechanical bleeding to death (2 cases). The common morphological signs of these glass injuries are exemplified and preventive measures are discussed.     

Fatalities associated with home-made pipe bombs in Northern Ireland

Pipe bombs are crudely constructed improvized explosive devices which are easily made at home. They are increasingly used by terrorists and others, and may inflict serious injuries and cause death. Four fatalities have occurred in association with their use in Northern Ireland between 1998 and 2002. In 2 cases, death was due to penetrating shrapnel injuries to the chest causing laceration of the great vessels, and a third fatality occurred due to a bomb fragment penetrating the cranial cavity. A pipe bomb exploded close to the back of the head of a fourth victim and this was associated with a severe brain injury. The pathologist was able to determine the position of the victim in relation to the explosion by interpreting the pattern of injuries. It seems likely that 2 of the victims had been involved in the construction, transport, or use of the devices. A third victim was entirely innocent and had been in the process of removing a pipe bomb, which had been thrown through the window of her home, when it exploded. The fourth victim was a member of the security forces who had been struck by a bomb fragment, in the region of the right eye, during a period of sectarian unrest.