Adolescent death: a 15-year retrospective review

Adolescents comprise an eclectic mix of people vitally important to society yet long-term comprehensive studies on the circumstances of their deaths are lacking in the pediatric forensic literature. The authors reviewed all forensic cases referred to the Medical University of South Carolina Forensic Pathology section over the fifteen years between January 1989 and December 2003. In accordance with the World Health Organization (WHO) definition of adolescents, only decedents 10-19 years of age were included. The authors examined the cause and manner of death, age, gender, and race of the victims in all cases. The toxicology results, perpetrator, death scenario and location, and victim traits were analyzed when available. For all adolescents, the most common manner of death was accident followed by homicide, suicide, natural, and undetermined. Within the adolescent population two distinct groups, 10-14 years old and 15-19 years old, were identified. Though both groups were similar in that they experienced a high number of accidental deaths, decedents of older age group suffered a higher percentage of violent deaths while decedents of the younger group were more likely to die of natural causes. Many of the accidental deaths in this review were preventable, including deaths due to motor vehicle collisions and drowning. In deaths due to homicide, the perpetrator was often known to the victim, whether as an acquaintance or family member. Toxicology testing was often positive in decedents of the older age group, while only rarely positive in decedents of the younger age group. With a solid understanding of the circumstances, it may be possible to predict, and hopefully prevent, future cases of adolescent death. The authors present their findings in this 15-year retrospective study to better aid forensic pathologists, death investigators, law enforcement, and epidemiologists.     

Characterization and Comparison of Injuries Caused by Accidental and Non‐accidental Blunt Force Trauma in Dogs and Cats

Motor vehicle accidents (MVA) are often difficult to distinguish from non‐accidental injury (NAI). This retrospective case–control study compared animals with known MVA trauma against those with known NAI. Medical records of 426 dogs and cats treated after MVA and 50 after NAI were evaluated. Injuries significantly associated with MVA were pelvic fractures, pneumothorax, pulmonary contusion, abrasions, and degloving wounds. Injuries associated with NAI were fractures of the skull, teeth, vertebrae, and ribs, scleral hemorrhage, damage to claws, and evidence of older fractures. Odds ratios are reported for these injuries. MVA rib fractures were found to occur in clusters on one side of the body, with cranial ribs more likely to fracture, while NAI rib fractures were found to occur bilaterally with no cranial–caudal pattern. Establishing evidence‐based patterns of injury may help clinicians differentiate causes of trauma and may aid in the documentation and prosecution of animal abuse.     

Postbariatric surgery deaths, which fall under the jurisdiction of the coroner

Obesity has attained epidemic proportions in the United States, with more than 50% of adults classified as overweight or obese. If untreated, morbidly obese patients have a 1 in 7 chance of reaching normal life expectancy. The surgical treatment of obesity has emerged as the most effective treatment modality in long-term weight control and has become increasingly popular, with attendant postoperative complications and death. We performed a cross-sectional, coroner based, 2-year retrospective review of archival case records for decedents who died following bariatric surgery for the treatment of obesity to identify underlying causes of death and forensic characteristics of this cohort. Fifteen (0.5%) out of 3097 archival cases died following bariatric surgery, with approximately 73% of decedents dying within 6 months of surgery. The underlying causes of death in 80% of decedents were natural comorbidities of obesity, with cardiovascular diseases (33%) being the most frequent causes of death, followed by gastrointestinal diseases (20%), acute pulmonary thromboembolism (13%), and acute bacterial pneumonia (13%). The majority of decedents were white females who remained morbidly obese after bariatric surgery. Only 2 decedents died of direct inadvertent/accidental surgical complications.     

Postmortem Computed Tomography in Firearm Homicides: A Retrospective Case Series,

Postmortem computed tomography (PMCT) is integrated into the evaluation of decedents in several American medical examiner offices and medicolegal death investigative centers in many other countries. We retrospectively investigated the value of PMCT in a series of firearm homicide cases from a statewide centralized medical examiner’s office that occurred during 2016. Autopsies were performed or supervised by board-certified forensic pathologists who reviewed the PMCT scans prior to autopsy. PMCT scans were re-evaluated by a forensic radiologist blinded to the autopsy findings and scored by body region (head–neck, thoracoabdominal, and extremities). Injury discrepancies were scored using a modified Goldman classification and analyzed with McNemar’s test. We included 60 males and 20 females (median age 31 years, range 3–73). Based on PMCT, 56 (79.1%) cases had injuries relevant to the cause of death in a single body region (24 head–neck region, 32 thoracoabdominal region). Out of these 56 cases, 9 had a missed major diagnosis by PMCT outside that region, including 6 extremity injuries visible during standard external examination. Yet all had evident lethal firearm injury. We showed that PMCT identifies major firearm injuries in homicide victims and excludes injuries related to the cause of death in other regions when a single body region is injured. Although PMCT has a known limited sensitivity for soft tissue and vascular pathology, it can be combined with external examination to potentially reduce or focus dissections in some of these cases depending on the circumstances and medicolegal needs.     

Hyperthermia,Thermal Injuries,and Death from a Forced Convection Heat Source: A Case Report and Experimental Model

Heat‐related deaths of children are most often encountered in the context of enclosed vehicles in summer months. Deviating from this, a 16‐month‐old boy was found unresponsive in a stroller that was placed adjacent to a space heater during mid‐winter. The cause of death was hyperthermia and thermal injuries. Manner of death determination was difficult due to alleged surrounding circumstances. To understand the time‐course of this child's injuries, a child death scene investigation was performed; the stroller and space heater were recovered. In a re‐enactment of the events, a slaughtered pig approximating the child's size was warmed using a water bath and placed in the stroller beside the space heater. Cutaneous temperature measurements showed rapid initial temperature rise with subsequent steady increases. Tanning of the skin was seen on periodic direct observations. Internal temperature monitoring illustrated steady increases. This experiment was essential in classifying the manner of death as homicide.     

Drug and alcohol use as determinants of New York City homicide trends from 1990 to 1998

In this population-level study, we analyzed how well changes in drug and alcohol use among homicide victims explained declining homicide rates in New York City between 1990 and 1998. Victim demographics, cause of death, and toxicology were obtained for all homicide (N = 12573) and accidental death victims (N = 6351) between 1990 and 1998 from the Office of the Chief Medical Examiner of New York (OCME). The proportion of homicide and accident decedents positive for cocaine fell between 1990 and 1998 (13% and 9% respectively); the proportion of homicide and accident decedents positive for opiates and/or alcohol did not change significantly. Changing patterns of drug and alcohol use by homicide victims were comparable to changing patterns of drug and alcohol use in accident victims, suggesting that changes in drug and alcohol use among homicide victims between 1990 and 1998 cannot solely explain the decline in NYC homicide rates.     

Correlations of injury, toxicology, and cause of death to Galaxy Flight 203 crash site

This report details the medical investigation of the crash of Galaxy Flight 203, on 21 Jan. 1985, near Reno, Nevada. Sixty-eight persons died at the scene, two died during hospitalization, and one victim survived. After completion of autopsies on all victims, pathologists determined causes of death based upon injuries, evidence of smoke inhalation, and toxicologic results. Our research shows that the majority of victims survived the impact only to succumb to toxic gas and fire. We correlated the causes of death, various injuries, and toxicologic findings to body location at the crash site to aid in reconstructing the events surrounding the accident and to address medicolegal problems and safety considerations. Our experience clearly supports the need for thorough medical investigation, including autopsy of each victim and determination of the precise cause of death for all fatalities.     

Injuries in fatal cases of falls downstairs

Downstairs falls frequently occur within domestic environments and are mainly associated with elderly and intoxicated individuals, often feature multiple injuries on various parts of the body. In most cases it is not possible to determine the cause of the fall and/or death solely by means of external examination. In this retrospective study, which covers a period of 11 years, all cases of death which included a fall downstairs in their case history, were collected from the Forensic Institutes of the Universities of Bonn and Greifswald, Germany. Falls downstairs made up to 2% (166 cases) of all postmortem examinations carried out within this period. Interestingly, almost double of the amount of such falls applied to males as to females. The primary cause of death was cranio-cerebral trauma and the vast majority of skull injuries associated with falls downstairs were found above 'the hat brim line'. Injuries were also often found on several other parts of the body at once. Nineteen of the 116 examined individuals exhibited agonal injuries. In these cases, postmortem examination revealed pre-existing disease or intoxication to be the cause of death and thus, cause of the fall. The injury pattern only allows a tendency towards vital or agonal incident as a conclusion.     

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.     

Injuries due to deliberate violence in Chile

An analysis was made over a period of 6 months of the incidents involving deliberate violence as registered in 'Vicaria', the clinic for out-patients within the Cathedral of Santiago de Chile. A total of 236 victims of deliberate violence were observed. Men aged 15-24 years were found to be victims of deliberate violence most frequently. 'Under education' was the most frequently registered occupation for both sexes, and a large group of male victims were 'Unemployed'. 82% of the victims were men and 14% women, 1.5% were boys and 1.5% girls less than or equal to 14 years of age. None of the victims were alcohol intoxicated when arriving in the clinic. The incidents took place in streets for 81% of the male victims and 79% of the female victims, and in the majority of the cases the aggressor(s) was one (or several) police officer(s). Six percent of the female victims had been injured at home. There was no reporting of the aggressor being a relative or acquaintance. The most frequent type of violence was blunt violence from baton(s) (44%), while blunt violence without the use of instruments was reported less frequently (33%). The use of firearms was registered in 18% of the cases, and of sharp instruments, combustion, electro-shock and chain in 1.4%, 1.4%, 1.1% and 0.4% of the cases respectively. A total of 517 primary and secondary diagnoses were applied to the patients. Most of the victims (99%) had moderate or less serious lesions according to the Abbreviated Injury Scale (AIS) (score less than or equal to 2). Twenty-four percent of the victims had more than 4 lesions, and 7% more than 10 lesions. The head/neck region and the trunk were affected with equal frequency, the frequency of injuries of the head/neck region being comparable with that observed among torture victims and in contrast to the pronounced predominance of injuries of the head/neck region observed in a Danish emergency ward study of deliberate violence.     

Deaths associated with choking in San Diego county

Death from choking is the fourth most common cause of unintentional-injury mortality, but little data are published on causes or locations of these episodes. These deaths typically are peaked at the extremes of age, with young children and the elderly having the greatest rate of fatal choking. Our objective was to characterize the causes of fatal airway obstruction in adults. The San Diego County Medical Examiner's database was searched for deaths attributed to choking in decedents 18 years and older during the 10-year period from 1994 to 2004. Data were abstracted regarding the underlying medical conditions, items choked on, location of the choking, and treatments involved in the individual cases. We found 133 victims who died from choking, with 14% having using alcohol or other sedatives and 55% having a documented neurological deficit or anatomic difficulty with swallowing. The most common specified food objects that victims choked on were meat products, and 45% occurred at home, followed by 26% at supervised facilities, and 14% at restaurants. Of the 19 choking episodes occurring in restaurants, only one employee was documented to attempt a resuscitative effort. Most victims who choked to death had an underlying neurological deficit, and occurred at home or supervised facilities appear to have an appropriate initial-response intervention.     

Atypical autoerotic death: part II

Autoerotic fatalities encompass a wide array of means and mechanisms used to attain sexual gratification. The most commonly encountered autoerotic practice, specifically, autoerotic asphyxia, denotes death resulting from failure of a release mechanism of the apparatus designed to attain cerebral hypoxia for heightened arousal. Historically, the majority of victims of autoerotic death are Caucasian males under the age of 30. While autoerotic death is most often associated with a constrictive cervical ligature tied to either other parts of the victim's body or to an inanimate object such as a door, several other methods have been reported. These modalities include ligature around the thorax or abdomen, plastic bags covering the face, electrical current, inhalation of a toxic gas or chemicals, or partial or total submersion, known as aquaerotic asphyxiation. This study highlights 11 cases of atypical autoerotic death, including asphyxia with a plastic bag, electrocution, and inhalation of butane and nitrous oxide (N2O). Whereas the manner of death in the majority of autoerotic death cases is deemed accidental, we present and analyze unique and equivocal cases representing 4 different manners of death: accident, natural, suicide, and homicide. The 11 victims were all Caucasian and between the ages of 17 and 55. Ten decedents were males, 1 female. A comprehensive investigation incorporating a thorough scene analysis, gathering of the victim's history, and complete postmortem examination is necessary to elucidate both the cause and manner of death in these atypical cases.     

Sudden Cardiac Deaths in Adults with Congenital Heart Disease with Structural Abnormalities: A Retrospective Review of Cases in the Cook County Medical Examiner's Office

Sudden cardiac death is a significant cause of mortality in adults with congenital heart disease (CHD). The Cook County Medical Examiner's Office database was queried for cases of CHD as a cause of death in the period between July 2008 and April 2019. Twenty-two cases were identified, including 11 decedents with simple defects and 10 decedents with complex defects. All of the subjects were in apparent good health at the time of death. In the absence of other obvious causes of death, simple defects were considered cases of sudden cardiac death. Significant cardiac morphological changes were common in complex defects. While 16 cases had known, diagnosed/treated CHD, 5 cases had no diagnosis prior to autopsy. In these cases, the ability to recognize CHD (sometimes subtle) helped in determining the causes of death. Therefore, forensic pathologists must be able to properly recognize various forms of CHD and request consultations, when needed.     

Hypothermia Secondary to Glioblastoma Multiforme? Autopsy Findings in Two Cases

Death due to accidental primary hypothermia in cold climates is relatively common, with previous case series reflecting this. In contrast, hypothermia‐related death as a result of an underlying medical cause, such as a brain tumor, is rare. The literature clearly illustrates a theoretical causal relationship between brain neoplasms and hypothermia through the infiltration of the hypothalamus; however, the number of reported cases is minimal. Two cases are presented where autopsy confirmed hypothermia as the cause of death with both cases revealing widespread glioblastoma multiforme in the brain. Both decedents were elderly with a number of comorbidities identified during autopsy that could explain death; however, hypothermia was deemed the most likely cause. It is proposed that both decedents died of hypothermia as a result of the tumor's effect on thermoregulation. These cases underline the importance of forensic pathologists to be aware of the relationship between brain tumors and hypothermia and to not dismiss death as being due to other disease processes.     

Kicking to death - forensic and criminological aspects.

A total of 36,274 forensic autopsies was performed in Berlin, between 1980 and 1987, including 152 cases (0.42%) in which death had been caused by blunt violence due to kicking. Data were collected on both victims and offenders, postmortem findings, causes of death and the way violence had been perpetrated. The greater part of victims and offenders had been males originating from lower social strata. Most of the victims and offenders had been in relationship with each other prior to the offence. Typical course of events: Victims and offenders, under influence of alcohol, became involved in a brawl, usually for trivial reasons, which soon led to physical fighting. When the victim had been knocked to the ground, the offender started forceful kicking. Bleeding to death and head injury were frequent causes of death. More than 50% of all offences were committed by single offenders. The diagnosis of kicking to death can at best be derived from presence of boot traces leaving shaped injuries. The trace-generating boot can be identified as offending tool by means of comparative police investigation. In addition to evaluation of shoe sole profiles, there is other trace-relevant material that may be sampled from a suspected offender's footwear (skin cells, hair, blood, body tissue) and used to identify findings by DNA analysis. There may be injuries with visible patterns supporting suspicion of kicking and trampling, although conclusive confirmation can be obtained only by testimony by a witness or confession by the offender.     

Cause and manner of death among users of anabolic androgenic steroids

Medicolegally investigated deaths among 34 male users of anabolic androgenic steroids (AAS) are described. Nine persons were victims of homicide, 11 had committed suicide, 12 deaths were judged as accidental and 2 as indeterminate. In two cases of accidental poisoning, the levels of pharmaceuticals and illicit drugs were considered too low to be the sole cause of death and AAS was considered part of the lethal polypharmacia. Chronic cardiac changes were observed in 12 cases. In two cases of accidental poisonous deaths, these changes were regarded as contributory cause of death. Homicides, suicides, and poisonings determined accidental or indeterminate in manner were related to impulsive, disinhibited behavior characterized by violent rages, mood swings, and/or uncontrolled drug intake. The observations in the present study indicate an increased risk of violent death from impulsive, aggressive behavior, or depressive symptoms associated with use of AAS. There are also data to support earlier reports of possible lethal cardiovascular complications from use of AAS. Furthermore, a contributing role of AAS in lethal polypharmacia is suggested. Finally, the observations indicate that use of AAS may be the gateway of approach to abuse of other psychotropic drugs.     

Schizophrenia as a cause of death

Schizophrenia is a chronic disorder that is associated with increased mortality. Although traumatic deaths account for most of this increase, there is also an increased rate of natural deaths in this population. Altered autonomic physiology in this group might contribute to death. To determine if there are schizophrenics in whom, after a complete autopsy, no recognizable cause of death other than schizophrenia is established, the records of the Office of Chief Medical Examiner of the City of New York were reviewed for deaths associated with schizophrenia and a natural manner of death. Six such decedents were identified, and their histories and autopsy results are described. We believe that schizophrenia per se is a potentially lethal disorder. Autonomic irregularities and their interactions with psychotropic drugs deserve further attention.     

Unexplained sudden death and the likelihood of drug abuse

The common history of drug abuse in adults with an undetermined cause of death has led us to hypothesize that chronic drug abuse increases the risk of sudden death. To begin evaluating this hypothesis, we conducted a retrospective case-control study of 61 decedents whose cause of death remained undetermined following autopsy matched one to one to a control group of pedestrians or passengers killed in motor vehicle collisions. In 21 pairs, the case subject had evidence of drug abuse but the control did not, and in 5 cases the reverse was true. Analysis showed that individuals with an undetermined cause of death are 4.2 times more likely to have evidence of drug abuse than are victims of a motor vehicle collision.     

A review of crane deaths in Jefferson County, Alabama

Cranes are machines used to move heavy objects. Cranes are operated by crane operators, usually working in conjunction with an assistant guiding the movements of the crane from his vantage point outside the crane. Few jurisdictions require that crane operators be either licensed or certified. We conducted a retrospective study of those dying of crane-related injuries in our jurisdiction during the 16 years from 1981 to 1996. All ten decedents were male, and the manner of each death was accidental. Neither ethanol nor drugs of abuse were detected in any case. Eight of the ten decedents died due to blunt force injuries, one due to mechanical asphyxia, and one due to thermal burns. Investigation by the Occupational Safety and Health Administration (OSHA) led to fines ranging from $80 to $2700 in six of the ten cases. Nationwide, electrocution is the most common cause of crane-related death, but no crane-related death in Jefferson County was caused by electrocution in our study. The absence of electrocutions was due to the planned, routine suspension of power to electrical lines in the vicinity of a crane during the crane's operation, a practice saving an estimated seven lives. Nevertheless, human error or lack of planning was still responsible for most of the deaths in our study. In addition to careful planning and adherence to safety standards established by planning, we recommend the mandatory licensure and certification of professional crane operators and the assessment of larger fines by OSHA for safety standard violations.     

Tardieu's spots and asphyxia--a literature study

Subpleural, epicardial and pericranial ecchymoses have been described in cases of suffocation since the 18th century. In the 19th century, great diagnostic importance was attributed to ecchymoses. Tardieu was the most determined defender of the specificity of ecchymoses for suffocations. He thought that he could diagnose violent suffocation by means of ecchymoses and claimed that he was able to differentiate violent suffocation from other unnatural causes of death (hanging, choking, strangulation, and drowning). Other physicians, among them numerous German medical examiners, proved Tardieu's opinions wrong by means of observations and animal studies. The most dedicated disputant against Tardieu's false doctrines was Liman. According to today's knowledge of pathophysiology, the haemorrhages concerned cannot have a specificity for suffocation or even a specific form of suffocation. Therefore, the confusing term of "suffocation haemorrages" should be avoided.