Medical responsibility in the operating room: the example of an amniotic fluid embolism

Amniotic fluid embolism (AFE) continues to be one of the most feared complications of pregnancy. A healthy 32-year-old woman died during delivery after a normal 39-week third pregnancy. The family filed a complaint with a criminal court as the causes of death appeared unclear. No risk factor associated with AFE was identified. Clinical presentation was typical, including sudden onset of cardiovascular and respiratory symptoms. Autopsy confirmed the histological diagnosis of amniotic embolism and excluded an iatrogenic cause of death or anesthetic malpractice. This article highlights the value of both antemortem records and histological features in establishing the diagnosis of AFE and demonstrates the fundamental importance of autopsy in an unexpected death related directly or indirectly to a medical procedure.     

羊水栓塞死亡医疗纠纷案件的法医学分析

目的分析引发医疗纠纷的羊水栓塞死亡病例的相关因素,以帮助提高对羊水栓塞诊治能力,减少医疗纠纷。方法对我中心2006～2009年间鉴定的8例医疗纠纷相关羊水栓塞死亡病例的临床资料及过失认定进行回顾性分析。结果（1）医疗因素分析：7例具有使用催产素史;3例发生于产前破膜后,5例发生于产后;具有典型临床症状5例,不典型临床症状3例;早期诊断7例;3例实施子宫次全切除术;发生在二级医院以下6例。（2）法医学鉴定分析：催产素使用不当及观察记录缺陷占87.5%（7/8）;7例早期诊断羊水栓塞,但在供氧、解痉和子宫切除方面存在治疗缺陷。结论提高对产前、产后羊水栓塞症状特点的认识和处置能力,强化病历记录规范、完整及充分告知说明,是减少医疗纠纷案件的关键,也是法医学鉴定判断的重要依据。     

Medicolegal Aspects of Post‐traumatic Gastroduodenal Ulcers: A Retrospective Study*

Abstract: Retrospective examination of 5‐year autopsy material showed the presence of posttraumatic gastroduodenal ulcers (PGDU) in 17.7% of decedents deemed to be at risk. They were more common in males (77%) and in patients aged over 50. In the majority of cases (76%) the survival period was <12 days; in 16.5% it was < 48 h. PGDU developed most commonly in victims of polytrauma and isolated craniocerebral injury, with ISS values ≥16; patients with spinal cord injuries were at greatest risk. Most frequently affected was the stomach, exhibiting numerous, usually superficial lesions, while solitary acute and exacerbated chronic peptic ulcers were more common in the duodenum. Complications of PGDU developed in 40% of cases, mostly in the form of hemorrhage; in 20% of cases PGDU have contributed to death. Medicolegal aspects of PGDU are, most frequently, concerned with the causal relationship between trauma, PGDU, and fatal outcome, as well as the potential for allegations of medical negligence.     

羊水栓塞诊断的方法学研究进展及法医学意义

羊水栓塞(amniotic fluid embolism,AFE)是指分娩过程中羊水进入母血循环,引起肺栓塞、休克甚至死亡等一系列严重症状的综合征。目前对于AFE的诊断为排除性诊断,方法缺乏灵敏性和特异性。因此随着以AFE为死因的孕产妇病死率的升高,寻找更精确的AFE诊断方法成为了法医学研究的重点。本文结合相关文献概述了AFE诊断方法的研究进展,希望能为法医学鉴定提供方法学参考。     

Trace Evidence Potential in Postmortem Skin Microbiomes: From Death Scene to Morgue

Microbes can be used effectively as trace evidence, at least in research settings. However, it is unknown whether skin microbiomes change prior to autopsy and, if so, whether these changes interfere with linking objects to decedents. The current study included microbiomes from 16 scenes of death in the City and County of Honolulu and tested whether objects at the scenes can be linked to individual decedents. Postmortem skin microbiomes were stable during repeated sampling up to 60 h postmortem and were similar to microbiomes of an antemortem population. Objects could be traced to decedents approximately 75% of the time, with smoking pipes and medical devices being especially accurate (100% match), house and car keys being poor (0%), and other objects like phones intermediate (~80%). These results show that microbes from objects at death scenes can be matched to individual decedents, opening up a new method of establishing associations and identifications.     

16例肺血栓栓塞猝死的法医学分析和临床研究

目的分析肺动脉血栓栓塞（pulmonary thromboembolism,PTE）猝死的法医病理学特点,探讨医疗过程中发生PTE的危险因素,为临床预防、治疗提供帮助。方法对本市2002年至2009年16例PTE猝死案件进行回顾性分析。结果每例均至少存在1项已知的高危因素,其中外伤12例,慢性疾病长期卧床1例,手术3例;发病到死亡的时间平均为1.2h,6例≤1h,3例≤12h。结论对于高龄（≥40岁）外伤或手术患者,预防、早期诊断和治疗PTE对于患者的生命至关重要,发现深静脉血栓形成者应采取紧急手段处理栓塞,谨防发生PTE致猝死。     

液基细胞学技术应用于血样羊水栓塞的诊断

目的：建立基于液基细胞学技术的血样羊水栓塞的诊断方法,并对其有效性进行研究。方法收集羊水栓塞者血液样本,分别用两种直接涂片法（上清涂片法、沉淀涂片法）和两种液基细胞涂片法（自动涂片法、人工涂片法）对血液样本中的羊水成分进行检测,对4种方法的羊水成分检出率进行比较。结果建立的两种液基细胞涂片法的羊水成分检出率（分别为84.6%、92.3%）明显高于直接涂片法（分别为53.8%、61.5%）。结论液基细胞涂片法可以提高羊水栓塞的检出率。     

Essential medicolegal death investigation services: standardization of a survey instrument based on the Essential Public Health Services

The National Academy of Sciences recommends that states assess the performance of medicolegal death investigation agencies. To aid in performance assessment, we adapted an instrument based on the CDC's 10 Essential Public Health Services by translating the terminology to that of essential medicolegal death investigation services. This produced a survey that could be used to standardize reporting practices and services of agencies. To validate the instrument, a stratified random sample of 12 death investigation chiefs in 12 states was interviewed. This sample represented both medical examiner and coroner jurisdictions within the varying medicolegal structures. A cognitive testing process elicited how well participants could respond to and interpret the survey questions. The response was favorable in that the respondents agreed that given specific revisions toward question clarification, the instrument would be a useful and relevant tool for assessing system performance.     

Massive lesions owing to motorcyclist impact against guardrail posts: analysis of two cases and safety considerations

Two motorcycle riders lost control of their vehicle, fell, and hit a guardrail, which acted as a blade and led to a rapid, fatal outcome. In one case, the high velocity of the body at the time of the impact resulted in complete detachment of the trunk. Reconstruction of the accident dynamics enabled the guardrail post to be identified as the means of injury in both cases. The two accidents occurred over a short period of time, highlighting a dangerous phenomenon that in less severe cases is presumably associated with different degrees of survivor disability. The accidents deserve mention, because a different design of the impact surface of the guardrail post might have prevented the lethal outcome. There is an urgent need for legislators to pass regulations that modify crash barrier homologation criteria, which have been devised primarily for the safety of car passengers but fail to protect motorcyclists.     

Schizophrenia and suicide: a 10-year review of Kentucky medical examiner cases

The risk of suicide is significantly increased in schizophrenics; it is estimated that 10-13% of individuals suffering from schizophrenia commit suicide. Schizophrenia is marked by psychotic exacerbations and remissions, with persistent deterioration in baseline functioning with each relapse. We present a 10-year (1993-2002) retrospective review of Medical Examiners' cases of suicide of schizophrenic victims. Twenty-nine cases were between the ages of 20 and 75 (mean age of 41.6 years). The majority of victims were male (62.1%) and Caucasian (86.2%). The leading method of suicide for both males and females was firearm injury (48.3%) mostly of the head, followed by overdose (20.7%), and hanging (13.8%). A comprehensive investigation of the biopsychosocial factors is warranted in cases of schizophrenics who commit suicide. This study offers an insightful analysis pertaining to the determination of intent in formulating the manner of death in this unique population.     

Sudden death in toddlers caused by influenza B infection: a report of two cases and a review of the literature

Sudden fatal cases of influenza B infection in a 4-year-old girl and a 2-year-old boy are presented. Both children complained of abdominal pain without respiratory, neurologic or cardiac symptoms; additionally the girl had vomiting within 2 days of death. Autopsy revealed histological changes in the respiratory system consistent with a viral infection. Influenza B infection was identified by immunohistochemistry in the girl and real-time polymerase chain reaction in the boy. Additional testing including cultures, toxicology, and screening for metabolic disorders were negative. These cases illustrate the usefulness of viral testing, especially for influenza, in the medical legal autopsy of children even when the classic respiratory symptoms of flu are lacking.     

肺动脉栓塞致死23例法医学分析

目的总结分析肺动脉栓塞致死的一般特点,探讨法医病理学鉴定要点及注意事项。方法对2001~2011年在中山大学法医鉴定中心鉴定的23例肺动脉栓塞案例进行回顾性分析。结果肺动脉栓塞致死以男性多见;发病年龄主要集中在31～70岁之间;主要诱因是严重外伤、长期卧床后运动,以下肢静脉系统血栓形成并脱落致肺动脉栓塞最为常见。结论对肺动脉栓塞致死案例法医病理学鉴定要点进行了总结。     

Retrograde venous cerebral air embolism from disconnected central venous catheter: an experimental model

There are few reported cases of death attributed to retrograde cerebral air embolism from central venous catheter. The pathophysiological mechanism and the necessary conditions are not fully understood, also because of missing experimental data. We performed experimental simulation while working on a possible case of retrograde cerebral air embolism. A hermetic system consisting of two containers connected to each other and to an electric pump by means of rubber hoses was built. In this system, a fluid (water and blood) could continuously flow under conditions similar to those of the common jugular vein. The part of the system representing the jugular vein could be freely positioned at angles between 0 and 90°. A central venous catheter was inserted into this part. After disconnection, the behavior of the air bubbles entering the hose through the tip of the catheter was evaluated at different positions. At angles between 0 and 45°, the air bubbles followed the fluid flow. At angles >45°, the air bubbles showed the tendency to flow upstream; this phenomenon was more evident the more vertically the hose was located. We were able to demonstrate that a retrograde air embolism can be caused by a disconnected catheter and is even more likely if the neck is in a vertical position.     

Pulmonary Cement Embolism After Kyphoplasty

Pulmonary polymethylmethacrylate (PMMA) cement embolism after kyphoplasty (KP) surgery is a quite frequent event as well as the pulmonary embolization of central venous catheter fragment. This report shows the case of a subject who, after KP, developed pulmonary embolism and who underwent thoracic surgery. After hospital discharge, the subject advanced a claim for damages toward the hospital where he was operated, complaining sensation of tenderness at the chest surgical scar and esthetic damage. To understand the nature of the embolism (either central venous catheter fragment or cement), chemical investigations were then ordered. Spectrometry identified the PMMA cement used for KP. When doubts rise about the origin of the embolized material, chemical investigations may reveal important data not only for clinical but also for forensic purposes.     

Suture Embolism of the Left Superior Lobar Pulmonary Artery

Endogenous pulmonary thromboemboli are a common cause of noncardiac sudden natural death. Embolism of exogenous material is a rare but potential finding in autopsies following surgeries, medical procedures, penetrating trauma, and nonparenteral drug abuse. This report describes the first case of a suture embolism of the left superior lobar pulmonary artery following complicated abdominal surgery.     

Trends in domestic animal medico-legal pathology cases submitted to a veterinary diagnostic laboratory 1998-2010*

Abstract: Pathologists at veterinary diagnostic laboratories receive medico‐legal cases from a variety of animal species for postmortem examination. A search of computerized records of the Animal Health Laboratory, University of Guelph, Guelph, Ontario, Canada from 1998 to 2010 identified 1706 medicolegal cases. These were categorized according to the history as criminal investigations, anesthetic‐related deaths, insurance, litigation, malpractice cases, and regulatory cases. Statistically significant linear trends in the proportion of medicolegal cases for all animals and criminal cases for companion animals were identified over the 12 year period. Companion animals had significantly greater odds of being a medicolegal case in all categories except for insurance and regulatory cases, compared to noncompanion animals. Based on pathology reports for the 271 criminal cases, 43.1% were consistent with neglect, 29.2% were compatible with non‐accidental injury, 4.80% were poisonings, 10.7% were deemed to be due to natural disease, and 11.43% were inconclusive.     

新疆地区66例多类型栓塞死亡法医学尸检分析

总结分析不同类型的栓子(血栓、脂肪、空气、羊水)栓塞致死的一般特点,探讨其法医病理学鉴定要点及注意事项.对2015～2021年在新疆医科大学司法鉴定所鉴定的66例栓塞致死案例进行回顾分析.经过研究分析,导致患者出现栓塞的因素较多,栓塞致死以肺动脉血栓栓塞多见,另外空气栓塞、羊水栓塞和脂肪栓塞也不容忽视,其均能导致呼吸、...     

Sudden death due to an unrecognized cardiac hydatid cyst: three medicolegal autopsy cases

Echinococcosis is a human infection caused by the larval stage of Echinococcocus granulosus. The most common sites of infection are the liver and the lungs. Cardiac hydatid cysts are very rare, even in regions where hydatic cysts are endemic (the Mediterranean, South America, Africa, and Australia). It has been reported that cardiac involvement is seen in about 0.5-3% of human echinococcosis cases. Three cases of cardiac hydatid disease that caused sudden death and which were histopathologically diagnosed are reported. Cardiac echinococcosis is rare, but due to its insidious presentation and affinity to cause sudden death, it is important that it be identified in the histopathological examination.     

Evaluation of Computed Tomography as a Screening Test for Death Inquest

Abstract: The Japanese method of inquest, which depends mostly on external examinations, may misdiagnose a considerable number of accidental deaths and suicides as death by disease. We conducted computed tomography (CT) scans of 80 cases for which police concluded death by disease or natural causes based on police investigations into the circumstances and results from external examinations. The cause of death was clearly determined by CT scan in 17 of 80 cases. Ten cases underwent autopsy after the police suspected criminality based on results of the CT examinations. The results suggest CT scan may be a tool for preventing a number of overlooked crimes and accidents in Japan. However, it cannot be a perfect tool for discerning between death by disease and other causes of death without cooperation from the investigative agencies and subsequent forensic examinations such as autopsy and toxicological tests.     

An Autopsy Case of Sudden Unexplained Death Caused by Malaria*

Abstract: Sudden unexplained deaths, especially those unwitnessed can lead to forensic issues and would necessitate the need for a meticulous and complete postmortem examination including ancillary investigations to discover the cause of death. We herein report a case of sudden unexplained death caused by malaria in an apparently healthy individual. This fatal case is presented to remind the forensic pathologist of the possibility of malaria as a cause of sudden unexplained death in malaria‐endemic regions. In the present case, histopathological examination demonstrated the presence of parasitized red blood cells with malarial pigment in the blood capillaries in the brain, myocardium, pericardium, lungs, kidneys, liver, and the spleen. Cerebral malaria with acute renal insufficiency or pulmonary edema with an acute respiratory distress syndrome might have been the cause of death.