Use of "therapeutic complication" as a manner of death

Analyses of deaths due to therapeutic complications (TCs) provide important quality of care information for medical providers. In New York City, 463 deaths were investigated by the Office of Chief Medical Examiner and certified with TC as the manner of death in 2003. The TC manner of death is used for fatalities due to predictable complications of appropriate medical therapy. All death certificates and select autopsy, hospital, and investigation reports were reviewed. Data concerning cause of death, contributing conditions, age, race, and sex were extracted. The types of complications and the causes of death were classified into various types of surgical and nonsurgical categories of complications. These included: postoperative infections, pulmonary emboli, and technical and medication complications. The use of TC as a manner of death has benefits and limitations. Without the TC option, one is forced to certify certain deaths (e.g., penicillin anaphylaxis) either as natural or accident. The TC option allows easy identification and tracking of medical complications for public health purposes and also allows more consistent reporting of natural and medical-accidental deaths. In general, complications that occur during emergency surgeries/procedures for natural disease, tend to be certified with a natural manner. The "but for" test may be used to distinguish natural from TC deaths. There are criteria for distinguishing TC from accidents and homicides. TCs that occur during treatment of a potentially life-threatening injury, are superseded by the manner dictated by the circumstances of the initiating injury. The certification of TC usually does not address errors of omission, clinical judgement/management, or missed diagnoses.     

Unexpected death as a result of infective endocarditis

Thirteen cases of infective endocarditis (IE) diagnosed for the first time at autopsy or, in those patients with a previous diagnosis of IE, not thought to be active at the time of death, are presented. Of the six patients who died within 24 h of the onset of symptoms, two died of obstruction of a valve orifice, two died of sepsis, one died of sepsis and alcoholic cardiomyopathy, and one died of a coronary artery embolus. Of the five patients with symptoms lasting more than 24 h, three died of sepsis and congestive heart failure. One died from sepsis alone and one died from congestive heart failure (CHF). In two patients whose duration of symptoms is unknown, one died of sepsis and CHF, and in the other the mechanism of death is unknown. Predisposing factors present in 11 of 13 patients included alcoholism (three), intravenous (IV) drug abuse (three), prosthetic valves (three), aortic stenosis (two), past rheumatic fever (one), and nonstenotic congenitally bicuspid valves (two). The reasons for no antemortem diagnosis were a missed or incorrect clinical diagnosis in three patients seen by a physician shortly before death, no signs or symptoms or found dead (four), non-specific signs and symptoms (three), refusal of medical treatment (one), and a solitary lifestyle (one); there was insufficient information about one patient. Individuals with needle tracks, generalized petechiae. Osler's nodes, splinter hemorrhages, intravenous catheters, pacemaker wires, and infected aortic-valve (A-V) shunts are at risk of IE. Blood and the vegetations should be cultured. The attending physician should be notified of the diagnosis in such cases.     

Ingestion of pointed objects in a complex suicide

A 51-year-old woman with a psychiatric history of depression and drug abuse was found hanged in her bedroom. The ligature was a scarf attached to the door handle. The autopsy findings suggested that two methods of suicide had been used one after the other. In the first stage, numerous nails, pins and needles were swallowed; in the second stage, the suicide was completed by hanging.     

The Difficult Task of Assessing Perimortem and Postmortem Fractures on the Skeleton: A Blind Text on 210 Fractures of Known Origin

The distinction between perimortem and postmortem fractures is an important challenge for forensic anthropology. Such a crucial task is presently based on macro‐morphological criteria widely accepted in the scientific community. However, several limits affect these parameters which have not yet been investigated thoroughly. This study aims at highlighting the pitfalls and errors in evaluating perimortem or postmortem fractures. Two trained forensic anthropologists were asked to classify 210 fractures of known origin in four skeletons (three victims of blunt force trauma and one natural death) as perimortem, postmortem, or dubious, twice in 6 months in order to assess intraobserver error also. Results show large errors, ranging from 14.8 to 37% for perimortem fractures and from 5.5 to 14.8% for postmortem ones; more than 80% of errors concerned trabecular bone. This supports the need for more objective and reliable criteria for a correct assessment of peri‐ and postmortem bone fractures.     

Identification of Tool Marks of a Sickle on a Telephone Cable

Linkage of a cutting tool (a sickle) with a telephone cable of 100 pairs of copper wires is reported in a case of theft of a telephone cable. Telephone cables contain numerous insulated copper wires of small diameter inside an outer covering and are stolen for the relatively precious copper. The cutting pattern of the cable can only point to the type of the tool but because of the large number of copper wires, it is practically difficult to make a definite linkage with the tool used to cut the cable by comparing the tool marks. The present work reports the successful attempt of the authors in establishing a definite linkage of a stolen telephone cable with a sickle recovered from the suspects. Spot microchemical test was performed for detection of copper on the blade of the sickle, and then tool mark comparison was performed to link the tool marks on the metal strip inside the outer covering of the cable to the blade of the sickle.     

A meta-analytic review of the frequency and patterning of laryngohyoid and cervical fractures in cases of suicide by hanging

The frequency and distribution of fractures are commonly utilized to assist in interpreting the manner of death. In cases of alleged suicide by hanging, however, the evidence base for the frequency and patterning of laryngohyoid and cervical vertebrae fractures resulting from such blunt force traumatic events is limited and so fractures cannot be reliably used to assist in interpreting the manner. Using meta-analytic techniques, this study aimed to estimate frequency and distribution of fractures in the context of relevant intrinsic and extrinsic variables. A systematic review of the literature identified 20 studies with relevant data (8523 cases of suicide by hanging). Meta-analyses identified the frequency and distribution of fractures present and how fracture frequency was affected by the subgroups of age, sex, completeness of suspension, ligature knot position and study design. Results indicated that fracture frequency was variable, there was no unique patterning, and high levels of heterogeneity were present in all variable sub-groups. Age was the only subgroup to show differences. Findings suggest that neck fracture frequency is inconsistent and cannot be predicted by the chosen variables. Subsequently, neck fractures in isolation should not be given weight in medico-legal interpretations of a hanging death as suicidal.     

Review of the significance of various low force fractures in the elderly

The elderly are more prone to sustain fractures with low force injury because they have an increased incidence of falls, and because their bones are often more fragile secondary to osteoporosis and other conditions. Cases with fracture are routinely reported to medical examiner and coroner offices because fracture reflects traumatic injury. If a fracture is judged to be a significant factor in a person's death, then the manner of death must reflect how the injury was sustained, which is "accidental" in most of these cases. Often times the best information on the significance of a fracture is obtained from the deceased's physician, nurse, family, or close acquaintance. However, this valuable clinical information is not always available. When this is the situation, it would be helpful to know generally what fractures are likely to be associated with increased mortality, and for how long any excess mortality might be expected to persist. With this in mind, a search of the literature was performed to clarify clinically which fractures in the elderly population were associated with excess mortality and the duration that any excess mortality tended to persist.     

The Frequency of Cranial Base Fractures in Lethal Head Trauma

The interpretation of cranial base injuries has never been investigated from a purely anthropological perspective. Very little exists in forensic literature in order to interpret the significance of cranial base fractures. We analyzed 296 cases of deaths due to skull–brain injuries. The frequency of vault fractures was 75.7% and that of base fractures was 91.9%. We observed the distribution of cases of death according to manner of death and manner of injury and number of fossae involved. These observations were analytically compared to different variables (age, sex, manner of injury, and mode of injury). The study presented the proportion of base fractures associated with vault fractures, and the frequency of absence of base fracture in subjects with no vault fractures. Interesting associations of base fractures to age and manner of death are shown.     

Commotio cordis: A case report of a fatal blow

Commotio cordis secondary to a blunt blow to the chest wall can result in ventricular fibrillation and sudden death in children. While it is commonly reported in adolescents during sporting activities, it may result from non-accidental trauma especially in infants and younger children. We report a case of a 6-month-old baby boy who presented to the emergency department in cardiac arrest. The patient's hospital records, postmortem imaging, and the autopsy results were reviewed. External examination of the infant did not reveal any evidence of trauma. Postmortem imaging revealed multiple healing posterior rib fractures and a metaphyseal corner fracture, both considered fractures highly specific for physical abuse. The autopsy revealed a structurally normal heart with no microscopic abnormalities. The infant's father confessed to hitting the child on the chest after which the child became unresponsive. Given the constellation of postmortem imaging and autopsy findings in addition to the father's confession, the child's death was ruled as a homicide secondary to commotio cordis. Since there are no structural and microscopic abnormalities in the heart autopsy in cases of commotio cordis, timely on-scene investigation and a thorough investigation regarding the mechanism of injury are required to make this diagnosis. Early identification of non-accidental trauma is crucial and can prevent further abuse in other siblings.     

Perimortem or Postmortem Bone Fractures? An Experimental Study of Fracture Patterns in Deer Femora*

The determination of perimortem trauma is important for forensic anthropologists. Characteristics of bone fractures such as sharp edges, presence of fracture lines, the shape of the broken ends, fracture surface morphology, fracture angle on the Z-axis, and butterfly fractures are said to differentiate perimortem from postmortem trauma. A Drop Weight Impact Test Machine was used to break 76 deer femora of various ages since death. The results of this study suggest that the characteristics listed above are unreliable at differentiating a perimortem fracture from a postmortem fracture in a forensic case. There are, however, statistically significant differences between fresh bones broken less than 4 days old and dry bones broken 44 days or 1 year old after death.     

Unusual Death of a Transvestite: Identification of Crime Weapon and Survival Time*

Abstract: The authors report a case of a transvestite found murdered near his automobile with several lacerated contused wounds to the face and cranial fractures. Autopsy revealed that the cause of death was a serious head trauma with subdural and subarachnoidal hemorrhages. In order to identify the crime weapon, a scanning electron microscopy (SEM) was used which revealed metallic residue on the skin fragments with the same molecular composition of the car paint. As for survival time, antibody anti‐beta‐amyloid precursor protein (APP) was applied to brain fragments and brainstem tissue, allowing for axonal varicosities (which form 2 to 3 h following death) to be observed under the optic microscope. So, by using SEM we understood that the fatal cranial‐encephalic lesions were the result of the victim’s head being repeatedly struck against the car door while anti‐betaAPP led to the understanding that the time elapsed between injury and death was less than 2 to 3 h.     

"Natural" death of a person under the care of a custodian

An ambulance service doctor was called to the death of a 76-year-old woman and attested cardiac arrest and psycho-organic brain syndrome as the cause of death on the death certificate. At the second external examination mandatory before cremation, extensive hematomas were detected on the right thorax and multiple haematomas in the face and on the forehead. The autopsy initially ordered by the public health officer revealed serial rib fractures and a fractured skull. After notifying the prosecutor, a forensic autopsy was ordered and death was found to have been caused by fat embolism following massive blunt force to the thorax with serial rib fractures and haematopneumothorax. After that, the adopted son, who had been appointed care custodian for the woman, and his wife were suspected, because they had given contradictory explanations for the injuries. At first, they were only suspected of failure to render assistance, but in the end they were both charged with murder. Only because of the second external examination prescribed by the law still in force could the errors of the improper first external examination be corrected.     

Healed fractures of the larynx and lingual bone in forensic autopsy]

Laryngohyoid fractures are a frequently investigated matter, especially in the forensic literature. On the other hand, there are only very few (old) forensic reports of such fractures in survived cases. However, healed fractures are not seldom found in forensic autopsies: In a personal series of 1160 forensic autopsies (adult persons) a careful dissection of the laryngohyoid complex was done by 1 investigator. Only a macroscopic examination of the cartilages was carried out; radiographs and histological slices were not regularly made. Therefore only a part of existing old fractures is detectable; for example, healed fissures are not visible with this simple method. Furthermore, asymmetries of the thyroid laminae cannot be declared as posttraumatic without additional examination, because this condition is described as possible anatomic anomaly. From that, the injury frequencies presented here only mark the lower threshold of the existence of such findings. Healed fractures of the upper thyroid horns and the major hyoid horns can be easily detected even in a routine examination, if healing resulted in a fixed dislocation or apposition of bone surrounding the former fracture site. In the present series, this was the predominant localization of old fractures: the upper thyroid horns (43 cases), followed by the hyoid cornua (12 cases), a combination of both sites (5) and cricoid fractures (5). Of the total 65 healed fractures (5.6%), 35 were found in the group of 290 chronic alcoholics (12.1%) and only 3.4% in non-alcoholics. In the subgroup of middle-aged alcoholics, the fracture rate increased up to 19%. However, this group did not present a higher rate of fresh laryngohyoid injuries (not related to strangulation) than the other cases. The old fractures probably resulted from minor "daily" injuries (like falls), which are common, especially in chronic alcoholics. The frequency of such findings should be in mind if an apparently fresh fracture, found in an actual autopsy, should be related to the cause of death: there is a real chance, that this fracture occurred prior, and without causal connection to the factors resulting in death. Therefore a histological examination of the age of this finding is necessary. Cricoid fractures are quite uncommon, except in serious external neck trauma. In 1 of our 5 cases, this fracture was caused by repeated cruelty, finally resulting in death.     

Alcohol‐Induced Osteopenia Among In‐Custody and Homicide Deaths from the Harris County Institute of Forensic Sciences

Four cases of in‐custody or unlawful death are presented as examples of increased bone fragility with an associated increase in fracture rates due to ethanol‐induced osteopenia. In addition, one of the individuals suffered fractures several weeks premortem, allowing some healing to take place. Using radiographs and physical examination, the ribs from these individuals are compared with those retained from three individuals with no history of alcoholism to illustrate diagnostic characteristics that will be notable using standard autopsy and anthropological procedures. Trabecular bone mass is notably decreased in the alcoholic group leading to a greater chance of fracture occurring during conflict, including arrest and in‐custody situations. The average number of perimortem fractures among the alcoholic individuals is 15, while the control group is six. In the case of the individual with healing, the degree of bone repair on the ribs was less than is expected considering the interval between injury and death.     

Frequency of laryngeal and hyoid bone trauma in nonhomicidal cases who died after a fall from a height

A retrospective study was carried out on 93 autopsy cases who died after a fall from a height. For each case, following parameters were reported: age, sex, manner of death, estimated height of fall, ground type, estimated site of primary impact, type of laryngeal and hyoid bone trauma, presence of associated local trauma in the neck and cephalic region. Mean age of the studied population was about 33 years. Sex ratio (men/women) was 1.8. Mean height of fall was about 15 m. Manner of death was, respectively, suicide and accident in 70 and 23 cases. The type of ground was concrete in 94% of the cases. The site of primary impact was, respectively, head, front of the body, back of the body, feet/lower limbs, and lateral body in 31, 26, 19, 12, and 5 cases. Cervical soft tissue bruising without laryngohyoid fractures was found in 5 cases. Laryngohyoid fractures were found in 5 cases. These fractures could be explained by direct impact of the neck structures against the ground. The mechanism of these fractures could also be indirect fractures due to high muscle strains on the hyoid bone or thyroid cartilage due to cervical hyperflexion or hyperextension or secondary to mandible or cervical vertebral column fractures.     

The occurrence of cervical fractures in victims of judicial hanging.

Cervical vertebrae from 34 victims of judicial hanging were examined. In only six cases was there a fracture of the axis and only one other fracture was seen in the series. The fractures were of two types. Three were the traditional 'Hangman's fracture' whilst three were of a type previously unreported. The incidence of fracture was unassociated with drop, date age or hangman. The results of the post mortems on these subjects were reviewed and found to be grossly inaccurate with regard to fractures. The results indicate that the traditional hangman's fracture occurred in only a small proportion of cases of judicial hanging. The cause of fractures and cause of death in judicial hanging are discussed with a brief history of judicial hanging in this country.     

Unusual self-electrocution simulating judicial electrocution by an adolescent

Electrocution is one of the rarest modes of suicide. In this case, one school going adolescent committed suicide by electrocution using bare electric wire. This is a rare case of suicidal death by applying live wires around the wrists, simulating the act of judicial electrocution. He positioned himself on armed chair and placed the nude wire loops from a cable around both wrists and switched on the current by plugging in to nearest socket by foot. There were linear electric contact wounds completely encircling around the both wrists. In addition to these linear electric burns all around wrists, there were electrical burns over both hands. This death highlights the need of supervision and close watch on children for self-destructing activities and behavior. This case also highlights unusual method adopted by adolescent to end his life.     

Fatal renal hemorrhage after extracorporeal shock wave lithotripsy

Renal hematoma is one of the most severe complications of extracorporeal shock wave lithotripsy (ESWL). ESWL is used in the noninvasive treatment of urinary calculosis. The shock waves can lead to capillary damage, renal parenchymal or subcapsular hemorrhage. We present a case with fatal complication and the result of the medico-legal evaluation. A 71-year-old woman was treated by ESWL, renal hematoma was detected during the clinical observation, and the patient died. The death occurred despite close clinical observation as a consequence of a rare complication of ESWL. The mechanism of death was hemorrhagic hypovolemic shock due to renal hemorrhage complications due to ESWL for treatment of renal calculi. This therapeutic complication is a known complication of appropriate treatment.     

Complete Cardiac Rupture Associated with Closed Chest Cardiac Massage: Case Report and Review of the Literature

Chest skeletal injuries are the most frequent complications of external chest massage (ECM) during cardiopulmonary resuscitation, but heart and great vessels lacerations that are indeed very rare. We report the case of a 35‐year‐old workman who collapsed and underwent ECM by his co‐workers for almost 30 min. At autopsy, no external injuries, fractures or bruises of the ribs or sternum, were observed. A hemopericardium with a rupture of the heart was found, with no signs of pre‐existent cardiac disease. Bruises of thoracic aortic wall, lung petechiae, a contusion of the liver, and bruises of lumbar muscles were found. The cause of death was due to sudden cardiac death with an extensive cardiac rupture. This is an unusual report of massive heart damage without any skeletal or muscle chest injuries, secondary to cardiopulmonary resuscitation. This kind of cardiac lesions may be considered when thoracic–abdominal trauma, or medical history, is unclear.