Iatrogenic tracheal laceration causing asphyxia

Endotracheal intubation is a simple, rapid, and safe technique that is being used as a standard procedure for airway management. However, airway injury during endotracheal intubation could be a significant source of morbidity or even mortality for patients and a source of liability for physicians as well. We report an unusual case of fatal tracheal occlusion by intraluminal blood clot complicating endotracheal intubation. The patient, a 62-year-old woman, with renovascular hypertension and incipient renal failure was scheduled for renal autotransplantation. The surgery was uneventful but the postoperative course was complicated with a lethal airway obstruction. At autopsy a linear longitudinal tracheal laceration was identified with an intraluminal blood clot obstructing the tracheal lumen. Tracheal laceration as a cause of death is a rare and potentially fatal complication of endotracheal intubation with intratracheal bleeding, clot formation, tracheal occlusion, and subsequent asphyxia.     

Artifactual injuries of the larynx produced by resuscitative intubation

Over a period of 9 months we examined a series of 50 deaths due to natural and unnatural causes in which there had been endotracheal intubation and chest compression during resuscitation at the scene or in the emergency department shortly before death. In 37 of 50 cases (74%) there were airway injuries directly resulting from the intubation procedure which we documented using a standardized protocol and photography. Specific airway injuries, ranging from petechiae to contusions, included oral injury (28%), posterior pharyngeal injury (16%), epiglottic injury (22%), piriform recess injury (12%), laryngeal and tracheal mucosa injury (64%), strap muscle hemorrhage (14%), and cutaneous injury of the neck (4%). In addition, we recorded the presence of facial (6%) and conjunctival petechiae (21%) and attributed these changes to resuscitative chest compression. No cases had associated fractures of the hyoid or thyroid cartilage. Based on our findings, we conclude that resuscitative intubation can cause artifactual injury that may mimic inflicted injuries caused by neck compression, including strangulation and neck holds.     

Potentially lethal complications of tracheostomy: autopsy considerations

Tracheostomy is widely used to facilitate respiration by protecting the airways. It may be performed to relieve upper airway obstruction from congenital stenoses or from acquired conditions such as foreign body impaction, swelling from neck trauma or anaphylaxis, benign or malignant tumors, and infection. Tracheostomy may also be performed in individuals with respiratory impairment who require suctioning for accumulated mucoid secretions and in those with obstructive sleep apnea. Review of autopsy files and the literature was undertaken to demonstrate the range of lethal circumstances that may involve tracheostomy. Unexpected death may result from incorrect positioning of an endotracheal tube with failure of oxygenation, tracheal perforation with pneumothorax, mucus plugging, accidental extubation, and hemorrhage from tracheovascular fistulas. Lethal tracheovascular fistulas usually involve the innominate artery and result from mural perforation by the tip of a tracheostomy tube, mural necrosis from a high-pressure cuff, prolonged intubation, radiotherapy, and low tracheal incisions. Increased movement of tubes in patients with impaired consciousness and excessive head movements may also increase the chances of hemorrhage, as may infiltrating tumors. Given the wide range of potential fatal mechanisms that may be found in such cases, careful autopsy evaluation and dissection will be required to demonstrate the exact nature and site of the lethal lesion in individuals who underwent tracheostomy and die unexpectedly.     

Determining the state of the deceased during cardiopulmonary resuscitation from tissue distribution patterns of intubation-related lidocaine

The objective of this study was to determine whether the concentrations of lidocaine, used for endotracheal intubation, in body fluids and tissues reflect the state of the circulation of the deceased during cardiopulmonary resuscitation. The tissue distribution of lidocaine was investigated in seven individuals (Cases 1-7) who underwent medical treatment with endotracheal intubation using Xylocaine jelly (a 2% lidocaine hydrochloride preparation), before being pronounced dead. Six patients (Cases 1-6) had cardiopulmonary arrest on arrival at hospital. In Cases 1-4, there was no restoration of heartbeat during cardiopulmonary resuscitation. However, systemic distribution of intubation-related lidocaine was observed and the kidney-to-liver ratios of lidocaine were less than 1. In Cases 5 and 6, the heartbeat resumed temporarily with cardiac massage, and a kidney-to-liver lidocaine ratio greater than 1 was observed. In Case 7, where the patient was comatose upon admission to hospital, the kidney-to-liver ratio of lidocaine was also greater than 1. These phenomena were substantiated in animal experiments. Our results indicate that the absorption of tracheal lidocaine during the artificial circulation resulting from cardiopulmonary resuscitation results in a kidney to liver ratio of less than 1, whereas absorption during natural circulation gives a ratio greater than 1. The kidney-to-liver ratio of intubation-related lidocaine may give useful information on the state of a patient during cardiopulmonary resuscitation.     

Tissue distribution of lidocaine in critical care patients after intubation

We investigated tissue distribution of lidocaine in 33 patients after endotracheal intubation with Xylocaine jelly that contains 2% lidocaine hydrochloride. Blood levels of monoethylglycinexylidide (MEGX), an active metabolite of lidocaine, were also determined. Five patients (Group A) were alive on arrival and six patients (Group B) resumed heartbeats after cardiopulmonary resuscitation (CPR). The survival times for Groups A and B ranged from 3 to 72 h. The remaining 22 patients (Group C) did not survive cardiopulmonary arrest on arrival (CPAOA). Systemic distribution of lidocaine was measured in nine patients from Group C. The liver-to-kidney lidocaine ratios and cerebrum-to-cerebrospinal fluid lidocaine ratios were: Group A, 0.1-0.7 and 1.4-3.6, respectively; Group B, 0.2-0.8 and 1.2-2.3, respectively; Group C, 0.1-17 and 0.2-1.0, respectively. MEGX was detected in all blood samples from Group A and only two samples from Group B. No MEGX was detected in samples from Group C. Our results indicate that the absorption of tracheal lidocaine during natural circulation results in a cerebrum-to-cerebrospinal fluid lidocaine ratio of 1.2 or more, whereas absorption during artificial circulation by cardiac massage gives a ratio of 1.0 or less. The cerebrum-to-cerebrospinal fluid lidocaine ratio may be a more useful index to estimate circulatory dynamics of patients during CPR than the liver-to-kidney lidocaine ratio. MEGX was not a useful parameter for monitoring circulatory changes during cardiac massage.     

大鼠溺死后气管纤毛变化的扫描电镜观察

应用扫描电镜对大鼠溺死后不同时间气管纤毛病理变化进行了观察，发现溺死大鼠气管纤毛局部紊乱，杯状细胞顶端开口增多，纤毛表面粘附有较多的絮网状结构．随死后时间延长，纤毛出现粘结、倒伏、结构破坏、消失等死后变化．结果表明，用扫描电镜观察上述变化有助于溺死死因诊断和死后经过时间的推断．     

Airway obstruction by laryngeal masses in sudden and homicidal deaths

We present two cases of autopsy detection of laryngeal masses with medico-legal implications. The first is a 56-year-old man who died suddenly of asphyxia due to upper airway obstruction caused by a large glosso-epiglottic retention cyst and glottic oedema. Hypothesis of medical liability was raised, due to delayed tracheotomy as the result of repeated failed attempts at oral intubation by various physicians. Difficult oral intubation due to the presence of a laryngeal mass in an asphyxiating subject requires rapid tracheotomy. The second case deals with a 43-year-old woman who died of asphyxia due to airway obstruction, as a result of injury of a cavernous laryngeal haemangioma after homicidal manual strangulation, with severe haemorrhagic infiltration of the surrounding soft tissues. Damage to laryngeal/hypopharyngeal masses should be considered as a possible sign of manual strangulation, as well as neck skin bruises/abrasions and laryngeal haemorrhages.     

Radiographic demonstration of esophageal and tracheal fistulas at autopsy using a contrasting medium that vulcanizes at room temperature

Esophageal and tracheal fistulas, which occur in 0.05% of medicolegal autopsies, were demonstrated in three cases by a postmortem radiographic technique using silicone rubber/lead oxide as a contrasting medium that vulcanizes at room temperature. In one 83-year-old male, a tracheoesophageal fistula was detected, which had developed after surgical repair of an esophageal rupture caused by a flexible fiberoptic endoscope. In a second case, carcinoma of the esophagus in a 78-year-old male had eroded the trachea and arcus of the aorta creating a fatal tracheoesophagoaortic fistula. In a third case, 55-year-old female developed a tracheobrachicephalic artery fistula as a result of an infiltrating cystic adenocarcinoma of the trachea, resulting in a fatal hemorrhage into the trachea. The results of this study indicate that diagnostic radiologic methods using a vulcanized contrasting medium are useful in supplementing normal dissection in autopsy cases with suspected fistulas of the esophagus or trachea.     

ABH and Lewis antigens of tracheal glands. II. Lewis negative individuals

Immunocytochemical studies were performed on tracheal wall samples embedded in paraffin; the samples were taken at 23 autopsies. In all cases, the red cells had been typed in postmortem serological studies as being Le(a-b-). Blood-group antigens were demonstrated by the indirect immunoperoxidase technique, using monoclonal Anti-A, Anti-B, Anti-Lea and Anti-Leb; H was detected by UEA 1. The secretor characteristics could clearly be diagnosed from the ABH staining pattern of the mucous glands. In 11 cases, the lewis antigen labeling patterns were identical to the group of Lewis-positive individuals. It seems probable, from the statistical point of view, that these 11 individuals were, in fact, Lewis-positive and that the negative serology resulted from deterioration of the cadaver blood samples. The immunocytochemistry was quite different in the remaining 12 cases: (a) secretors (n = 9) were completely negative for Lea, Leb was equally negative in one case, but in the remainder it was detectable within mucous epithelia in minimal amounts and in an atypical granular distribution; (b) nonsecretors (n = 3) reversely exhibited complete negativity for Leb but a minimal staining for Lea. These findings are in harmony with the well established Lewis serology typing of secretions in Lewis negative individuals. Thus, a minimal Lewis antigen biosynthesis and secretion seem to occur in the absence of the Le gene: A alpha-4-L-fucosyltransferase of low activity might be the product of the allele le.     

Arterial-esophageal fistulae in patients requiring nasogastric esophageal intubation

A rare and potentially fatal cause of hematemesis is fistula formation between the esophagus and the vascular system. A case report of a 39-year-old woman with congenital aortic arch anomalies hospitalized for treatment of head injuries demonstrates the potential for iatrogenic esophageal trauma to initiate fistula formation between the esophagus and an anomalous arterial system. A literature review revealed 6 other cases of vascular-esophageal fistulae caused by nasogastric esophageal intubation. It is concluded that aortic arch anomalies increase the risk of esophageal injury and subsequent fistula formation from nasogastric esophageal intubation. In addition, the clinical features and pathologic findings of vascular-esophageal fistulae are reviewed.     

Respiratory,Circulatory, and Neurological Responses to Hanging: A Review of Animal Models

Abstract: The pathophysiology of hanging is still poorly understood. This article presents a review of eight animal models: four models of isolated occlusion of the vessels of the neck (group 1), one model of combined tracheal and vessel occlusion (group 2), and three models of true animal hanging (group 3). Occlusion of the airway passages in group 2 did not accelerate respiratory arrest compared to group 1. Cessation of cerebral blood flow, rather than airway obstruction, seems to be the main cause of respiratory decline. In general, muscular movements ceased after 1–3.5 min and early generalized tonic‐clonic convulsions were described. Complete circulatory collapse seems to occur between 4 and 8.5 min. These observations from animal models of hanging are compared with the data collected from filmed human hangings. Avenues to improve animal models are discussed.     

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。     

11例迷路震荡的法医临床学鉴定分析

目的 探讨迷路震荡的法医临床学鉴定的有关问题。方法 对11例15耳迷路震荡的法医临床学鉴定资料进行回顾性研究。结果 11例迷路震荡伤者,均有头部受伤史,伤后短时间内出现耳鸣、听力下降,其中4例伴前庭症状;常规耳科检查和头颅及颞骨CT扫描无异常;各种听力学检查提示感音神经性聋或混合性聋;选择ABR和/或40Hz AERP检测客观听阂,11例有不同程度听力损失,以高频听力损失为主,其中双耳4例,单耳7例;鉴定时间在伤后2-8个月;鉴定为轻伤6例,重伤5例。结论 头部外伤后短时间内出现耳鸣、听力下降,可伴前庭症状,常规耳科检查和头颅及颞骨CT扫描无异常,以及各种听力学检查提示感音神经性聋或混合性聋,可诊断迷路震荡,损伤程度鉴定至少在伤后2-3个月进行。     

Stability of plasma total cholesterol, triglycerides, and apolipoproteins B and A-I during the early postmortem period

The stability of plasma lipids and apolipoproteins during the early postmortem period was studied by taking four duplicate blood samples from eight cadavers 2, 6, 12, and 24 h after death. The bodies were kept at +4 degrees C. The plasma samples were analyzed for total cholesterol (TC), triglycerides (TG), apolipoprotein B (apo B), and apolipoprotein A-I (apo A-I). In TC, values rose by 6 and 11% in two cases, and in six cases diminished 3 to 15% during the first 6 h compared to values obtained 2 h postmortem. The greatest changes were a continuing rise in one case by 33% and a fall by 21% in another case during 24 h. In TG values marked changes took place including one case with a rise of 67% within 24 h. The concentrations of apo B rose by 9 to 11% in three cases and fell by 3 and 4% in two cases during 6 h, but during the whole study period a rise up to 78% occurred. In the concentrations of apo A-I, cases fell by as much as 42% in 6 h, and in one case rose by 20% during 6 h. The results indicate that unpredictable fluctuations occur in plasma lipid and apolipoprotein values within 24 h after death, and they should be interpreted cautiously if the samples have been taken after a prolonged postmortem period.     

Tissue distribution of intubation-related lidocaine in brain-dead patients

Tissue distribution of lidocaine that was used for endotracheal intubation during cardiopulmonary resuscitation (CPR) was measured in 3 patients who were brain-dead or near brain death. Case 1 was a 69-year-old female whose heartbeat was restored by CPR but stopped 10 hours later. The lidocaine ratios of cerebrum to blood (2.04) and diencephalon to blood (1.01) were within ranges of those found in non-brain-dead patients. Case 2 was a 77-year-old female whose heart resumed beating after CPR but stopped 66 hours later. The lidocaine ratios of cerebrum to blood (5.69), diencephalon to blood (18.7), and cerebellum to blood (11.3) were much higher than those in non-brain-dead patients. Case 3 was a 48-year-old male who had cardiopulmonary arrest following an acute subarachnoid hemorrhage. His heart resumed beating after resuscitation but ceased beating 114 hours after admission. Lidocaine was detected only from the cerebrum, cerebellum, and blood clots in the superior sagittal sinus at levels of 0.028, 0.024, and 0.007 mug/g, respectively. Tissue distribution of intubation-related lidocaine in brain-dead patients is useful as supplementary data for reviewing hemodynamic changes in their brains during medical treatment.     

人脑挫伤后GFAP,PCNA的法医病理学研究

采用在实际工作中所遇到的脑挫伤案例标本 ,利用免疫组织化学染色 ,观察人脑挫伤后GFAP ,PCNA的改变 ,用图象分析仪对免疫组织化学染色阳性细胞的面积和灰度等进行定量测量 ,EpiInfo统计软件分析 ,得出人脑挫伤后GFAP ,PCNA变化的时间性规律 ,为脑挫伤形成时间推断 ,提供新的形态学依据。GFAP阳性细胞面积、灰度伤后24h即有显著增加 (P<0 01) ,7天达高峰 (P<0 01) ,以后有逐渐下降的趋势 ;PCNA阳性细胞面积、灰度于伤后4天达到最大值 (P<0 01) ,以后逐渐下降。因此 ,伤后人脑组织GFAP、PCNA免疫组织化学染色阳性细胞面积、灰度改变有时间规律 ,GFAP、PCNA可作为2天到20天间不同时间脑损伤的推断指标。     

Problems associated with the diagnosis of vitality in burned bodies

The most important signs of vitality in burned bodies are soot deposits in the respiratory tract, the esophagus and the stomach as well as elevated CO-Hb values in the blood. But these findings show only that a person was exposed to fire fumes while alive; they are no indicator for vital heat exposure. As the external findings in burned bodies are often not very conclusive due to postmortem consumption by the fire, the internal findings are all the more important. Macroscopic signs that hot fumes were inhaled may be edematous swelling and vesicular detachment of the mucosa in the pharynx, the larynx and/or the upper section of the esophagus. As histological changes in the respiratory tract soot deposits, vesicular detachment of the epithelium, hyperemia and edema of the tracheal and bronchial mucosa as well as increased secretion of mucus have been described. These findings may partly be absent although the victim was alive during the fire, which can make diagnosis more difficult. Especially in peracute deaths vitality findings are usually sparse. The significance of the macroscopic and histological parameters of vitality was systematically investigated on the basis of our own autopsy material from the years 1996-2002 (88 cases) and compared with the statements found in the literature. In our study material, the vitality parameters were incomplete in 23% of the burned corpses. In 3% of the cases the question whether there was an antemortem heat exposure could not be answered.     

43例心脏外科手术后死亡医疗纠纷法医学分析

目的 探究心脏外科手术后死亡引起医疗纠纷的原因及特点,重点分析心脏外科手术后病理改变及法医学解剖要点,为心脏外科手术临床诊治及司法鉴定提供病理学证据,为此类案件医疗纠纷防范提供参考.方法 收集中山大学法医鉴定中心2013—2018年受理的心脏外科手术后死亡引发医疗纠纷的法医病理学案件,从死亡原因、病理诊断、手术情况和医...     

Correlation between 'on admission' blood toluene concentrations and the presence or absence of signs and symptoms in solvent abusers

For 1 year, from June 1987 to June 1988, toluene concentrations in blood samples of patients admitted to a psychiatric hospital after inhaling solvent vapor, collected on admission and 4 h later, were analyzed by gas chromatograph. Toluene levels in the first urine samples collected after admission were also analyzed and case histories were kept listing age, sex and physical and psychiatric effects. In all, 51 cases were studied--34 males and 17 females. (1) The average age of the males was 21.4 years and of the female 16.2 years. (2) The toluene concentrations in the blood collected on admission ranged from 0.3 to 22.8 micrograms/g. (3) Physical signs were observed in 9 patients with an "on admission" blood toluene concentrations of more than 3.0 micrograms/g; twice as many subjects (18), however, with blood toluene concentration greater than 3.0 micrograms/g were without physical signs. (4) The blood toluene concentrations of three cases in the condition known as twilight state were more than 10.0 micrograms/g. (5) In 24 cases with blood toluene concentrations below 3.0 micrograms/g, there were no physical signs. (6) Five subjects with blood toluene concentrations in the 0.8-5.2 micrograms/g range showed neuropsychiatric effects; however, 23 subjects in the same blood toluene concentration range did not exhibit psychiatric effects, and none of the subjects with blood toluene concentrations greater than 5.2 micrograms/g, 15 in all, had such effects.