Fatal "crack" cocaine ingestion in an infant

This report describes a 10-month-old infant girl who died of cocaine poisoning. The infant was found apneic and in ventricular fibrillation after the parents summoned rescue personnel and claimed she had ingested rat poison. The parents later admitted that 2 hours before calling for assistance, the infant's 2-year-old brother was found eating "crack" cocaine and also feeding it to the infant. Investigators found "crack" cocaine throughout the house and in the infant's crib. At autopsy, the infant had two pieces of "crack" cocaine in the duodenum. The brain exhibited a markedly thinned corpus callosum. Toxicologic examination showed high concentrations of cocaine in the blood and in other specimens. The manner of death was classified as homicide because the infant was willfully placed in a hazardous environment with an easily accessible toxic substance, medical attention was deliberately delayed for 2 hours, and medical personnel were deceived when they were falsely told she had ingested rat poison. These features were thought to constitute neglect. The toxicologic characteristics of this case are unique. There are numerous reports of passive cocaine inhalation in infants and children less than 5 years of age, but ingestion of cocaine in this age group has rarely been documented. This age group also has no reported deaths due to cocaine ingestion and no cases of "crack" cocaine ingestion. The high concentrations of cocaine seen in this case, combined with the "crack" cocaine found in the duodenum, indicate ingestion as the route of exposure. The thinned corpus callosum in this case may be a consequence of intrauterine cocaine exposure.     

Biomechanical fragility of the infant skull

Following previous experiments on postmortem skull fractures of infants, falls from 82-cm heights onto stone (A), carpet (B) and foam-backed linoleum (C), 35 further falling tests were carried out onto softly cushioned ground. In 10 cases a 2-cm thick foam rubber mat (D) was chosen and in 25 further cases a double-folded (8-cm-thick) camel hair blanket (E). Hence the results of altogether 50 tests could be evaluated. In test groups A-C on a relatively hard surface, skull fractures of the parietale were observed in every case; in test group D this fracture was seen in one case and in test group E in four cases. Measurements along the fracture fissures showed bone thickness of 0.1-0.4 mm. The fracture injuries originated in paper-thin single-layer bone areas without diploe, which can also be considered the preferred regions for skull fractures of older infants following falls from low heights. These results indicate that it is no longer possible to assume that the skull of infants is not damaged after falls from table height.     

Fatal pediatric head injuries caused by short-distance falls.

Physicians disagree on several issues regarding head injury in infants and children, including the potential lethality of a short-distance fall, a lucid interval in an ultimately fatal head injury, and the specificity of retinal hemorrhage for inflicted trauma. There is scant objective evidence to resolve these questions, and more information is needed. The objective of this study was to determine whether there are witnessed or investigated fatal short-distance falls that were concluded to be accidental. The author reviewed the January 1, 1988 through June 30, 1999 United States Consumer Product Safety Commission database for head injury associated with the use of playground equipment. The author obtained and reviewed the primary source data (hospital and emergency medical services' records, law enforcement reports, and coroner or medical examiner records) for all fatalities involving a fall. The results revealed 18 fall-related head injury fatalities in the database. The youngest child was 12 months old, the oldest 13 years. The falls were from 0.6 to 3 meters (2-10 feet). A noncaretaker witnessed 12 of the 18, and 12 had a lucid interval. Four of the six children in whom funduscopic examination was documented in the medical record had bilateral retinal hemorrhage. The author concludes that an infant or child may suffer a fatal head injury from a fall of less than 3 meters (10 feet). The injury may be associated with a lucid interval and bilateral retinal hemorrhage.     

Biomechanical features of spinal trauma depending on conditions of the trauma

The aim of the study was to investigate biomechanical features of spinal trauma (fractures) depending on external impact, position of a human body or its parts in the moment of the trauma and before it; to reveal morphological signs of fractures characterizing specific trauma mechanisms. From a position of theoretical mechanics, the vertebral column is an elastic stem the strength of which depends on elastic properties of the pulpous nuclei and intervertebral disks, the column length and curvature. To determine the mechanism of the trauma, it is recommended to make the following measurements: the length of the body, the length of the vertebral column, the length of the cervical, thoracic, lumbar parts, size of the chest kyphosis.     

Fatal birth trauma due to an undiagnosed abdominal teratoma: case report and review of the literature

The fetus is subjected to mechanical forces during labor and delivery, which may result in traumatic injuries. Such injuries include intracranial hemorrhage, spinal cord lesions, cephalhematoma, cranial or peripheral nerve palsies, intraabdominal organ rupture, or bony fractures. Risk for perinatal trauma and mortality is increased in primigravidas, multiple gestations, abnormal presentations, maternal-fetal disproportion, oligohydramnios, forceps or vacuum extractions, and internal version maneuvers. Very-low-birth-weight neonates (<1500 g) are at high risk due to ease of deformity of the cranium. Infants with certain congenital anomalies or pathologic processes that distort normal anatomy are also at increased risk, especially when a prenatal diagnosis is lacking. The authors present a case of a term gestation neonate who sustained a cervical spine dislocation fracture of C5-7, with subtotal transection of the spinal cord and resultant paralysis. The fetus was in vertex presentation, and a manual vaginal delivery was attempted. When the infant lodged in the birth canal following a difficult delivery of the head and arms, its enlarged abdomen was palpated, and the delivery was converted to an emergent cesarean section. The infant lived for 3 days and then expired due to neurologic complications of trauma sustained during the attempted vaginal delivery. Autopsy revealed a previously undiagnosed intraabdominal immature teratoma. The pathology of teratomas, the most common neonatal tumor and occasionally implicated in cases of birth trauma, will be addressed, followed by a review of the literature concerning birth trauma.     

Fatal trauma to the neck: immunohistochemical study of local injuries

As fatal trauma to the neck is often associated with short survival times, proof of vitality may often be difficult using standard histochemical techniques. Soft tissue neck injuries resulting from strangulation by ligature or manual strangulation were examined immunohistochemically using antibodies to myoglobin, fibronectin, C5b-9 and MRP14, and compared to controls consisting of accidental soft tissue neck injuries as well as undamaged neck soft tissue. Although survival times in the study and control groups were unknown and certainly some individual variation may be expected in the time course of normal wound development, both the study and control groups demonstrated similar time courses in the immunohistochemical detection of antigen. Myoglobin was always found in those samples in which only one antigen was shown to be involved in an injury-specific pattern; myoglobin and fibronectin were found in samples with dual antigen involvement. Samples involving three antigens always included C5b-9 in addition to myoglobin and fibronectin. The single positive MRP14 sample in the study and control groups was simultaneously positive for the other markers used. Myoglobin, fibronectin, C5b-9 and MRP14 are therefore suitable for immunohistochemical detection of vital reactions and estimation of temporal relationships in the early posttraumatic period after neck trauma.     

Blunt basal head trauma: rupture of posterior inferior cerebellar artery.

Two cases are reported of rupture of posterior inferior cerebellar artery (PICA) from blunt basal head trauma. The anatomy at the site of rupture is discussed as a prerequisite for rupture. The rapid fatal course is also discussed. The authors propose that the forensic term "traumatic subarachnoid haemorrhage" ought to be abandoned and replaced by the nature and localization the source of bleeding, analogous to clinical practice at the spontaneous haemorrhage from rupture of aneurysm.     

Fatal head injuries from firearms. An autopsy study of 270 cases

Autopsy findings in 270 fatal head injuries from firearms are reported, including 243 suicides and 27 homicides. The most frequent weapon used for both groups were shot guns which are easily available in Norway. For suicides the most favored sites were right tempoparietal, frontal, and mouth. Twenty-six percent of the victims from homicides had multiple wounds in their head. Suicide by firearms showed marked male predominance, whereas the sex ratio for homicide was rather equal between the two sexes.     

Fatal blunt trauma of the larynx in a child

We report an autopsy case of an 11-year-old girl who suffered mechanical asphyxia from falling off the metal bars in the playground. This autopsy case is interesting because of the atypical trauma and lesions. To our knowledge there has been no similiar published case reports in the forensic literature. The young age of the victim, the setting and the pattern of the injuries are rare in a fall at playground by a child.     

头部外伤后精神损伤的法医学鉴定(附204例分析)

目的　研究颅脑外伤所致精神障碍的损伤程度评定标准。方法　通过对２０４ 例由司法部门委托进行法医学精神损伤程度鉴定实践,重点对颅脑外伤所致神经症的损伤程度评定标准及其他相关问题进行了讨论。结果　２０４ 例中,男、女比例无差异。年龄组以２１ ～３０ 岁（６３ 例） 、３１～４０ 岁（５３ 例） 居多。表明上述年龄组的社会活动多,受到伤害的可能性大;职业以工人、农民为多,文化程度相对较低。损伤原因以伤害（１０７ 例） 、交通事故（４９ 例） 为多。损伤与精神障碍间隔时间,半年以内１５２ 例,半年至１ 年为２３ 例,表明鉴定时间选择在１ 年内为佳。精神障碍的种类与性质：器质性精神障碍１０８ 例,占５２－８％ ;功能性精神障碍８４ 例,占４１－４％ ,其中外伤后神经症（ 含癔症３５ 例）６６ 例,占３２－３ ％ 。社会功能评定：无社会功能受损７７ 例,轻度受损４１ 例,明显受损８６ 例。神经系统检查：２０４ 例中有一过性神经体征３８ 例,有明显阳性体征６２ 例。损伤与精神障碍的关系：直接因果关系１０４ 例、间接因果关系６１ 例;条件相关３４ 例、无相关５ 例。损伤程度评定结果：重伤８５ 例,轻伤６７ 例,伤病关系评定４７ 例。结论　通过对２０４ 例头部外伤     

Massive pulmonary embolization by cerebral tissue after head trauma in an adult male

We report a case of an adult man who was run over by a car, suffering severe head trauma. After 3 hours in the hospital, he experienced sudden and severe hemodynamic deterioration, dying immediately. The autopsy showed massive cerebral tissue pulmonary embolization (CTPE), confirmed by immunohistochemistry. Multiple fractures of the skull, tear of the transverse sinus, and brain laceration of the occipital lobe were present. CTPE is very infrequent. In children and adults, it occurs as a complication of severe closed or penetrating head trauma. Although laceration of a large cerebral venous sinus is not always essential, in some cases (like in the present one) this laceration is the mechanism of entry of the cerebral tissue to the blood circulation. The clinical repercussion of CTPE is variable. In some cases, it could be an incidental finding of autopsy. In other cases, coagulation abnormalities and disseminated intravascular coagulation have been reported. Finally, such as in the present case, the immediate cause of death is the sudden hemodynamic failure due to the massive CTPE.     

Biomechanical and morphologic reconstruction of a questionable case of child abuse

A 3-month-old baby died 8 days after admission to the hospital as a result of injuries received under unknown circumstances. The forensic autopsy revealed a fracture of the scull and a severe blunt injury to the head and brain. Histological investigation of the reactive changes at and around the edges of the fracture showed that the trauma could not possibly have been congenital. According to the defendant, the baby boy had been lying on the table used for changing his nappy and almost fell off it. The defendant moved "instinctively" to catch him, and this "reflex movement" caused the injuries observed. The event was then reconstructed by the criminal investigators and this reconstruction, coupled with the authors' biomechanical experiments using stroboscopic recording, revealed that the defendant's statement could not be true, as the force necessary to inflict the injuries was much greater than could be explained by an attempt to catch the baby.     

Fatal craniocerebral trauma in a young child. I: Forensic documentation,model generation and geometric impact conditions

The aim of forensic biomechanics is the reconstruction of traumatic events based on the pathological findings in the victim's morphology and on the traces and shapes of the traumatizing tools. The introduction of Streifenlichttopometrie into forensic science enables 3-dimensional and proportionally accurate documentation of the victim's body and injuring agent with submillimeter precision. The advantages of this method of documentation are the possibilities of producing animated models which correspond exactly to the body's shape and injury topography, and of ascertaining the physical parameters (centers of mass, moments of inertia) of the various body parts and the geometrical impact conditions for the reconstruction of the injury dynamics. This way of proceeding thus enables more precise models than hitherto possible for kinetic and dynamic reconstruction. In the case of an infant who was fatally injured by a wooden sculpture the generation and application of computer aided 3-dimensional reconstruction models are shown.     

Fatal Candida tropicalis infection in an 8-month-old infant with an aplasia of the thymus as a rare cause of death in infancy

Anomalies of the thymus can lead to immunodeficiencies that are often associated with complex syndromes. The clinical relevance of those anomalies varies a lot. Regarding mortality and morbidity, opportunistic infections play a major role in immunocompromised individuals. Case report: An 8-month-old infant died of a sepsis with multi-organ failure after 32 days in intensive care. At autopsy, no thymus gland could be found; toxicological examinations yielded high morphine concentrations. Autopsy findings and the results of further examinations performed postmortem are discussed in view of the clinical findings, the classification and the cause of death.     

Desquamative interstitial pneumonia in an infant. Mimicry of sudden infant death syndrome

A 15-week-old infant girl, without a prior history of overt illness, was found dead while sleeping between her two parents. The gross examination at autopsy showed only congested lungs, and the initial diagnosis was sudden infant death (SID). On microscopic examination, a desquamative interstitial pneumonia (DIP) was observed. The widespread, patchy intraalveolar histiocytic desquamation was associated with lymphocytic infiltration of bronchiolar and aveolar walls, which together provided convincing evidence that an interstitial pneumonitis was the cause of death. A viral etiology seems most likely in view of the accompanying chronic inflammation of bronchial submucosal glands.     

Venous air embolism in homicidal blunt impact head trauma. Case reports

From 1992 through 1997, there were 41 deaths by homicidal blunt impact head trauma in Hillsborough County, Florida. Twenty-one cases were excluded from the study because of putrefaction or survival beyond the emergency department doors, leaving 20 cases for the study. One of the 15 nonputrefied victims found dead at the scene and 1 of the 5 victims pronounced dead in the emergency department had definite venous air embolism. Victim 1 was found dead, bludgeoned with a concrete block, and had open vault and comminuted basilar skull fractures. The dura forming the right sigmoid sinus at the jugular foramen was lacerated. A preautopsy chest radiograph and examination under water documented gas in the pulmonary artery and right ventricle. Victim 2 was bludgeoned with a steel stake and was pronounced dead on arrival in the emergency department. He had open comminuted vault fractures, a transverse basilar skull fracture, and lacerations of the brain. Direct examination and preautopsy chest radiography revealed air in the right side of the heart. A third victim, with basilar fractures, had a small gas bubble in the pulmonary artery not detected by the case pathologist. A fourth victim, with a basilar skull fracture, had an unusual radiographic finding that was thought to be air in the posteromedial aspect of the lower lobe of the left lung but could not be excluded as an air embolus. Optimal postmortem documentation of venous air embolism includes the demonstration of the embolus and the site of air ingress. This study demonstrates that venous air embolism occurs in some victims of homicidal bludgeoning and suggests that when significant, it is easily demonstrated in the absence of putrefactive gas formation. The presence of venous air embolism can serve as evidence that a victim was alive and breathing at the time of the infliction of head wounds. In the belief that venous air embolism might be underdiagnosed in many medical examiner offices, the authors have sought to bring attention to the entity by publishing their experience with it in cases of bludgeoning.     

头部外伤后精神损伤的法医学鉴定(附204例分析)

目的研究颅脑外伤所致精神障碍的损伤程度评定标准.方法通过对204例由司法部门委托进行法医学精神损伤程度鉴定实践,重点对颅脑外伤所致神经症的损伤程度评定标准及其他相关问题进行了讨论.结果 204例中,男、女比例无差异.年龄组以21～30岁(63例)、31～40岁(53例)居多.表明上述年龄组的社会活动多,受到伤害的可能性大;职业以工人、农民为多,文化程度相对较低.损伤原因以伤害(107例)、交通事故(49例)为多.损伤与精神障碍间隔时间,半年以内152例,半年至1年为23例,表明鉴定时间选择在1年内为佳.精神障碍的种类与性质:器质性精神障碍108例,占52.8%;功能性精神障碍84例,占41.4%,其中外伤后神经症(含癔症35例)66例,占32.3%.社会功能评定:无社会功能受损77例,轻度受损41例,明显受损86例.神经系统检查:204例中有一过性神经体征38例,有明显阳性体征62例.损伤与精神障碍的关系:直接因果关系104例、间接因果关系61例;条件相关34例、无相关5例.损伤程度评定结果:重伤85例,轻伤67例,伤病关系评定47例.结论通过对204例头部外伤后精神损伤鉴定实践,对当前法医学精神损伤鉴定的疑难问题,如颅脑外伤所致神经症的损伤程度评定标准,提出了具体的可操作性的意见,以期在实践中进一步深入研究.     

Drugs in oral fluid: Part II. Investigation of drugs in drivers

As part of the European project, Impaired Motorists, Methods of Roadside Testing and Assessment for Licensing, otherwise known as IMMORTAL (Deliverable R4.2), the University of Glasgow was required to analyse 1396 oral fluid samples, collected from drivers, for a wide range of drugs. A previously described method to include 49 drugs and metabolites was used. To include cannabis in the study a separate extraction method was required because of interferences caused by the collection device. The study group included drivers who were stopped at random and participation was entirely voluntary. The results showed that out of the 1396 samples tested, 16.8% were positive for at least one drug. In the majority of positive cases (85%), monodrug use was found and the most commonly detected drug was 3,4-methylenedioxymethamphetamine. This study showed that a significant number of the driving population are positive for at least one drug.