Sudden death resulting from lesions of the cardiac conduction system

Sudden unexpected deaths in young persons with noncontributory histories, autopsy results, and drug screen results are a common problem in forensic pathology. As part of the evaluation of such cases, the cardiac conduction system (CCS) should be studied. To determine the type and incidence of lethal CCS lesions, the authors reviewed their files of sudden unexpected cardiac deaths with particular attention to cases with causes of death in the conduction system. Cases of sudden cardiac death in patients aged < or=40 years during a 10-year period (Michigan) and a 4 year-period (Spain) were selected from the files. From this group, cases were identified in which the cause of death was a lethal change in the CCS. The portions of the heart containing the CCS were excised, and at least one hematoxylin and eosin slide and at least one trichrome or elastic trichrome slide per block were studied. In the two centers, 381 cases of sudden cardiac death were identified. The most common causes of sudden cardiac death were arteriosclerotic narrowing of the coronary arteries, cardiomyopathy, and myocarditis. In 82 cases, there was no identifiable cause of death even after complete gross and microscopic autopsy was performed, a medical history was obtained, and a drug screen was performed. In 11 cases, the CCS contained lesions that were considered lethal: narrowing of the atrioventricular node artery by fibromuscular hyperplasia (7 cases) and atrioventricular node tumors (4 cases). The 11 cases accounted for 2.9% of the 381 cases of sudden cardiac death and 11.8% of the indeterminable cases. It was concluded that examination of the CCS in deaths in which the gross and microscopic autopsy, history, and drug screen fail to provide a cause of death can yield a cause of death in a significant percentage of cases. If heart block was not documented during life and no explanatory lesions were found during routine cardiac examination, examination of the CCS can yield valuable information.     

The spectrum of intramyocardial small vessel disease associated with sudden death

Intramyocardial small vessel abnormalities are not commonly recognized. The best known abnormality is fibromuscular dysplasia involving the sinoatrial or atrioventricular nodal arteries. Small vessel disease has been reported as an isolated cardiac anomaly in individuals with sudden death, and may also be associated with other cardiac conditions including hypertrophic cardiomyopathy and mitral valve prolapse. The nature of the association is unknown, and the mechanism causing sudden death is sometimes obscure. We describe pathological changes of the intramyocardial small vessels of three individuals with sudden death. Abnormalities involved small vessels at different levels. In all the cases, the abnormalities were thought to have caused or contributed to the individual's death. The possible mechanisms of this are discussed.     

Bizarre impalement fatalities--where is the implement?

Two fatalities due to unusual impalement injuries are reported. (1) A large branch broken off during a storm had entered a passing car and perforated the chest of the driver and the back of the seat. The chest organs were grossly lacerated. The car was subsequently stopped by another tree and this second impact removed the wood from the body. (2) A man suffered anorectal impalement by the leg of a stool turned upside down. He had introduced one stool leg into his anus for sexual stimulation and fell onto it. This resulted in a wound channel 36 cm long including perforation of the rectum, urinary bladder, mesentery, transverse mesocolon and liver. Before autopsy, the mode of death was unclear because the man had removed the stool leg himself, his wife had hidden the stool from the scene, and there were no relevant external injuries. In both cases, a reliable reconstruction required investigation of the scene and consideration of extremely unlikely circumstances or of bizarre human activities.     

Evaluation of some oxygen, sulfur, and selenium substituted ninhydrin analogues, nitrophenylninhydrin and benzo[f]furoninhydrin

Six ninhydrin analogues containing oxygen, sulfur, and selenium substituents at the C-5 position, 5-(4-nitrophenyl)ninhydrin, and benzo[f]furoninhydrin were evaluated as fingerprint development reagents. The analogues all showed good fingerprint color development but were not superior to ninhydrin in this respect. The benzo[f]furoninhydrin complex was strongly luminescent at room temperature following zinc complexation, while the remaining analogues required cooling to -196 degrees C to produce optimum luminescence. The benzo[f]furo, nitrophenyl, and methyl selenide analogues showed the best potential as fingerprint reagents with the benzo[f]furo analogue comparing favorably with DFO.     

An unusual case of driving under the influence of enflurane

An unusual case of driving under the influence of the volatile anaesthetic enflurane is reported. A markedly affected anaesthetist was sniffing at an enflurane-moistened handkerchief before he crashed into a lorry at a red traffic light. In the blood sample enflurane (2.92 mg/l) as well as diclofenac (0.28 mg/l) and 4-aminophenazone (24.4 mg/l) were found. The way of driving and the accident and the deficiency symptoms could be explained by the central suppressing effects of enflurane. The physician was considered as impaired and not suitable to drive at the time of the incidence.