Fatal air embolism during renal dialysis

Air embolism during renal dialysis is extremely rare because of the safeguards built into the apparatus and procedures currently used. This case is attributable to improper techniques used with venous access outside the monitored system.On completion of dialysis and disconnect from the machine and its safeguards, this patient had leg cramps. This common postdialysis complaint is routinely treated with intravenous saline from a fresh bag hung outside the machine for this purpose. Unfortunately, a previously used bag had not been replaced and soon ran empty after being connected to the patient's venous access. It was replaced hurriedly with a new bag without first bleeding the system of air.The patient collapsed, was transported to a hospital, and died 72 hours later without regaining consciousness. The diagnosis was confirmed by radiological and pathological examinations.The various mechanisms and pathways of venous to material transit are discussed.     

Gas at postmortem computed tomography - An evaluation of 73 non-putrefied trauma and non-trauma cases

Postmortem computed tomography (PMCT) has become an important complement in investigating forensic cases allowing an accurate detection of gas accumulations. The present study investigated the presence and distribution of gas in a large number of non-putrefied cases of traumatic and non-traumatic deaths. Furthermore the possibility of pneumobilia secondary to blunt abdominal trauma was studied. Retrospectively, 73 cases, underwent a whole-body PMCT prior to autopsy. These were divided into four groups: penetrating trauma (20 gunshot cases, 13 stabbing cases), blunt abdominal trauma (20 cases) and a control group of 20 non-trauma cases. Exclusion criteria were visible signs of decomposition. Each group was screened for gas accumulations in the vascular system, internal organs, soft tissues and body cavities. Gas accumulations were present in 98% of the trauma cases, compared to 80% of the control group. The most affected structures and/or organs in the trauma group were soft tissues, vessels and the liver. In most cases of the trauma group gas was associated with open injuries and lacerations of vessels. Furthermore, in the gunshot group gas was frequently seen in the intracranial cavity. Pneumobilia occurred in one case of the blunt trauma group; in that control group gas was also seen, but less frequently. Gas accumulation showed a strong association with traumatic events, but even the majority of non-trauma cases showed gas accumulations. Despite the exclusion of cases with visible decomposition signs, a putrefactive origin of gas was assumed in some cases. Gas accumulations are a frequent finding in PMCT with a higher incidence in (open) trauma cases. Even though a differentiation between putrefactive and traumatic gas accumulations is still difficult, knowledge of the circumstance surrounding the case may help identify the origin of gas.     

Use of Craniofacial Superimposition in Historic Investigation

A skeleton discovered in Grand Forks, North Dakota was purported to belong to Clelland “Clell” Miller, a James‐Younger gang member, who was killed during the Northfield Bank robbery on September 7, 1876. A 3‐D image from a computer tomography (CT) scan of the skull was obtained, and a craniofacial superimposition was conducted to determine if the skull could belong to Miller. The superimposition method used in this case was to overlay the CT image of the skull onto Miller's postmortem photograph. In addition to the craniofacial superimposition, the images were juxtaposed to compare similarities or differences in facial morphology between the skull and photograph. Superimposition methods can be used to exclude identifications; however, they should not be used as a conclusive method for identification. In this case, there were sufficient similarities between the skull and Miller's photograph; therefore, the skull could not be eliminated as possibly being that of Miller.     

Fingering a Murderer: A Successful Anthropological and Radiological Collaboration*

Abstract: We illustrate an interdisciplinary approach to identify a victim in a case with complex taphonomic and procedural issues. Burning, fragmentation, species commingling, and examination by multiple experts required anthropological preparation and analysis combined with radiographic adaptations to image and match trabecular patterns in unusually small, burned specimens. A missing person was last seen in the company of a reclusive female on a remote rural property. A warranted search found several burn sites containing human and animal bones. Fragment preparation, analysis, and development of a biological profile by anthropologists enabled examination by the odontologist, molecular biologist, and radiologist, and justified use of antemortem radiographs from one potential victim. Visual and radiological comparison resulted in a positive (later confirmed) identification of the victim by radiological matches of three carpal phalanges. Although some dimensional changes are expected with burning, morphological details were preserved, aided by selection of relatively intact, small bones for comparison.     

Infant death due to air embolism from peripheral venous infusion

An otherwise healthy male infant was brought to the hospital because the mother suspected superficial infection at the operative site 5 days after an inguinal hernia repair. He was admitted to the pediatric unit overnight to be evaluated by his surgeon the next morning. When a venous infusion of maintenance fluids was started, the patient immediately went into cardio-respiratory arrest and was pronounced dead after resuscitation efforts failed. Subsequently, air collections were found in both venous and arterial circulations, including the splenoportal system. Detailed review of the clinical presentation and course, laboratory results, radiological, and pathological findings, along with a review of pertinent literature provides an explanation for the death by air embolism. Apparent inconsistent findings both radiographically and at autopsy are resolved. The mechanism of distribution of air to both systemic and splenoportal circulation is discussed. We believe this to be only the eighth case reported in English-language literature of infantile death from peripheral venous infusion. In all age groups, we find only six other cases in the English-language literature of gas found concomitantly in both the systemic and portal venous systems.     

Using pre- and post-surgical foot and ankle radiographs for identification

An evaluation of the effect of surgical intervention on foot and ankle radiographic comparisons was performed. In this study, 34 sets of pre-surgical ("premortem") and post-surgical ("postmortem") foot and ankle radiographs were retrospectively evaluated simulating a postmortem identification. In each radiographic set, the films were separated by a surgical event to reproduce the effects of an alteration in the anatomy. The radiographs included both matches and mismatches. This study also presents a numerical representation of the reliability of a radiographic match following a surgical procedure. Results indicate that surgical intervention with subsequent healing does not preclude positive identification in foot and ankle radiographic comparisons.