A fatal complication of a vena caval filter associated with pulmonary thromboembolism.

Vena caval filters are increasingly used for the prevention of pulmonary thromboembolism in patients with deep vein thrombosis ever since the introduction of the stainless steel Greenfield filter in the 1970s. Although complications associated with their use are rare, they can be fatal, and therefore it is important for forensic pathologists to be aware of their occurrence. Because of the ramifications of a medical device failure, a thorough documentation of the autopsy findings is essential. We describe an unusual case of a 75-year-old woman who developed a fatal pulmonary thromboembolism with concurrent migration of a lesser known type of vena caval filter to the right ventricle occurring 19 days after filter placement. A review of the types of vena caval filters in current use, and their complications, are discussed.

Fentanyl epidemic in Chicago, Illinois and surrounding Cook County.

INTRODUCTION: Epidemics related to illicit fentanyl abuse have been reported and the potential exists for a national epidemic associated with high mortality. This report describes emergency department visits for opioid toxicity and a recent outbreak of illicit fentanyl fatalities in Chicago, Illinois and surrounding Cook County. METHODS: Retrospective chart review of opioid-related overdoses seen in our emergency department and a retrospective review of data from the Cook County Medical Examiner's Office Fentanyl Fatality Database from April 2005 through December 2006. RESULTS: Our emergency department treated 43 patients with a total of 55 emergency department visits during this time. Paramedic transport was utilized for 83.6% of the emergency department visits and naloxone was administered during 80.4% of transports. Naloxone was administered during 47.3% of emergency department visits with total doses ranging from 0.4 mg to 12 mg. Eighty percent of cases were treated and discharged from the emergency department. During this same time frame, the Medical Examiner's office identified 342 fentanyl-related fatalities. In 2006, illicit fentanyl fatalities represented 6.9% of all Medical Examiner cases for that year. Approximately 80% of deaths occurred in Chicago. A peak in fentanyl-related deaths occurred in the spring of 2006 and again in the fall of 2006 while the number of emergency department visits peaked during May of 2006. CONCLUSION: Chicago and surrounding Cook County experienced an outbreak of 342 fentanyl-related deaths between April 2005 and December 2006. The experience demonstrated a clear need for an interdisciplinary approach to identifying, communicating, and managing an outbreak.

An epidemic of illicit fentanyl deaths in Cook County, Illinois: September 2005 through April 2007.

Between September 2005 and April 2007, 350 fentanyl intoxication deaths were investigated and certified by the Cook County Medical Examiners Office. Investigations revealed that the majority of these fatalities were by intravenous injection of a white powder followed by a rapid collapse. The fentanyl was clandestinely produced in a lab in Toluca, Mexico and sold by the Mickey Cobra street gang. The term "Drop Dead" was coined for this "tainted heroin." Postmortem samples were screened by ELISA and confirmed by standard GC-MS methods. Fentanyl fatalities peaked at 47 per month in May and June 2006. Fifty-two percent were single fentanyl intoxications, with the remainder accompanied by either cocaine, morphine from heroin, or alcohol. This epidemic stressed the limited resources of the toxicology laboratory and autopsy service of the Medical Examiners Office. The clandestine lab was terminated, distributing gang members and leaders arrested, and the epidemic ceased in April 2007.

An atypical gunshot wound from a home-made zip gun--the value of a thorough scene investigation.

Zip guns and the atypical gunshot wounds they produce are rare in forensic pathology. Because of this, investigators and forensic pathologists may be unfamiliar with their construction, appearance, and the wounds associated with them. A 43-year-old mechanic, with a history of depression was found dead in a washroom stall at work with an atypical gunshot wound of the head. Upon initial investigation, no weapon was found at the scene. Due to the nature of the scene, and the unusual characteristics of the wound, the manner of death was at first thought to be a homicide. Subsequently, a simple zip gun, which had been overlooked during the scene investigation, was discovered by a co-worker while he was cleaning the stall. Examination of the wound revealed evidence of contact range firing. A markedly deformed bullet was recovered from the head, consistent with the use of the home-made gun. These findings, along with further police investigation and review of the past medical history, indicated that the manner of death was a suicide.

Practical pathology of gunshot wounds.

CONTEXT: Gunshot wounds are the most common cause of homicidal death in the United States. Analysis and interpretation of fatal gunshot wounds is an important and common practice among forensic pathologists. Additionally, for pathology residents, it is an integral aspect of their training during their rotations at medical examiner or coroner offices. OBJECTIVE: The correct interpretation of gunshot wounds by forensic pathologists not only provides valuable information that can assist law enforcement in their investigation but also is essential for the final determination of manner of death. Discussion of the practical, basic, and essential skills required to interpret gunshot wounds include distinguishing a classic entrance wound from an exit wound; recognizing atypical entrance and exit wounds; utilizing the features of soot and stippling patterns to differentiate among contact, close, and distant range gunshot wounds; understanding of the trauma produced by gunshot wounds; and understanding the importance of recovering and documenting/handling any projectiles recovered at autopsy. DATA SOURCES: This article reviews numerous standard forensic pathology textbooks and the pertinent literature to formulate practical guidelines to assist the pathologist in the performance of forensic autopsies and the investigation of gunshot wound fatalities. CONCLUSIONS: Pathologists who perform investigations and autopsies to determine the cause and manner of death in gunshot wound cases must be aware of the implications, requirements, and pitfalls in interpretation of the injuries so that the examination fulfills its expectations to the community and the justice system.

Fatal accidental hanging from a lanyard key chain in a 10-year-old boy.

Lanyard chains are commonly worn around the neck to hold keys and identification badges. A ten-year-old Black male child was home alone jumping and swinging of the raised crossbars on his mother's four-poster bed. He commonly did this. He also wore a lanyard around his neck with his house key, which he used to let himself in after school. His mother found him hanging on the corner of the bedpost by the lanyard when she returned from work. The death scene showed that he was jumping on the bed and the lanyard hooked over the top of the corner bedpost, causing first and second cervical vertebrae dislocation of an abrupt "drop-type" hanging with neck abrasion marks. Lanyards, or any loose rope material around the neck, are inherently dangerous due to their strength and ability to catch fixed or moving objects. Safety modifications to the lanyards are easily made with "breakaway" Velcro-type or plastic clip fasteners. This is the first reported case of an accidental hanging after review of the medical literature and files of the U.S. Consumer Products Safety Commission.