Analysis of pulmonary fat embolism in blunt force fatalities.

OBJECTIVE: To investigate the incidence, severity, and origin of pulmonary fat embolism (PFE) in persons dying from blunt force trauma within 24 hours of injury. METHODS: The study population consisted of blunt force fatalities. Controls were subjects dying from natural causes or nonblunt force injury. Tissue was removed from lung lobes and prepared for histologic examination using osmium tetroxide to stain for fat. Lung sections were graded for PFE on a scale of 0 (no emboli) to 4 (five or more emboli in a majority of fields). RESULTS: The blunt force group consisted of 56 decedents. Mortality was 93% within 4 hours. Fractures were present in 54 (96%) of decedents, and soft tissue injury was universal. Thirty eight (68%) of decedents were positive for PFE vs. 3 of 20 (15%) in controls. Mean score for PFE was 2.94 +/- 1.15 and 1.01 +/- 0.94, respectively (p < 0.005). Bone marrow emboli were not observed in any of the sections. Severity of PFE was positively associated with survival time. Analysis of PFE against sex, age, height, weight, number of injuries, and number of fractures showed no significant correlations. CONCLUSIONS: A significant degree of PFE develops rapidly in a majority of persons dying of blunt force trauma. Although the source of fat for embolization has been suggested to be bone marrow, no evidence of myeloid tissue was found in any of the lung sections. Nor was there a correlation of PFE and number of fractures. Soft tissue injury is considered the primary cause of PFE.

Late recurrence of seminoma.

Patients with testicular cancer usually are cured if they survive disease-free for 2 years after therapy. We report a case of documented seminoma that recurred at both 21 years and 32 years after the patient's orchiectomy. We discuss late recurrences in germ cell cancer, possible mechanisms of recurrence, and the need for life-long surveillance.

Repeat visitors to a pediatric forensic medicine program.

Since the inception in 1990 of a Clinical Forensic Medicine Program at the Louisville Office of the Kentucky Medical Examiner Program, six children have undergone repeat evaluations for physical injuries. Herein, we examine the overall number of cases from January 1991 through December 1994, and the circumstances and outcomes of the six children undergoing reevaluation. Despite the implementation of an organized Forensic Medicine Program, some children in our area suffer repeated episodes of recognized abuse and death.

Airbag module cover injuries.

Serious and fatal injuries can be sustained when anatomic structures are in close proximity to an airbag module cover at the moment of airbag deployment. Three cases of injuries in vehicle operators associated with airbag module covers are reviewed and discussed. Injuries ranged from the traumatic avulsion of a thumb to the development of a subdural hematoma with associated cerebral edema and respiratory arrest. Motor vehicle operators should be aware that although airbags can significantly reduce the severity of injuries sustained in frontal collisions the module cover has the potential to inflict serious, even fatal injuries.

Infant deaths due to unintentional injury. An 11-year autopsy review.

OBJECTIVE: The number and causes of unintentional infant deaths were determined to identify common, preventable infant deaths. DESIGN: Retrospective autopsy review. SUBJECTS: Infants aged 1 day to 1 year undergoing complete autopsies. SETTING: Autopsies performed by the Louisville Office of the Kentucky Medical Examiner's Program from 1979 through 1989. METHOD: The manner of death was designated as an "accident" based on review of autopsy findings, scene investigation, and investigation by law enforcement officials. The cases were divided into groups based on the nature of the unintentional injury. RESULTS: Causes of death included asphyxia in mechanically unsafe sleeping environments, overlying, drowning, scald burns, plastic bag suffocation, house fires, motor vehicle collisions, aspiration of foreign bodies, hypothermia, blunt head trauma, and alcohol toxicity. The largest group of deaths in this series resulted from mechanically unsafe sleeping environments. CONCLUSIONS: The majority of deaths in this series could have been prevented by minor changes in the household environment. The causes of fatal unintentional injury to infants are different from those in older children. Pediatricians should be aware of hazards unique to this age group.

Body packing with a twist. Death of a salesman.

Reported cases of death due to oral ingestion of lidocaine are rare. We report the case of a known cocaine dealer who died after swallowing a small packet of white powder, thought to be cocaine, during a relatively routine arrest. The authors describe how the deceased differed from the usual "body packer" and alert the forensic community to be wary of what may first appear to be another "garden-variety" cocaine death.

Dirty diving. Sudden death of a SCUBA diver in a water treatment facility.

We report a case of a sudden death in a SCUBA diver working at a water treatment facility. The victim, an employee of the facility with a specialty in electronics, was a sport diver not qualified in commercial diving. While attempting to clean sludge from a blocked drain 25 ft under water, the diver was suddenly pinned against the drain valve when the sludge plug was broken up. We review the mechanics of the incident and the actual cause of death, asphyxia, as opposed to drowning. We believe this to be the first reported case of traumatic (pressure) asphyxia in a SCUBA diver.

Unnatural deaths in nursing home patients.

Nursing home residents comprise a large and rapidly growing segment of the national population. Despite this fact, the majority of deaths occurring in nursing homes are not investigated because of the significant medical illnesses suffered by most residents. Herein, we report a series of unnatural deaths in nursing home residents, including two homicides and seven accidental deaths. In four of the deaths, there was an attempted concealment of the cause and manner of death. Fearing criminal or civil proceedings, nursing home personnel may attempt to conceal homicidal or accidental deaths in nursing home residents. Because of the serious, chronic illnesses suffered by these patients, attending physicians are often willing to sign death certificates without personally investigating the circumstances surrounding the patient's demise. The authors contend that unnatural deaths of nursing home patients are significantly underreported. Attending physicians and death investigators should be urged to investigate more fully sudden deaths in nursing home patients.

Cerebral tissue pulmonary embolization due to head trauma: a case report with immunohistochemical confirmation.

Pulmonary embolization of cerebral tissue as the result of severe head trauma is an uncommon, if not rare, phenomenon, and few cases have been reported in the literature. The authors discuss the case of a 51-year-old male who died six days after suffering extensive head trauma in a motor vehicle collision. At autopsy, white-gray emboli were found in several subsegmental pulmonary arteries. The results of histologic examination with the hematoxylineosin stain gave the impression that the emboli were necrotic cerebral tissue; however, routine special stains for neural tissue produced inconclusive results. Immunohistochemical staining of the emboli with monoclonal mouse anti-human neurofilament protein (Dako Corp., Carpinteria, California) confirmed the cerebral nature of the emboli. To the authors' knowledge, this is the first reported case of pulmonary embolization of cerebral tissue confirmed by immunohistochemistry.

Fetal death due to nonlethal maternal carbon monoxide poisoning.

Fetal death due to acute carbon monoxide poisoning is rarely reported in the medical literature. Of the eight cases found in literature review, only one documented the fetal carboxyhemoglobin concentration. This paper reports a fetal death due to accidental nonlethal maternal carbon monoxide intoxication in which both maternal and fetal carboxyhemoglobin concentrations were obtained. The corrected carboxyhemoglobin concentration was 61% at the time of death in utero, while the maternal carboxyhemoglobin was measured at 7% after one hour of supplemental oxygen. The authors review the mechanisms of fetal death and emphasize the different carbon monoxide kinetics in the fetal circulation.

Death associated with abuse of a "designer drug".

A case of death is reported in a 26-year-old male previously thought to be healthy. At autopsy, the anterior descending branch of the left coronary artery was markedly atherosclerotic with a superimposed thrombus. Toxicologic analysis revealed 3,4 methylene dioxyamphetamine (MDA) in the blood at a concentration of 0.08 mg per deciliter. The authors draw attention to the reappearance of designer drugs in Kentucky and to the need for awareness of these deadly substance.

In the shadow of the Baron: sudden death due to Munchausen syndrome.

The authors describe a woman who died suddenly in an emergency department restroom after self-injection of corn starch in an attempt to gain admission to the hospital. At autopsy, multiple pulmonary vascular corn starch granulomata were identified, as well as pulmonary arteries filled with brewer's yeast. Retrospective evaluation of the patient's medical history showed multiple signs of Munchausen Syndrome. The authors suggest that the case illustrates the importance of scene investigation and review of the medical history by emergency department personnel and the forensic pathologist.

Nonfracture-associated fatal fat embolism in a case of child abuse.

Fatal fat embolism is usually thought of as a sequel to long-bone fracture, although cases secondary to soft tissue injury and atraumatic conditions have been infrequently reported. In this case of a two-year-old child-abuse victim who sustained multiple blunt traumatic injuries without skeletal fractures, pulmonary and systemic (brain and kidney) fat emboli were identified. At autopsy, all thoracic and abdominal viscera were intact; cranial contents exhibited only diffuse symmetrical petechial hemorrhages of the white matter. Because of the severe and widespread nature of soft tissue hemorrhage, and the absence of a grossly discernible cause of death, fat embolism was suspected. Using a combination of frozen section with oil red O staining and formalin-fixed osmium stained tissues, the immediate cause of death was determined to be diffuse fat embolism. Review of the literature reveals a pathophysiologic basis for fat embolism in the absence of fracture, both as a consequence of an acute increase in local pressure at the site of trauma and an alteration of the emulsification of blood lipids during shock. In light of these findings, we present this case to remind the forensic science community to consider fat embolism as the cause of death in cases of blunt-force injury without fracture.

Sudden death due to fibromuscular dysplasia of the sinoatrial nodal artery.

A case of sudden death is reported in a previously healthy 28-year-old female. No gross abnormalities of the heart or other organ systems were identified at autopsy. Routine microscopic sections of heart were unremarkable; however, sections of the cardiac conduction system revealed marked fibromuscular dysplasia of the sinoatrial node artery. The authors suggest that pathologists and clinicians index of suspicion be high when confronted with the enigma of sudden death in a patient with no apparent anatomic or toxicologic cause of death.

The forensic pathologist and the determination of driver versus passenger in motor vehicle collisions. The need to examine injury mechanisms, occupant kinematics, vehicle dynamics, and trace evidence.

Five cases of vehicular homicide are presented in which the determination of an occupant's role in a motor vehicle collision was an important medicolegal question. The identification of the occupant's role in a motor vehicle collision can be determined by the forensic pathologist. The investigation that coordinates an examination of injury mechanisms, occupant kinematics, vehicle dynamics, and trace evidence will facilitate such a determination. This determination protects the innocent passenger, when faced with criminal or civil charges, from being falsely prosecuted as the driver. The examination of the above-mentioned components in a multi-occupant collision takes on particular forensic importance when a surviving driver claims to be a passenger: the victim rather than the assailant.

MR imaging in acute cervical spine trauma.

Fourteen patients with cervical spine injuries, 12 with resultant neurological deficits, were scanned with magnetic resonance (MR) imaging within 7 days following injury. Useful information concerning the status of the spinal canal and disks was obtained in most cases. In addition, MR was able to suggest the nature of the pathological changes within the spinal cord, as well as hemorrhage and edema in the extraspinal soft tissues. These observations indicate that following acute cervical spine trauma, MR is a valuable technique in assessing injury to the spinal cord, surrounding soft tissues, vertebra, and disks.

Fatal hemorrhage from minor trauma following massive salicylate ingestion.

The anticoagulant property of aspirin has long been appreciated. Recently, the physiologic mechanism has been identified and documented extensively. Despite the long-lasting inhibition of platelet function and clinically significant postoperative hemorrhage following aspirin use, few serious complications or fatalities are reported in the current literature. We report a case in which fatal hemorrhage resulted from minor trauma following massive salicylate ingestion. A review of the cyclo-oxygenase mechanism is presented.