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Difference between revisions of "Autopsy"
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[[Image:Rembrandt Harmensz. van Rijn 007.jpg|thumb|300px|An autopsy.]] | |||
'''Autopsy''' was once a mainstay of [[pathology]]. It is now in decline and uncommonly done. Fetal autopsy is dealt with in a separate article called ''[[fetal autopsy]]''. | '''Autopsy''' was once a mainstay of [[pathology]]. It is now in decline and uncommonly done. Fetal autopsy is dealt with in a separate article called ''[[fetal autopsy]]''. | ||
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===Who has authority?=== | ===Who has authority?=== | ||
*Consent should be given by the '' | *Consent should be given by the ''executor of the estate''.<ref name=olduhnconsent>URL: [http://www.docstoc.com/docs/51609856/CONSENT-FOR-AUTOPSY http://www.docstoc.com/docs/51609856/CONSENT-FOR-AUTOPSY]. Accessed on: 27 September 2010.</ref> | ||
====Hierarchy==== | ====Hierarchy==== | ||
If the '' | If the ''executor of the estate'' is not specified the hierarchy is as follows:<ref name=olduhnconsent/> | ||
#Spouse - by marriage (same sex ''or'' opposite sex) ''or'' by common-law ''or'' by together the parents of a child ''or'' by cohabitation agreement (in law). | #Spouse - by marriage (same sex ''or'' opposite sex) ''or'' by common-law ''or'' by together the parents of a child ''or'' by cohabitation agreement (in law). | ||
#If no spouse, any children 16+ years old, | #If no spouse, any children 16+ years old, | ||
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Notes: | Notes: | ||
*The power a person that is designated as ''power of attorney for health care decisions'' does not have the authority to consent for an autopsy; their power ends with death (unless they are also the '' | *Exact hierarchy may vary by jurisdiction. | ||
*The power a person that is designated as ''power of attorney for health care decisions'' does not have the authority to consent for an autopsy; their power ends with death (unless they are also the ''executor of the estate''). | |||
*In clinical medicine, it is allowable to skip down the hierarchy if ''the'' "consent giver" is not reachable, e.g. if a child of the patient is present they can consent in emergency circumstances, if the spouse is ''not'' reachable. In the context of (non-corner's) autopsies, '''the hierarchy has to be followed strictly''', as there is no such thing as an "emergency autopsy"; it is ''not'' acceptable to ask the child of the decedent 'cause they aren't distraught like the spouse of the decedent. | *In clinical medicine, it is allowable to skip down the hierarchy if ''the'' "consent giver" is not reachable, e.g. if a child of the patient is present they can consent in emergency circumstances, if the spouse is ''not'' reachable. In the context of (non-corner's) autopsies, '''the hierarchy has to be followed strictly''', as there is no such thing as an "emergency autopsy"; it is ''not'' acceptable to ask the child of the decedent 'cause they aren't distraught like the spouse of the decedent. | ||
*In non-corner's cases, a physician ''cannot'' consent an autopsy. | *In non-corner's cases/non-medical examiner's cases, a physician ''cannot'' give consent for an autopsy. | ||
===Religious objections=== | ===Religious objections=== | ||
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Body should be examined for ''defensive-type wounds'': | Body should be examined for ''defensive-type wounds'': | ||
*Between the | *Between the fingers - especially thumb and pointing finger. | ||
*Dorsal aspect of the hand. | *Dorsal aspect of the hand. | ||
*Forearm. | *Forearm. | ||
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===Before the first incision=== | ===Before the first incision=== | ||
If there is suspicion of pneumothorax - one the the three following can be done:<ref name=Ref_HospAuto120-1>{{Ref HospAuto|120-1}}</ref> | If there is suspicion of [[pneumothorax]] - one the the three following can be done:<ref name=Ref_HospAuto120-1>{{Ref HospAuto|120-1}}</ref> | ||
#Create a "pleural window" (between ribs by removing soft tissue... without entering the pleural cavity). | #Create a "pleural window" (between ribs by removing soft tissue... without entering the pleural cavity). | ||
#Open chest underwater and watch for air bubbles. | #Open chest underwater and watch for air bubbles. | ||
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*Y-shaped incision (standard): | *Y-shaped incision (standard): | ||
**Superior "points" of the Y ~ at the deltoid muscle. | **Superior "points" of the Y ~ at the deltoid muscle. | ||
**" | **"Confluence of lines" in the Y ~ inferior to the suprasternal notch. | ||
*Neck dissection incisions: | *Neck dissection incisions: | ||
**Deltoid to mastoid process. | **Deltoid to mastoid process. | ||
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Notes: | Notes: | ||
*The | *The sternum may have cleft or foramen - as an anatomical variant.<ref name=pmid10803333>{{cite journal |author=Fokin AA |title=Cleft sternum and sternal foramen |journal=Chest Surg. Clin. N. Am. |volume=10 |issue=2 |pages=261–76 |year=2000 |month=May |pmid=10803333 |doi= |url=}}</ref> | ||
*If the decedent has a history of a [[CABG]] removal of the chest plate should be done with care to preserve the grafts. | *If the decedent has a history of a [[CABG]] removal of the chest plate should be done with care to preserve the grafts. | ||
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==Neck organ pluck== | ==Neck organ pluck== | ||
===Non-suspicious cases=== | |||
#Trim tissue posterior to horns of the thyroid. | #Trim tissue posterior to horns of the thyroid. | ||
#Cut between thyroid horns & hyoid. | #Cut between thyroid horns & hyoid. | ||
#Cut off base of tongue. | #Cut off base of tongue. | ||
===Suspicious cases=== | |||
*In Canada, it is convention to do ''layered neck dissection''. | |||
**The strap muscles of the neck are lifted of in layers to look for injuries (mostly contusions). | |||
**Strap muscle hematomas may arise in a number of contexts, e.g. they are reported in drowning.<ref>{{Cite journal | last1 = Püschel | first1 = K. | last2 = Schulz | first2 = F. | last3 = Darrmann | first3 = I. | last4 = Tsokos | first4 = M. | title = Macromorphology and histology of intramuscular hemorrhages in cases of drowning. | journal = Int J Legal Med | volume = 112 | issue = 2 | pages = 101-6 | month = | year = 1999 | doi = | PMID = 10048667 }}</ref> | |||
====Hyoid bone==== | ====Hyoid bone==== | ||
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#*Check renal veins. | #*Check renal veins. | ||
#Separate IVC. | #Separate IVC. | ||
#Transect esophagus (~2 cm) distal to inferior margin of the cricoid cartilage. | #Transect [[esophagus]] (~2 cm) distal to inferior margin of the cricoid cartilage. | ||
#Take down esophagus using blunt dissection (to separate from thorax). | #Take down esophagus using blunt dissection (to separate from thorax). | ||
#Separate thorax and abdomen - by dissecting through the pericardium. | #Separate thorax and abdomen - by dissecting through the [[pericardium]]. | ||
===Common finding(s)=== | ===Common finding(s)=== | ||
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===Respiratory system=== | ===Respiratory system=== | ||
#Open trachea + bronchus (see ''Note''). | #Open [[trachea]] + bronchus (see ''Note''). | ||
#Examine proximal airway. | #Examine proximal airway. | ||
#Examine proximal pulmonary arteries. | #Examine proximal pulmonary arteries. | ||
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===Esophagus=== | ===Esophagus=== | ||
*Should be everted, if portal hypertension is suspected, as varices are thus more readily demonstrated.<ref name=Ref_HospAuto140>{{Ref HospAuto|140}}</ref> | {{Main|Esophagus}} | ||
*Should be everted, if [[portal hypertension]] is suspected, as [[esophageal varices]] are thus more readily demonstrated.<ref name=Ref_HospAuto140>{{Ref HospAuto|140}}</ref> | |||
*#Stomach opened (''without opening GE junction''). | *#Stomach opened (''without opening GE junction''). | ||
*#String tied to proximal esophagus. | *#String tied to proximal esophagus. | ||
*#Forceps inserted from stomach to grasp tied end and invert esophagus. | *#Forceps inserted from stomach to grasp tied end and invert [[esophagus]]. | ||
===Omentum=== | ===Omentum=== | ||
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**Capsule of the spleen is white - resembles sugar-coating. | **Capsule of the spleen is white - resembles sugar-coating. | ||
**Importance: ''none'' - benign. | **Importance: ''none'' - benign. | ||
*Splenomegaly secondary to portal hypertension. | *[[Splenomegaly]] secondary to [[portal hypertension]]. | ||
===Kidney=== | ===Kidney=== | ||
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**''Flea-bitten appearance'' - seen in [[hypertension]].<ref name=pmid9356598>{{Cite journal | last1 = Ono | first1 = H. | last2 = Ono | first2 = Y. | title = Nephrosclerosis and hypertension. | journal = Med Clin North Am | volume = 81 | issue = 6 | pages = 1273-88 | month = Nov | year = 1997 | doi = | PMID = 9356598 }}</ref> | **''Flea-bitten appearance'' - seen in [[hypertension]].<ref name=pmid9356598>{{Cite journal | last1 = Ono | first1 = H. | last2 = Ono | first2 = Y. | title = Nephrosclerosis and hypertension. | journal = Med Clin North Am | volume = 81 | issue = 6 | pages = 1273-88 | month = Nov | year = 1997 | doi = | PMID = 9356598 }}</ref> | ||
*[[Acute tubular necrosis]] (ATN). | *[[Acute tubular necrosis]] (ATN). | ||
**ATN is difficult | **ATN is difficult to prove on autopsy material. | ||
** | **On microscopy, look for:<ref name=pmid19207286>{{Cite journal | last1 = Kocovski | first1 = L. | last2 = Duflou | first2 = J. | title = Can renal acute tubular necrosis be differentiated from autolysis at autopsy? | journal = J Forensic Sci | volume = 54 | issue = 2 | pages = 439-42 | month = Mar | year = 2009 | doi = 10.1111/j.1556-4029.2008.00956.x | PMID = 19207286 }}</ref> | ||
*** | ***Tubular epithelial whorls. | ||
*** | ***Tubulorrhexis. | ||
***Interstitial edema. | |||
===Liver=== | ===Liver=== | ||
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=Histology= | =Histology= | ||
===General=== | ===General=== | ||
It's the at the pathologists discretion. In ''decomp'' cases it is reasonable to submit nothing. | It's the at the pathologists discretion. In ''[[decomp]]'' cases it is reasonable to submit nothing. | ||
===Forensic context=== | ===Forensic context=== | ||