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Forensic pathology (view source)

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'''Forensic pathology''' is figuring-out why, when, where and how people died, if the manner of death is ''not'' obviously natural.
'''Forensic pathology''' is figuring-out why, when, where and how people died, if the manner of death is ''not'' obviously natural.


=Manner of death=
=Death categorization=
Deaths are categorized foremost by the '''manner of death'''. The manner is the single most important legal categorization for a death.
The '''cause of death''' is important for understanding what happened.  The '''mechanism of death''' is the pathophysiologic reason for death and can be inferred from the cause.
 
Examples:
{| class="wikitable sortable"
!Cause of death
!Manner of death
!Mechanism of death
!Scenario
|-
| [[Electrocution]]
| accident
| [[cardiac arrhythmia]]
| man struck by lightning
|-
| Hyperthermia
| accident
| arrhythmias, seizures<ref name=fmuk>URL: [http://www.forensicmed.co.uk/pathology/mechanisms-of-death/ http://www.forensicmed.co.uk/pathology/mechanisms-of-death/]. Accessed on: 19 April 2012.</ref>
| man lost on hiking trip in desert
|-
| [[Epidural hemorrhage]] due to [[blunt force trauma]] to the head
| homicide
| brain stem compression or cerebral vascular spasm leading to autonomic dysregulation
| man hit with a hammer in the head
|-
| [[Carbon monoxide toxicity]]
| suicide
| cerebral hypoxia (CO binds to hemoglobin impairing oxygen transport)
| woman found in car with suicide note, long history of depression, previous suicide attempts
|-
| [[Atherosclerotic heart disease]]
| natural
| cardiac arrhythmia due to ischemia
| man found dead in bed, apartment locked, 95% stenosis of LMCA at autopsy, no other significant autopsy findings
|- <!--
| [[Peritonitis]] due to duodenal perforation as a consequence of [[peptic ulcer disease]]
| natural
| cerebral hypoxia secondary to hypotension
| man found in locked apartment, complained of abdominal pain before dead
|-
| Coronary artery stent thrombosis complicating the treatment of a [[myocardial infarction]] due to atherosclerotic heart disease
| natural
| cardiac arrhythmia due to ischemia
| woman found dead following hospital stay for a myocardial infarction, post-angioplasty and coronary stenting -->
|}
 
==Manner of death==
The manner of death is a legislatively defined classification. It varies slightly between jurisdictions.
<!--
<!--
MANNER OF DEATH
MANNER OF DEATH
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*#Undetermined.
*#Undetermined.


=Cause of death=
==Mechanism of death==
This is occasionally of interest. It is usually based on physiology.
 
The mechanism is often asked for [[asphyxial death]]s. The short answer it is: brain stem hypoxia due to ischemia caused by venous obstruction in the neck.<ref>URL: [http://www.forensicmed.co.uk/pathology/mechanisms-of-death/ http://www.forensicmed.co.uk/pathology/mechanisms-of-death/]. Accessed on: 1 May 2012.</ref><ref>URL: [http://www.forensicmed.co.uk/pathology/pressure-to-the-neck/ http://www.forensicmed.co.uk/pathology/pressure-to-the-neck/]. Accessed on: 1 May 2012.</ref>
 
==Cause of death==
*Abbreviated ''COD''.
===General===
===General===
*The cause of death should be what started the sequence of events that lead to death.
*The cause of death should be what started the sequence of events that lead to death.


===="Word form"====
====Word form for cause of death====
Example:
Examples:
*''[[C. difficile colitis]] complicating antibiotic treatment for a dental abscess''.<ref>MSP. 8 September 2010.</ref>
*''[[C. difficile colitis]] complicating antibiotic treatment for a dental abscess''.<ref>MSP. 8 September 2010.</ref>
*''Complications of laparoscopic cholecystectomy for ascending cholangitis with [[mesothelioma]] and atherosclerotic heart disease''.<ref>TR. 3 September 2010.</ref>
*''Complications of laparoscopic cholecystectomy for ascending cholangitis with [[mesothelioma]] and atherosclerotic heart disease''.<ref>TR. 3 September 2010.</ref>
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*''A'' complicating ''B'' for the treatment of ''C'' with ''D'' and ''E''.
*''A'' complicating ''B'' for the treatment of ''C'' with ''D'' and ''E''.


====WHO form====
====World Health Organization form for cause of death====
General form:<ref name=pmid15914304>{{cite journal |author=Pollanen MS |title=Deciding the cause of death after autopsy--revisited |journal=J Clin Forensic Med |volume=12 |issue=3 |pages=113–21 |year=2005 |month=June |pmid=15914304 |doi=10.1016/j.jcfm.2005.02.004 |url=}}</ref>
General form:<ref name=pmid15914304>{{cite journal |author=Pollanen MS |title=Deciding the cause of death after autopsy--revisited |journal=J Clin Forensic Med |volume=12 |issue=3 |pages=113–21 |year=2005 |month=June |pmid=15914304 |doi=10.1016/j.jcfm.2005.02.004 |url=}}</ref>
*1a = immediate cause of death.
*1a = ''immediate cause of death''.
*1b = what lead to the immediate cause of death.
*1b = what lead to the ''immediate cause of death''.
*1c... 1[x] -- where 'x' is the last letter used; 1x = What started the sequence of events.
*1c... 1[x] -- where 'x' is the last letter used; 1x = What started the sequence of events. This is known as the ''underlying cause of death''.
*2 = contributing factors.
*2 = contributing factors.


Example 1:
Example 1:
*1a. Ketoacidosis.
*1a. [[Ketoacidosis]].
*1b. Diabetes mellitus.
*1b. [[Diabetes mellitus]].
*1c. Alcoholism.
*2. [[Alcoholism]] and acute [[bronchopneumonia]].
*2.  Acute bronchopneumonia.


Example 2:
Example 2:
*1a. Hemoperitoneum.
*1a. Hemoperitoneum.
*1b. Splenic laceration.
*1b. [[Splenic laceration]].
*1c. Blunt force trauma.
*1c. Blunt force trauma.
*2. Liver [[cirrhosis]].
*2. Liver [[cirrhosis]].


===Natural deaths===
===Natural deaths===
{{Main|Natural death}}
*The cause should be a medical diagnosis, '''not''' the mechanism (e.g. ''cardiac arrest'', ''cachexia'', ''kidney failure'').
*The cause should be a medical diagnosis, '''not''' the mechanism (e.g. ''cardiac arrest'', ''cachexia'', ''kidney failure'').
*The mechanism is irrelevant.
*The [[mechanism of death|mechanism]] is irrelevant.


Notes:
Notes:
*Unnatural causes trump natural ones.  If a guy with (nothing more than) a 70% proximal LAD stenosis and an old [[myocardial infarct]] is found in the water, they are usually called drowning.
*Unnatural causes trump natural ones.  If a guy with (nothing more than) a 70% proximal LAD stenosis and an old [[myocardial infarct]] is found in the water, they are usually called [[drowning]].
*Cancer is rarely the immediate cause of death - it is usually something else.<ref>PS. 2009.</ref>
*[[Cancer]] is rarely the immediate cause of death - it is usually something else.<ref>Shannon, P. 2009.</ref>
*Things (mechanisms) that shouldn't be used: [http://www.pallimed.org/2008/03/unacceptable-causes-of-death-other-web.html http://www.pallimed.org/2008/03/unacceptable-causes-of-death-other-web.html]
*Things (mechanisms) that shouldn't be used: [http://www.pallimed.org/2008/03/unacceptable-causes-of-death-other-web.html http://www.pallimed.org/2008/03/unacceptable-causes-of-death-other-web.html]


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====General====
====General====
*In Ontario, the ''manner'' is determined by the coroner.
*In Ontario, the ''manner'' is determined by the coroner.
*Coroners, in Ontario, are MDs -- usually family docs.
*Coroners, in Ontario, are MDs -- usually [[family docs]].
*The cause (e.g. "gunshot wound to the head") is determined by the pathologist.
*The cause (e.g. "gunshot wound to the head") is determined by the pathologist.


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*All ''A cases'' are done at regional centers by certified forensic pathologists.
*All ''A cases'' are done at regional centers by certified forensic pathologists.


=Forensic triangle=
=Forensic golden triangle=
*History.
*Scene.
*[[Autopsy]].
 
=Forensic diagnostic triangle=
Most general differential diagnosis:
Most general differential diagnosis:
*Natural:
*Natural:
**Haemorrhage (e.g. cerebral bleed, gastrointestinal bleed, aortic aneurysm).
**Haemorrhage (e.g. cerebral bleed, gastrointestinal bleed, aortic aneurysm).
**Infection (e.g. pneumonia).
**Infection (e.g. [[pneumonia]]).
**Coronary [[atherosclerosis]] (cardiac arrhythmias - more common in the forensic context than myocardial infarction (MI); individuals with MIs don't usu. drop dead-- they go to the ER).
**[[Coronary artery atherosclerosis]] ([[cardiac arrhythmia]]s - more common in the forensic context than [[myocardial infarction]] (MI); individuals with MIs don't usu. drop dead-- they go to the ER).
***Post myocardial infarction (free wall rupture).
***Post [[myocardial infarction]] (free wall rupture).
***Ruptured (atherosclerotic) plaque.
***Ruptured (atherosclerotic) plaque.
*Toxic (memory device: ''PAIRO''):
*Toxic (memory device: ''PAIRO''):
**Poisons.
**Poisons.
**Alcohol (EtOH).  
**[[Alcohol]] (EtOH).  
**Illicit (e.g. cocaine, heroin, LSD).  
**Illicit (e.g. [[cocaine]], heroin, LSD).  
**Rx.  
**Rx.  
**Over-the-counter (OTC) (e.g. acetaminophen, warfarin).
**Over-the-counter (OTC) (e.g. acetaminophen, warfarin).
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**[[asphyxial deaths|Asphyxial]].  
**[[asphyxial deaths|Asphyxial]].  
**[[Gunshot wounds]] (GSWs).  
**[[Gunshot wounds]] (GSWs).  
**Environmental (e.g. hypothermia, hyperthermia, drowning, lack of oxygen, electrocution).
**Environmental (e.g. hypothermia, hyperthermia, [[drowning]], lack of oxygen, [[electrocution]]).
**Blunt force trauma.  
**[[Blunt force trauma]].  
**Sharp force trauma.  
**[[Sharp force trauma]].  


Difficulties arise when more than one point of the triangle is in play, i.e. the forensic pathologist has to earn their pay when an old man with a heart condition is known to be into erotic asphyxia, and dies after doing some drugs and whilst indulging in erotic asyphxiation with a friend...
Difficulties arise when more than one point of the triangle is in play, i.e. the forensic pathologist has to earn their pay when an old man with a heart condition is known to be into erotic asphyxia, and dies after doing some drugs and whilst indulging in erotic asyphxiation with a friend...
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*Liver mortis becomes fixed some time after death.   
*Liver mortis becomes fixed some time after death.   
**Liver mortis does NOT tell one the position the decedent was in at the time of death-- only the position the decedent was at the time liver mortis became fixed.  '''If''' the decedent wasn't moved liver mortis can help determine the position the person was in when they died.
**Liver mortis does NOT tell one the position the decedent was in at the time of death-- only the position the decedent was at the time liver mortis became fixed.  '''If''' the decedent wasn't moved liver mortis can help determine the position the person was in when they died.
Averages:
*Start: 30 minutes to 2 hours
*Fixed: 8-12 hours.
DDx:
*[[Blunt force trauma]] - especially to the inexperienced eye.
*Post-mortem hypostatic bruising.
===Tache noire===
Literally ''black spot''.
Features:<ref name=emed1680032>URL: [http://emedicine.medscape.com/article/1680032-overview http://emedicine.medscape.com/article/1680032-overview]. Accessed on: 6 March 2012.</ref>
*Brown/black horizontal line of the eye due to drying.
**Arises if the eye remains open after death.
**May mimic a traumatic injury.
Images:
*[http://img.medscape.com/pi/emed/ckb/pathology/1603817-1607640-1680032-1714463.jpg Tache noire (medscape.com)].<ref name=emed1680032/>
*[http://www.demussen.net/carbon-monoxide/images/1856_23_12-vitreous-potassium.jpg Tache noire (demussen.net)].<ref>URL: [http://www.demussen.net/carbon-monoxide/chemical-changes-in-body-fluids.html http://www.demussen.net/carbon-monoxide/chemical-changes-in-body-fluids.html]. Accessed on: 6 March 2012.</ref>


===Post-mortem decomposition/preservation===
===Post-mortem decomposition/preservation===
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#*Green colour due to break down of hemoglobin (biliverdin).<ref>{{cite journal |author=NOIR BA, GARAY ER, ROYER M |title=SEPARATION AND PROPERTIES OF CONJUGATED BILIVERDIN |journal=Biochim. Biophys. Acta |volume=100 |issue= |pages=403–10 |year=1965 |month=May |pmid=14347937 |doi= |url=linkinghub.elsevier.com/retrieve/pii/0304416565900097}}</ref>
#*Green colour due to break down of hemoglobin (biliverdin).<ref>{{cite journal |author=NOIR BA, GARAY ER, ROYER M |title=SEPARATION AND PROPERTIES OF CONJUGATED BILIVERDIN |journal=Biochim. Biophys. Acta |volume=100 |issue= |pages=403–10 |year=1965 |month=May |pmid=14347937 |doi= |url=linkinghub.elsevier.com/retrieve/pii/0304416565900097}}</ref>
#Adipocere - transformation into wax (due to anaerobic bacterial hydrolysis of fat).
#Adipocere - transformation into wax (due to anaerobic bacterial hydrolysis of fat).
#*Useless for toxicology and DNA.


*A mix of the above often occur, i.e. part of the corpse is mummified... part of it decomposed through putrefaction.
*A mix of the above often occur, i.e. part of the corpse is mummified... part of it decomposed through putrefaction.
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=Wounds=
=Wounds=
===Classification (gross pathology)===
==General==
*''Wound'' - definition: defect in skin or mucous membrane<ref>URL: [http://dictionary.reference.com/browse/wound http://dictionary.reference.com/browse/wound]. Accessed on: 20 April 2012.</ref> - usually due to trauma.
 
Special types of wounds:
*[[Gunshot wounds]].
*Incised wounds - see [[sharp force trauma]].
 
===Gross pathologic classification of injuries===
Mnemonic ''CALI'':
Mnemonic ''CALI'':
*'''C'''ontusion - "bruise", haematoma.
*'''C'''ontusion - "bruise", [[hematoma]].
**Age (usual colour change sequence): red, blue, green, yellow, brown.<ref name=Ref_HospAuto108>{{Ref HospAuto|108}}</ref>
**Age (usual colour change sequence): red, blue, green, yellow, brown.<ref name=Ref_HospAuto108>{{Ref HospAuto|108}}</ref>
**Etiology: bleeding from arterioles or venules (not capillaries).<ref name=Ref_HospAuto105>{{Ref HospAuto|105}}</ref>
**Etiology: bleeding from arterioles or venules (not capillaries).<ref name=Ref_HospAuto105>{{Ref HospAuto|105}}</ref>
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***Skin tags suggest directionality; they are found at the distal point / point of last contact.<ref name=Ref_HospAuto105>{{Ref HospAuto|105}}</ref>
***Skin tags suggest directionality; they are found at the distal point / point of last contact.<ref name=Ref_HospAuto105>{{Ref HospAuto|105}}</ref>
*'''L'''aceration - "tear", indicates blunt force trauma; contact point may be distant from where skin splits.
*'''L'''aceration - "tear", indicates blunt force trauma; contact point may be distant from where skin splits.
*'''I'''ncised - "cut", e.g. caused by a knife.<ref name=Ref_HoFP154>{{Ref_HoFP|154}}</ref>
*'''I'''ncised - "cut", e.g. caused by a knife,<ref name=Ref_HoFP154>{{Ref_HoFP|154}}</ref> subdivided as follows:
*#"Cut" or "slash" = length > depth.
*#"Cut" or "slash" = length > depth.
*#"Stab" = depth > length.
*#"Stab" = depth > length.
*#"Chop" = typically have a contusion at the margin of the wound, classically caused by an axe. May be caused by a propeller.<ref name=pmid19733336>{{Cite journal  | last1 = Ihama | first1 = Y. | last2 = Ninomiya | first2 = K. | last3 = Noguchi | first3 = M. | last4 = Fuke | first4 = C. | last5 = Miyazaki | first5 = T. | title = Fatal propeller injuries: three autopsy case reports. | journal = J Forensic Leg Med | volume = 16 | issue = 7 | pages = 420-3 | month = Oct | year = 2009 | doi = 10.1016/j.jflm.2009.04.006 | PMID = 19733336 }}</ref>


====Images====
<gallery>
Image:Hand_Abrasion_-_32_minutes_after_injury.JPG | Abrasion. (WC)
Image:Black_eye_2.jpg | Contusion ("black eye"). (WC)
</gallery>
====DDx====
====DDx====
How to decide what you're looking at:
How to decide what you're looking at:
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**Lacerations are classically on the skull and face.  They are rarely on the abdomen.
**Lacerations are classically on the skull and face.  They are rarely on the abdomen.


===Dating===
===Wound dating===
*Colour is somewhat useful for bruises.
*Colour is somewhat useful for contusions (bruises).
*Post-mortem injuries tend to be orange-yellow.<ref name=pmid19237864>{{Cite journal  | last1 = Campobasso | first1 = CP. | last2 = Marchetti | first2 = D. | last3 = Introna | first3 = F. | last4 = Colonna | first4 = MF. | title = Postmortem artifacts made by ants and the effect of ant activity on decompositional rates. | journal = Am J Forensic Med Pathol | volume = 30 | issue = 1 | pages = 84-7 | month = Mar | year = 2009 | doi = 10.1097/PAF.0b013e318187371f | PMID = 19237864 }}</ref>
*Post-mortem injuries tend to be orange-yellow.<ref name=pmid19237864>{{Cite journal  | last1 = Campobasso | first1 = CP. | last2 = Marchetti | first2 = D. | last3 = Introna | first3 = F. | last4 = Colonna | first4 = MF. | title = Postmortem artifacts made by ants and the effect of ant activity on decompositional rates. | journal = Am J Forensic Med Pathol | volume = 30 | issue = 1 | pages = 84-7 | month = Mar | year = 2009 | doi = 10.1097/PAF.0b013e318187371f | PMID = 19237864 }}</ref>
*Wounds age is difficult to determine as [[wound healing]] is affected by a large number of variables.
*Old wounds (scars), generally, cannot be dated - one can only say they are ''old''.


===Microscopic===
===Microscopic===
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**PMNs replaced monocytes in 24-48 hours.
**PMNs replaced monocytes in 24-48 hours.


=Fractures=
===Stains===
===Artefactual===
*[[Iron stain]] for siderophages (hemosiderin-laden macrophages) -- presence suggests 2-3 days or older.<ref name=pmid7529545>{{Cite journal  | last1 = Betz | first1 = P. | title = Histological and enzyme histochemical parameters for the age estimation of human skin wounds. | journal = Int J Legal Med | volume = 107 | issue = 2 | pages = 60-8 | month =  | year = 1994 | doi =  | PMID = 7529545 }}</ref>
 
=Bone fractures=
*[[AKA]] ''fractures''.
*[[AKA]] ''fracture of bone''.
 
==Artefactual fractures==
*"Undertaker's fracture" - cervical fracture due to rough handling.<ref>URL: [http://www.the-crankshaft.info/2010/07/postmortem-changes_29.html http://www.the-crankshaft.info/2010/07/postmortem-changes_29.html]. Accessed on: 29 September 2010.</ref>
*"Undertaker's fracture" - cervical fracture due to rough handling.<ref>URL: [http://www.the-crankshaft.info/2010/07/postmortem-changes_29.html http://www.the-crankshaft.info/2010/07/postmortem-changes_29.html]. Accessed on: 29 September 2010.</ref>
*Basal skull fracture due to opening of skull.<ref>MSP. 29 September 2010.</ref>
*Basal skull fracture due to opening of skull.<ref>MSP. 29 September 2010.</ref>
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**Mechanism to explain trauma not present in history; a fall/tripping not sufficient.
**Mechanism to explain trauma not present in history; a fall/tripping not sufficient.


===Healing===
==Healing of fractures==
*Osteochrondral reaction - early.
===Simplified classification===
*Primary callus (cartilaginous) - early.
*Secondary callus (bone) - late.


===Child abuse-related===
===Microscopic===
*Paravertebral nodules = classic location for rib fractures in child abuse.
Features:
*Metaphyseal fractures  - "classical metaphyseal lesions".<ref name=pmid8615271>{{Cite journal  | last1 = Kleinman | first1 = PK. | last2 = Marks | first2 = SC. | title = A regional approach to classic metaphyseal lesions in abused infants: the distal tibia. | journal = AJR Am J Roentgenol | volume = 166 | issue = 5 | pages = 1207-12 | month = May | year = 1996 | doi =  | PMID = 8615271 }}</ref>
*Fragmentation of bone.
*+/-Dead bone = lacunae have no osteocytes.<ref name=pmid22460748>{{Cite journal  | last1 = Fondi | first1 = C. | last2 = Franchi | first2 = A. | title = Definition of bone necrosis by the pathologist. | journal = Clin Cases Miner Bone Metab | volume = 4 | issue = 1 | pages = 21-6 | month = Jan | year = 2007 | doi =  | PMID = 22460748 }}</ref>
**Takes days for osteocyte loss.
*+/-Inflammatory cells.
*+/-Hemosiderin-laden macrophages.
*+/-Osteoblastic rimming.


===Healing===
DDx:
Simplified classification:
*Fracture secondary to a tumour:
*Primary callus (cartilaginous) - early.
**Metastatic carcinoma.
*Secondary callus (bone) - late.
**[[Osteosarcoma]] - typically does '''not''' have osteoblastic rimming.  


Notes:
Notes:
*Radiology is not good at dating fratures,<ref name=pmid15788611>{{Cite journal  | last1 = Prosser | first1 = I. | last2 = Maguire | first2 = S. | last3 = Harrison | first3 = SK. | last4 = Mann | first4 = M. | last5 = Sibert | first5 = JR. | last6 = Kemp | first6 = AM. | title = How old is this fracture? Radiologic dating of fractures in children: a systematic review. | journal = AJR Am J Roentgenol | volume = 184 | issue = 4 | pages = 1282-6 | month = Apr | year = 2005 | doi =  | PMID = 15788611 | url=http://www.ajronline.org/cgi/content/full/184/4/1282 }}
*Radiology is not good at dating fratures;<ref name=pmid15788611>{{Cite journal  | last1 = Prosser | first1 = I. | last2 = Maguire | first2 = S. | last3 = Harrison | first3 = SK. | last4 = Mann | first4 = M. | last5 = Sibert | first5 = JR. | last6 = Kemp | first6 = AM. | title = How old is this fracture? Radiologic dating of fractures in children: a systematic review. | journal = AJR Am J Roentgenol | volume = 184 | issue = 4 | pages = 1282-6 | month = Apr | year = 2005 | doi =  | PMID = 15788611 | url=http://www.ajronline.org/cgi/content/full/184/4/1282 }}
</ref> but good at finding 'em.
</ref> however, it is good at finding 'em.


===Motor vehicle vs. pedestrian===
==Pattern and cause==
===Child abuse-related===
*Paravertebral (bony) nodules = classic location for rib fractures in child abuse.
*Metaphyseal fractures  - "classical metaphyseal lesions".<ref name=pmid8615271>{{Cite journal  | last1 = Kleinman | first1 = PK. | last2 = Marks | first2 = SC. | title = A regional approach to classic metaphyseal lesions in abused infants: the distal tibia. | journal = AJR Am J Roentgenol | volume = 166 | issue = 5 | pages = 1207-12 | month = May | year = 1996 | doi =  | PMID = 8615271 }}</ref>
 
===Motor vehicle versus pedestrian===
If the pedestrian is standing during the initial impact one classically finds, at bumper level, a lower limb fracture with a ''Messerer wedge'' (German: ''Messerer-Kiel'');<ref name=pmid11376986>{{Cite journal  | last1 = Karger | first1 = B. | last2 = Teige | first2 = K. | last3 = Fuchs | first3 = M. | last4 = Brinkmann | first4 = B. | title = Was the pedestrian hit in an erect position before being run over? | journal = Forensic Sci Int | volume = 119 | issue = 2 | pages = 217-20 | month = Jun | year = 2001 | doi =  | PMID = 11376986 }}
If the pedestrian is standing during the initial impact one classically finds, at bumper level, a lower limb fracture with a ''Messerer wedge'' (German: ''Messerer-Kiel'');<ref name=pmid11376986>{{Cite journal  | last1 = Karger | first1 = B. | last2 = Teige | first2 = K. | last3 = Fuchs | first3 = M. | last4 = Brinkmann | first4 = B. | title = Was the pedestrian hit in an erect position before being run over? | journal = Forensic Sci Int | volume = 119 | issue = 2 | pages = 217-20 | month = Jun | year = 2001 | doi =  | PMID = 11376986 }}
</ref> the wedge points in the direction of the (impact) force.
</ref> the wedge points in the direction of the (impact) force.
==Location or type==
===Orbital floor fractures===
*[[AKA]] ''blow-out fractures''.<ref name=pmid17333039>{{Cite journal  | last1 = Punke | first1 = C. | last2 = Fritsche | first2 = A. | last3 = Martin | first3 = H. | last4 = Schmitz | first4 = KP. | last5 = Pau | first5 = HW. | last6 = Kramp | first6 = B. | title = [Investigation of the mechanisms involved in isolated orbital floor fracture. Simulation using a finite element model of the human skull]. | journal = HNO | volume = 55 | issue = 12 | pages = 938-44 | month = Dec | year = 2007 | doi = 10.1007/s00106-007-1545-5 | PMID = 17333039 }}</ref>
====General====
*Classically due to fights, followed by traffic accidents.<ref name=pmid20165966>{{Cite journal  | last1 = Gosau | first1 = M. | last2 = Schöneich | first2 = M. | last3 = Draenert | first3 = FG. | last4 = Ettl | first4 = T. | last5 = Driemel | first5 = O. | last6 = Reichert | first6 = TE. | title = Retrospective analysis of orbital floor fractures--complications, outcome, and review of literature. | journal = Clin Oral Investig | volume = 15 | issue = 3 | pages = 305-13 | month = Jun | year = 2011 | doi = 10.1007/s00784-010-0385-y | PMID = 20165966 }}</ref>
*Thought to result from loading on the orbital rim directly or the orbit - both are transmitted to the orbital floor.<ref name=pmid17333039/>
Note:
*The orbital floor tends to the be weaker than other components of the orbital cavity wall; thus, it is the most common site of fracture in the orbital cavity wall.
===Basal skull fracture===
====General====
Etiology:
*Blunt force trauma - high energy & velocity.
**Seen in ''motor vehicle collisions'', ''descent from height''.
Clinical/external findings:
*Raccoon eyes = periorbital ecchymosis.
*Battle sign = mastoid ecchymosis.
**Associated with orbital roof fractures.<ref>URL: [http://emedicine.medscape.com/article/1680107-overview#showall http://emedicine.medscape.com/article/1680107-overview#showall]. Accessed on: 28 March 2012.</ref>
*Cerebrospinal fluid rhinorrhea.
*Hemorrhage from nose and ears.
*Hemotympanum.
Note:
*There is a dictum that states ''bilateral petrous bone fractures are due to impact to the side of the head'' - it isn't true.<ref name=pmid7391790>{{Cite journal  | last1 = Harvey | first1 = FH. | last2 = Jones | first2 = AM. | title = Typical basal skull fracture of both petrous bones: an unreliable indicator of head impact site. | journal = J Forensic Sci | volume = 25 | issue = 2 | pages = 280-6 | month = Apr | year = 1980 | doi =  | PMID = 7391790 }}</ref>
===Hinge fracture of the skull===
*A special type of [[basal skull fracture]].
*Complete hinge fractures are considered severe; they are a 4 on the ''abbreviated injury scale'' (AIS).<ref>{{Cite journal  | last1 = Adams | first1 = VI. | last2 = Carrubba | first2 = C. | title = The Abbreviated Injury Scale: application to autopsy data. | journal = Am J Forensic Med Pathol | volume = 19 | issue = 3 | pages = 246-51 | month = Sep | year = 1998 | doi =  | PMID = 9760090 }}</ref>
*Classically due to a blow to the chin - resulting in a fracture across the medial fossa and sella turcica.<ref>URL: [http://wiki.answers.com/Q/Hinge_fracture_of_skull_is_seen_in_accidents_involving http://wiki.answers.com/Q/Hinge_fracture_of_skull_is_seen_in_accidents_involving]. Accessed on: 28 March 2012.</ref>
===Pathologic fracture===
{{Main|Pathologic fracture}}
*A fracture due to an underlying pathology.
===Hip fractures===
*[[Traumatic fracture of the femoral neck]].


=Autopsy=
=Autopsy=
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===External exam findings===
===External exam findings===
Colour of the corpse:<ref name=Ref_Shkrum33>{{Ref Shkrum|33}}</ref>
Colour of the corpse:<ref name=Ref_Shkrum33>{{Ref Shkrum|33}}</ref>
*Red (Pink) = carbon monoxide, cyanide, fluoroacetate.<ref name=pmid17288493>{{cite journal |author=Proudfoot AT, Bradberry SM, Vale JA |title=Sodium fluoroacetate poisoning |journal=Toxicol Rev |volume=25 |issue=4 |pages=213–9 |year=2006 |pmid=17288493 |doi= |url=}}</ref>
*Red (Pink) = [[carbon monoxide toxicity|carbon monoxide]], cyanide, fluoroacetate,<ref name=pmid17288493>{{cite journal |author=Proudfoot AT, Bradberry SM, Vale JA |title=Sodium fluoroacetate poisoning |journal=Toxicol Rev |volume=25 |issue=4 |pages=213–9 |year=2006 |pmid=17288493 |doi= |url=}}</ref> [[hypothermia]].
*Purple (intense) = propane.
*Purple (intense) = propane.
*Green = hydrogen sulfide.
*Green = [[hydrogen sulfide]].
*Brown = nitrites (methemoglobinemia).
*Brown = nitrites (methemoglobinemia).


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*''Gutter butter'' = adipose tissue in a decomp case; looks like butter topping put on popcorn.  A Toronto-ism.
*''Gutter butter'' = adipose tissue in a decomp case; looks like butter topping put on popcorn.  A Toronto-ism.
*''Gutter blood'' = blood in the empty thorax - after extraction of the organ block.
*''Gutter blood'' = blood in the empty thorax - after extraction of the organ block.
*''Tardieu spots'' = postmortem hypostatic hemorrhages;<ref name=pmid19901802>{{cite journal |author=Pollanen MS, Perera SD, Clutterbuck DJ |title=Hemorrhagic lividity of the neck: controlled induction of postmortem hypostatic hemorrhages |journal=Am J Forensic Med Pathol |volume=30 |issue=4 |pages=322–6 |year=2009 |month=December |pmid=19901802 |doi=10.1097/PAF.0b013e3181c17ec2 |url=}}</ref> look like large petechiae - in dependent areas.
*''Tardieu spots'' = postmortem hypostatic hemorrhages;<ref name=pmid19901802>{{cite journal |author=Pollanen MS, Perera SD, Clutterbuck DJ |title=Hemorrhagic lividity of the neck: controlled induction of postmortem hypostatic hemorrhages |journal=Am J Forensic Med Pathol |volume=30 |issue=4 |pages=322–6 |year=2009 |month=December |pmid=19901802 |doi=10.1097/PAF.0b013e3181c17ec2 |url=}}</ref> look like petechiae - in dependent areas, i.e. in the zone of livity.


===Autopsy on decomposed remains===
===Autopsy on decomposed remains===
*[[AKA]] "decomp autopsy" or simply "decomp".
====General====
====General====
*[[AKA]] "decomp autopsy" or simply "decomp".
*Histology usually very limited ''or'' useless.
*Histology usually very limited ''or'' useless.
*Often done to exclude trauma.
*Often done to exclude trauma.
*Typical scenario: decedent lives alone -- body not discovered for prolonged period of time.
*Typical scenario: decedent lives alone -- body not discovered for prolonged period of time.
*More likely to be a ''[[Autopsy#Negative autopsy|negative autopsy]]'' than non-decomp cases.
*More likely to be a ''[[negative autopsy]]'' than non-decomp cases.


====Suspicious decomp====
====Suspicious decomp====
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==Environmental==
==Environmental==
Includes:  
{{Main|Environmental causes of death}}
*Hypothermia.  
They include:  
*Hyperthermia.  
*[[Hypothermia]].  
*[[Hyperthermia]].  
*Drowning - see [[asphyxial deaths]].
*Drowning - see [[asphyxial deaths]].
*Lack of oxygen - see [[asphyxial deaths]].  
*Lack of oxygen - see [[asphyxial deaths]].  
*Electrocution.
*[[Electrocution]].
 
===Hypothermia===
Features:<ref name=>{{cite journal |author=E. E. Türk, J. P. Sperhake, K. Pueschel and Michael Tsokos |title=An approach to the evaluation of fatal hypothermia |journal=Forensic Science, Medicine, and Pathology |volume=1 |issue=1 |pages=31–35 |year=2005 |month= |pmid= |doi= |url=http://www.springerlink.com/content/n785314u75m71j8h/fulltext.pdf}}</ref>
*Reddening of exposed skin areas "frost erythema" - '''classic feature'''.
*Wischnewski spots ([[AKA]] Leopard spots) - '''classic feature'''.
**Brown/black spots of the gastric mucosa ~ 0.1-0.4 cm; thought to represent pre-mortem/perimortem hemorrhage.<ref>{{cite journal |author=Tsokos M, Rothschild MA, Madea B, Rie M, Sperhake JP |title=Histological and immunohistochemical study of Wischnewsky spots in fatal hypothermia |journal=Am J Forensic Med Pathol |volume=27 |issue=1 |pages=70–4 |year=2006 |month=March |pmid=16501354 |doi=10.1097/01.paf.0000202716.06378.91 |url=http://journals.lww.com/amjforensicmedicine/Abstract/2006/03000/Histological_and_Immunohistochemical_Study_of.14.aspx}}</ref>
*Paradoxical undressing; decedent has removed clothes due to perception of being too hot.<ref name=pmid20151230>{{cite journal |author=Turk EE |title=Hypothermia |journal=Forensic Sci Med Pathol |volume=6 |issue=2 |pages=106–15 |year=2010 |month=June |pmid=20151230 |doi=10.1007/s12024-010-9142-4 |url=}}</ref>
 
Notes:
*Findings are often non-specific.<ref name=pmid16948514>{{cite journal |author=Nixdorf-Miller A, Hunsaker DM, Hunsaker JC |title=Hypothermia and hyperthermia medicolegal investigation of morbidity and mortality from exposure to environmental temperature extremes |journal=Arch. Pathol. Lab. Med. |volume=130 |issue=9 |pages=1297–304 |year=2006 |month=September |pmid=16948514 |doi= |url=http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165%282006%29130%5B1297%3AHAHMIO%5D2.0.CO%3B2}}</ref>
*Non-specific findings seen in hypothermia:<ref name=pmid16948514/>
**[[Pulmonary edema]].
**Hemorrhagic pancreatitis.
**Hemorrhage of the iliopsoas muscle.
*DDx of reddening of skin includes [[Asphyxial_deaths#Carbon_monoxide|carbon monoxide poisoning]].
Image:
*[http://www.springerlink.com/content/n785314u75m71j8h/fulltext.pdf Wischnewski spots (springerlink.com)].
 
===Hyperthermia===
Features:
*Findings are non-specific.<ref name=pmid16948514>{{cite journal |author=Nixdorf-Miller A, Hunsaker DM, Hunsaker JC |title=Hypothermia and hyperthermia medicolegal investigation of morbidity and mortality from exposure to environmental temperature extremes |journal=Arch. Pathol. Lab. Med. |volume=130 |issue=9 |pages=1297–304 |year=2006 |month=September |pmid=16948514 |doi= |url=http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165%282006%29130%5B1297%3AHAHMIO%5D2.0.CO%3B2}}</ref>
*Short survival:
**+/-Petechiae - serosal (pleural, epicardial, pericardial) and cerebral periventricular.
**+/-Cerebral edema.
*Long survival:
**Findings consistent with hypovolemic shock (hepatic [[necrosis]], cerebral edema, [[DAD]] in lung, acute [[pancreatitis]]).
**Clinical/biochemical: rhabdomyolysis, [[DIC]], [[ATN]].
 
===Electrocution===
General:
*May be missed - as can be subtle.
 
Gross features:
*Usually burns on the hands - brown.
 
Microscopic features:
*Palisading of basal cells (like cautery artefact).


=Gunshot wounds=
=Gunshot wounds=
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**Includes: carbon monoxide poisoning.
**Includes: carbon monoxide poisoning.
*''Suffocation'' - usually no signs of neck compression.
*''Suffocation'' - usually no signs of neck compression.
**Includes: Smothering, choking, positional asphyxia, drowning.
**Includes: smothering, [[choking]], positional asphyxia, [[drowning]].


==Blunt force trauma==
=Blunt force injury=
===General===
*[[AKA]] ''blunt force trauma''.
*Weapon: fist, foot, baseball bat... pretty much anything.
==General==
Classification:
*Contusions.
*Laceration.
*Acceleration/deceleration injury, e.g. [[diffuse axonal injury]].
 
Weapons:  
*Fist.
*Foot.
*Baseball bat... pretty much anything.
*Beer bottles are common... and strong enought to fracture a skull.
*Beer bottles are common... and strong enought to fracture a skull.
**Empty bottles have a higher fracture energy than full ones.<ref name=pmid19239964>{{cite journal |author=Bolliger SA, Ross S, Oesterhelweg L, Thali MJ, Kneubuehl BP |title=Are full or empty beer bottles sturdier and does their fracture-threshold suffice to break the human skull? |journal=J Forensic Leg Med |volume=16 |issue=3 |pages=138–42 |year=2009 |month=April |pmid=19239964 |doi=10.1016/j.jflm.2008.07.013 |url=}}</ref>
**Empty bottles have a higher fracture energy than full ones.<ref name=pmid19239964>{{cite journal |author=Bolliger SA, Ross S, Oesterhelweg L, Thali MJ, Kneubuehl BP |title=Are full or empty beer bottles sturdier and does their fracture-threshold suffice to break the human skull? |journal=J Forensic Leg Med |volume=16 |issue=3 |pages=138–42 |year=2009 |month=April |pmid=19239964 |doi=10.1016/j.jflm.2008.07.013 |url=}}</ref>


==Cause of death==
===Commotio cordis===
===Commotio cordis===
Features:<ref name=pmid11334832>{{cite journal |author=Kohl P, Nesbitt AD, Cooper PJ, Lei M |title=Sudden cardiac death by Commotio cordis: role of mechano-electric feedback |journal=Cardiovasc. Res. |volume=50 |issue=2 |pages=280–9 |year=2001 |month=May |pmid=11334832 |doi= |url=}}</ref><ref>{{cite journal |author=Maron BJ, Estes NA |title=Commotio cordis |journal=N. Engl. J. Med. |volume=362 |issue=10 |pages=917–27 |year=2010 |month=March |pmid=20220186 |doi=10.1056/NEJMra0910111 |url=http://www.nejm.org/doi/full/10.1056/NEJMra0910111}}</ref>
Features:<ref name=pmid11334832>{{cite journal |author=Kohl P, Nesbitt AD, Cooper PJ, Lei M |title=Sudden cardiac death by Commotio cordis: role of mechano-electric feedback |journal=Cardiovasc. Res. |volume=50 |issue=2 |pages=280–9 |year=2001 |month=May |pmid=11334832 |doi= |url=}}</ref><ref>{{cite journal |author=Maron BJ, Estes NA |title=Commotio cordis |journal=N. Engl. J. Med. |volume=362 |issue=10 |pages=917–27 |year=2010 |month=March |pmid=20220186 |doi=10.1056/NEJMra0910111 |url=http://www.nejm.org/doi/full/10.1056/NEJMra0910111}}</ref>
*Often negative autopsy; no cardiac pathology.
*Often negative autopsy; no cardiac pathology.
*Etiology: arrhythmia.
*Etiology: [[cardiac arrhythmia|arrhythmia]].
*History: trauma to chest.
*History: trauma to chest.


Note:
Note:
*May be spelled ''Commodio cordis''.<ref name=pmid11555799>{{cite journal |author=Perron AD, Brady WJ, Erling BF |title=Commodio cordis: an underappreciated cause of sudden cardiac death in young patients: assessment and management in the ED |journal=Am J Emerg Med |volume=19 |issue=5 |pages=406–9 |year=2001 |month=September |pmid=11555799 |doi=10.1053/ajem.2001.24455 |url=}}</ref>
*May be spelled ''Commodio cordis''.<ref name=pmid11555799>{{cite journal |author=Perron AD, Brady WJ, Erling BF |title=Commodio cordis: an underappreciated cause of sudden cardiac death in young patients: assessment and management in the ED |journal=Am J Emerg Med |volume=19 |issue=5 |pages=406–9 |year=2001 |month=September |pmid=11555799 |doi=10.1053/ajem.2001.24455 |url=}}</ref>
*Analogous to ''[[commotio medullaris]]''.


==Scenarios==
===Motor vehicle collisions===
===Motor vehicle collisions===
*Pedestrian vs. motor vehicle: heel to injury measurement.<ref>{{Ref OPMfP|18}}</ref>
*Pedestrian vs. motor vehicle: heel to injury measurement, remember to include the thickness of the heel/sole of shoe.<ref>{{Ref OPMfP|18}}</ref>
===Seromuscular tear===
*Dicing injuries: tempered glass used in side window construction fragments into cubes when fractured causing L-shaped wounds.
Features:
* Intestinal injury associated with motor vehicle collisions and more specifically seatbelts.
* [[AKA]] ''seatbeat syndrome''.
* Def'n: separation of inner muscularis from submucosa.<ref name=pmid12198344>{{Cite journal  | last1 = Slavin | first1 = RE. | last2 = Borzotta | first2 = AP. | title = The seromuscular tear and other intestinal lesions in the seatbelt syndrome: a clinical and pathologic study of 29 cases. | journal = Am J Forensic Med Pathol | volume = 23 | issue = 3 | pages = 214-22 | month = Sep | year = 2002 | doi = 10.1097/01.PAF.0000023001.32202.2D | PMID = 12198344 }}</ref>


===Descent from height===
===Descent from height===
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*+/-Haemoaspiration (due to facial trauma) - presence suggest that decendent was alive shortly after landing/impact and thus likely very alive during the descent.
*+/-Haemoaspiration (due to facial trauma) - presence suggest that decendent was alive shortly after landing/impact and thus likely very alive during the descent.
**Patchy red centrilobular spots on gross examination.
**Patchy red centrilobular spots on gross examination.
==Injury patterns==
===Seromuscular tear===
* [[AKA]] ''seatbeat syndrome''.
* Intestinal injury associated with motor vehicle collisions and more specifically seatbelts.
Features:
* Def'n: separation of (inner) muscularis propria from submucosa.<ref name=pmid12198344>{{Cite journal  | last1 = Slavin | first1 = RE. | last2 = Borzotta | first2 = AP. | title = The seromuscular tear and other intestinal lesions in the seatbelt syndrome: a clinical and pathologic study of 29 cases. | journal = Am J Forensic Med Pathol | volume = 23 | issue = 3 | pages = 214-22 | month = Sep | year = 2002 | doi = 10.1097/01.PAF.0000023001.32202.2D | PMID = 12198344 }}</ref>
===Bite injury===
*A special type of [[blunt force trauma]].
*May be seen in the context of a sexual assault.
*A ''forensic dentist'' may be able to assist.
In the context of a suspicious case:
*Human vs. animal.
*Bite marks, as evidence, have a limited value for identification purposes.
**In the context of identifying a potential perpetrator, it is essential to swab the bite mark for saliva, which is rich in DNA.<ref>{{Cite journal  | last1 = Pretty | first1 = IA. | title = Forensic dentistry: 2. Bitemarks and bite injuries. | journal = Dent Update | volume = 35 | issue = 1 | pages = 48-50, 53-4, 57-8 passim | month =  | year =  | doi =  | PMID = 18277695 }}</ref>
====Images====
<gallery>
Image: Dog_bite.JPG | Bite injury. (WC)
</gallery>
===Aortic trauma===
*Classic location of transection of the aorta is distal the the left subclavian branch point near the insertion of the ligamentum arteriosum (e.g. peri-isthmus).<ref name=pmid1934437>{{cite journal |author=Kodali S, Jamieson WR, Leia-Stephens M, Miyagishima RT, Janusz MT, Tyers GF |title=Traumatic rupture of the thoracic aorta. A 20-year review: 1969-1989 |journal=Circulation |volume=84 |issue=5 Suppl |pages=III40–6 |year=1991 |month=November |pmid=1934437 |doi= |url=}}</ref>
*[[Aortic dissection]] due to trauma is often catastrophic. Several mechanisms have been proposed and there is a body of trauma biomechanics research that explores this.


==Trauma with delayed death==
==Trauma with delayed death==
*Epidural hemorrhage - lucid interval.
*[[Epidural hemorrhage]] with a lucid interval.
*Subcapsular splenic hematoma with subsequent rupture.
*Subcapsular splenic hematoma with subsequent rupture.
*Subcapsular hepatic hematoma with subsequent rupture.
*Subcapsular hepatic hematoma with subsequent rupture.
*Aortic dissection with subsequent rupture.
*[[Aortic dissection]] with subsequent rupture.


=Sharp force trauma=
=Sharp force injury=
===Characteristics<ref name=Ref_HospAuto111-2>{{Ref HospAuto|111-2}}</ref>===
*[[AKA]] ''sharp force trauma''.
*Incised wound (see: ''[[Forensic_pathology#Classification_of_wounds|Classification of wounds]]'').
===General===
**"Clean" edge (no contusion, no abrasion).
Injuries caused by:<ref name=Ref_HospAuto111-2>{{Ref HospAuto|111-2}}</ref>
**Well-demarcated edges.
 
Subclassified into ''cut/slash'' and ''stab'' (see: ''[[Forensic_pathology#Classification_of_wounds|Classification of wounds]]'').
 
===Weapons<ref name=Ref_HospAuto111-2>{{Ref HospAuto|111-2}}</ref>===
*Knife.
*Knife.
*Scissors - classic "Z" shape.
*Scissors - classic "Z" shape.
Line 412: Line 558:
*Glass.
*Glass.


=Blunt force trauma=
===Gross===
==Aortic trauma==
Features:<ref name=Ref_HospAuto111-2>{{Ref HospAuto|111-2}}</ref>
*Classic location of injury is subclavian branch point.<ref name=pmid1934437>{{cite journal |author=Kodali S, Jamieson WR, Leia-Stephens M, Miyagishima RT, Janusz MT, Tyers GF |title=Traumatic rupture of the thoracic aorta. A 20-year review: 1969-1989 |journal=Circulation |volume=84 |issue=5 Suppl |pages=III40–6 |year=1991 |month=November |pmid=1934437 |doi= |url=}}</ref>
*Incised wound (see: ''[[Wounds|Classification of wounds]]'').
*[[Aortic dissection]] due to trauma is often catastrophic.
**"Clean" edge (no contusion, no abrasion).
**Well-demarcated edges.
*+/-Hilt mark.
**Due to contact of hilt.
 
Subclassified into - see ''[[Wounds|classification of wounds]]'':
*''Cut/slash''.
*''Stab''.
*''Chop'' - a mixed injury, sharp force and blunt force.
 
====Images====
<gallery>
Image: Thorax-Messerstichwunden.jpg | Sharp force trauma - thorax. (WC)
</gallery>


=Head injuries=
=Head injuries=
Line 425: Line 584:
**Location:
**Location:
***Above hat brim line (HBL).
***Above hat brim line (HBL).
***Ear.
***[[Ear]].
***Left-sided.
***Left-sided.
*Fractures:
*Fractures:
Line 454: Line 613:
*Tears - corpus callosum.
*Tears - corpus callosum.
*Haemorrhage.
*Haemorrhage.
Other (chronic) changes:<ref name=Ref_AoGP639>{{Ref AoGP|639}}</ref>{{fact}}
*Thalamus - shrinkage.
*Enlargement of third ventricle.
DDx (medical imaging):<ref name=pmid22406792>{{Cite journal  | last1 = Kumar | first1 = S. | last2 = Gupta | first2 = V. | last3 = Aggarwal | first3 = S. | last4 = Singh | first4 = P. | last5 = Khandelwal | first5 = N. | title = Fat embolism syndrome mimicker of diffuse axonal injury on magnetic resonance imaging. | journal = Neurol India | volume = 60 | issue = 1 | pages = 100-2 | month =  | year =  | doi = 10.4103/0028-3886.93597 | PMID = 22406792 }}</ref>
*[[Cerebral fat embolism]].


===Microscopic===
===Microscopic===
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*Degeneration of fibre tracts.
*Degeneration of fibre tracts.


Grading:<ref>URL: [http://wiki.cns.org/wiki/index.php/Diffuse_axonal_injury_%28DAI%29 http://wiki.cns.org/wiki/index.php/Diffuse_axonal_injury_%28DAI%29]. Accessed on: 27 November 2011.</ref>
Grading:<ref>URL: [http://wiki.cns.org/wiki/index.php/Diffuse_axonal_injury_%28DAI%29 http://wiki.cns.org/wiki/index.php/Diffuse_axonal_injury_%28DAI%29]. Accessed on: 13 February 2012.</ref>
*Grade 1: only microscopic findings.
*Grade 1: only microscopic findings.
*Grade 2: macroscopic corpus callosal injury + microscopic DAI.  
*Grade 2: macroscopic corpus callosum injury + microscopic findings of DAI.  
*Grade 3: macroscopic and microscopic findings.
*Grade 3: macroscopic corpus callosum and midbrain injuries + microscopic findings of DAI.
 
===Stains===
*[[Bielschowsky stain]] to highlight axonal swellings - appear 12-18 hours after injury.<ref name=Ref_Shkrum_562>{{Ref Shkrum|562}}</ref>


===IHC===
===IHC===
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==Intracranial hemorrhage==
==Intracranial hemorrhage==
{{main|Intracranial hematoma}}
{{main|Intracranial hematoma}}
Intracranial hemorrhage may be a consequence of blunt force trauma.


Classification:
Classification:
*Epidural hematoma.
*[[Epidural hematoma]].
*Subdural hematoma.
*[[Subdural hematoma]].
*Subarachnoid hematoma.
*[[Subarachnoid hematoma]].
*[[Intracerebral hematoma]].
 
==Cerebral contusion==
===General===
*Due to blunt force trauma.
 
===Gross===
Features:
*Focal superficial hemorrhage.
*Location, usually, ''frontal lobe'' and ''temporal lobe''.<ref name=Ref_HoFP_102>{{Ref HoFP|102}}</ref>
 
Notes:
*Classically, come in pairs:<ref name=Ref_HoFP_102>{{Ref HoFP|102}}</ref>
*#''Coup contusion'' - at the site of the (primary) impact
*#''Contrecoup contusion'' - secondary internal impact.
**Example - fall on back of head:
***Occipital lobe contusion = coup contusion.
***Frontal lobe contusion = contrecoup contusion.
*May be associated with contusions of the:<ref name=Ref_HoFP_103>{{Ref HoFP|103}}</ref>
**Deep brain structures, known as an "intermediary coup".
**Dorsal surface of the cerebral hemispheres, known as "gliding contusions".
*Resolve as a yellow lesion (like at other sites), known as a ''[[plaque]] jaune'' in the brain.
**Classically, inferior aspect of the frontal lobe.
 
DDx:
*Hemorrhagic [[stroke]] - usually temporal lobe and/or parietal lobe.


==Traumatic brain injury in infants==
==Traumatic brain injury in infants==
{{main|Traumatic brain injury in infants}}
{{main|Traumatic brain injury in infants}}


*Shaken-impact syndrome.
*Shaken-impact syndrome, [[AKA]] shaken baby syndrome.
*Shaken baby syndrome.


==Commotio medullaris==
==Commotio medullaris==
Line 488: Line 683:
*Sudden death after head trauma that is insufficient to explain death.
*Sudden death after head trauma that is insufficient to explain death.
*Etiology: unknown - thought to be related to apnea.
*Etiology: unknown - thought to be related to apnea.
*Analogous to ''commotio cordis'' (see ''blunt force trauma'').
 
Note:
*Analogous to ''[[commotio cordis]]''.


=Excited delirium=
=Excited delirium=
General:
*[[AKA]] ''agitated delirium''.<ref name=pmid8768172>{{cite journal |author=Wetli CV, Mash D, Karch SB |title=Cocaine-associated agitated delirium and the neuroleptic malignant syndrome |journal=Am J Emerg Med |volume=14 |issue=4 |pages=425–8 |year=1996 |month=July |pmid=8768172 |doi= |url=}}</ref>
*Also known as "agitated delirium".<ref name=pmid8768172>{{cite journal |author=Wetli CV, Mash D, Karch SB |title=Cocaine-associated agitated delirium and the neuroleptic malignant syndrome |journal=Am J Emerg Med |volume=14 |issue=4 |pages=425–8 |year=1996 |month=July |pmid=8768172 |doi= |url=}}</ref>
===General===
*Dx is considered controversial, especially outside of the forensic pathology community.<ref>[http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2374865 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2374865]</ref>
*[[Diagnosis]] is considered somewhat controversial outside of the forensic pathology community.<ref name=pmid18450833>{{Cite journal  | last1 = Stanbrook | first1 = MB. | last2 = Hébert | first2 = PC. | last3 = Kale | first3 = R. | last4 = Sibbald | first4 = B. | last5 = Flegel | first5 = K. | last6 = MacDonald | first6 = N. | title = Tasers in medicine: an irreverent call for proposals. | journal = CMAJ | volume = 178 | issue = 11 | pages = 1401-2, 1403-4 | month = May | year = 2008 | doi = 10.1503/cmaj.080592 | PMID = 18450833 |PMC = 2374865 }}</ref>
*The diagnosis has garnered considerable attention in the context of electroshock weapon use, as ''Taser International'' (a manufacturer of electroshock weapons) has blamed all deaths involving its weapons on it.
*The [[diagnosis]] has garnered attention in the context of electroshock weapon use, as ''Taser International'' (a manufacturer of electroshock weapons) has often ascribed the deaths involving its weapons to it - when it is alleged that their electroshock weapon caused the death.


*There is no "official" definition for ''excited delirium''.
*There is no "official" definition for ''excited delirium''.
Line 505: Line 702:


Excited delirium - hypothesis:
Excited delirium - hypothesis:
*Thought to arise in the context of severe chronic mental disorders (e.g. schizophrenia) and protracted cocaine binges.<ref name=pmid9645173>{{Cite journal  | last1 = Pollanen | first1 = MS. | last2 = Chiasson | first2 = DA. | last3 = Cairns | first3 = JT. | last4 = Young | first4 = JG. | title = Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the community. | journal = CMAJ | volume = 158 | issue = 12 | pages = 1603-7 | month = Jun | year = 1998 | doi =  | PMID = 9645173 | PMC = 1229410 | url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1229410}}</ref>
*Thought to arise in the context of severe chronic mental disorders (e.g. schizophrenia) and protracted [[cocaine]] binges.<ref name=pmid9645173>{{Cite journal  | last1 = Pollanen | first1 = MS. | last2 = Chiasson | first2 = DA. | last3 = Cairns | first3 = JT. | last4 = Young | first4 = JG. | title = Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the community. | journal = CMAJ | volume = 158 | issue = 12 | pages = 1603-7 | month = Jun | year = 1998 | doi =  | PMID = 9645173 | PMC = 1229410 | url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1229410}}</ref>
*Thought to result from alteration of dopamine receptor density.  The D2 receptor in particular, which is thought to be important in temperature regulation, is decreased in psychotic cocaine abusers.<ref name=pmid8768172/>
*Thought to result from alteration of dopamine receptor density.  The D2 receptor in particular, which is thought to be important in temperature regulation, is decreased in psychotic cocaine abusers.<ref name=pmid8768172/>


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===Vitreous===
===Vitreous===
*Creatinine and urea - approximate those at time of death.<ref name=Ref_HospAuto222>{{Ref HospAuto|222}}</ref>
*Creatinine and urea - approximate those at time of death.<ref name=Ref_HospAuto222>{{Ref HospAuto|222}}</ref>
*Glucose - used to assess for hyperglycemia (due to [[diabetes mellitus|diabetic coma]]) in life.<ref name=pmid19167848>{{Cite journal  | last1 = Zilg | first1 = B. | last2 = Alkass | first2 = K. | last3 = Berg | first3 = S. | last4 = Druid | first4 = H. | title = Postmortem identification of hyperglycemia. | journal = Forensic Sci Int | volume = 185 | issue = 1-3 | pages = 89-95 | month = Mar | year = 2009 | doi = 10.1016/j.forsciint.2008.12.017 | PMID = 19167848 }}</ref>


===Toxicology===
===Toxicology===
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#Suspected toxicologic death - need details on drugs.
#Suspected toxicologic death - need details on drugs.


====Mandated by case<ref>{{Ref OPMfP|14}}</ref>====
====Mandated by case====
*Sudden death in children under five years old.
In Ontario, the following are mandated by the case:<ref>{{Ref OPMfP|14}}</ref>
*Workplace deaths.
*Sudden death of child under five years old.
*Fatal motor vehicle collision.
*Workplace death.
*Aviation deaths.
*Fatal motor vehicle collision - esp. driver.
*Fire-related deaths (carboxyhemoglobin).
*Aviation death - esp. pilot & co-pilot.
*Fire-related death (carboxyhemoglobin).


===Toxins===
===Toxins===
====Ethanol====
====Ethanol toxicity====
{{Main|Ethanol abuse}}
*Usually measured (in Canada) as: ''mass of EtOH (mg)/volume of blood (mL)''.
*Usually measured (in Canada) as: ''mass of EtOH (mg)/volume of blood (mL)''.
**Limit (Ontario): 80 milligrams of alcohol in 100 millilitres of blood (0.08 gm/100 mL).<ref>URL: [http://www.mto.gov.on.ca/english/safety/impaired/fact-sheet.shtml http://www.mto.gov.on.ca/english/safety/impaired/fact-sheet.shtml]. Accessed on: 28 September 2010.</ref>
**Limit (Ontario): 80 milligrams of alcohol in 100 millilitres of blood (0.08 gm/100 mL).<ref>URL: [http://www.mto.gov.on.ca/english/safety/impaired/fact-sheet.shtml http://www.mto.gov.on.ca/english/safety/impaired/fact-sheet.shtml]. Accessed on: 28 September 2010.</ref>
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**Ethanol's molar mass = 46.07 g/mol.
**Ethanol's molar mass = 46.07 g/mol.


====Cocaine====
====Methanol toxicity====
*Minimum lethal dose: 40 mg/dl.<ref>URL: [http://path.upmc.edu/cases/case242/dx.html http://path.upmc.edu/cases/case242/dx.html. Accessed on: 13 January 2012.</ref>
 
*Typically an accidental death; person consumes methanol as an ethanol substitute.
*Blindness.
*[[Putamen]] [[necrosis]] (bilateral).<ref name=pmid16484428>{{Cite journal  | last1 = Blanco | first1 = M. | last2 = Casado | first2 = R. | last3 = Vázquez | first3 = F. | last4 = Pumar | first4 = JM. | title = CT and MR imaging findings in methanol intoxication. | journal = AJNR Am J Neuroradiol | volume = 27 | issue = 2 | pages = 452-4 | month = Feb | year = 2006 | doi =  | PMID = 16484428 }}</ref>
*+/-Pancreatic injury.<ref name=pmid10866330>{{Cite journal  | last1 = Hantson | first1 = P. | last2 = Mahieu | first2 = P. | title = Pancreatic injury following acute methanol poisoning. | journal = J Toxicol Clin Toxicol | volume = 38 | issue = 3 | pages = 297-303 | month =  | year = 2000 | doi =  | PMID = 10866330 }}</ref>
 
====Cocaine toxicity====
*No agreed upon toxic dose<ref name=pmid15075681>{{cite journal |author=Stephens BG, Jentzen JM, Karch S, Wetli CV, Mash DC |title=National Association of Medical Examiners position paper on the certification of cocaine-related deaths |journal=Am J Forensic Med Pathol |volume=25 |issue=1 |pages=11–3 |year=2004 |month=March |pmid=15075681 |doi= |url=}}</ref> - due to tolerance.
*No agreed upon toxic dose<ref name=pmid15075681>{{cite journal |author=Stephens BG, Jentzen JM, Karch S, Wetli CV, Mash DC |title=National Association of Medical Examiners position paper on the certification of cocaine-related deaths |journal=Am J Forensic Med Pathol |volume=25 |issue=1 |pages=11–3 |year=2004 |month=March |pmid=15075681 |doi= |url=}}</ref> - due to tolerance.
*Usual mechanism ''cardiac failure''.


Features (see: ''[[Heart#Cocaine toxicity|cocaine toxicity]]''):
Features - heart:
*Usually anatomically normal heart.
*Usually anatomically normal heart.
*+/-Advanced atherosclerosis for age.
**+/-Advanced [[coronary artery atherosclerosis]] for age.
*+/-Infarction.
**+/-[[Myocardial infarction]].
*+/-Contraction band necrosis.
***+/-Contraction band necrosis.
*+/-Cardiac hypertrophy.
**+/-Cardiac hypertrophy.


====Ethylene glycol====
Other:
*+/-Nasal septum perforation.
*+/-Track marks (other drug use).
*+/-Finger burns (during preparation of crack).
*+/-Drug paraphernalia, e.g. crack pipe.
 
====Ethylene glycol toxicity====
:For a more general discussion see ''[[Crystals_in_body_fluids#Urine_crystals|urine crystals]]''
:For a more general discussion see ''[[Crystals_in_body_fluids#Urine_crystals|urine crystals]]''
*Not done in routine toxicology screening.
*Not done in routine toxicology screening.
*Birefringent calcium oxalate crystals found in kidney (with polarized light).<ref name=Ref_KFP589>{{Ref KFP|589}}</ref>
*Birefringent calcium oxalate crystals found in kidney (with [[polarized light]]).<ref name=Ref_KFP589>{{Ref KFP|589}}</ref>


====Anaphylaxis====
====Anaphylaxis====
Serology:<ref name=pmid20176258>{{cite journal |author=Simons FE |title=Anaphylaxis |journal=J. Allergy Clin. Immunol. |volume=125 |issue=2 Suppl 2 |pages=S161–81 |year=2010 |month=February |pmid=20176258 |doi=10.1016/j.jaci.2009.12.981 |url=}}</ref>
*Allergic reaction, e.g. peanut allergy.
 
Diagnosis - serology:<ref name=pmid20176258>{{cite journal |author=Simons FE |title=Anaphylaxis |journal=J. Allergy Clin. Immunol. |volume=125 |issue=2 Suppl 2 |pages=S161–81 |year=2010 |month=February |pmid=20176258 |doi=10.1016/j.jaci.2009.12.981 |url=}}</ref>
*IgE.
*IgE.
*Tryptase.
*Tryptase.
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Generally, these things are:
Generally, these things are:
*Cardiovascular:
*Cardiovascular:
**Arrhythmia.
**[[Cardiac arrhythmia|Arrhythmia]].
**Myocardial infarction.
**[[Myocardial infarction]].
**Haemorrhage.
**Haemorrhage.
***Ruptured aneurysm.
***Ruptured aneurysm.
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*GI:
*GI:
**Haemorrhage.
**Haemorrhage.
***Esophageal varices.
***[[Esophageal varices]].
***Gastric varices.
***Gastric varices.
*Neurologic:
*Neurologic:
**Intracranial haemorrhage.
**Intracranial haemorrhage.
***Ruptured aneurysm.
***Ruptured aneurysm.
***Spontaneous subdural haemorrhage.
***Spontaneous [[subdural hemorrhage]].
**Stroke:
**[[Stroke]]:
***Haemorrhagic.
***Haemorrhagic.
***Thrombotic (more common than haemorrhagic).
***Thrombotic (more common than hemorrhagic).


=Forensic entomology=
=Forensic entomology=
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*[http://cap-acp.org/forensic.cfm Forensic pathology (cap-acp.org)].
*[http://cap-acp.org/forensic.cfm Forensic pathology (cap-acp.org)].
*[http://neurobio.drexelmed.edu/goldmanweb/forensicanthro/trauma.pdf Fractures (drexelmed.edu)].
*[http://neurobio.drexelmed.edu/goldmanweb/forensicanthro/trauma.pdf Fractures (drexelmed.edu)].
*[http://www.forensicmed.co.uk/pathology/mechanisms-of-death/ Mechanisms of death (forensicmed.co.uk)].


==Post-mortem changes==
==Post-mortem changes==
*[http://emedicine.medscape.com/article/1680032-overview Post-mortem changes (emedicine.medscape.com)].
*[http://emedicine.medscape.com/article/1680032-overview#showall Post-mortem changes (emedicine.medscape.com)].
*[http://emedicine.medscape.com/article/1680107-overview#showall Autopsy of blunt force trauma (emedicine.medscape.com)].
*[http://www.the-crankshaft.info/2010/07/postmortem-changes_29.html Post-mortem changes (the-crankshaft.info)].
*[http://www.the-crankshaft.info/2010/07/postmortem-changes_29.html Post-mortem changes (the-crankshaft.info)].


[[Category:Autopsy]]
[[Category:Autopsy]]
[[Category:Forensic pathology]]
[[Category:Forensic pathology]]
Michael
48,466

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