Elisabeth E. Türk

Pathologic features of fatal falls from height.

Deaths due to falls from height are common in urban settings. At the time the body is found, it is often unclear whether the mode of death is accident, suicide, or homicide. To assess the injury pattern in fatal falls from height with special regard to criteria that might be helpful in discrimination between accident, suicide, and homicide, respectively, we reviewed 68 medicolegal autopsy cases (22 females, 46 males, age range 13–89 years) of fatal falls from height regarding demographic data, findings at the death scene, results of the postmortem examination, psychiatric history, and toxicologic findings. Among the 68 cases, there were 34 suicides, 23 accidents, and 11 unclarified cases, in 3 of which homicide was suspected. In general, suicides were from greater heights than accidents (mean height 22.7 m for suicides and 10.8 m for accidents, respectively; 79% of suicides from more than 16 m). Strikingly, severe head injuries predominantly occurred in falls from heights below 10 m (84%) and above 25 m (90%), whereas in the group of falls from 10 to 25 m, these lesions were seen less frequently (28%). Neck injuries like muscle bleeds and fractures of the hyoid bone were found in 33% of falls from more than 10 m and did not occur from less than 10 m. Our data stress that the evaluation of pathologic features alone is not sufficient to assess the mode of death in fatal falls from height. Instead, postmortem findings have to be considered within the framework of the subjects social, medical, and psychiatric history in conjunction with findings at the death scene and toxicology results to obtain the clearest possible picture of the circumstances of death.

Fatal methanol intoxication with different survival times—Morphological findings and postmortem methanol distribution

Three corresponding cases of fatal methanol intoxication with different survival times were investigated ante-mortem and postmortem. Ante-mortem serum methanol concentrations were determined during treatment in hospital for 4 days. Furthermore, postmortem distribution of methanol in various tissues and fluids was measured after autopsy. Morphological and toxicological findings are discussed based on the literature. The morphological findings correlated with the different survival times. The results of the toxicological analyses were partly in keeping with previously published data. Interestingly, very high methanol levels were determined in brain with very low concentrations in femoral venous blood. These results may have implications for postmortem toxicological analysis, brain death diagnosis and organ explanation for transplantation.

Room temperature DNA preservation of soft tissue for rapid DNA extraction: an addition to the disaster victim identification investigators toolkit?

In mass fatality incidents, for example following a vehicle accident or terrorist event, severe fragmentation of bodies may occur, making identification by the use of traditional techniques such as fingerprinting or odontology difficult. In such situations DNA profiling can be employed for individualization and re-association of fragmented remains. As at times disrupted soft tissue may be the predominate tissue type requiring identification and re-association. We have investigated the use of two buffer solutions for preservation of soft tissue samples that may be collected during such investigations, when buccal cells, blood samples or teeth or bone may not be available. Both buffer solutions have shown sufficient DNA preservation over a 12-month period of storage at room temperature to allow for DNA profiling to be successfully performed when 5-1000 mg muscle tissue was stored in each solution.

Pseudomembranous colitis with fatal outcome in a 43-year-old man

Pseudomembranous colitis is a life-threatening complication of broad spectrum antibiotic therapy caused by Clostridium difficile. Untreated, the disease can lead to severe and in many cases fatal complications such as peritonitis due to colonic wall perforation, shock as a consequence of volume depletion, toxic megacolon and massive lower gastrointestinal haemorrhage. Fatal complications mostly occur in elderly people with a high degree of comorbidity. We report the case of a 43-year-old patient with AIDS who was admitted to hospital with abdominal pain of unknown origin and died before the correct diagnosis could be established. Autopsy and postmortem stool cultures revealed severe pseudomembranous colitis due to C. difficile with toxic cardiac and circulatory failure as cause of death.

Fatal Falls from Height

Especially in urban settings, falls from height are a phenomenon that significantly contributes to population morbidity and mortality. The injuries sustained vary depending on the falling height, the composition of the impact surface, the position of the body when landing and individual factors such as age, body weight and preexisting disease. Cases of fatal falls from height can carry a high forensic relevance, because at the time the body is found, the manner of death is often unclear. Injuries sustained prior to the actual fall that might have been inflicted by another person might well be masked by the impact injuries. It is thus especially important in these cases to take into account not only the autopsy findings but also toxicology results, findings at the death scene, and the medical, psychiatric, and social history of the victim. The aim of this review is to summarize the most important findings in cases of fatal falls from height and to discuss the possibilities and limits in interpreting these findings with special regard to the manner of death.

Fatal bleeding from major femoral vessels: three case reports.

We present three unusual cases of fatal bleeding from eroded femoral blood vessels. Erosion was due to tumor metastases in one and abscess formation in two cases. Bleeding occurred from the femoral vein in two cases and from the femoral artery in one case. Extensive bloodstains at the death scene were suspicious of homicide, which was ruled out by medico-legal autopsy in all cases.

Iliopsoas muscle bleeding as a complication of septic disseminated intravascular coagulation.

We recently investigated a case of extensive bilateral psoas muscle haemorrhage as a complication of septic disseminated intravascular coagulation (DIC) in the sequel of polytrauma. The 35-year-old woman was admitted to hospital with several rib fractures and lung injuries after a suicide attempt by jumping out of the window of her fourth-floor flat under the influence of alcohol and bromazepam. In hospital she developed sepsis and died 9 days after admission under the clinical signs of septic multiple organ failure (MODS). External examination revealed sparse post-mortem lividity as a sign of internal blood loss and bruises in the upper trunk region. At medico-legal autopsy, several ventral rib fractures were seen, resulting from the sustained trauma. The impact site was stated as the upper thoracic region. In addition, signs of septic MODS, namely shock lungs and kidneys, soft tissue oedema and a yellow discoloration of the skin were present. The woman also had early signs of peritonitis. Furthermore, mucosal haemorrhages of the gastrointestinal tract and respiratory tract and extensive bleedings of both psoas muscles (Fig. 1) extending into the retroperitoneal cavity were seen, attributable to septic DIC. It could be excluded that the haemorrhage resulted from the initial trauma as there were no surrounding soft tissue or pelvic bleedings, and the major and minor blood vessels in the vicinity of the psoas muscles were unaffected. Based on the autopsy results, death was caused by a combination of septic MODS and internal blood loss. Extensive haemorrhages of the psoas muscles are a well-known complication of anticoagulant therapy [1, 3, 4], but have, to the best of our knowledge, not yet been described in septic DIC. The psoas muscles are considered as a relatively uncommon bleeding site in coagulation disorders [3], and, thus, haemorrhages in this body region are frequently overlooked in the clinical setting. Moreover, the wide range of symptoms in cases of psoas muscle bleeding, varying from mild pain to severe femoral neuropathy and haemorrhagic shock [1, 3, 4], can lead to additional problems in establishing the correct diagnosis. This is especially true if symptoms of the primary illness are more prominent, e.g., a high body temperature or signs of organ failure in sepsis. Moreover, in patients under anaesthetics, obvious symptoms might be weakened or completely absent [4]. However, the establishment of the correct diagnosis is essential, as psoas muscle haemorrhages may lead to life-threatening and sometimes even fatal internal blood loss [3, 4]. Our case demonstrates that in patients with septic DIC, the possibility of psoas muscle haemorrhage has to be considered. Abdominal ultrasonography or computed

Sudden infant death due to pulmonary embolism.

To the Editor: With great interest we read the most recent case report of fatal pulmonary embolism in a 12-month-old boy by de la Grandmaison and Durigon (1). Recently, we have seen embolism of both pulmonary arteries as a cause of sudden death in an 11-year-old boy after surgery for epiphysiolysis capitis femoris. Postoperative prophylaxis of thrombosis was performed lege artis by subcutaneous heparin injections and physiotherapy. When the boy first got out of bed 4 days after surgery, he suddenly felt unwell. Shortly thereafter, he lost consciousness. Resuscitation was performed but yielded no success. The clinical cause of death remained unclear, and a medicolegal autopsy was performed. At external examination, an obese boy with two fresh but unobtrusive operation scars over both hips was seen. At autopsy, acute embolism of both pulmonary arteries, extending to the small branches of the vessels, was found. No pulmonary infarct was seen. Despite thorough examination of the body veins, the source of the embolism could not be detected. The operation sites were unobtrusive with no signs of inflammation. No other preexisting pathologic conditions of the inner organs were present. A hypercoagulable state, however, could not be ruled out. Sudden death due to pulmonary embolism has been reported to occur very rarely in children (2). The main risk factors have been described as congenital heart disease, recent surgery, indwelling intravenous devices, sepsis, arteriovenous malformation, occult malignancy, and prolonged immobility (2). Most likely, the operation was the predisposing condition for the formation of thrombosis in the present case. Obesity as a possible additional risk factor was also present. Signs of preexisting congenital malformations, sepsis, or malignancy, as well as idiopathic arterial calcification (3), were not found at autopsy. Signs of exsiccosis, identified as the predisposing factor for thrombosis by de la Grandmaison and Durigon (1), were also not present. In earlier studies, pulmonary emboli have been reported to arise from cardiac, mesenteric, or cerebral veins, as well as from the superior and inferior vena cava (4), whereas in adults, the deep pelvic and leg veins are the most common sources of pulmonary embolism. In our case, however, the source of the embolus could not be identified at autopsy. No thrombus was found in the superior or inferior vena cava or in the cardiac, mesenteric, or cerebral veins. Likewise, the deep leg and pelvic veins as well as the renal veins were free of thrombotic material, suggesting that the whole thrombus, from an unknown origin, had become detached and was carried to the pulmonary arteries. This case illustrates once more that pulmonary embolism has to be considered as a cause of sudden death in children after surgery, even if careful prophylaxis against thrombosis is performed.

Die gerichtsverwertbare Dokumentation von Verletzungen

Die sorgfaltige Dokumentation von Verletzungen und Spuren ist ein unverzichtbarer Bestandteil der Verletzungsbegutachtung und sollte zum fruhestmoglichen Zeitpunkt erfolgen – wenn moglich vor einer medizinischen Versorgung und bevor sich das Opfer reinigt, etwa nach einem Sexualdelikt. Die Sicherung von DNA-Spuren hat Vorrang. Eine Verletzung, die nicht rechtzeitig dokumentiert wird, ist fur ein spateres Verfahren fur immer verloren! Neben der schriftlichen Dokumentation gehort dazu auch eine Fotodokumentation, die bestimmten Standards genugt, sowie eine fachmannische Dokumentation und Sicherung von Spuren am Korper und deren fachgerechte Aufbewahrung. Ohne eine nachvollziehbare, gerichtsverwertbare Dokumentation fehlt ggf. im Gerichtsverfahren wichtiges Beweismaterial.

Die körperliche Untersuchung von Tatverdächtigen im Rahmen des Strafverfahrens

Die korperliche Untersuchung von Tatverdachtigen kann, ebenso wie die Untersuchung von Gewaltopfern, einen wesentlichen Beitrag zur Rekonstruktion von Tatablaufen liefern. So kann sie dazu dienen, einen bestehenden Tatverdacht zu erharten, Schutzbehauptungen zu entkraften oder zu Unrecht Beschuldigte zu entlasten. Leider wird trotz der potenziell grosen Bedeutung einer fruhzeitigen Untersuchung des Tatverdachtigen im Strafverfahren haufig auf sie verzichtet. Da der rechtsmedizinische Sachverstandige mit juristischem Denken vertraut ist und die wesentlichen Fragestellungen kennt, sollte die Untersuchung eines Tatverdachtigen durch einen klinisch-forensisch versierten Rechtsmediziner in Zusammenarbeit mit der Polizei erfolgen.