Gregory G. Davis

Preexisting conditions and mortality in older trauma patients.

BACKGROUND Among older trauma patients, those with preexisting chronic medical conditions (CMCs) appear to have an elevated risk of death. Whether this association is dependent on the severity of injury or other occult factors remains unanswered. This study evaluated the association between preexisting CMCs and risk of death among older trauma patients according to injury severity. METHODS This was a retrospective cohort study using data from the National Trauma Data Bank, a registry of trauma patients admitted to 131 trauma centers across the United States. The main outcome measure was in-hospital mortality. RESULTS In patients 50 to 64 years of age who sustain severe (Injury Severity Score [ISS] of 26+) and moderate injuries (ISS of 16-25), the presence of one or more CMCs is not associated with an increased relative risk (RR) of death (RR, 0.80 and 95% confidence interval [CI], 0.71-0.90; RR, 1.09 and 95% CI, 0.95-1.24, respectively). Those with minor injuries (ISS < 16) have increased risk of death (RR, 2.80; 95% CI, 2.33-3.36). For those patients 65 years of age and older who sustain severe, moderate, and minor injuries, the pattern of results is similar (RR, 0.91 and 95% CI, 0.83-1.00; RR, 1.13 and 95% CI, 1.04-1.23; and RR, 1.88 and 95% CI, 1.73-2.05, respectively). CONCLUSION Older trauma patients with CMCs who present with minor injuries should be considered to have an increased risk of death when compared with their nonchronically ill counterparts.

Methamphetamine as a risk factor for acute aortic dissection

Acute aortic dissections are catastrophic vascular events that have a high rate of mortality. Aortic dissections have been associated with a variety of factors, particularly hypertension. We reviewed 84 medical examiner autopsies on individuals dying from acute aortic dissections with particular emphasis on the role of drugs. Previous case reports have associated aortic dissections with both cocaine and methamphetamine intoxication. We found that seven of the 35 cases tested for drugs of abuse were positive for methamphetamine. Our study had no cases of solely cocaine-related dissection, although one of the cases was positive for both methamphetamine and the cocaine metabolite benzoylecgonine. No significant association was found with any other drugs. As with other studies, we found the most common risk factor to be hypertension. Surprisingly, methamphetamine use was the second most common risk factor. The association between methamphetamine use and aortic dissection is most likely due to its hypertensive effect. Although methamphetamine appears to pose a greater risk than cocaine, both drugs should be considered as possible factors in all aortic dissections.

Comparison of Anti-Epileptic Drug Levels in Different Cases of Sudden Death

Sudden unexplained death syndrome (SUDS) in epilepsy is identified as death in an epileptic individual with no anatomic cause found at autopsy. SUDS appears to be associated with subtherapeutic levels of anticonvulsants. Sudden death with no demonstrable cause at autopsy accounts for 5% to 30% of deaths in epileptic individuals. In the majority of cases, however, the cause of death in epileptic individuals can be demonstrated at autopsy. We examined the anti-epileptic drug concentrations in decedents who died as a direct result of epilepsy and compared these findings with those from a control population of epileptic patients who died suddenly due to some unrelated cause. This retrospective study was conducted on all deaths involving patients with epilepsy examined at the Jefferson County Coroner/Medical Examiner office from 1986-95. Out of 115 total cases the underlying cause of death was epilepsy in 60 cases--52 cases of SUDS and 8 deaths caused by an accident precipitated by a seizure. In 44 cases death was unrelated to the decedents epilepsy. In 11 cases the contribution of epilepsy to death could not be determined. Published articles on SUDS report subtherapeutic anti-epileptic medication levels in 63% to 94% of cases. We found subtherapeutic drug levels in 69% of the 52 cases of SUDS, in 75% of the 8 cases where a seizure precipitated an accident causing death, and in 34% of the control population. The incidence of subtherapeutic anticonvulsants is significantly greater in patients dying as a direct result of their epilepsy than in those dying of an unrelated cause.

Acute Aortic Dissections and Ruptured Berry Aneurysms Associated with Methamphetamine Abuse

Sudden, unexpected death can occur following rupture of an artery weakened by aneurysmal dilatation or by medial dissection. In both of these diseases the arterial abnormality is exacerbated by hypertension. This arterial weakness could also be aggravated by the use of drugs with a hypertensive effect. We report seven cases of sudden death in patients abusing methamphetamine--four cases of ruptured berry aneurysms and three cases of aortic dissection with cardiac tamponade. The autopsy findings are reviewed, and various mechanisms are considered by which methamphetamine may contribute to death in such cases.

Pelvic trauma in rapidly fatal motor vehicle accidents.

Objective To study the incidence and nature of pelvic fractures in rapidly fatal automobile accidents. Design Retrospective. Setting County Medical Examiners Office. Patients The files of 255 consecutive motor vehicle accident fatalities examined at the Jefferson County Coroner/Medical Examiners office (study period 1996–1998) were reviewed. We orrelated this information with our previous findings, derived from a review of 392 such cases (study period 1994–1996). Results Approximately 25% of decedents involved in rapidly fatal automobile accidents sustained pelvic fractures. In 93% of the cases, postmortem radiographs were available and suitable for scoring according to the Orthopaedic Trauma Association nomenclature. The distribution of pelvic fractures by type was type A, 16%; type B, 32%; and type C, 52%, with the most common pelvic fracture being type C1 (26%). Additionally, pedestrians and motorcyclists were twice as likely to sustain a pelvic fracture, and the severity of pelvic fracture type seemed to correlate with increasing speed of the automobile. No correlation between drug use or direction of impact and incidence or type of pelvic fracture was observed. Compared with published studies on survivors of automobile accidents, our data suggest that pelvic injuries may tend to be more severe in victims who do not survive to hospitalization. Conclusions Our data indicate that current estimates about the mortality of pelvic fractures may be faulty due to exclusion of victims who fail to survive to hospitalization. This series suggests that an appreciation of the full spectrum of pelvic ring disruptions requires collaboration between orthopaedic surgeons and forensic pathologists.

THE INCIDENCE OF ACUTE COCAINE OR METHAMPHETAMINE INTOXICATION IN DEATHS DUE TO RUPTURED CEREBRAL (BERRY) ANEURYSMS

Acute intoxication with either cocaine or methamphetamine may contribute to formation and rupture of a berry aneurysm by causing transient hypertension and tachycardia. We report the results of a retrospective study to determine the incidence of acute cocaine or methamphetamine intoxication in deaths due to ruptured berry aneurysm in our jurisdictions. We reviewed all deaths from ruptured cerebral aneurysms that fell within our jurisdictions during the seven years from 1 January 1987 to 31 December 1993 and found 83 cases. The mechanism of death invariably involved subarachnoid hemorrhage, although some cases also had intracerebral hemorrhage. A history of drug abuse was found in 13 cases. Toxicological analysis was performed in 39 cases. Of these methamphetamine was detected in six cases and cocaine in three cases--an incidence of 21%. (In one case both methamphetamine and cocaine were detected). The incidence of acute cocaine intoxication in all autopsies in Jefferson County was 13.6%. The incidence of methamphetamine intoxication in all autopsies in San Diego County was 4.9%. Although the exact mechanism by which berry aneurysms form remains undetermined, research indicates that propagation and rupture of the aneurysm are aggravated by hypertension and tachycardia, both of which are pharmacologic side effects of cocaine and methamphetamine. Based on the preponderance of methamphetamine associated with deaths due to ruptured berry aneurysms it appears that methamphetamine is more toxic than cocaine, perhaps owing to the longer half-life of methamphetamine.

Complete republication: National Association of Medical Examiners position paper: Recommendations for the investigation, diagnosis, and certification of deaths related to opioid drugs.

The American College of Medical Toxicology and the National Association of Medical Examiners convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance. The panel finds the following:1. A complete autopsy is necessary for optimal interpretation of toxicology results, which must also be considered in the context of the circumstances surrounding death, medical history, and scene findings.2. A complete scene investigation extends to reconciliation of prescription information and pill counts.3. Blood, urine, and vitreous humor, when available, should be retained in all cases. Blood from the femoral vein is preferable to blood from other sites.4. A toxicological panel should be comprehensive and include opioid and benzodiazepine analytes, as well as other potent depressant, stimulant, and anti-depressant medications.5. Interpretation of postmortem opioid concentrations requires correlation with medical history, scene investigation, and autopsy findings.6. If death is attributed to any drug or combination of drugs (whether as cause or contributing factor), the certifier should list all the responsible substances by generic name in the autopsy report and on the death certificate.7. The best classification for manner of death in deaths due to the misuse or abuse of opioids without any apparent intent of self-harm is “accident.” Reserve “undetermined” as the manner for the rare cases in which evidence exists to support more than one possible determination.The American College of Medical Toxicology and the National Association of Medical Examiners convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance. The panel finds the following: 1. A complete autopsy is necessary for optimal interpretation of toxicology results, which must also be considered in the context of the circumstances surrounding death, medical history, and scene findings. 2. A complete scene investigation extends to reconciliation of prescription information and pill counts. 3. Blood, urine, and vitreous humor, when available, should be retained in all cases. Blood from the femoral vein is preferable to blood from other sites. 4. A toxicological panel should be comprehensive and include opioid and benzodiazepine analytes, as well as other potent depressant, stimulant, and anti-depressant medications. 5. Interpretation of postmortem opioid concentrations requires correlation with medical history, scene investigation, and autopsy findings. 6. If death is attributed to any drug or combination of drugs (whether as cause or contributing factor), the certifier should list all the responsible substances by generic name in the autopsy report and on the death certificate. 7. The best classification for manner of death in deaths due to the misuse or abuse of opioids without any apparent intent of self-harm is “accident.” Reserve “undetermined” as the manner for the rare cases in which evidence exists to support more than one possible determination.

A 15 year retrospective review of homicide in the elderly.

With constant improvements in socioeconomic conditions, the people of most industrialized nations are living longer. Most elderly individuals lead productive lives within the community. Unfortunately, when elderly individuals suffer from a debilitating disease or injury, society seems ill-equipped to care for them. The frailty and social isolation that comes with illness or advanced age renders the elderly more vulnerable to crime. This study examines the circumstances that surround homicides of those 65 years of age or older which occurred in Jefferson County, Alabama over a 15 year span. We conducted a retrospective study of all decedents brought to the Jefferson County Coroner/Medical Examiner Office during the 15 years from 1981-1995. A computer search identified 150 homicide victims who were 65 years or older. In these 150 cases the causes of death were as follows: gunshot wound 50%, blunt force injuries 19%, knife wounds 14%, and asphyxiation 10%. Younger homicide victims were much less likely to be killed as the result of a direct physical assault; blunt force injuries and asphyxiation combined caused death in only 7% of the younger population. Robbery was the most common motive for death in the elderly population, which accounted for 37% of cases. The most common location for homicides in the elderly population was in their own residence, which accounted for 71% of cases. Four elderly homicide victims were shot by the police. Three elderly decedents died as a result of abuse.

MIND YOUR MANNERS. PART I : HISTORY OF DEATH CERTIFICATION AND MANNER OF DEATH CLASSIFICATION

Every death is unique, but deaths also share similar features that allow them to be grouped into categories. Since its initial description over 800 years ago, the position of coroner has been charged with the determination of manner of death. This determination has been made by examination into the circumstances surrounding death and of wounds on the surface of the body. Over the years, physicians have gained sufficient understanding of the body such that the autopsy became an important part of a death investigation. With additional time, laws were changed so that individuals charged with the determination of manner of death were required to have appropriate training. Death certification is the means by which deaths are grouped together according to similar characteristics. The practice of death certification has led to effective public health programs and the advancement of medical science. The addition of manner of death to the death certificate is an American contribution to vital statistics registration. The purpose of the autopsy report differs from that of the death certificate; the report fully addresses the unique aspects of a death, while the certificate captures the essence of the circumstances surrounding death in a few words.

The April 8, 1998 tornado: assessment of the trauma system response and the resulting injuries

BACKGROUND On April 8, 1998, an F5 tornado touched down in two counties of Alabama producing a wide path of destruction. The presence of a regional trauma system in this area presents an opportunity to evaluate the effectiveness of the system in responding to the victims of this natural disaster. METHODS Emergency room logs and the regional trauma system database were searched for all patients treated for injuries sustained from the tornado, and medical records were reviewed for demographic information, mode of transportation to hospital, injuries, treatment, and outcome. Fatalities were identified by means of the coroners office. RESULTS A total of 224 patients were evaluated at nine area hospitals, of whom 63 (28%) required admission. There were 32 deaths: 30 persons were dead at the scene, and 2 patients subsequently died at Level I trauma centers. Among patients with nonfatal injuries, 39% were managed at Level I facilities, 46% at Level III facilities, and 15% at nontrauma facilities. Forty patients (55%) seen at Level I facilities required admission compared with 15 patients (17%) at Level III facilities and 8 patients (29%) at nontrauma facilities; Level I facilities also had the highest Injury Severity Score. Of patients requiring admission, 83% were transported by emergency medical services; these patients also had the highest Injury Severity Score. CONCLUSION The regional trauma system facilitated appropriate and efficient triage to system hospitals, routing the most severely injured patients to the Level I centers without overwhelming them with the more numerous, less severely injured patients.