Kelly Olds

Injuries associated with resuscitation - An overview.

External cardiopulmonary resuscitation is a potentially lifesaving intervention aimed at preserving the cerebral function of a person in cardiac arrest. However, certain injuries can be caused by the various techniques employed. Although these are seldom consequential, they may complicate the forensic evaluation of cases. Fractures of the ribs and sternum are the most common internal injuries and are frequently acknowledged as a consequence of resuscitation. Nonethlesss, the recognition that less common fractures such as of the larynx or injuries involving the stomach, spleen, heart and liver can occur due to resuscitation will assist the forensic examiner assess the significance of these findings when they present in cases of sudden death.

Injury patterns and features of cycling fatalities in South Australia

There has been an increase in cycling in Australia. This means that more cyclists are at risk of injuries, which account for a proportion of transport-related fatalities. In this study, all cyclist fatalities from 2002 to 2013 in South Australia where post-mortem examinations were performed were investigated. There were 42 deaths representing 3% of the total road fatalities over the same time. Of this total number of cases, 13 deaths (31%) involved collapse (mostly natural causes from an underlying medical condition) and 29 (69%) resulted from trauma. There were no cases of hyperthermia. Of the decedents 95% were male, and the mean age at death was 47 years. Fatal incidents were more likely to occur during April and November, and on a Monday. However, statistical analysis was not possible due to the small number of cases. Fatalities (traumatic and collapse) predominantly occurred whilst the cyclist was riding (86%). The majority of riding fatalities were as a result of collision with vehicles (81%). Drugs (including alcohol) were detected in two (15%) of the 13 cases of the collapses, and in seven (26%) of the 27 trauma cases tested. In trauma cases, death was most often due to multiple injuries. The most frequent area for injury was the head (found in 90% of traumatic deaths). Despite the increasing numbers of cyclists on South Australian roads over the last decade, death rates have trended downwards suggesting that road safety campaigns and the provision of more dedicated bicycle lanes have had a positive outcome.

Heterotopic ossification following surgery: an unusual cause of resuscitation injury

Case reportA 55-year-old male with a medical history of cerebrovas-cular accident, coronary artery bypass grafting, type IIdiabetes mellitus, and infection of the leg (following cor-onary bypass grafting), collapsed after sexual intercourse.Resuscitation was unsuccessful.At autopsy, a healed vertical thoracotomy scar extend-ing to the xiphisternum, associated with underlying denseperi- and epicardial fibrous adhesions was found. Patentcoronary artery bypass grafts were connected to the leftanterior and posterior descending coronary arteries, withthe distal native vessels demonstrating marked atheroscle-rosis with significant stenosis. Myocardial fibrosis with fullthickness scarring of the left ventricular free wall wasconfirmed microscopically, with no evidence of acuteischemic myocardial damage. An area of previous ischemicinjury was identified in the right basal ganglia of the brain.There were no injuries; toxicology and biochemistry testswere unremarkable. No other underlying organic illnesseswere present which could have caused or contributed todeath. Death was therefore attributed to ischemic heartdisease.Also noted at autopsy were multiple rib fractures and alaceration of the liver, the results of attempts at resuscita-tion. Specifically, there were recent fractures (withoutintercostal muscle/soft tissue hemorrhage) of the second toseventh ribs on the left, and the second to ninth ribs on theright, in the mid-clavicular lines. Within the abdomen therewas a 3 cm long vertical laceration of the anterior surfaceof the left lobe of the liver in the midline, which extendedto a depth of approximately 1 cm (Fig. 1). There wassubcapsular bruising surrounding the tear but no intra-abdominal bleeding. Histological examination of samplesfrom the region of the laceration revealed no inflammatoryreaction.Of note, the liver laceration had been caused by a3.5 cm bony spur that projected downwards from thexiphisternum (Fig. 2). The bony spicule measuredapproximately 0.3 cm in diameter and ended in a terminalnodule 0.5 cm in diameter (Fig. 3). The bone spur hadarisen from heterotopic ossification within an area of densefibrous scar tissue associated with the previous coronaryartery bypass surgery. This calcified extension had causedthe tear in the liver when resuscitation was performed.Radiography confirmed the bony nature of the tissue(Fig. 4) and that it was not an extension of the wire suturethat had been used to close the sternum after cardiacsurgery.DiscussionHeterotopic ossification refers to the phenomenon of boneformation within extraskeletal soft tissues or organs. It canfollow trauma, surgery or burns, as well as being found incertain genetic disorders [1, 2]. It may also arise in bothbenign and malignant tumors, the latter caused by possiblestromal fibroblast metaplasia [3]. Heterotopic ossificationhas to be distinguished from extraskeletal or metastaticosteosarcoma as the pathogenesis and prognosis areentirely different [4, 5].

The pathological features of Wernicke encephalopathy

Case reportA 47-year-old man with a history of alcoholic liver diseasewas found dead at his home address on the floor, lying facedown. He had been unwell for 2 months prior to death andhad complained of abdominal pain. He also had a diagnosisof prolonged QT interval.At autopsy there was no evidence of liver failurealthough the liver was fatty and fibrotic. There was acongenital anomaly of the coronary arteries with the cir-cumflex coronary artery arising from the right sinus ofValsalva with significant narrowing of the ostium. Therewas no evidence of trauma and toxicological screening ofblood was unremarkable. Biochemical analysis of vitreoushumor revealed elevated sodium (144 mmol/L) and creat-inine (217 lmol/L) levels in keeping with terminal dehy-dration and renal failure, with a normal b-hydroxy butyrate(thus excluding alcoholic ketoacidosis).Althoughthebrainappearedexternallyunremarkablewithnovermal atrophy of the cerebellum, sectioning of the mammillarybodiesdemonstratedsymmetricalhemorrhagehighlysuggestiveof Wernicke encephalopathy (Figs. 1, 2). Focal hemorrhagicareas were also noted within the walls of the third ventricle.Microscopically the mammillary bodies displayedrecent microhemorrhages and prominent microvascularproliferation with endothelial swelling typical of Wernickeencephalopathy (Fig. 3). The mammillothalamic tracts andthe walls of third ventricle also contained microhemor-rhages. There was patchy microvacuolation of the neuropilwith unremarkable neurons, fibrous astrocytes, and occa-sional perivascular macrophages containing hemosiderin,indicative of more chronic disease. Mild extravasation oferythrocytes and prominent congested vessels were notedwithin medullary dorsal motor vagal nuclei.Death was attributed to natural causes, most likelyinvolving a combination of cardiac and alcohol-relateddisease. The striking finding was of clinically unsuspectedWernicke encephalopathy.DiscussionWernicke encephalopathy is a neurological disorderresulting from thiamine (vitamin B-1) deficiency [1].Although in Western countries it occurs predominantly inalcoholics, related to poor dietary intake and impairedutilization, it can also be caused by a variety of otherconditions that interfere with normal thiamine metabolism.These include starvation, bariatric surgery, hyperemesisgravidarum, human immunodeficiency virus/acquiredimmunodeficiency syndrome (HIV/AIDS), and in infantsgiven thiamine-deficient formulas [1, 2].The clinical prevalence of Wernicke encephalopathy isuncertain as autopsy studies indicate that the condition islikely under-diagnosed during life [3]. Delay in diagnosismay result from nonspecific symptoms that resembleintoxication. The symptoms, severity, and the regions ofthe brain that are affected are also variable due to a

Can trends in coronial post-mortem examinations be determined from the ncis database?

S S93 light sources to enhance the visibility of bruising should be undertaken with caution. CAN TRENDS IN CORONIAL POST-MORTEM EXAMINATIONS BE DETERMINED FROM THE NCIS DATABASE? Kelly Olds, Michael Rodriguez, Neil Langlois 1Forensic Science South Australia, Adelaide, and The University of Adelaide, School of Medical Sciences, Adelaide, SA, and 2Prince of Wales Hospital, Randwick, NSW, Australia There have been changes to Coronial Acts in some States to allow limited examinations or promote the minimum examination necessary to determine a cause of death. Has this impacted on Coronial autopsy numbers and the proportion of partial or external only examinations? An answer to this question was sought using the National Coronial Information Service (NCIS) database. However, this service does not code post-mortem examinations as external, partial or full. An automated method to extract the data using key phrases was devised and tested. However, it was only possible to apply this data extract technique to two States. The trends over ten years will be shown and the data discussed. KAWASAKI DISEASE: A REVIEW OF 2 CASES OF SUDDEN DEATH Sarah Parsons, Matthew Lynch Victorian Institute of Forensic Medicine and Monash University, Vic, Australia Kawasaki disease is a febrile, usually self-limited illness of childhood, which commonly starts with an arteritis. We will present two cases of Kawasaki disease leading to sudden death; one in the acute phase and one 22 years after the initial illness. The first case was a 5-month-old infant who presented to a tertiary hospital with a febrile illness, conjunctivitis and erythema of the skin of the hands. Kawasaki disease was considered in the list of differentials, however as he responded to antibiotic treatments he was discharged home. At autopsy the deceased was found to have a haemopericardium with a ruptured coronary artery aneurysm. He had widespread arteritis. The second case was that of a 22-year-old man who collapsed whilst playing football. He had been diagnosed at 6 months of age with Kawasaki disease complicated by left and right coronary artery aneurysms. Autopsy findings (gross and histological) and PM CT images will be presented in these cases along with a review of current guidelines into diagnosis. SUDDEN CARDIAC DEATH WHILST PLAYING AUSTRALIAN RULES FOOTBALL: A RETROSPECTIVE 14 YEAR REVIEW Sarah Parsons, Matthew Lynch Victorian Institute of Forensic Medicine and Monash University, Vic, Australia Australian Rules football (AFL) is a sport unique to Australia. It is played and followed widely in most states of Australia but particularly in Victoria. The death of a player during a professional or recreational game of AFL is usually widely reported and affects not only the family but the whole club, often raising questions about whether more can be done to ensure that sudden cardiac deaths don’t occur in these settings. Pre-participation screening is often discussed as a way to avoid sudden cardiac deaths at least at a semi-professional level. A good understanding of the autopsy findings in young men who die during particular sport will help to add to the discussion on whether testing will help to decrease the incidence of these deaths occurring. This paper will examine 14 cases where sudden cardiac death has occurred whilst playing AFL over a 14 year period in the state of Victoria in young males. This cohort demonstrates a wide variety of cardiac findings both expected and unexpected. There will be a discussion on the variety of autopsy findings which range from possible anatomic causes of death, to genetic finding and other causes (such as commotio cordis). The contribution of anatomical or genetic findings alone as the cause of death will also be explored. Given the wide variety of causes of death in this cohort it is probable that pre-participation screening may have been able to detect a small number of cases but most would have gone undetected. VEHICLE ASSISTED LIGATURE STRANGULATION Bianca Phillips, Nathan Milne Forensic and Scientific Services, Health Support Queensland, Queensland Department of Health, Qld, Australia This is a case report of an unemployed young adult male with a history of substance abuse and recent domestic dispute that committed suicide by vehicle assisted ligature strangulation (VALS). VALS is a rare method of suicide in which a motor vehicle is used to apply pressure to the neck by a ligature, which is fixed to a structure outside of the vehicle. There are only a handful of cases previously documented in the literature. The findings in these cases are varied and show one of three patterns of injury: complete decapitation, lethal injury to the internal structures of the neck or sustained pressure to the neck. This case showed a combination of findings with both significant injury to the internal structures of the neck and features of sustained pressure to the neck. Review of the literature showed that some of the variation in pattern of injury seen could be attributed to the intactness of the ligature. It is likely that other factors also play a role including the force applied by the motor vehicle and the characteristics of the ligature used such as material and width. Further case reports are required to further our understanding of this rare mechanism of suicide.

How useful are ultraviolet, infrared, and narrow band light sources for enhancing occult bruises in cases of assault?

Bruises result from the application of blunt forces that cause tearing of blood vessels within the dermis causing leakage of blood into the surrounding tissues [1]. Thus, a bruise can be identified by the presence of erythrocytes in the tissue adjacent to blood vessels. Bruising is often noted in cases of violence including child abuse, and is documented in up to 65 % of sexual assaults [2–4]. These injuries serve as evidence of trauma that can be extremely important in a forensic context. However, bruises may not always be visible to the naked eye due to factors such as skin color and depth of injury [5, 6]. Therefore, enhancing their detection may improve forensic assessments. The human eye perceives light in the 400–700 nm wavelength range of the electromagnetic spectrum that is commonly referred to as normal light or ‘‘white’’ light, as it combines all the individual wavelengths of colors from red to violet. On either side of this spectrum are ultraviolet and infrared; ultraviolet is shorter in wavelength (400–10 nm) and infrared is longer, ranging from 700 to [10,000 nm [7]. In usual circumstances a bruise would be viewed by observation of the light it reflects. The visual perception of a bruise occurs due to scattering and absorption of regions of the illuminating white light spectrum [8–10]. Narrow band light sources emit a reduced part of the spectrum (one color) that provides an alternative method of viewing bruises using the phenomenon of Stokes shift [11]. A filter blocks the illuminating light so that the fluoresced light of a longer wavelength is recorded [12]. Ultraviolet and infrared lighting may also be used; collectively these light sources can be termed alternative light sources. Alternative light sources have been employed in the forensic field to enhance the visibility of items of evidentiary importance including bite marks, bodily fluids, and latent fingerprints [13–15]. It has been proposed that alternative light sources could also be useful in revealing occult bruises; for example, in the 1990s the use of ultraviolet photography was recommended to enhance the appearance of bruises for forensic purposes [16]. Following this, further studies were conducted that also supported the use of ultraviolet light [17– 19]. However, there has been little further research on the validity of ultraviolet light sources in this context in more recent years. There has also been some interest in the use of infrared photography to reveal the presence of notor barely-visible bruises due to the ability of near infrared light (up to 1000 nm) to penetrate the skin more deeply than visible light [10, 20, 21]. Although a recent study did show that infrared photography was able to identify unapparent bruising [22], most studies have failed to show that infrared light sources are any better than white light illumination [23–25]. In 2004, the United States Department of Justice recommended the use of narrow band light sources to enhance subtle injury [26], even though definitive evidence to validate this method of assessment was lacking. Despite this, there are forensic programs in the United States that recommend the use of these light sources to identify unapparent bruising [13]. Two recent studies which found that the use of narrow band light sources in the visible spectrum did enhance & Neil E. I. Langlois neil.langlois@sa.gov.au