Michael Tsokos

Frequent and rare complications of resuscitation attempts

IntroductionResuscitation attempts require invasive iatrogenic manipulations on the patient. On the one hand, these measures are essential for survival, but on the other hand can damage the patient and thus contain a significant violation risk of both medical and forensic relevance for the patient and the physician. We differentiate between frequent and rare resuscitation-related injuries. Factors of influence are duration and intensity of the resuscitation attempts, sex and age of the patient as well as an anticoagulant medication.Materials and methodsReview of current literature and report on autopsy cases from our institute (approximately 1,000 autopsies per year).ResultsFrequent findings are lesions of tracheal structures and bony chest fractures. Rare injuries are lesions of pleura, pericardium, myocardium and other internal organs as well as vessels, intubation-related damages of neural and cartilaginous structures in the larynx and perforations of abdominal organs such as liver, stomach and spleen.ConclusionWe differentiate between frequent and rare complications. The risk of iatrogenic CPR-related trauma is even present with adequate execution of CPR measures and should not question the employment of proven medical techniques.

Death due to ingestion of nicotine-containing solution: Case report and review of the literature

Nicotine, a lipid-soluble alkaloid obtained from the dried leaves of Nicotiana, is most frequently encountered in tobacco products for smoking, chewing or sniffing as well as in a limited number of pesticides. Though nicotine is one of the most toxic drugs of abuse, it has rarely led to fatalities. Sudden death can be caused by cardiovascular arrest, respiratory muscle paralysis and/or central respiratory failure. A 42-year-old man was found dead by his wife. He was lying on the floor, next to a box containing many empty bottles of beer and vodka. Some labeled chemical bottles found at the scene contained various substances, including nicotine and brucine. Gross examination of the organs at autopsy revealed no specific findings. The toxicological examination failed to disclose any lethal toxic agents other than a high concentration of nicotine and its primary metabolite cotinine in femoral venous blood (2.2 microg/mL). Blood alcohol was determined to be 2.1 g/L in femoral venous blood. Only a paucity of fatal cases of nicotine poisoning has been reported in the literature so far.

Clinical diagnosis versus autopsy findings in polytrauma fatalities.

ObjectivesThe aim of the study was to determine if differences in clinical diagnosis versus autopsy findings concerning the cause of death in polytrauma fatalities would be detected in 19 cases of fatal polytrauma from a Level 1 trauma centre.MethodsClinical diagnoses determining the cause of death in 19 cases of fatal polytrauma (2007 - 2008) from a Level 1 trauma centre were correlated with autopsy findings.ResultsIn 13 cases (68%), the clinical cause of death and the cause of death as determined by autopsy were congruent. Marginal differences occurred in three (16%) patients while obvious differences in interpreting the cause of death were found in another three (16%) cases. Five fatalities (three with obvious differences and two with marginal differences) were remarked as early death (1-4 h after trauma) and one fatality with marginal differences as late death (>1 week after trauma). Obvious and marginal discrepancies mostly occurred in the early phase of treatment, especially when severely injured patients were admitted to the emergency room undergoing continued cardiopulmonary resuscitation, i. e. limiting diagnostic procedures, and thus the clinical cause of death was essentially determined by basic emergency diagnostics.ConclusionsAutopsy as golden standard to define the cause of death in fatal polytrauma varies from the clinical point of view, depending on the patients pre-existing condition, mechanism of polytrauma, necessity of traumatic cardiopulmonary resuscitation, survival time, and thus the possibility to perform emergency diagnostics. An autopsy should be performed at least in cases of early fatal polytrauma to help establishing the definite cause of death. Moreover, autopsy data should be included in trauma registries as a quality assessment tool.

Multidrug poisoning involving nicotine and tramadol

A fatal case of multidrug poisoning by tramadol and nicotine is reported. Tramadol is a centrally acting analgesic used in the treatment of moderate to severe acute or chronic pain. Nicotine, a lipid-soluble alkaloid, is one of the most readily available drugs in modern society. A 46-year-old man was found dead in his bed, and a suicide note was discovered near the body. He had 25 transdermal nicotine patches attached to his thorax and abdomen. Two half emptied bottles were found on the bedside table; the toxicological examination revealed that they contained tobacco and nicotine as well as other drugs such as diphenhydramine. At autopsy, areas of fresh and old myocardial infarction as well as diffuse pulmonary congestion and edema were present. The tramadol concentration was 6.6 microg/mL in femoral venous blood, while levels of nicotine and its primary metabolite cotinine were determined to be 0.6 and 2.0 microg/mL in femoral venous blood. Based on these results, we determined the cause of death to be cardiorespiratory failure induced by the additive effects of tramadol and nicotine shortly after consumption.

Fatal aspiration of barium sulfate.

Five weeks after a laparoscopic cholecystectomy an obese 64-year-old woman swallowed 100 ml of barium sulfate as part of a diagnostic radiographic contrast medium examination for a suspected invasive gastric carcinoma. After drinking the medium, she suddenly started vomiting while lying supine with resultant aspiration and minimal coughing. She was transferred to the Intensive Care Unit (5 h later). Chest X-rays showed bilateral alveolar opacities, predominantly on the right (Fig. 1) and bronchoscopy revealed white foamy barium residue in both lungs. Due to increasing dyspnea, she underwent endotracheal intubation with controlled artificial respiration. Subsequent radiographs showed bilateral aspiration pneumonia. Her clinical course was marked by adult respiratory distress syndrome (ARDS) with death 35 h after the event due to respiratory insufficiency from aspiration of barium sulfate complicated by aspiration pneumonia. A medicolegal autopsy confirmed the clinical findings with extensive pneumonia caused by contrast medium aspiration, particularly of the right lung, and a malignant gastric neoplasm with widespread lymphatic node metastases. Histology of the lungs showed polarizing rhomboid crystalline accumulations within the alveolar spaces with granulocytic infiltration, and hyaline membrane formation. Macrophages had also incorporated barium sulfate particles (Fig. 2).

Natürliche Mumifikation im häuslichen Milieu

Abstract The forensically relevant aspects of mummification were investigated in six fatalities from the years 1996–¶1998. The deceased (6 males between 22 and 77 years) had lived socially isolated. The postmortem interval was between 8 months and 5 years. On external examination the bodies showed – mostly combined – putrefaction, postmortem insect artifacts and different stages of decomposition, especially mummification (so-called secondary mummification). The differentiation of certain organs by inspection with the naked eye was a problem to some extent. Histopathological examinations presented relevant findings for further elucidation of the cause of death. Immunhistochemical staining with myeloperoxidase revealed confluent bronchopneumonia in one case of 19 months postmortem interval. In a case of known chronic heroin consumption morphine was detected after a postmortem interval of 31 months. Apart from forensic pathology and toxicology aspects and criminal investigations, these fatalities are also noteworthy from the point of view of social medicine.Zusammenfassung Sechs Todesfälle mit natürlicher Mumifikation aus den Jahren 1996–1998 wurden im Hinblick auf forensisch verwertbare Befunde untersucht. Es handelte sich um 6 Männer zwischen 22 und 77 Jahren, die, sozial isoliert, in mehrgeschossigen Wohnblöcken aufgefunden wurden. Die Leichenliegezeit betrug 8 Monate bis 5 Jahre. Bei äußerer Leichenschau fanden sich, in den meisten Fällen kombiniert, die Befunde der Fäulnis, des Insektenfraßes, der Verwesung und insbesondere der vorgeschrittenen Mumifikation (sekundäre Mumifikation). Makroskopisch war an den noch erhaltenen Organresten eine Organdiagnose z.u2002T. problematisch. Histopathologisch kamen Befunde zur Darstellung, die wesentlich zur Abklärung der Todesursache beitragen konnten. Durch immunhistochemische Anfärbung (Myeloperoxidase) gelang der Nachweis einer konfluierten Bronchopneumonie nach 19-monatiger Leichenliegezeit. Ein positiver Morphin-Nachweis bei chronischem Heroinkonsum war noch nach 31 Monaten möglich. Über das rechtsmedizinische und kriminalistische Interesse hinaus ist der sozialmedizinische Aspekt derartiger Todesfälle beachtenswert.

Child starvation and neglect: a report of two fatal cases.

Fatal starvation is a rare cause of death in industrialised countries. In such cases, investigation of death is never an easy task for forensic pathologists who need to couple autopsy findings with full investigation of the crime scene and family record to establish if death results from deliberate neglect, maltreatment and withholding of food. The present article describes two cases of death caused by child neglect. The first case involved a 16-month-old female who died from starvation with dehydration as a contributing factor. In the second case a 7-year-old girl died from ultimate aspiration of stomach contents that had been vomited during the childs last meal because of the fecal concretions blocking the intestinal passage. In both cases macroscopic and histological findings revealed severe chronic malnutrition; crime scene investigations confirmed stories of child maltreatment and neglect.

Injury pattern after a fatal feet-first fall from a building

A 49-year-old man was found dead in front of a building. A stairway window (freely accessible, 9th floor) directly above a porch (1st floor) was open. Witnesses close to the building heard a noise and found the man lying on the ground, but the fall itself had not been observed. Emergency personnel were called to the scene immediately, but on arrival—7 min after the incident—resuscitation procedures were not carried out, as the man was dead at the scene. On cursory inspection of the body at the scene— without undressing him—the body seemed to the emergency physician ‘‘too uninjured to have sustained a fall from the 9th floor’’ (approx. 27 m), although both legs were shortened and the lateral seams of the jeans were disrupted on the left side (Fig. 1). Despite the absence of indications of a struggle at the scene, investigators could not exclude involvement of a third party. Forensic pathological examination of the victim, which was performed at the site of the incident, showed that fragments of distal tibia and fibula shafts protruded through the soles of the man’s feet and shoes (Fig. 2). Pelvic and chest areas were unstable, which was consistent with severe internal injury due to a fall from height. In view of autopsy findings, death was attributed to extensive injuries involving severe craniocerebral, chest, vertebral column and pelvic trauma with severe visceral damage, e.g. rupture of the heart and the aortic root. In

Circumstantial and toxicological features of deaths from self-administered intravenous anesthetic/narcotic agents

For a better understanding of circumstantial and toxicological findings of fatalities resulting from self-administration of intravenous anesthetic/narcotic agents, medico-legal autopsy files of the State Institute of Legal and Social Medicine Berlin from 1998 to 2011 were reviewed retrospectively. Of a total of 15,300 autopsies, 9 cases of such deaths were identified, and all were health care professionals. Medical supplies for injection were found still on, or near, the body at the scene. Anesthetic/narcotic agents detected were classified into 3 categories, and administered solely or in combination. Propofol was the most common agent, being detected in 6 cases. In 2 out of 6 cases, propofol was detected substantially above therapeutic levels and was considered the cause of death. In the remaining 4 cases, propofol levels were within the therapeutic range, but propofol intoxication was considered as lethal due to it being administered by rapid continuous injection. In 5 cases, injection of opioid narcotics was fatal. Alongside the 2 propofol-detected cases, there was one case where a higher-than-therapeutic level of piritramide and a therapeutic level of alfentanil was identified. Despite suspected usage, remifentanil was not detected due to its rapid metabolism by elastases in one case, and sufentanil was undetectable due to putrefaction in another, but death was attributed to their potent respiratory depressant effects without respiratory assistance. Benzodiazepines were detected in 4 cases. All of them were used together with propofol or opioids, and contributed to death by inhibiting respiration. It is essential to consider means of administration as well as additive or synergistic effects of combined agents when interpreting toxicological results in such cases.

Bowel wall hemorrhage after death by hanging

We describe and discuss autopsy findings of bowel wall hemorrhage in a study population comprising cases of suicidal death by hanging. Intramural hemorrhages were seen in approximately 12% of the cases examined; no preexisting bowel diseases were found. In hanging deaths with a longer agonal phase, we opine that abdominal congestion during the hanging process provides a viable pathophysiological explanation for bowel wall hemorrhage. Though we are not dealing here with obligatory autopsy findings, the detection of bowel wall hemorrhage might be used as another sign of vital hanging after considering differential diagnostic aspects.