Thomas T. Noguchi

Preventable or potentially preventable mortality at a mature trauma center.

OBJECTIVE The objective of this study was to analyze the preventable and potentially preventable deaths occurring at a mature Level I trauma center. METHODS All trauma patients that died during their initial hospital admission during an 8-year period (January, 1998 to December, 2005) were analyzed. The deaths were initially reviewed at a weekly Morbidity and Mortality (M&M) conference followed by a multidisciplinary (Trauma Surgery, Critical Care, Emergency Medicine, Neurosurgery, Nursing, and Coroner) Combined Trauma Death Review Committee, and were classified into nonpreventable, potentially preventable, and preventable deaths. All preventable and potentially preventable deaths were identified for the purpose of the study. Quality improvement death forms included data on epidemiology, vital signs, injury severity, type of injury, probability of survival with Trauma and Injury Severity Score methodology, preventability (nonpreventable, potentially preventable, and preventable deaths), errors in the evaluation and management of the patient, and classification of errors (system, judgment, knowledge). Additional injury details, clinical course, circumstances leading to the death and autopsy findings were abstracted from the trauma registry and individual chart review. RESULTS During the study period, 35,311 patients meeting trauma registry criteria were admitted and a total of 2,081 (5.9%) deaths occurred. Fifty-one deaths were classified as preventable or potentially preventable deaths (0.1% of admissions, 2.5% of deaths). Eleven of them (0.53% of deaths) were classified as preventable and 40 (1.92% of deaths) as potentially preventable deaths. Mean age was 40 years, 66.7% were men, mean Injury Severity Score was 27, 74.5% were blunt. The most common cause of death was bleeding (20, 39.2%) followed by multiple organ dysfunction syndrome (14, 27.5%) and cardiorespiratory arrest (8, 15.6%). This was caused by a delay in treatment (27, 52.9%), clinical judgment error (11, 21.6%), missed diagnosis (6, 11.8%), technical error (4, 7.8%), and other (3, 5.9%). The deaths peaked at two time periods: 26 (51.1%) during the first 24 hours and 16 (31.4%) after 7 days. Only one patient (2.0%) died in the first hour. The most common location of death was the intensive care unit (28, 54.9%), operating room (13, 25.5%), and emergency room (5, 9.8%). CONCLUSION Preventable or potentially preventable deaths are rare but do occur at an academic Level I trauma center. Delay in treatment and error in judgment are the leading causes of preventable and potentially preventable deaths.

Blunt thoracic aortic injuries: an autopsy study.

OBJECTIVE The objective of this study was to identify the incidence and patterns of thoracic aortic injuries in a series of blunt traumatic deaths and describe their associated injuries. METHODS All autopsies performed by the Los Angeles County Department of Coroner for blunt traumatic deaths in 2005 were retrospectively reviewed. Patients who had a traumatic thoracic aortic (TTA) injury were compared with the victims who did not have this injury for differences in baseline characteristics and patterns of associated injuries. RESULTS During the study period, 304 (35%) of 881 fatal victims of blunt trauma received by the Los Angeles County Department of Coroner underwent a full autopsy and were included in the analysis. The patients were on average aged 43 years±21 years, 71% were men, and 39% had a positive blood alcohol screen. Motor vehicle collision was the most common mechanism of injury (50%), followed by pedestrian struck by auto (37%). A TTA injury was identified in 102 (34%) of the victims. The most common site of TTA injury was the isthmus and descending thoracic aorta, occurring in 67 fatalities (66% of the patients with TTA injuries). Patients with TTA injuries were significantly more likely to have other associated injuries: cardiac injury (44% vs. 25%, p=0.001), hemothorax (86% vs. 56%, p<0.001), rib fractures (86% vs. 72%, p=0.006), and intra-abdominal injury (74% vs. 49%, p<0.001) compared with patients without TTA injury. Patients with a TTA injury were significantly more likely to die at the scene (80% vs. 63%, p=0.002). CONCLUSION Thoracic aortic injuries occurred in fully one third of blunt traumatic fatalities, with the majority of deaths occurring at the scene. The risk for associated thoracic and intra-abdominal injuries is significantly increased in patients with thoracic aortic injuries.

Anatomical Distribution of Human Bite Marks in a Series of 67 Cases

A study was made of the anatomical distribution of human bite marks, as well as their distribution by age of victim and type of crime involved. Bite marks in this study occurred primarily in sex-related crimes, child abuse cases, and cases involving other types of physical altercations. Bite marks were found on virtually all areas of the body, with more than one bite mark on 40% of the victims. Female victims were most commonly bitten on the breasts, arms, and legs, while male victims were most commonly bitten on the arms and shoulders.

Optimal positioning for emergent needle thoracostomy: a cadaver-based study.

BACKGROUND Needle thoracostomy is an emergent procedure designed to relieve tension pneumothorax. High failure rates because of the needle not penetrating into the thoracic cavity have been reported. Advanced Trauma Life Support guidelines recommend placement in the second intercostal space, midclavicular line using a 5-cm needle. The purpose of this study was to evaluate placement in the fifth intercostal space, midaxillary line, where tube thoracostomy is routinely performed. We hypothesized that this would result in a higher successful placement rate. METHODS Twenty randomly selected unpreserved adult cadavers were evaluated. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. The needles were secured and thoracotomy was then performed to assess penetration into the pleural cavity. The right and left sides were analyzed separately acting as their own controls for a total of 80 needles inserted into 20 cadavers. The thickness of the chest wall at the site of penetration was then measured for each entry position. RESULTS A total of 14 male and 6 female cadavers were studied. Overall, 100% (40 of 40) of needles placed in the fifth intercostal space and 57.5% (23 of 40) of the needles placed in the second intercostal space entered the chest cavity (p < 0.001); right chest: 100% versus 60.0% (p = 0.003) and left chest: 100% versus 55.0% (p = 0.001). Overall, the thickness of the chest wall was 3.5 cm ± 0.9 cm at the fifth intercostal space and 4.5 cm ± 1.1 cm at the second intercostal space (p < 0.001). Both right and left chest wall thicknesses were similar (right, 3.6 cm ± 1.0 cm vs. 4.5 cm ± 1.1 cm, p = 0.007; left, 3.5 ± 0.9 cm vs. 4.4 cm ± 1.1 cm, p = 0.008). CONCLUSIONS In a cadaveric model, needle thoracostomy was successfully placed in 100% of attempts at the fifth intercostal space but in only 58% at the traditional second intercostal position. On average, the chest wall was 1 cm thinner at this position and may improve successful needle placement. Live patient validation of these results is warranted.

Drug analyses of skeletonizing remains.

A 47-year old white female was reported missing by her family after an argument with her husband and son. The arguments were of long and continuing nature with sharp differences as to the use of real properties. Her body was discovered by the family dog eight months later in a desolate area on the family ranch on the slope of a hill.

Blunt cardiac trauma: lessons learned from the medical examiner.

OBJECTIVE The objective of this study was to analyze autopsy findings after blunt traumatic deaths to identify the incidence of cardiac injuries and describe the patterns of associated injuries. METHODS All autopsies performed by the Los Angeles County Forensic Medicine Division for blunt traumatic deaths in 2005 were retrospectively reviewed. Only cases that underwent a full autopsy including internal examination were included in the analysis. The study population was divided into two groups according to the presence or absence of a cardiac injury and compared for differences in baseline characteristics and types of associated injuries. RESULTS Of the 881 fatal victims of blunt trauma received by the Los Angeles County Forensic Medicine Division, 304 (35%) underwent a full autopsy with internal examination and were included in the analysis. The mean age was 43 years +/- 21 years, patients were more often men (71%) and were intoxicated in 39% of the cases. The most common mechanism was motor vehicle collision (50%), followed by pedestrian struck by auto (37%), and 32% had a cardiac injury. Death at the scene was significantly more common in patients with a cardiac injury (78% vs. 65%, p = 0.02). The right chambers were the most frequently injured (30%, right atrium; 27%, right ventricle). Among the 96 patients with cardiac injuries, 64% had transmural rupture. Multiple chambers were ruptured in 26%, the right atrium in 25%, and the right ventricle in 20% of these patients. Patients with cardiac injuries were significantly more likely to have other associated injuries: thoracic aorta (47% vs. 27%, p = 0.001), hemothorax (81% vs. 59%, p < 0.001), rib fractures (91% vs. 71%, p < 0.001), sternum fracture (32% vs. 13%, p < 0.001), and intra-abdominal injury (77% vs. 48%, p < 0.001) compared with patients without cardiac injury. Of the 96 patients with a cardiac injury, 78% died at the scene of the crash and 22% died en route or at the hospital. CONCLUSION Cardiac injury is a common autopsy finding after blunt traumatic fatalities, with the majority of deaths occurring at the scene. Patients with cardiac injuries are at significantly increased risk for associated thoracic and intra-abdominal injuries.

Phencyclidine-Related Deaths in Los Angeles County, 1976

Concentrations of phencyclidine in blood and liver are presented in five fatal cases occurring in Los Angeles County in 1976. Eleven other deaths in which phencyclidine contributed to death are described; acute psychotic reactions were observed in some of these cases. Two cases involved the drowning of individuals whose swimming capabilities may have been diminished from the effects of PCP. One case is presented in which a 20-year-old male took a massive overdose of phencyclidine for suicidal purposes.

The determination of cocaine and its major metabolite, benzoylecgonine, in postmortem fluids and tissues by computerized gas chromatography/mass spectrometry.

An analytical procedure for the simultaneous determination of both cocaine and benzoylecgonine in postmortem fluid and tissue samples has been developed by using computerized gas chromatography/mass spectrometry and gas chromatography using a nitrogen/phosphorus (N/P) detector. Both methods are accurate and sensitive and allow the determination of tissue concentrations of cocaine and benzoylecgonine as low as 0.015 microgram/mL.

The epidemiology of fatal burn injuries.

The paper retrospectively reviews 80 burn fatalities from accidents or attempted suicides with patients admitted to the LAC-USC Medical Center from 1983 to 1987 to determine demographic factors, etiology of the burn injury, and existence of predisposing risk factors. The average age of fatal burn victims was 44 years; 74% were males, 39% were Caucasian, 35% were black, 21% were Hispanic, and 5% were of Asian descent. Blacks and Caucasians were overrepresented and Hispanics underrepresented in relation to all autopsy cases. Major etiologic factors included suicide, falling asleep while smoking, accidents while working with volatile solvents, housefires, scalds, cooking accidents, and accidents involving motor vehicles. Gasoline was the commonest solvent involved with burn fatalities. Significant risk factors for burn fatality were substance abuse (25% of cases) and impaired mental function (19% of cases).

Fixed Human Tissues: A Resource for the Identification of Individuals

Polymorphic genetic loci of the deoxyribonucleic acid (DNA) present in formalin-fixed, paraffin-embedded tissues were successfully analyzed by utilizing the polymerase chain reaction. Using this analysis, with three different polymorphic loci [human leucocyte antigen (HLA) DQ alpha, low-density lipoprotein receptor, and parathyroid hormone], fixed tissues representing 14 different individuals were genotyped and could be distinguished from each other. The techniques were further applied to the fixed autopsy tissues of a man in which a question of paternity arose postmortem. Since many individuals have surgical procedures or autopsy, these readily available fixed tissues represent an additional resource for the identification of individuals.