U1 LEC: POSTMORTEM EXAMINATION Flashcards
“We must turn to nature itself to the observations of the body in health and disease, to learn the truth”
Hippocrates
Autopsy can be categorized by five different rulings for manner of death:
- natural
- accident
- homicide
- suicide
- undetermined
T/F: A medical examiner can order an autopsy without consent from next of kin.
True
First recorded autopsy
Antistius examines Julius Caesar’s body
T/F: One wound to the chest led to rutpure of Caesar’s aorta.
True
1806 painting by Vincenzo Camuccini
La mort de Cesar / The Death of Julius Caesar
This is an instruction manual on how to conduct medico-legal investigations, examine corpses, and determine the time and cause of death.
Hsi Yuan Lu / The Washing Away of Wrongs
Hsi Yuan Lu (The Washing Away of Wrongs) was written by?
1247 Song Ci
Forensic issues mentioned in Hsi Yuan Lu
- poisoning
- decomposition
- wounds from various weapons
- strangulation
- fake wounds
Who conducted the first known legal autopsy with the use of human eye, in which was requested by the magistrate in Bologna?
Bartolomeo de Varignana (1302)
During the renaissance period, autopsies were watched in an operating theater and cadaver is opened by a?
lay dissector
They performed a number of autopsies and observing anatomy unseen by the naked eye.
Leonardo da Vinci and Michelangelo
Father of Modern Pathology
Rudolf Ludwig Karl Virchow
Virchow characterized a case of?
leukemia
PME is performed
wherever __________ is practiced
scientific medicine of high quality
PME is performed
when a _________ knows why he lost a patient
conscientious physician
PME is performed
when ______ is enforced
criminal law
PME is performed
when a ___________ shows accurately the causes of death and confirmed medical diagnosis for the assembling of vital statistics
death certificate
PME is performed
whenever there is _______ on causes and nature of diseases, and transplantation medicine
medical research
PME is performed
A _______ requires PME in human death for the good of medical science, for the public’s health and for the future care of living patient
informed society
Preparations before the Postmortem Examination
- Administrative preparations
- Preparation of the autopsy room
- Confirmation of the decedent identity
Preparations before PME
under Administrative preparations
- Obtain and confirm consent
- Obtain and review clinical records
- Contact clinical team and staff pathologist
Preparations before PME
under Preparation of the autopsy room
- Set up dissection instruments and tools
- Lay out swabs, media, etc. for any ancillary studies to be performed
- Prepare photographic equipment
- Assemble PPE
Preparations before PME
under Conformation of decedent identity
- most important step
- Identifiers on the body must be confirmed and matched with autopsy consent form
- Confirm any limitations or restrictions to the autopsy at this time
Documents for autopsy
- Written consent from the next of kin (abide by restrictions or extent allowed)
- Death certificate
- Medical abstract / clinical data
- Medicolegal clearance
Order of consent for autopsy
- Spouse
- Adult children
- Adult grandchildren
- Parent
- Siblings
T/F: If autopsy is not required by law, it cannot be done until the next of kin gives permission.
True
PME in which all body cavities are examined, including the head/brain.
Complete
PME in which may exclude examination of the head/brain.
Limited (Partial)
PME in which specific organs only are examined.
Selective
Autopsy without consent can be done under the following conditions:
- ordered by police or coroner
- necessary to complete death certificate
- deceased gave consent before he died (Advance directive)
- deceased military service who dies in active duty/training in military service
Autopsies are usually carried out within?
48 hours after death
Autopsies can be?
hospital-based or coronial
These are autopsies ordered by the state coroner.
Coronial autopsies
These are autopsies to be performed at the request of the family of the deceased.
Hospital based autopsies
Criteria for Autopsy (College of American Pathologists)
- Help explain unknown and unanticipated medical complications
- Cause of death/major diagnosis is not known with reasonable certainty
- Help to allay concerns of family or to the public regarding death, provide reassurance to them
- Unexpected deaths occuring during any dental, medical, or surgical diagnostic procedures
- Death of those who participated in clinical trials
- Natural unexplained deaths and not subject to forensic medical jurisdication
- Natural deaths, waived by forensic medical jurisdiction
- Deaths resulting from contagious diseases
- All obstetric deaths
- All perinatal, and pediatric deaths
- Deaths at any age for suspected illness or bearing on recipients of transplant organs
- Deaths from environmental hazard
CAP Criteria
- Deaths in which autopsy may help to explain _____________ to the attending physician
unknown and unanticipated medical complications
CAP Criteria
- All deaths in which the cause of death or major diagnosis is ___________ on clinical grounds
not known with reasonable certainty
CAP Criteria
- Cases in which autopsy may help to _________ and or to the public regarding the death, and to provide reassurance to them regarding the same.
to allay concerns of the family
CAP Criteria
- Deaths of patients who have participated in _________ approved by institutional review boards.
clinical trials
CAP Criteria
- Unexpected or unexplained deaths which are apparently ______ and not subject to a _______.
natural, forensic medical jurisdiction
CAP Criteria
- Natural deaths but waived by a forensic medical jurisdiction, such as:
a. persons dead on arrival
b. deaths in hospitals within 24 hours of admission
c. patient sustained injury while hospitalized
CAP Criteria
- Deaths resulting from ________ diseases
high-risk infectious and contagious
CAP Criteria
- and 10. All ____ deaths
obstetric, perinatal, pediatric
CAP Criteria
- Deaths at any age in which is believed that autopsy would disclose a _______ which also have a bearing on survivors or recipients of _________.
known or suspected illness, transplant organs
CAP Criteria
- Deaths known to have resulted from __________ hazards
environmental or occupational
This refers to a person who has jurisdiction in medicolegal cases.
Medicolegal examiner or coroner
T/F: The coroner may authorize the pathologist to proceed with an autopsy.
True
Jurisidiction for Medicolegal cases
- All deaths within 24 hours of admission
- Newborns in the first 24 hrs of life
- All injury cases
- All deaths due to unknown cases
- All deaths due to suspicious cases
- All abortion cases
- All violent deaths
- All accidental deaths
- All sudden deaths
- All cases without medical attendance within 36 hours prior to death
- All deaths due to drowning, hanging, or strangulation
- All deaths due to shooting, stab wounds, burns, electricity, lightning, tetanus, etc.
- All homicides
- All suicides
- All cases in which there is suspicion of poisoning
- Stillborns
- Prematures
This refers to death of an organism or bodily death (brain dead).
Somatic death
This is the earliest definition of death of an organism.
Cessation of circulation and respiration (1960s)
Criteria for pronouncement of death
- Advanced in resuscitation techniques
- Advanced life-sustaining equipment
- Redefinition from cessation to irreversible cessation
- Brain death
Criteria for pronouncement of death
- Advances in _____ techniques that are capable of reviving effectively cases of clinical death.
resuscitation techniques
Criteria for pronouncement of death
- Advanced ___________ capable of maintaining cardiovascular and respiratory functions despite severe brain injury.
life-sustaining equipment
Criteria for pronouncement of death
Redefinition from _________ of cardiorespiratory functions after resuscitation attempts
cessation to irreversible cessation
Criteria for brain death
- Coma and cerebral unresponsiveness
- Apnea
- Absent cephalic (brainstem) reflexes)
- Electrocerebral silence
This refers to slow breathing.
Apnea
Criteria for brain death should be present for how many minutes, at least 6 hours after onset of coma and apnea?
30 minutes
the American Bar Association and the National Conference of Commissioners of Uniform State Laws legislative definition of death:
- Irreversible cessation of circulatory and respiratory functions
- Irreversible cessation of all functions of the entire brain (brainstem is dead)
American Academy of Neurology
- Coma
- Absence of multiple brain functions
American Academy of Neurology
Absence of the ff includes:
- Motor response
- Pupillary response to light and pupils at mid- position
- Corneal reflexes
- Caloric response
- Gag reflex
- Coughing in response to tracheal suctioning
- Sucking and rooting reflexes
RA 7170
Organ Donation Act of 1991
Amendment of RA 7170
RA 7885
Medical Certification of Death
- Immediate cause of death
- Antecedent cause of death
- Underlying cause of death
This is the final disease, injury or complication directly causing death.
Immediate cause of death
This precedes death as consequence of an underlying cause.
Immediate cause of death
The violent act or accident is the ______ to an injury entered
antecedent
This is the condition that led or precipitate the immediate cause of death.
Antecedent cause of Death
These are other intervening causes of death occuring between underlying and immediate causes.
Antecedent cause of death
This is defined for public health and legal purposes as “the disease or injury that initiated the train of events leading to death”
Underlying cause of death
Other term for underlying cause of death
Promixate cause of death
This is the circumstances of accident which produced the fatal injury
Underlying cause of death
T/F: Without an underlying cause, the death would still have happened.
False
This is the most important entry in the certificate since mortality statistics is based on this.
Underlying causes
3 copies of the death certificate should be made for:
- Relative
- City Health Office
- Funeral home
This is death resulting from a disease.
Natural
This is death resulting from environmental influence.
Accidental
This is death intentionally self-inflicted.
Suicide
This is death resulting from the deliberate action of another person.
Homicide
This is death resulting from an unknown cause.
Indeterminate or Undetermined
This refers to a continuum of changes that occur in a dead body, following death.
Postmortem changes
Postmortem changes include:
- Livor mortis
- Rigor mortis
- Decomposition
- Taphonomy
This is the first demonstrable change after death.
Algor Mortis
This refers to the cooling of the body,
Algor Mortis
1st hour
2 to 2.5 deg F/hr
next 12 hrs
1.5 to 2 deg F/hr
next 12-18 hrs
1 deg F/hr
50% of cases, body cools at?
1.5 deg F/hr
T/F: Algor mortis is not a reliable indicator as to time of death.
True
This is the rigidity of the body due to hardening of skeletal muscles, caused by a series of physiochemical events after death.
Rigor mortis
Rigor Mortis
lack of ATP regeneration and increased acidity result in the?
formation of locking-chemical bridges between actin & myosin
Rigor Mortis
Glycogen stores are rapidly deleted, preventing energy dependent breakage of sarcomere contraction
Depletion of ATP and accumulation of lactic acid
T/F: In rigor mortis, interlocking is fixed without shortening of muscle
True
Rigor Mortis
Sets within?
2 hours after death, small muscles > larger muscle groups
Rigor Mortis
Complete and fully fixed after approx?
6-12 hrs
Rigor Mortis
Dissipates after?
36-48 hrs
This is fixed rigor mortis of the upper extremities wherein the arms are suspended against gravity indicating they were previously held in that position while rigor was fixing.
Antigravitational rigor mortis
This is characterized by a deep purple-red discoloration in skin and organs.
Livor Mortis
Other name for Livor Mortis
Postmortem (Lividity) Hypostasis
T/F: Blood supply gravitates to the skin vessels which becomes toneless and dilate after circulation ceases.
True
This occurs in gravity dependent areas that come into contact with firm surfaces.
Blanching
Livor mortis is spared in blanched areas due to?
localized pressure preventing blood from entering the skin
Livor Mortis
Evident as early as?
20 mins after death
Livor Mortis
Fully evident within?
4 hrs
Livor Mortis
Fixed within?
8-12 hrs
Tardien spots are also known as?
Tardieu petechiae, Tardieu spots
First described tardieu
Auguste Ambroise Tardieu
Evident in the death of a newborn child by strangulation or suffocation
Tardieu’s ecchymoses (subpleural spots of ecchymosis)
Lividity is _____ discoloration of skin from blood pooling in dependent areas of the body.
pink to purple
Tardieu spots are what colors?
purple to black spots
Other Postmortem changes
- Postmortem clotting of blood
- Discoloration of tissues
- Autolysis and putrefaction
- Dessication (Tache noir)
This is a horizontal linear scleral blackening along the equator of the glove of eye.
Tache noir de la sclerotique
Tache noir is often initially what color in appearance, and over time becomes what color?
red, black
These darken with postmortem drying.
Lips, tip of tongue, scrotum
Primary Autopsy Incisions
For scalp
Mastoid-to-Mastoid incision
Primary Autopsy Incisions
For trunk
- I shaped
- Y shaped
- Modified Y shaped
Primary Autopsy Incisions
What is commonly used for females?
Y shaped, Modified Y shaped
Secondary Autopsy Incisions
Cutting of bones to expose cavities
- Sawing of skull
- Cutting of the sternal plate
This incision is a straight line incision extending from the chin to the symphysis pubis.
I shaped incision
This type of incision starts near the acromian process and progresses downwards towards the xiphoid process, then extended til the symphysis pubis.
Y shaped
This incision is made from the suprasternal notch over the clavicle, to symphysis pubis.
Modified Y shaped
Goal of performing the Incisions
- expose chambers of heart, lungs, liver, GIT lumen
- open urinary bladder cavity
This technique removes and dissects organs individually.
Technique of Virchow
Order of Virchow’s Technique
Head > Thoracic (Cervical) > Abdominal
This technique is in-situ dissection in part with en bloc- technique.
Technique of Rokitansky
This technique utilizes en bloc- technique.
Technique of Ghon
This technique utilizes en masse technique.
Technique of Letulle
Minimally invasive technique
Needle autopsy
This refers to multiple percutaneous needle biopsies after death.
Blind biopsies
This refers to extensive organ sampling or removal via a limited incision.
Mini-autopsy
Non Forensic Autopsy Record Retention
Wet Tissue
3 months
Non Forensic Autopsy Record Retention
Paraffin blocks, Slides, Reports
10 years
Forensic Autopsy Record Retention
Wet tissue
3 years
Forensic Autopsy Record Retention
Body Fluids and Tissues for Toxicology
1 year
Forensic Autopsy Record Retention
Paraffin blocks, Slides, Reports, Gross Photographs/Negatives, Dried Blood stain or frozen tissue for DNA
Indefinitely
Hic locus et urbi mors gaudet, succarrere vitae
This is the place where the dead delights teaching the living
