External examination in autopsies with pro forma

External examination in autopsies with pro forma

1. External Examination in Autopsies with Pro forma Presenter : Dr. Varughese George Moderator : Dr. Bhavani K

2. Introduction Prior to undertaking the evisceration & internal examination, the pathologist should perform a systematic external examination. Many pathologists are of the impression the external examination is of less importance than the internal examination . This often results in cursory and poorly documented external examinations with lots of errors.

3. The importance of an external examination to ensure that the person is dead . yields information about the natural diseases that the deceased suffered from in life. To know the identification of the deceased. To know the time of death. To know the place of death. To know the cause of death. To know the manner of death.

4. Ideal external examination must be started prior to cleaning the body as critical evidence can be lost at this point. should include both the front and the back of the body . best performed by turning the body completely over so that it is lying prone . must be documented in writing on to a pro forma. must use lay words to record descriptions . Must record findings on the body by digital photography and surface body scanners.

5. PRELIMINARIES  Consent (hospital administrator (RMO/coroner) and relatives)  Identification of body  Clinical details

6. Should have a statement pertaining to retention of body parts/ organs Get specific permission for an unusual examination (removal of eyes/limbs) even if signed as NO RESTRICTIONS Make sure the case is not medicolegal, like delayed accidents, homicides, deaths after abortions, occupational diseases, suspicious cases of poisoning, deaths on table.

7. Dictate as follows  Autopsy no, date and time  Pathologists Name and designation  Patient’s age (look for disparity) and sex  State of body (built and nourishment)  State any restrictions  Final clinical diagnosis  Clinical summary  Height (crown to heel)  Weight

8. Dictate as follows  Rigor mortis  Livor mortis  Algor mortis  Post mortem drying  Body built  Nourishment  Edema  Cyanosis  Skin  Nails

9. Identification Determination of the individuality of a person based on certain physical characteristics . Before starting an autopsy the pathologist must be satisfied that the body about to be examined is that of the deceased . No matter how the identification of the body is established , the means, location, time and date of the identification should be recorded within both the autopsy notes and report

10. Identification Known individuals In the majority of cases the identity of the deceased will be known . The body will have been booked into the mortuary under this name and often allocated a unique identifying number, the details of which will be recorded on at least one identification band usually secured to the wrist or ankle area . The autopsy examination should not proceed until the body has been identified.

11. Identification Unknown individuals The pathologist may be faced with one or more individuals whose identification at the time of the autopsy is unknown. This can be made worse if the body is disrupted, decomposed, skeletonised or comingled with parts from other bodies. In these circumstances the pathologist assists in the gathering of information that will be used to identify the deceased.

12. Identification Means can be used to assist in the identification of an individual : • primary – a characteristic considered unique to the individual that can be used on its own to identify an individual. e.g. fingerprints, odontology , DNA, prosthesis etc.

13. Identification Means can be used to assist in the identification of an individual : • secondary – a characteristic that is not unique but can be used in combination with another secondary or primary characteristic to identify an individual. e.g jewellery , personal effects, distinctive marks, distinctive scars, X-rays, physical disease, blood grouping, tissue identification etc.

14. Identification Means can be used to assist in the identification of an individual : assistance – a characteristic that is not unique to an individual but can be used to assist identification in combination with a primary or secondary characteristic or only on its own as a matter of last resort. e.g. photographs, body locations, clothing, etc.

15. Identification More specialist means can be engaged at times , including for example podiatry, pollen, anthropology, facial reconstruction and isotopic/elemental tracing . If these systems are unfamiliar, the pathologist should seek specialist advice or refer to specialist.

16. Clothing Most bodies will arrive naked or in a shroud or hospital gown which should be documented. If the body is within a body bag, this should be documented, including the colour of the bag and whether the bag is sealed. If sealed, the nature of the seal and any unique identification number should all be recorded. In the case of mass fatalities, a unique number and scene book should have been attached to the outside of the bag and should be removed and checked prior to the opening of the bag.

17. Dressed bodies If the body arrives dressed in the deceased’s own clothing , each article of clothing should be examined before and after its removal from the body . Type , make and size of a piece of clothing should be recorded. Pockets should be examined with forceps(sharps) and any personal effects documented. Cutting of pockets is permitted provided a record is kept.

18. Undressed bodies If the body was undressed prior to the pathologist’s arrival , consideration should always be given to obtaining the clothing and examining it. Particular importance in cases of sudden infant death, as children are often redressed prior to going to the mortuary and the clothing they are presented in may not be the clothing they died in. Most infants pass urine prior to or at the time of death, so it may not be possible to collect a urine sample for metabolic screening from the bladder

19. J ewellery The presence or absence, site and type of all jewellery should be carefully documented to prove that it has not been removed by a member of staff for any purpose other than the autopsy examination. Simple descriptions of metal ( e.g. ‘ a yellow metal ring was present to the ring finger of the left hand’). In police cases, jewellery should be handed to the exhibits officer and processed as for clothing .

20. General examination Cleanliness Examine for u nwashed body. Examine for faecal or urinary incontinence. Examine for presence of head lice. Examine for presence of scars or decubitus ulcers noted. Examine for features seen in case of possible maltreatment or neglect .

21. General examination Height and weight All bodies should have their naked length and weight recorded. Length (height) should be measured from the heel to the vertex of the skull, not from the toe (coffin size ) in SI units. A weight is important for the estimation of the time since death using temperature-based algorithms, the interpretation of toxicological results and the interpretation of apparently enlarged organs.

22. General examination Height and weight If available, the weight should be recorded in kilograms, or the last known body weight recorded in life obtained from the hospital notes and reported in SI units . Body mass index (BMI) can be calculated using the formula BMI = kg/m 2  where kg is a person's  weight  in kilograms and m 2  is their  height  in metres squared. Body mass index (BMI) is useful if the deceased appears to be malnourished or obese. Death may have been in part due to morbid obesity only if the body mass index > 40 kg/ m 2

23. Fluids, blood and exogenous material Distribution, colour and constituency of any fluid (gastric contents or pulmonary oedema , froth) should be recorded. The presence of blood should be recorded and sampled in consideration as to whether it is the victim’s or the offender’s blood. Other exogenous material( oil from vehicle, ink) noted. Other biological and non-biological evidential material – gunshot residue, paint, fibres , glass, semen, saliva (both human and animal) or third-party DNA – may be present to the external surface of the body. General examination

24. General examination Gender, age and race The colour of the skin may also offer clues to potential natural or unnatural diseases. A careful examination of the external genitalia and anus should be performed. Gender of individual may be obvious. Individuals can be described in broad terms as fetuses, neonates, infants, children, young adults, middle-aged adults and elderly adults. Specialist examinations can assist in more precise ageing estimates radiology for dental eruption and epiphyseal fusion. anthropological examination of bones such as the ribs and pelvis.

25. General examination Congenital and dysmorphic features The presence of congenital or dysmorphic features should be recorded. Should include anything from an extra digit and accessory nipples to spina bifida or syndromic facies .

26. RIGOR MORTIS Rigor is tested by trying to lift eyelids, trying to depress the jaw and bending the neck and various joints of the body

27. RIGOR MORTIS  Primary flaccidity (till ATP remains) – rigor – secondary flaccidity  Secondary flaccidity due to onset of putrefaction  Mechanism (4-8 hrs, 24-48hrs)  NYSTEN’S rule – doesnot appear in all muscles simultaneously and both voluntary and involuntary muscles affected  Contraction of erector pilae – cutis anserina/goose flesh

28. RIGOR MORTIS  Commences in the heart (LV-RV-atria) , in sytole  Diaphragm  Skeletal musculature – first jaw, neck, face, arms, lower extremities, last ankle joint  Passes off in the same order  Contraction of tracheal muscles causes white dots on mucosa  Postmortem intususception  Iris – dilatation (postmortem) and then contraction (rigor)  Handling causes loss of rigor – patchy distribution

29. Factors affecting rigor  Age – absent in fetus, early and milder in children and old  Early onset, short duration – wasting diseases, strychnine poisoning  Late onset – asphyxia, hemorrhage, pneumonia, paralytic diseases  Increased duration – CO poisoning  Less duration – bacterial infection d/t early putrefaction  Environment – cold – late onset, more duration, heat – early onset, less duration

30. CADAVERIC SPASM / INSTANTANEOUS RIGOR / CATALEPTIC RIGIDITY

31. CADAVERIC SPASM  Muscles that were contracted during life become rigid immediately after death without passing into a stage of primary relaxation  Affects single group of voluntary muscles, frequently hands  Sudden death, excitement, severe pain, convulsions, strychnine poisoning

32. L I V O R M O R T IS

33. LIVOR MORTIS Hypostasis  Initially intravascular (can blanch), then extravascular  Begins 30 to 45 mins after death in dependent parts, max in 6-12 hrs  Can enlarge the extent of subcutaneous hemorrhages, can mimick suboccipital hemorrhage  Initially cut on the area of livor shows delicate hemorrhagic dots showing transected congested vessels.  Not possible to distinguish from antemortem cyanosis

34. BLANCHING TEST

35.  Colour is a shade of blue  No livor – hemorrhage, anemia, wasting diseases  Red in bodies kept in moist refrigeration – higher affininty for O2  Cherry red – cyanide, CO  Methemoglobinemia – smoky green, brown  Hydrogen sulfide – black

36. Tardieu spots develop in areas of lividity, such as this individual's shoulder area, as decomposing capillaries rupture.

37. ALGOR MORTIS  Rectal temp falls @ 1 deg/hr  Also inferior surface of liver/EAC/nasal passages  Time of death = n body tem – rect t / rate of cool  Post mortem caloricity – stroke, convulsions, strychnine poisoning, septicemia

38. POST MORTEM DRYING develops when the eyelids are not completely shut, the areas of the sclera exposed to the air dry out, which results in a first yellowish, then brownish- blackish band like discoloration zone cholera, wasting dis (Tache noire )

39. DRYING  Skin is wrinkled and leathery  Loosening of hair, apparent lengthning of finger nails due to shrinkage of finger tips

40. Body built and nourishment

41. BODY BUILT  Gigantism – Hereditary/endocrine P roportioned/dys proportioned  Endocrine – Pituit a ry d/t excess GH acromegaly, gigantism Hypogonadism E unuchoid – K l ine felter ‘s Syndrome

42. BODY BUILT  DWARFISM – hereditary / endocrine perfect/imperfect  Hereditary – pygmies ( primordial) sporadic (mutation) achondroplasia   Endocrine – Hypothyroidism – cretinism Pituitary dwarfism – GH deficiency Gonadal dwarfism – Turner’s syndrome

43. TURNER SYNDROME

44. Spinal deformities Old age Chronic emphysema Rickets Os t e o ma l a cia Acromegaly Tuberculosis

45. NOURISHMENT  OBESITY  Exogenous – food intake Double chin and abdominal  Endogenous - glandular Cushing’s – truncal – moon face, buffalo hump, protuberant abdomen, thin extremities Hypothyroidism – non pitting myxedema – eyelids, hands and tibia – hyaluronic acid infiltrn

46. NOURISHMENT  CACHEXIA Cancer TB Thyrotoxicosis Addison’s disease Anorexia nervosa Starvation

47. EDEMA  Generalized and localized  Pitting and non pitting (lymphedema/myxedema)

48. GENERALISED/ LOCALISED  GENERALISED Congestive heart failure Nephrotic syndrome Hypoproteinemia Cirrhosis  LOCALISED Filariasis Post operative Insect bites Vena caval syndromes

49. CYANOSIS

50. CYANOSIS  CENTRAL Conjunctive, mouth, nose, lips Pneumonia, chronic bronchitis, fallot’s, shunts as in cirrhosis Associated with clubbing  PERIPHERAL Extremities, not associated with clubbing Localised obstruction to blood flow like raynaud’s, arterial obstruction, varicose veins

51. Hands and Feet

52. General examination Hands and feet The dorsal and volar surfaces of the hands, feet and the digits should be examined for evidence of natural or unnatural disease. The presence/absence of normal creases is noted particularly in children. The state , length and colour of the nails (including the presence or absence of nail polish, decorations and extensions) are recorded as well as the presence of injuries.

53. General examination Hands and feet Nails may give clues as to the presence of natural disease e.g clubbing, leuconychia , koilonychia , yellow nails, pitting or splinter haemorrhages . Digits can be used for identification purposes by their prints, and the nails can be used for toxicology , DNA , and geometric fingerprinting techniques .

54. K O ILON Y C HIA

55. General examination Hands and feet The assistance of a forensic podiatrist may be considered in mass fatality investigations. In police cases, a careful inspection for the presence of trace evidence ( e.g.fibres or hairs) must be undertaken. Any evidence should be photographed prior to lifting with adhesive tape. The interdigital webspaces may contain needle puncture marks in individuals dying from drug overdoses .

56. SKIN PIGMENT DISTURBANCES  Hyperpigmentation Generalised  Jaundice, Addison’s, Hemochromatosis, chronic malaria Localised  Chloasma, Acanthosis nigricans  Hypopigmentation Albinism, vitiligo Fungal disease (tinea vericolor, pityriasis alba), leprosy

57. HAIR AND FACE

58. General examination Hair Assessment of whether they are present and whether they are the body’s own. The distribution of hair (male and female patterns) to the entire body should be noted. Hair may be lost from the body by natural disease or by shaving, e.g from the legs, pubic area, armpits or chest. The presence/absence of head hair (male balding pattern), its colour (natural or dyed), length (measured) and style should be recorded. Natural hair can also be used for race determination, toxicology (for drug and poison analysis) and DNA testing. The presence and make of a wig should be noted. Injuries to natural or false hair should be recorded.

59. HAIR  Loss – debilitating illness, malignancy, typhoid, male pattern baldness, alopecia, ringworms, thallium poisoning  Female distribution in male – portal cirrhosis, after castration  Hirsuitism – Male pattern hair in female – Cushing’s, ovarian tumors  Thinning and drying of scalp hair – myxedema

60. Cicatrical alopecia male pattern baldness

61. F ACE  Hippocratic facies - A pinched expression of the face, with sunken eyes, hollow cheeks and temples, and relaxed lips, observed in one dying after an exhausting illness  Moon face – cushing’s  Potter facies - oligohydramnios  Mask like facies - parkinsonism  Leonine facies - lepromatous leprosy

62. Potter's facies. Parrot-beaked nose. Recessed chin. Epicanthic folds. micrognathia Low set ears (helices often folded). Hypertelorism.

63. E Y ES

64. EYES – POST MORTEM CHANGES  Loss of corneal reflex – not reliable  Opacity of cornea – cholera, wasting diseases  Flaccidity of eyeball – sunken  Pupils – dilatation then constriction  Retina – Kevorkian sign – shunting/tracking of blood due to fall in bp  Steady rise in potassium values of vitreous upto 100 hrs

65. E Y ES  Exophthalmos Hyperthyroidism, myopia  Enophthalmos Cachexia, Horner’s syndrome  Cornea – Ulceration, opacity, Arcus senilis, Kayser- Fleischer ring  Sclera – Icterus Blue sclera (osteogenesis imperfecta, marfan’s)

66. General examination Ears The presence or absence, placement, shape and size of the ears can be recorded . They should be examined for diseases, such as blood within the external auditory process (which may indicate a basal skull fracture) petechial haemorrhages behind the pinna . gouty tophi or lobar creases associated with cardiac disease. Ear morphology may be unique to individuals and can be used for identification purposes

67. General examination Teeth The absence of teeth/dentures at the time of the autopsy does not preclude a dental identification. If charting of the teeth is required , the assistance of a dental practitioner or forensic odontologist is advisable . The pathologist should not put fingers into the mouth except under direct vision as this is a sure way to receive a glove puncture injury from broken teeth, projecting bone or foreign objects which can be placed maliciously into the mouth.

68. Tongue Geographic tongue – Vitamin B12 deficiency. Protuberant tongue – Cushing’s Syndrome. Macroglossia and fissured tongue – Down’s Syndrome

69. ORI F I C ES

70. NECK

71. NECK  Look for neck veins  Prominence indicates RVF

72. LYMPH NODES – NECK, AXILLA AND INGUINAL

73. CH E S T

74. CHEST  Pectus carinatum aka alar chest Prominence of vertebral border of sternum  Pigeon Chest Nasopharyngeal obstruction, respiratory disease  Barrel Chest Emphysema, chronic bronchitis  Pectus excavatum Occupational deformity, cobblers  Rachitic Chest Pigeon breast, keel breast, Harrison’s sulci, Verical grooves, Rickety rosary

75. RI BS

76. LIVER AND SPLEEN

77. Signs of liver failure

78. U MB I L I CUS

79. Detailed examination Once the general examination has been undertaken, the body is examined in detail for P resence of signs of natural disease & modifications. Medical intervention. D rug misuse. Injuries (both fresh and historical).

80. Detailed examination Body modifications A wide range of permanent and non-permanent modifications can be made to the body which can used for identification purposes. result in disease and death due to complications of procedures Includes tattoos, piercings, brandings,scarification , non-surgical and surgical modifications

81. Detailed examination Body modifications - Tattoos can be found anywhere on the skin and occasionally on the internal aspects of the body . can be unintentional/related to the occupation of the individual e.g coal miner’s tattoos, amalgam tattoos related to dental restoration ballistic tattooing from gunshot residue .

82. Detailed examination Body modifications - Tattoos Intentional tattoos can be Artistic - expensive, complex, colourful , professional tattoos, or simple, monochrome, home-made or prison tattoos, tattoos made with inks that fluoresce under ultraviolet light. Therapeutic - related to beam areas used in radiotherapy. Non-permanent henna tattoos are prevalent within some cultural groups. Non-permanent tattoos produced with black ink are commonly associated with surrounding skin irritation The nature, size and site of tattoos on the body should be recorded.

83. Detailed examination Body modifications - Tattoos Tattoos may be found inside the mouth particularly the mucosa of the lips. Tattoos may be altered or even removed - this can result in one or more tattoos at one site or a tattoo scar.

84. Detailed examination Body modifications - Piercings not confined to the ear and may be seen at a multitude of sites on the body. The site and nature of the jewellery should be noted Body piercings on the ear.

85. Detailed examination Body modifications – Brandings and scarification involves scratching, etching, burning / branding, or superficially cutting designs, pictures, or words into the  skin  as a permanent  body modification. t end to occur in specific countries like the US especially in college age group.

86. Detailed examination Body modifications Non-surgical e.g. cosmetics , hair treatments, nail extensions and dermabrasion . S urgical e.g. dental treatment and filing (to produce animal-like teeth ), surgical implants, prostheses and gender reassignment

87. Detailed examination Medical intervention Acts of medical intervention may have been performed on the deceased prior to death even if they have not died in hospital e.g. bystanders or a paramedic ambulance crew. Presence and location of all tubes, catheters and operation sites should be documented. Craniotomy scars or intracranial pressure monitor sites may be present and may be sutured or stapled, closed with Steri -Strips or covered by dressings. Nasogastric and endotracheal tubes may be present.

88. Detailed examination Medical intervention ECG monitor pads may be present, as may automated defibrillator pads and external pacing wires, The site and correct placement of automated defibrillation pads should be checked and noted, may be associated with shaving of chest hair to ensure close contact of the pads with the skin. If tracheostomies , gastrostomies , colostomies or urinary catheters are done, they should be documented.

89. Detailed examination Drug misuse This should alert the pathologist to the possibility of a toxicological death, so that additional precautions should be taken during the autopsy procedures. Needle marks, both fresh and old, of differing sizes depending on the calibre of needle used may be seen not only on the external surface of the body. Knowledge of any medical intervention is essential for the interpretation of needle marks to the neck, bend of the arm, wrist and groin areas.

90. Detailed examination Drug misuse The use of a ligature may leave a mark at a level above the needle mark should be recorded. Perforated nasal septum and sinuses in the groins should be recorded. Tablet dye residue can sometimes be found on the palm of the hand in those that have taken a ‘handful’ of tablets. Scars resulting from self-inflicted injuries can be found in those who misuse drugs. A careful search of the mouth, foreskin, vagina and anus should be undertaken for concealed drugs.

91. Detailed examination Injuries Each injury is characterized by its: i . Type/nature of injury. ii. Size (length, breadth and depth). iii. Shape. iv. Site (in relation to two external anatomical landmarks). v. Direction of application of the force. vi. Margins, edges and base. vii. Distance of the wound from the heel. viii. Time of infliction of the injury should be studied from inflammatory and color changes. ix. Vital reaction. x. Foreign materials, e.g. hair, grass, fibers, etc.

92. Detailed examination Injuries After full preliminary examination and forensic sampling the area is cleaned, shaved if necessary, and photographed with a scale adjacent to the injuries.

93. Detailed examination Injuries Where there are numerous similar injuries, it assists the clarity of the autopsy report if numbers used during photography match those listed in the autopsy protocol.

94. When an individual has external marks/injuries these should be drawn onto the pro forma or onto separate anatomical diagram sheets

95. Special procedures utilized during external examination Photography for the purposes of identification and documentation. Infrared and UV photography will enhance trace materials, tattoos, bruises and patterned injuries. High contrast black-white photography or computer directed image enhancement can be used to enhance patterned injuries. Autopsy radiology: In well equipped hospital where radiographic facility is available, radiological examination should be done in select cases before starting the autopsy X-ray examination assists in identification, locating foreign objects such as projectiles and documenting old and recent bony injury.

96. Indications of radiological examination Identification and dentistry Mutilated/charred remains Gunshot wounds Air embolism Sharp force wounds Barotrauma Explosives deaths Child abuse Decomposed body

97. Example of a concise report

98. References Ludwig J. Handbook of autopsy practice. Springer Science & Business Media; 2002. Waters BL. Handbook of autopsy practice. Springer Science & Business Media; 2010. Finkbeiner WE, Connolly AJ, Ursell PC, Davis RL. Autopsy Pathology: A Manual and Atlas E-Book. Elsevier Health Sciences; 2009 Burton JL, Rutty GN. The hospital autopsy. Arnold; 2001. Saukko P, Knight B. Knight's forensic pathology. CRC press; 2004