Journal of Forensic Pathology

An Evaluation of the Autopsies Performed on Victims of Major Disaster Who Died from Traumatic Asphyxia

Nida Fatima^{* *}Correspondence: Nida Fatima, Department of Biotechnology, IBST, Shri Ramswaroop Memorial University, Lukhnow, India, Tel: +91 9891164332, Email:

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INTRODUCTION

In forensic medicine, determining the cause of death has frequently depended heavily on the discovery of a single finding. Empiricism has so emerged as a significant and popular approach to acquiring knowledge. To meet the requirements for practicing evidence-based medicine, empirically acquired knowledge must be put to the test through experiments or analysis of significant case series. Although the process of moving from observation to evidence is not always simple, it is essential to complete in order to authenticate empirical findings and guarantee the caliber of forensic scientific evidence. Because autopsy procedures are mostly based on human customary behaviors and expertise, getting evidence-based scientific argumentation can be challenging. Inference on causal pathways is challenging with this style of experience-based practice. There is a generally acknowledged need for forensic pathology to adopt more evidence-based approaches. The belief that "no two cases are comparable in forensic medicine" and the difficulties of adapting conventional medical study designs to a forensic environment balance this need. Little systematic study has been done to validate the fundamental assumptions and methods employed in many fields of forensic medicine in Denmark, as well as in many other western nations. Due to the variety in the clinical presentation of the patients seen in forensic pathology, it is challenging to assess the difference in autopsy techniques. This barrier to evaluating autopsy procedures is decreased in the uncommon situation where several deaths occur simultaneously from the same cause. In a semi-controlled environment, such an event offers some insight into the variation of individual autopsy practice. In this article, we present a case series of autopsy conducted on numerous victims who passed away simultaneously, at the same scene of an incident, and due to comparable damage mechanisms. Five different pathologists performed autopsies on each victim within hours of one another, and the senior pathologist oversaw all of the autopsies. We discuss the parallels and differences in the ensuing reports and look at the differences in the perspective of how a more systematic approach, like pre-autopsy data collection or the use of check lists, may have enhanced the thoroughness and correctness of the final autopsy report.

Nine concertgoers perished in a stampede at a rock concert that took place at a music festival in Denmark one evening in June 2000. A crowd of almost 50,000 concertgoers had gathered for the event, and as soon as the band started performing, a steady stream of concertgoers and aggressive crowd behavior caused tremendous wave movements in the audience. About fifty concertgoers who were standing in front of the stage were knocked over by these motions. The throng was so crowded that it was impossible for the injured to get up, and attempts to assist them were ineffective. The music ceased. Guests dropped roughly 20 minutes after the concert, and it took an extra It took seven minutes to convince the audience to move away from the stage so that the injured could be assisted and taken to a hospital for care. Some of the concertgoers who had passed away lacked vital signs, not with standing despite heroic efforts to save them, five people were pronounced deceased at the site. upon arrival at a local hospital, three more people. The final victim originally pulled through and was taken to an intensive care unit, where he was declared dead five days following the stampede. All eight initially deceased individuals who had autopsies have The following day, five different pathologists visited our department. All The same senior pathologist who oversaw the autopsies also. All eight autopsy reports were read and co-signed. The reason behind every death is the cases as severe asphyxia brought on by compression of the chest wall. There were eight distinct autopsy reports, and served as evidence of the incident and a basis for further inquiry. Not the victim who passed away five days after the incident a medico-legal autopsy was not requested by the police, so the body was autopsied. Traumatic asphyxia is brought on by an injury to the upper abdomen or thoracic wall that prevents breathing.

The thoracic cage becoming trapped (positional asphyxia) and physical trauma splinting the thoracic cage and/or the diaphragm but not causing continuous compression (crush asphyxia) are two mechanisms. Automobile accidents as well as occurrences in industry and agriculture are frequent causes. Traumatic hypoxia is one of the most frequent causes of mortality in human stampedes. Cervico-facial congestion and cyanosis, conjunctival hemorrhage, and cutaneous petechiae are the three key symptoms of acute asphyxia. These results are thought to be connected to a rise in intrathoracic pressure brought on by the compressive force. When there is ongoing arterial blood flow, the compression induces retrograde blood flow in the valveless intrathoracic veins, which causes the cephalic venules to enlarge with desaturated blood, causing congestion and cyanosis. Conjunctivae and palpebrae, where the connective tissue around the venules is least supportive, show the most pronounced petechiae when the venules eventually break, creating them. Depending on the severity of the trauma, a number of additional related injuries can be noticed in addition to the cardinal ones [1].

These include pneumothorax, contusions and lacerations of both intrathoracic and intraabdominal organs, acute pulmonary emphysema, submucosal petechiae on the larynx, trachea, subepicardium, epicardium, pleura, and brain, and skin lesions such as haematomas, excoriations, and contusions. Prior to the examinations in this instance, the police notified the pathologists that the victims had been crushed to death in front of hundreds of concertgoers. Therefore, the goal of the autopsies was to see how well this information coincided with the autopsy results. Prior to the autopsy, the pathologist must be given all necessary medical and legal documentation, which must be obtained and provided by the police. However, due to the short period between a death and an autopsy, such records are not always easily accessible in an acute situation. It is typical in these situations to note not only whatever records were available prior to the autopsy but also which pertinent documents were not. Ventilation and chest compression injuries that result from resuscitation techniques might mimic the symptoms of acute asphyxia. Petechial hemorrhages on the face, eyelids, and conjunctivae, as well as bruising and abrasions in the face and neck region, pulmonary barotraumas, aspiration of stomach contents, rib fractures, epicardial petechiae, and heart lesions have all been reported as side effects of CPR. It would have been pertinent to note in all autopsy reports whether information on CPR efforts was available or not and, in the case of availability, whether CPR efforts had been performed. This is because the observed lesions could have been caused by both the crush trauma and efforts at resuscitation. The police in the case discussed in this paper were present during the autopsies and very likely could have given oral details on the CPR performed on each victim. Only one autopsy report noted the presence of each of the three cardinal indications [2,3].

All eight accounts included conjunctival hemorrhage and cutaneous petechiae, therefore it seems that face cyanosis and congestion were purposefully disregarded. Skin lesions, fractures, and pneumothorax were the linked injuries that received the most good and negative comments.

This may be somewhat explained by the fact that all eight victims had full-body conventional radiographs taken to check for fractures and that all eight victims had cutaneous lesions, which were all positive findings. In order to assess pneumothorax, it was also standard operating procedure to open the chest wall while submerged. Histological examination's place in forensic autopsies is controversial because of the requirement to keep up a high volume of histology and the desire for a more reasoned, evidence-based approach. Although histological examination is useful in some circumstances, the authors came to the conclusion that it cannot be expected to significantly change the cause or method of death when such factors are determined by gross inspection. However, we found that histological testing can be useful in identifying disease, such as inflammatory lung disease or emphysema, that is not always detected by gross examination and that may have contributed to the cause of death. In order to standardize the autopsy findings and to ensure the accuracy of the presumed cause of death, histological testing should have been carried out consistently in each case. Suffocation by aspirating stomach contents was mentioned as a potential contributing factor in one case. This discovery is dubious because it was based on a gross inspection and not histological confirmation. The level of intoxication from alcohol, narcotics, or other substances can affect the victims' capacity to recognize danger and flee a perilous situation, hence toxicological screening is important [4,5].

Discussions

Thus, intoxication becomes a potential contributing factor to the cause of death and need to be considered, as it was, in every instance. Despite the differences between the cases that have been described, traumatic asphyxia from thoracic wall compression was listed as the cause of death in each case. The same senior pathologist who cosigned all eight autopsy reports oversaw all eight autopsies. There is no reason to think that the differences were purposefully overlooked or disregarded when the cause of death was determined. It is more likely, in our opinion, that the pathologists have given greater weight to the information on the trauma mechanism (crushed in a human stampede) provided by the police prior to the autopsies than the actual autopsy findings. Furthermore, none of the victims had any indications of a different cause of death, which would have bolstered the idea that traumatic asphyxia was the cause of death [6]. Due to the remarkably comparable case conditions in autopsies carried out concurrently in the same forensic department, one might anticipate little variation in autopsy techniques in the context of this case series. Due to this unpredictability, the autopsy report is of lower quality both as a legal record and as a source of information [7].

Our case series demonstrates that there is still a need for such protocols or the adoption of currently existing standards despite several attempts to create uniform guidelines for forensic examinations. With the aim of creating a uniform nationwide application of these guidelines, we recommend, when appropriate, the establishment and use of case specific autopsy guidelines on the level of the single forensic department. Such guidelines could very easily take the form of check lists, which have been shown effective in many other fields of medicine. They should be based on current, peer-reviewed literature and existing guidelines. In forensic pathology, check lists may be used in well defined instances such carbon monoxide poisoning, drowning, or severe asphyxia due to compression to aid the pathologist in adhering to key indicators and determining which supplemental examinations should be carried out. Checklists, however, may also be helpful in a wider context, such as when determining when it is required to do pre-autopsy data gathering from institutional databases, peer-reviewed journals, or traditional forensic textbooks in order to prepare for the autopsy. Normally, consulting forensic textbooks would be sufficient, but in cases that are more unusual or rarely encountered, consulting textbooks should be accompanied by a search of peer-reviewed literature. Only 11 autopsy of people who had suffered severe asphyxia due to compression had been done prior to this case series, according to a search of our department's database. It is less likely that the individual pathologist would use a "customary" approach to looking into the cause of death in suspected traumatic asphyxia instances because the putative mechanism of death in these cases was uncommon. The current case series is a good illustration of the kind of situation where a checklist, literature search, or reference to standard texts might have been useful to augment the pathologist's knowledge and expertise [8].

Conclusions

The distinctness of the instances discussed here provided a chance to assess the variation in individual autopsy procedures. This analysis revealed several significant discrepancies and omissions in the autopsy reports, which can be attributed to variations in usual practices and how each medical examiner applies knowledge. These discrepancies and omissions reduce the autopsy report's thoroughness and correctness, making it less relevant as a legal document and for upcoming research. In light of the case at hand, we propose that the use of check lists in conjunction with preautopsy data gathering from standardized textbooks, peer-reviewed papers, and/or institutional databases may provide a more appropriate evidence-based setting for performing an autopsy, ensuring a higher level of standardization and ultimately improving the quality of the autopsy report. Our department is now implementing these adjustments, and they will be assessed afterward.

References

1. Lignitz E. and Véronique H. "New autopsy signs in violent death." Forensic science international 165.2-3 (2007): 172-177.

   [Google Scholar] [Cross ref]

2. Pollanen, S. "Forensic pathology and the miscarriage of justice." Forensic science, medicine, and pathology 8.3 (2012): 285-289.

   [Google Scholar] [Cross ref]

3. Broeders, A. "Of earprints, fingerprints, scent dogs, cot deaths and cognitive contamination—a brief look at the present state of play in the forensic arena." Forensic Science International 159.2-3 (2006): 148-157. [Google Scholar]

   [Cross ref]

4. Rutty G. "The academic forensic pathologist." Forensic Science, Medicine, and Pathology 1.3 (2005): 167-168.

   [Google Scholar] [Cross ref]

5. Byard, W., et al. "The pathological features and circumstances of death of lethal crush/traumatic asphyxia in adults—a 25-year study." Forensic science international 159.2-3 (2006): 200-205.

   [Google Scholar] [Cross ref]

6. Ngai M, et al. "Human stampedes: a systematic review of historical and peer-reviewed sources." Disaster medicine and public health preparedness 3.4 (2009): 191-195.

   [Google Scholar] [Cross ref]

7. Karger, Bet al. "Fatalities related to medical restraint devices—asphyxia is a common finding." Forensic Science International 178.2-3 (2008): 178-184.

   [Google Scholar] [Cross ref]

8. Miles, Steven H. "Autopsy findings in asphyxia in medical bed rails." The American Journal of Forensic Medicine and Pathology 30.3 (2009): 256-261.

   [Google Scholar] [Cross ref]