[Fat embolism in forensic pathology].
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Embolism, Fat↗
Biomedical subjects
Jelena Micić
Publications and source records attributed to Jelena Micić.
[Sudden cardiac death caused by complicated atherosclerosis of the anterior intraventricular branch of the left coronary artery with a myocardial muscle bridge].
When coronary artery, which is located subepicardially, submerges into myocardium and then, after a short intramural course, again appears subepicardially, it is called embedded coronary, while a part of myocardium above--a myocardial bridge. Muscular bridges are usually small and have no clinical significance. In the proximal part of coronary artery, preceding a myocardial bridge, there occurs a disturbance of blood course and myocardial perfusion, turbulence, collecting of lipids and mucopolysaccharides, lesion of elastica, which all leads to atheromatous lesions of intima of the arterial proximal part and to the resultant complications of atheroma. Degenerative changes of myocardium and its blood vessels, and in connection with it myocardial vulnerability, could be a consequence of this congenital arterial variation. We report a case of a 40-year-old male, without medical data about previous diseases, who died suddenly and unexpectedly in his apartment. The autopsy and microscopical examination revealed an acute ischemic lesion, myocardial bridge in the middle part of the left coronary artery descending branch and the complicated atherosclerotic plaque proximally of this bridge.
Adult↗
[Factors which could affect the severity of post-traumatic pulmonary fat embolism--a prospective histological study].
INTRODUCTION: Each fracture of long or pelvic bones as well as large contusions of subcutaneous fat tissue cause releasing of fat globules that rapidly penetrate into circulation through the ruptured veins of the injured tissue, and reach the lung circulation [1,2]. During the first phase, fat emboli block the functional lung circulation by their mechanical effect in capillaries producing so called isolated post-traumatic lung fat embolism [3]. The surface layer of a fat embolus, which is practically in liquid state, behaves as a membrane of very high density, i.e., as it is under high pressure which obstruct the blood stream [4] that is finally stopped at the level of lung blood vessels with diameter of approximately 20 mu [5]. This pathophysiological mechanism produces cor pulmonale acutum, with poor pathological findings [8]. Nowadays, the post-mortem diagnosis of lung fat embolism is based on microscopical examination of tissue specimens, usually prepared with special histological staining (Sudan III) [9]. The grading of fat embolism according to Sevitt's criteria is generally accepted [10]. Taking of slices from apicoventral areas of the lungs has been recommended [11]. With longer outliving period, the total number of fat emboli in the lung circulation gradually decreases, due to their disintegration and resorption. It has been stated that fat globules completely disappear about 4-6 weeks after injury, and that they should not be searched for microscopically in this post-traumatic phase [11]. OBJECTIVES: The aim of our work was to determine whether the age of injured, their gender, total severity of trauma, outliving period, and hypovolemic shock that develops after injuring, may induce development of more severe forms of post-traumatic lung fat embolism. MATERIAL AND METHODS: A prospective histological study was performed on the autopsy material of the Institute of Forensic Medicine in Belgrade. The analyzed sample consisted of individuals with injuries that might be a source of fat emboli (fractures of long bones, large contusions of subcutaneous fat tissue). The lung slices were systematically taken and stained with special fat staining (Sudan III). In each particular case, the grade of lung fat embolism was counted on the basis of microscopical appearance, according to Sevitt's criteria. The total severity of trauma was estimated by calculation of the Injury Severity Score (ISS) [13, 14]. In no cases from the analyzed sample, the fat embolism was mentioned as either singular or plural cause of death. The obtained results were analyzed by means of appropriates statistical methods (ANOVA, LSD-test, chi 2 test. Man-Whitney test, Fischer's test of correct probability). RESULTS AND DISCUSSION: The analyzed sample included 58 fatally injured individuals, 39 males and 19 females. The average age was 54.10 years (SD = 16.56), the average value of ISS was 34.69 (SD = 5.88), and the average outliving period was 3.74 days (SD = 5.88). However, all these data look differently when the analyzed sample has been stratified and analyzed according to the estimated grade of lung fat embolism. It was not showed that severity of lung fat embolism depends on sex of the injured (chi 2 = 0.842; p > 0.05). The groups with the slightest and the most severe grade of lung fat embolism are statistically significantly different in relation to age of individuals (ANOVA, p = 0.017). By means of LSD test, it has been showed that the group with the most severe grade of lung fat embolism (grade III) is statistically significantly different comparing to other two groups (with grade I and II) in relation to the age of injured (the values are p = 0.16 and p = 0.19 respectively, and the both groups are less than p = 0.05). In the group with the most severe grade of lung fat embolism, the older individuals are statistically significantly represented comparing to other two groups. CONCLUSION: The analysis of our sample showed that the most severe grade of post-traumatic lung fat embolism (microscopical grade III according to Sevitt's criteria) was determined in older individuals, more severely injured, and with shorter outliving period. The severity of fat embolism depends neither on sex of the injured, nor on development of post-traumatic hypovolemic shock. The obtained results related to the influence of hypovolemic shock on severity of fat embolism should be accepted with a caution. Namely, sometimes there is an intention to simplify a procedure of creating of autopsy conclusion about the cause of death, so that loss of blood is not mentioned at all, in spite of fact that it could have been a concurrent cause of death, while in other cases exsanguination is designated as a sole cause of death, forgetting the possibility that fat embolism could have really been the immediate cause of death.
Adult↗
[An accident after an accident--an unusual death in a hospitalized patient].
The authors present a case of accidental fatal laryngopharyngeal obstruction with bolus of food, in hospital, in a patient who has been treated for twenty days because of injuries sustained in a traffic accident. The injuries were multiple fractures and brain contusions that were not clinically diagnosed, while their symptomatology (somnolence) was attributed to morbous lesions--multifocal brain infarction. Mechanical asphyxiation and death occurred when the patient was fed in hospital by his brother. Unofficially we got an information that whole event was very dramatical, and that medical staff tried to attempt resuscitative measures, but without any written note about that in medical documentation. The terminal phase of his chronic desompensated cardiomyopathia was clinically announced as a cause of death. For forensic pathologists it was relatively easy task to prove mechanical asphyxiation due to laringopharyngeal blockage as a real cause of death on medicolegal autopsy.
Accidents, Traffic↗
[Suicide by electrocution--2 case reports].
Suicides by electrocution are extremely rare in our country. In these cases, specific or characteristic external lesions caused through contact with conductors at the sites of entry and exit of the current, as well as general autopsy findings, and excluding the other possible causes of death, are important to elucidate them. Dilemma if death was suicidal, homicidal or accidental in manner, could be solved through good police investigation, and properly explained circumstantial events. Herein, we reported two cases of suicidal deaths, caused by electrocution. In the first case, it was a male, age of 32, who wrapped the electrical cord around his wrists, and killed himself by plugging it in. In second case, it was a female, age of 46, abused by her husband, who committed suicide by putting the switched hear-dryer into the water in bathtub.
Adult↗
[Correlation between the survival duration and trauma severity in persons who died from posttraumatic fat embolism].
INTRODUCTION: Posttraumatic fat embolism follows the injury. The fat emboli in circulation could cause death in three ways: isolated lung fat embolism, systemic fat embolism and fat embolism syndrome (FES). In forensic pathology, only two trauma scores, based on disintegration of anatomic structures, could be used for objectivization, comparison and establishment of severity of injuries. One of them is Injury Severity Score--ISS, based on Abbreviated Injury Scale--AIS. The second one is Hannover Polytrauma Score--HPTS, based on the total sum of all injuries and age of the injured person. OBJECTIVE: The objectives of this paper were to establish the correlation between outliving period and trauma severity (based on ISS and HPTS values), in persons died from posttraumatic fat embolism and/or its complications, and to establish which of these score systems could be better for prediction of development of the posttraumatic fat embolism. METHOD: The retrospective autopsy study was performed and it included the material of the Institute of Forensic Medicine in Belgrade for period 1988-2001. The autopsy reports and clinical medical data were analyzed, for persons died from posttraumatic fat embolism and/or its complications. In all cases, the fat embolism was the single cause of death, verified by autopsy. In each case, ISS and HPTS values were obtained. The sample was statistically prepared (chi2 test, correlation coefficient, regression line). RESULTS AND DISCUSSION: The sample included 50 persons: 41 males and 9 females. The proportion of men was statistically significant (chi2 = 20.480; p < 0.001). Average age of male was 55.26 years (SD = 21.39) and of female was 55.78 (SD = 17.45). There was no statistically significant disproportion among the age distribution of the sample (chi2 = 6.4; p > 0.05). The outliving period varied from 1-14 days: the average was 5.92 (SD = 3.39; Med. 5.50; Mod. 2). The average value of 1SS was 19 (SD = 7.70; Med. 19; Mod. 14), and for HPTS average value was 28.16 (SD = 12.87; Med. 26.50; Mod. 12). In literature, there have been data about critical ISS value: 12-20. HPTS value of 20 to 35 was lethal in 25%. Each injured of our sample had, at least, one long bone or pelvic fracture. There was negligible negative correlation between outliving period and 1SS and HPTS values in our sample: coefficient of linear correlation r = -0.117, t = 0.83 and r = -0.088, t = 0.59. Our sample was representative (t = 8.37). These data pointed out that the outliving period of the observed patients, died from post-traumatic fat embolism, was not in relation to general severity of injuries but to fat embolism per se and its consequences. There was low positive correlation between ISS and HPTS values: r = 0.296, t = 2.147, coefficient of determination r2 = 0.0876 and linear regression HPTS = 18.7588+0.4948 ISS. These data indicated that direct correlation between scores was only about 9% and the rest of correlation i.e. 91% depended on other factors. CONCLUSION: There was negative negligible correlation between outliving period and severity of injury based on ISS and HPTS, in patients died from posttraumatic fat embolism. So, these score systems are useless for prediction of duration of the outliving period in the injured died from fat embolism as well as for prediction of posttraumatic fat embolism as cause of death.
Embolism, Fat↗