By U. Ford.

A suicide note was present Hanging is a common cause of suicide in Victoria order discount topamax, at the scene when the deceased was found by his father purchase topamax with a visa. He any photographs taken in situ are ofen crucial in mak- ordered that no further examination of the deceased’s ing the correct diagnosis buy 100 mg topamax mastercard. In cases with any unusual features that are not read- ily explained through discussions with the scene police Case Study 23: Cautionary Cases investigators, a full internal examination with formal neck dissection is mandatory. It was alleged there had been an altercation Case Study 22: Postmortem Angiography earlier in the evening. Loosely adherent with the coroner and a postmortem angiogram was per- to the periosteum were numerous small fragments of formed, and a full autopsy examination was ordered. Afer strip- ἀ e postmortem angiogram showed a “cast” of con- ping away the periosteum an unusual patterned qual- trast within the small bowel (Figure 1. A male was charged and con- of postmortem angiograms to examine the vertebral victed of inficting fatal head injuries with the car lock. Approximately 150 ml of radiographic of consciousness afer which he was helped back to his K13836. By working ἀ e cause of death was a posterior fossa extradural in the medicolegal area we are aware of the importance hematoma. We are also acutely aware of the importance Forensic Issues It is not particularly difcult to fnd of experts keeping to their feld of expertise. One clearly cannot reasonably expect a the second case it is quite likely the pathologist might not forensic pathologist to approach the expertise of a con- identify the posterior fossa extradural hematoma, which sultant radiologist. However, they do highlight the young adults, disease processes and changes associated potential for important information to go undetected. A far more important fac- those with signifcant underlying disease processes can tor in the investigation is information on the case. Progressive gas autopsy and classical autopsy discrepancies: Radiologist’s formation in a deceased person during mortuary storage error or a demonstration of post-mortem multi-detector demonstrated on computed tomography. As the assessment of purely skeletal remains is a relatively Abrasions can display directionality. As a hard object uncommon occurrence in routine forensic practice, it is moves forcefully across the surface of the skin small fundamental for the forensic pathologist to interpret a portions of skin are ofen raised above the surface of the fracture with respect to the associated sof tissue inju- surrounding skin. An understanding of skin and sof tissue injuries is ally referred to as “skin tags. Furthermore, it is advisable that forensic forceful, yet as the object decelerates the abrasion can photographs are taken of any important injury or feature then become more pronounced. Types of Skin Injury ἀ e presence of abrasions in particular regions of the body is consistently seen in certain situations. In the context of blunt force trauma, the most important Classical examples include abrasions over the bony types of skin injury are abrasions, lacerations, and bruises. In general, the larger the degree moment of collapse one may see the injuries in the mid- of inficting force, the greater the skin injury. In any event the injuries numerous other factors may contribute to the size of an tend to occur in a single plane. Common examples include changes to the abrasion will tend to be more obvious when the forceful inguinal skin in association with extreme hyperextension contact was in a perpendicular orientation. Generally the patterned quality of the injury is easier to recognize than it is to Lacerations match the abrasion to a causal object (Figure 2. Incised injuries are due to the applica- tact with fragmented tempered glass in motor vehicle tion of sharp force as may occur from a razor, knife, or incidents. Because other information to provide an opinion on such mat- lacerations result from blunt force injury, the nerves, ters. In general, the individual who is closest to the vessels, and other connective tissues in the depths of the broken tempered glass has the greater concentration of wound may be crushed but tend to remain intact. A laceration may be caused when the sharp end of a In addition to external direct blunt force, another fractured bone extends through the skin. The injury clearly shows the shapes of wheel nuts and central axle that struck the chest of a cyclist. There is a broad abraded injury indicating a minimum width of con- tact between the weapon and the deceased’s head. The injury immediately above the left ear was continuous with an abrasion and bruise across the occiput. The location of the injury suggests the injury may have occurred while she was trying to defend herself. A second type of patterned in frm contact with an unyielding surface as the skin is bruise usually associated with opposing crescentic abra- punctured, forming an abrasion around the wound. In the medicolegal investigation of a death where a Bruises signifcant period of time has elapsed between the onset A bruise may be defned as extravasation of blood from of the injury and the subsequent death of the victim, it vessels into the surrounding sof tissues. A bruise results is highly likely a bruise would have changed in size and from the application of blunt force. Blood may track along tissue planes some dis- ἀ e extent of a bruise will tend to increase with tance from the site of origin. Other factors infuence the lead to bilateral periorbital hematomas, and a fractured size of a bruise from a given amount of force. When the body is struck with any rod- the papillary dermis are damaged, causing bleeding shaped object, the blood vessels directly beneath the into the superfcial layers of the skin. A typical forensic object will be compressed, whereas the blood vessels example is the patterned bruise caused by forceful con- along the edge of the rod will be stretched (Figure 2. The brown color of the injuries clearly indicate the bite marks were not associated with the incident that lead to death. For completeness, a brief description of gunshot injuries In darker-skinned individuals this issue is compounded. Conversely, a severe blow Gunshot Injuries to the abdomen may not be associated with any discern- able changes to the skin even though the blow may cause Firearms may be divided into smooth bore and rifed lethal blood loss from a ruptured liver or spleen. Rifed Bruises are much more pronounced when there weapons include the various handguns and long arm is diferential movement between the body and the weapons. When the end of the barrel and the surface of the skin, and the there is a substantial diference between the size of an presence of overlying clothing or hair. When the end of the barrel is hard against the skin, arm is applied to the neck of a smaller assault victim. When the barrel of the weapon acute and chronic phases but is of course a continuous is close to the skin soot produced from burning of the process. However, a recent labora- Apart from contact gunshot injuries the determi- tory study on human cadavers investigating postmor- nation of the range of fre is a ballistics question that tem hypostatic hemorrhages in the anterior neck and requires test fring with the weapon in question and strap muscles of cadavers showed “bufy coat” sedimen- identical ammunition. Furthermore, the study demonstrated hemorrhages that Exit Wounds were histologically indistinguishable from true ante- Simple exit injuries do not have an abrasion collar. Shored exit wounds have an associated abrasion around On the other hand, the absence of neutrophil mar- the skin perforation.

Rotate syringe and catheter clockwise while using traction to withdraw catheter References 1 order 200mg topamax with amex. Pepi M purchase topamax without a prescription, Muratori M: Echocardiography in the diagnosis and management of pericardial disease order discount topamax online. It is estimated that up to $3 billion is spent in the United States annually on preop laboratory and diagnostic studies. Unnecessary testing is inefficient and expensive, and it requires additional technical resources. Inappropriate studies may lead to evaluation of “borderline” or false-positive laboratory abnormalities. Surgical patients require preop lab and diagnostic studies that are consistent with their medical conditions, the proposed operative procedures, and the potential for blood loss. Preop lab and diagnostic testing should be ordered for specific clinical indications rather than simply because the patient is about to undergo a certain surgical procedure. Practice guidelines should be modified based on clinical needs and individual practice, to ensure the highest quality of anesthesia and surgical patient care. Johansson T, Fritsch G, Flamm M, et al: Effectiveness of non-cardiac preoperative testing in non-cardiac elective surgery: a systematic review. The updated report continues to give a Class I recommendation to continue beta-blockers in patients undergoing surgery who are already receiving the drugs for management of other conditions. Choose medications that are Beta-1 selective (examples: atenolol, metoprolol, and bisoprolol). Bangalore S, Wetterslev J, Pranesh S, et al: Perioperative beta blockers in patient having non-cardiac surgery: a meta-analysis. Specific drugs and drug dosages should be individualized, based on the physiological and pharmacological status of the patient, including factors such as age, weight, concurrent medication, and comorbidities. Recent studies have suggested that a strategy of lung protective ventilation may improve postop outcomes in a variety of surgical patient populations. The open administration of O should be limited to a maximum concentration of 30% O2 2 for procedures above T4 to minimize fire risk. Light-to-moderate levels of sedation (± analgesia) can be maintained using a propofol infusion (25–100 mcg/kg/min), or with intermittent bolus injections of midazolam (0. Alternatively, dexmedetomidine (an α−2 agonist) can produce excellent sedation and analgesia without respiratory depression. The same principles apply in children requiring surgery and in those who may have full stomachs. If iv access is difficult, O /sevoflurane induction with cricoid2 pressure, and succinylcholine (2–4 mg/kg im) will permit intubation and minimize risks of gastric aspiration. In a recent large survey of perioperative pain management, about 80% of patients experienced acute pain postop, with 86% of those patients characterizing their pain as ranging from moderately to extremely painful. Furthermore, postop pain management was the most common concern of the patients surveyed. The anesthesiologist’s expertise in neuraxial and regional anesthesia, as well as analgesic pharmacology, makes this physician the ideal advocate for improving perioperative pain management. The Joint Commission has recognized the importance of perioperative pain management as a means to reduce perioperative pain and suffering while facilitating improvements in functionality. Poor pain control leads to adverse clinical outcomes, including decreased ability to ambulate with increased risk for thromboembolic events and fatal pulmonary embolism. Inadequate pain control following abdominal and thoracic surgeries may → splinting, atelectasis, and pneumonia. The neuroendocrine stress response to surgery involves the release of stress hormones and catecholamines, which lead to many deleterious clinical effects and outcomes. These include weight loss, fatigue, immunosuppression, thromboembolism, hypercoagulability, dysrhythmias, urinary retention, and impaired pulmonary function. Furthermore, ongoing, uncontrolled pain in the postop period is a risk factor for chronic postsurgical pain. The continuous nociceptive barrage to the spinal cord and brain can lead to central sensitization, or “windup”, which is thought to result in persistent pain beyond the acute recovery period. As we learn more about perioperative pain management, we can minimize pain and suffering while reducing morbidity and mortality in our surgical patients. However, these medications must be used with caution to avoid respiratory depression. Managing perioperative pain in patients with a preexisting chronic pain condition and/or opioid tolerance presents many challenges. These patients are more likely to have a respiratory depression event, dependence, opioid-induced hyperalgesia as well as decreased testosterone levels, depressed immune function, and even morphological brain changes. Furthermore, the chronic use of high-dose opioids may contribute to a patient’s overall lack of functionality and slowed recovery. From a public health perspective, keeping the current prescription drug epidemic in mind, reducing postop opioid utilization could be of benefit to society. Utilizing agents that act on several receptor systems in the nociceptive pathway is more effective at providing postop analgesia. Postop pain management and patient recovery are most successful when an integrated, multispecialty, rehabilitation-orientated approach is utilized. Input from surgeons, anesthesiologists, rehabilitation specialists, nursing, pharmacy, and other key health care providers is necessary for this to occur. Best outcomes require that the patient be given appropriate preop education, excellent perioperative nociceptive blockade and attenuation of the neuroendocrine stress response, postop exercise, and early enteral nutrition. The benefit of preventing sensitization is a reduction in the patient’s risk of developing chronic pain after surgery. It has been demonstrated clinically that preincisional analgesics help improve poor postop pain control. A number of perioperative agents have been studied in this context with promising results, including lidocaine, iv ketamine, neuraxial anesthesia, peripheral nerve blockade, topical anesthetics, peripheral opioid, and central opioid agonists. Traditionally, the mainstay treatment of postop pain control included mainly short-duration opiates, which was suboptimal. Providing the patient with a more comprehensive perioperative pain management regimen leads to less reliance on short-acting opioids and their associated side effects, as well as reduced risk of sensitization and development of chronic postop pain. When used in conjunction with a structured postop rehabilitation program, these techniques can lead to decreased patient morbidity and mortality, increased patient satisfaction, decreased recovery time, and shorter hospitalization. An Example of Multimodal Analgesia for a 70-kg Patient Without Specific Drug Contraindications, Undergoing Major Surgery. Concentrations of opioids used for epidural infusions (in preservative-free solution): Morphine, 0. Then, if patient hemodynamically stable, give 1/2 bolus dose 30 min before end of surgery.

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The brain showed virtually no subarachnoid hemorrhage and no contusions topamax 200mg with amex, though there were extensive lacerations generic topamax 200 mg mastercard. Absence of hemorrhage following lacerations to the brain has been reported as much as 1 h after injury buy topamax 200 mg visa, and is presumably due to prolonged spasm of vessels. This is due to subarachnoid hemorrhage causing scarring of the arachnoid villi, such that it impedes their ability to reabsorb cerebrospinal fluid. Subarachnoid hemorrhage can be produced postmortem secondary to decomposition, with lysis of blood cells, loss of vascular integrity, and leakage of blood into the subarachnoid space. In addition, minimal subarachnoid hemorrhage may be produced during the process of removing the brain. In this case, in the process of removing the skull cap, cerebral veins and the arachnoid are torn, with subsequent diffusion of blood into the subarachnoid space in the posterior aspect (dependent portion) of the cerebral hemispheres and cerebellum. While this hemorrhage is usually very minor, if the brain is not removed from the cranial cavity immediately but rather left to sit for a while, a considerable quantity of subarachnoid hemorrhage may accumulate. Trauma to the Skull and Brain: Craniocerebral Injuries 175 Vertebral Artery Injury (Laceration) Blunt trauma to the neck can cause severe injury to the vertebral arteries. The upper third of the cervical region is the area where the vertebral artery is most susceptible to trauma. In the most common form, there is a traumatically induced dissection in the vessel wall, along a length of vertebral artery, with rupture into the subarachnoid space at the base of the brain (Figure 6. The second type of injury also involves dissection but, instead of rupture of the vessel wall, there is thrombosis of the lumen with infarction of brain tissue. The remaining two cases had rupture, but death was too rapid for subarachnoid hemorrhage. The most common causes of vertebral artery trauma are blows to the neck, motor vehicle accidents, falls, and cervical spine manipulation. Injury of the vertebral artery should be suspected when an individual collapses and dies almost immediately after receiving a blow to Figuren 6. In cases caused by rupture of the artery, an autopsy reveals sub- arachnoid hemorrhage primarily concentrated on the ventral surface of the brain and around the brain stem. In rupture of the artery due to blunt trauma, Opeskin and Burke noted bruising and abrasions below and behind the ear in 50% of 18 cases. Demonstration of the vertebral artery injury is easiest by injection of radio-opaque dye into the vertebral arteries with radiological demonstration of the injury. Only after such demonstration should there be dissection of the neck, because dissection is extremely difficult and, if not done correctly, may produce artifactual defects in the vessels. Of 19 individuals with rupture and subarachnoid hemorrhage in the study of Opeskin and Burke, 14 died immediately and five in 10 h to 3 days. Of the four individuals who died secondary to vertebral artery thrombosis, symp- toms did not appear for 1 d to 4 weeks, with survival time of 3 days to 7 weeks. Traumatic Injury of the Carotid Artery This entity is probably more common than realized. In the neck, it may be found in association with hyperextension injury or spinal fracture. The injury was incurred in a low-speed motor vehicle collision and was due to deploy- ment of an airbag. Traumatic Dissection of Intracranial Arteries Dissection of intracranial arteries due to trauma is relatively uncommon. It is caused by Trauma to the Skull and Brain: Craniocerebral Injuries 177 subintimal dissection of the intracranial anterior circulation arteries. Unlike other areas of the body where dissection is in the media, here it occurs subintimal, with resultant occlusion of the lumen by mechanical effects and the production of infarction. Traumatic Brain Swelling and Edema Following significant head injury, whether clinically mild or severe, swelling of the brain can occur. Brain swelling may be focal, adjacent to an area of brain injury; or diffuse, involving one or both cerebral hemispheres. Brain swelling is due to an increase in intravascular cerebral blood volume second- ary to vasodilatation (congestive brain swelling), or an absolute increase in the water content of the brain tissue, or a combination of the two. An increase in tissue water content, or cerebral edema, is often incorrectly considered synonymous with brain swelling. If continued long enough, brain swelling caused by an increase in the intravascular cerebral blood volume progresses to cerebral edema, presumably due to increased vascular permeability. The magnitude of the brain swelling does not necessarily correspond to the sever- ity of the injury. Massive cerebral (congestive) swelling can occur within 20 minutes following head trauma. The secondary swelling may, in fact, cause a more serious mass effect than the hematoma. With severe brain injury, diffuse brain swelling of a severe degree may occur immediately without the individual regaining consciousness. Brain swelling, however, might not occur immediately after an injury, but rather develop minutes to hours later. It is usually diffuse and more often associated with the less severe forms of brain injury. Typically, the patient receives a concussion, regains consciousness, only to become stuporous and lapse into coma minutes to hours later. Until recently, it was felt that children were more susceptible than adults to developing diffuse swelling, even after minor trauma. If brain swelling develops to a severe degree and continues over a suffi- cient time, there can be herniation of the brain or secondary brain stem hemorrhage. A rapidly expanding intracranial mass or severe brain swelling 178 Forensic Pathology Figure 6. Herniation may be either symmetrical, due to brain swelling, or asym- metrical, due to a mass in one side of the brain or subdural space, e. In the case of diffuse brain swelling, there is usually symmetrical herniation of the cerebellar tonsils without brain stem hemorrhage. The brain stem and cerebellar tonsils are forced into the foramen magnum, with resultant dysfunction or even infarc- tion of the brain stem. The individual becomes unconscious and develops respiratory difficulty that proceeds to arrest and death. In some individuals with pro- longed survival, the authors have seen the upper spinal cord encased in necrotic cerebellar tissues shed into the cerebrospinal fluid. In dealing with an asymmetrical herniation caused by a subdural hematoma, in addition to ipsilateral cerebellar tonsil herniation, one often has a secondary brain stem hemorrhage (a Duret hemorrhage) involving the midbrain and pons. Transtentorial or uncal herniation is due to a rapidly expanding suprat- entorial mass lesion. It may be either unilateral or bilateral, though unilateral herniation is more common because rapidly expanding lesions are usually unilateral. A rapidly expanding mass in a cerebral hemisphere means that ipsilateral uncal herniation can be expected. If severe enough, there will be displacement of the brain stem against the contralateral tentorial edge with injury to the brain stem and production of Kernohan’s notch.

An S and S originating from the right ventricle often are audible buy 200 mg topamax, most readily in the3 4 fourth intercostal space at the left parasternal area topamax 200 mg on-line, and are augmented by inspiration order 200mg topamax free shipping. This murmur is high-pitched, blowing, and decrescendo, beginning immediately after P , and is most prominent in the2 left parasternal region in the second to fourth intercostal spaces. Both the pulmonary artery and right ventricle are usually enlarged, but these signs are nonspecific. Abnormal motion of the septum characteristic of volume overload of the right ventricle in diastole and septal flutter may be evident. Additionally, the density of the Doppler profile of the jet is increased, and reversal of flow in the pulmonary artery by color flow imaging can be detected a distance from the valve. Multivalvular Disease Various clinical and hemodynamic syndromes can be produced by different combinations of valvular abnormalities. It frequently is caused by rheumatic fever but is also seen with congenital heart disease, carcinoid heart disease, radiation heart disease, and connective tissue disorders. Marfan syndrome and other connective tissue disorders may cause multivalve prolapse and dilation, resulting in multivalvular regurgitation. Congenital heart disease may predispose to infective endocarditis or degenerative disease. In patients with multivalvular disease, the clinical manifestations depend on the relative severity of each of the lesions. When the valvular abnormalities are of approximately equal severity, clinical manifestations produced by the more proximal (upstream) of the two valvular lesions (i. It is important to recognize multivalvular involvement preoperatively because failure to correct all significant valvular disease at the time of operation increases mortality. Specific guideline 13,40 recommendations exist for concomitant valve surgery in patients undergoing surgery on another valve. In patients with multivalvular disease, the relative severity of each lesion may be difficult to estimate by clinical examination because one lesion may mask the manifestations of the other. Therefore, patients with suspected multivalvular involvement being considered for surgical treatment should undergo careful clinical evaluation and full Doppler echocardiographic evaluation. Mixed stenotic and regurgitant lesions can be assessed with a combination of two- and three-dimensional imaging, including planimetry of stenotic orifices, color flow imaging, and Doppler. Multiple valves can be systematically assessed during 41 exercise; this is particularly helpful in assessing the patient with exertional symptoms, especially when these seem disproportionate to findings on imaging at rest. Rheumatic aortic valve disease may result in primary regurgitation, stenosis, or mixed stenosis and regurgitation. Echocardiography is of decisive value in the evaluation of patients with rheumatic disease and allows accurate diagnosis of the presence and severity of multivalve involvement, taking into consideration the altered flow conditions with serial lesions. It is vital to recognize the presence of hemodynamically significant aortic valvular disease (i. Physical findings may be confusing because it may be difficult to recognize two distinct systolic murmurs. When both valvular leaks are severe, this combination of lesions is poorly tolerated. With severe combined regurgitant lesions, regardless of the cause of the mitral lesion, blood may reflux from the aorta through both chambers of the left side of the heart into the pulmonary veins. An intrinsically normal mitral valve that is regurgitant because of a dilated annulus should not be replaced. Surgical Treatment of Multivalvular Disease Replacement or repair of multiple valves presently comprises 12% of valve procedures and usually is 43 associated with a higher risk and poorer survival than replacement of either of the valves alone. The operative risk of double-valve replacement is approximately 70% higher than for single-valve replacement. In view of the higher risks, a higher threshold is required for multivalvular versus single-valve surgery. Diagnosis and treatment of tricuspid valve disease: current and future perspectives. Evaluation of tricuspid valve morphology and function by transthoracic three-dimensional echocardiography. Trends and outcomes of tricuspid valve surgery in North America: an analysis of more than 50,000 patients from the Society of Thoracic Surgeons database. Right ventricular systolic function in organic mitral regurgitation: impact of biventricular impairment. Significant lead-induced tricuspid regurgitation is associated with poor prognosis at long-term follow-up. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Pathophysiology of tricuspid regurgitation: quantitative Doppler echocardiographic assessment of respiratory dependence. In vitro characterization of the mechanisms responsible for functional tricuspid regurgitation. Dynamics of the tricuspid valve annulus in normal and dilated right hearts: a three-dimensional transoesophageal echocardiography study. Excessive respiratory variation in tricuspid regurgitation systolic velocities in patients with severe tricuspid regurgitation. Surgical outcomes of severe tricuspid regurgitation: predictors of adverse clinical outcomes. Three-dimensional dynamic assessment of tricuspid and mitral annuli using cardiovascular magnetic resonance. Differentiation of tricuspid regurgitation from constrictive pericarditis: novel criteria for diagnosis in the cardiac catheterisation laboratory. Impact of functional tricuspid regurgitation on heart failure and death in patients with functional mitral regurgitation and left ventricular dysfunction. Impact of tricuspid regurgitation on survival in patients with chronic heart failure: unexpected findings of a long-term observational study. Combined mitral and tricuspid valve repair in rheumatic valve disease: fewer reoperations with prosthetic ring annuloplasty. Prognostic value of preoperative right ventricular geometry and tricuspid valve tethering area in patients undergoing tricuspid annuloplasty. Preoperative factors associated with adverse outcome after tricuspid valve replacement. Geometric changes after tricuspid annuloplasty and predictors of residual tricuspid regurgitation: a real-time three-dimensional echocardiography study. Heterotopic transcatheter tricuspid valve implantation: first-in-man application of a novel approach to tricuspid regurgitation. Birth prevalence of congenital heart disease worldwide: a systematic review and meta-analysis. Outcomes of pulmonary valve replacement in 170 patients with chronic pulmonary regurgitation after relief of right ventricular outflow tract obstruction: implications for optimal timing of pulmonary valve replacement. The clinical use of stress echocardiography in non- ischaemic heart disease: recommendations from the European Society of Cardiovascular Imaging and the American Society of Echocardiography. The spectrum of low-output low-gradient aortic stenosis with normal ejection fraction.

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