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Autopsy: Pediatric
Autopsy: Pediatric KA Collins, LifePoint Organ and Tissue Donations Services, Charleston, SC, USA r 2016 Elsevier Ltd. All rights reserved. This article is a revision of the previous edition article by H.F. Krous, T.S. Corey, volume 1, pp 176–183, © 2005, Elsevier Ltd.
Abstract Pathology is a branch of medicine, and the autopsy is a medical procedure. However, like many medical procedures, performance of the autopsy varies depending upon the age of the patient. The overall death investigation including the scene and history gathered is distinctive for the pediatric death. Likewise, the autopsy equipment, autopsy performance, special autopsy dissections and techniques, and ancillary studies are modified for the pediatric decedent. This chapter will highlight distinctive aspects of the pediatric autopsy with focus on the gross examination and proper collection of specimens for pertinent laboratory analyses.
Glossary Early neonatal period The first week of life. Embryonic period Time from fertilization to the end of the eighth week of gestation. Extremely low birthweight infant Infant weighing o1000 g. Fetal death Death after 20 weeks gestational age. Some areas in the world use 22 weeks gestational age. Full term Child born between 37 and 42 weeks gestation. Infant A child from 1 month to 1 year of age. Intrapartum death Death which occurs during labor and delivery.
Late fetal death Death after 28 weeks gestation. Neonatal death Death during the first month, or 28 days, of life. Neonate A child from birth to 1 month, or 28 days, of age. Premature Born less than 37 weeks gestational age. Small for gestational age (SGA) o10th percentile. Stillbirth Fetus born with no signs of life after 28 weeks gestational age. Very low birthweight infant Infant weighing o1500 g.
Introduction
Scene Investigation
The autopsy has numerous roles in science and medicine. The gold standard for quality assessment – the autopsy has important clinical implications not only to discover discrepancies but also to confirm clinical diagnoses, assess effectiveness of treatment, and improve standard of care (Burton and Mossa-Basha, 2012; Shojania et al., 2003; Combes et al., 2004; Newton et al., 2004). In the forensic arena, the autopsy is the key tool in death investigation. It is important in certifying the cause and manner of death, estimating time of death, identification, trauma documentation, accident reconstruction, correlating physical findings with a given history, evidence and specimen collection, and epidemiology and public health initiatives. The forensic autopsy has both a medical and a legal role. When the decedent is a child, the approach to the death investigation differs from that of an adult in several ways including the scene investigation, collection of history, performance of the external and internal examination, and the ancillary studies performed.
Investigation of the scene of death or the incident which led to death is often crucial to the accuracy of the autopsy conclusions. Table 1 serves as a list of important details that should be known to the forensic pathologist before beginning the autopsy. Likewise, any history of the decedent should be gathered to include medications, diet, natural diseases, previous injuries or illnesses, family history, and social history. Table 2 provides a list of important investigative details relating to decedent’s history. It is imperative to obtain details of the scene investigation and the history before beginning the autopsy as such findings can prevent overlooking and/or overcalling certain physical findings.
Encyclopedia of Forensic and Legal Medicine, Volume 1
Gross Examination Before commencing with the pediatric forensic autopsy, the proper instruments must be available. Some of these are the same as for the adult autopsy, but many are
doi:10.1016/B978-0-12-800034-2.00037-9
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Table 1
Autopsy: Pediatric
Scene investigation
The scene location
Initial body examination
Exact body location (house, adult bed, sofa, and car) Time of examination Bed and bedding Environmental hygiene Infestation Environmental hazards (heater, chemicals, tools, pool, medications, and electrical wiring) Source of heating and cooling Temperature (indoors and outdoors) Weather Food in home Siblings and pets Drug paraphernalia Floor surface(s) Hot water heater temperature and water temperature
Body position and face position Time of examination Rigor, livor, and algor (temperature) Imprints, pallor, and signs of bed-sharing Changes of decomposition Purge and body fluids Animal or insect activity Hygiene Well-nourished and well-developed? Nearby objects, toys, pillows, and bedding Position(s)/arrangement of clothing on body Cardiopulmonary resuscitation attempted? Trauma
Table 2
Decedent’s history
When found, last seen alive Recent health history Birth and prenatal history Pediatric history Remote illnesses Recent illnesses History of trauma Feeding history Sleep history, location, bedding, and bed-sharing, Medications Sibling history Family medical history Family social history (drugs, tobacco, and alcohol) Department of social services history
Table 3
Pediatric autopsy instruments
Scale for weighing the body Digital scale for weighing organs, calibrated to 0.1 g String Ruler (short and long) Forceps (preferably without teeth to preserve tissue integrity) Scalpel Sterile and non-sterile scalpel blades Small hemostats, straight and curved Small-to-medium blunt scissors Small tapered scissors Large scissors for calvarium and bone-cutting scissors Knives for organ sectioning Small probe with rounded ends Sterile syringes and needles Magnifying glass
specialized for smaller sizes and weights of organs, tissues, and vessels. Recommended instruments are listed in Table 3. A complete gross examination of the body begins with photography and documentation. The body is initially examined as it is received, any clothing
Table 4
External examination
Weight (unclad, minus medical devices) Body length¼crown-heel Crown-rump length Head circumference Chest circumference Abdominal circumference Foot length Fontanels (anterior and posterior), sutures Scalp hair growth pattern Symmetry of eyes, irides, and pupils Position and formation of ears Hard and soft palates Teeth, gingiva, buccal mucosa, and tongue Palmar and solar creases Extremity development, symmetry, and contractures Digits Nail development Patency of nares Overall assessment of facies Patency of anus Genitalia, hymen, and circumcision Birth marks, scars, and pigmentation Maceration and decomposition
itemized and then removed, and evidence of medical treatment documented. The clothing should be carefully inspected and photographed. If present, the diaper should be inspected for urine or fecal material, evidence of poor hygiene, or infestation. The gross examination then proceeds with the body weight and measurements (Table 4). The body should be weighed unclad and devoid of medical devices on a scale appropriate for the size of the body. Standard pediatric measurements not usually taken on the older child or adult body are best assessed using a string which is then placed against a ruler. The crown-heel is the body length, measured from the top of the head to the bottom of the heel while in the extended supine position. The crown-rump length, which is usually two-third of the crown-heel, is
Autopsy: Pediatric
measured from the top of the head to the bottom of the buttocks when the hips are flexed. The head circumference is the maximum circumference of the head taken from the frontal prominence around the occipital prominence. The chest circumference is taken around the thorax at the level of the nipple. The abdominal circumference is measured around at the level of the umbilicus. Foot length, the best measurement to estimate gestational age, is from the heel to the tip of the great/ first toe. Other measurements, such as arm length and interpalpebral distance, although useful in pediatric autopsy pathology are not standard in the forensic autopsy (Gilbert-Barness, 2005). Some external features and/or assessments are unique to the pediatric postmortem examination and can correlate with underlying organic diseases or the cause of death. The anterior and posterior fontanels should be palpated for fullness or depression as in cases of meningitis and/or cerebral edema or dehydration, respectively. If apparent, suture lines of fetuses and infants can be evaluated for depression, widening, or irregularity with overlapping skull plates. The scalp hair and growth pattern should be documented including any areas of alopecia, dermatitis, or unusual whorls. Symmetry of the upper and lower extremities, number and formation of digits, nails, and creases on the soles and palms can be abnormal in malformations and deformations. The position and formation of the ears, eyes, and nose are important in several underlying intrauterine infections, deformations, prenatal toxic exposures, and chromosomal abnormalities. Patency of the external auditory meatus, nares, and anus should be evaluated with a small, blunt-tip probe. Visual and digital examination of the hard and soft palate for completeness is important in all age groups especially in cases of asphyxia and failureto-thrive. The location of the testes (within the scrotum), penis, vulva, vagina, perineum, and anus should be inspected for trauma, infection, hygiene, and/or congenital abnormality. Identifying marks are documented such as Mongolian spots, birth marks, and scars. The entire surface is inspected for traumatic injuries including the oral cavity, postauricular region, axillae, and anogenital area.
Radiographs Postmortem imaging studies include standard radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI). The use of such studies has several purposes including the assessment of skeletal development, nutritional status, organic diseases, pneumothorax, remote/recent/acute trauma as well as identification of air/gas in the respiratory and gastrointestinal systems of newborns (Michiue et al., 2013). The standard radiograph is the first and most common study used. The whole body ‘baby-gram’ is insufficient
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as it causes geometric distortion, varying exposures, and will not properly delineate features needed to assess the above conditions. Instead, a multiple-film, skeletal survey is recommended especially in cases of suspected child abuse. The survey consists of a series of images collimated to each body region. The series includes frontal and lateral views of the skull, frontal and lateral views of the spine, frontal views of the chest (ribs) and pelvis, and frontal views of the extremities, including the hands and feet (Nimkin and Kleinman, 2001). Any fractures identified by radiograph can be excised during the autopsy, re-radiographed focusing particularly on the area in question, and examined histologically. The skeletal survey is widely available, inexpensive, and has a high sensitivity for acute and healing fractures. This type of survey is the same as used with living suspected child abuse victims.
Internal Examination The internal examination begins with the standard ‘Y’incision on the anterior thoracoabdominal region. The chest plate is removed by separating the sternoclavicular joints. The organs are first examined in situ to assess specific locations, anatomic relations, distribution of the vasculature, and rotation of the intestines. Volume and appearance of body cavity fluids are described. The serosal surfaces are examined for adhesions, petechiae, or abnormal texture. The thickness of the abdominal panniculus is recorded. At this time, specimens are taken for ancillary studies such as blood cultures, serology, and toxicology (see below). Using blunt dissection, the neck organs can be exposed and the thymus removed. The neck organs can then be removed in continuity (en bloc) with the thoracic, abdominal, and pelvic organs to maintain anatomical relationships and vascular connections. The dissection proceeds and the organs are each weighed in the fresh state and compared to tabulated expected weights based on crown-heel length. When dissecting the heart, the cardiac ventricular wall thicknesses, interventricular septal thickness, and valve circumferences should be measured. The volume and description of urine and bile are documented. The volume and description of gastric, small intestinal, and large intestinal contents are also recorded (Table 5). Routine sections are taken for histologic preparation as well as any additional sections depending on the case history or gross examination (Table 6). Organ and tissue sections are also to be taken for any additional ancillary studies (Table 7). The scalp is reflected via an intermastoidal incision to expose the calvarium. The calvarium is carefully removed and the underlying dura examined. Next, the brain is removed and weighed. The pituitary is removed,
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Table 5
Autopsy: Pediatric
Internal examination measurements
Abdominal panniculus Body cavity fluids Organ weights (fresh state) Heart valve circumferences Left and right ventricles, cardiac interventricular thicknesses Gastric contents Small intestinal contents Large intestinal contents Bile Urine
Table 6
Sections for histology
Routine sections Heart (right and left ventricles, interventricular septum) Lungs (one from each pulmonary lobe) Thymus Liver Spleen Pancreas (head and tail) Kidneys (right and left) Adrenal glands Costochondral junction Trachea Larynx Lymph node Cerebrum (cortex with white matter) Cerebellum with dentate nucleus Brainstem, pons Hippocampus Basal ganglia, thalamus, and internal capsule Pituitary Spinal cord (cervical, thoracic, and lumbar) Dura Discretionary sections (depending on the case) Cervix, uterus, and vagina Ovary and fallopian tube Prostate and testes Urinary bladder Ileum with ileocecal valve Esophagus Stomach Gastroesophageal junction Colon, appendix, and anus Breast Vertebrae Bony fractures Mucocutaneous and/or muscular trauma Normal bone and/or skin control and/or muscle control Eyes and optic nerve Peripheral nerve Skeletal muscle Umbilical cord and fetal/neonatal end Umbilical cord, placenta, and membranes Tongue
and the dura is stripped from the floor of the skull. The petrous ridge portion of the temporal bones can be resected for examination of the middle ears (Conran,
2010). Cultures of any exudate should be taken at this time with a culturette. The spinal cord may be examined, especially in cases of blunt head/neck/back trauma or rotational head injury. A posterior neck and back dissection allows visualization of the bony column and supporting musculature followed by removal of the cord (Doberson, 2010). The spinal cord can be removed by the posterior or anterior approach, with or without maintaining continuity with the brain (Miller and Kendall, 2010). The ocular globes and optic nerves can be removed and dissected in cases of intracranial trauma via the superior/ posterior (internal) approach through the orbital roofs (Sinard, 2010). The brain and globes should be fixed before sectioning unless a section of fresh brain is needed for toxicology. In addition to the ventral ‘Y’-incision, a dorsal ‘Y’incision contiguous with single incisions along the long axes of the upper and lower extremities may be performed. The skin and underlying soft tissues are reflected and the underlying musculature adequately examined for soft tissue trauma (Ross, 2010).
The ‘Float Test’ The lung float test, also known as the hydrostatic test, is one that has been postulated to determine whether or not a child was born dead (a stillborn fetus) or alive (Ostendorf et al., 2013). Variations of the test exist. If performed, most forensic pathologists tie a ligature around each bronchus, resect the lungs, and place each in water. If the lung(s) is aerated, it will float indicating that air/gas is present, a possible marker of postnatal breathing. However, cardiopulmonary resuscitation, other movements of the body, and decomposition can result in a false positive float test. A piece of liver is used as the control. If the liver floats, then the test is of no value. Certain entities such as congenital pneumonia and postmortem atelectasis, may cause lungs to sink, resulting in a false negative float test. Histologic examination of lung sections is also useful to assess aeration.
Sections for Microscopic Examination As the organs are removed, weighed, and dissected, routine sections are placed in cassettes for histologic preparation into paraffin blocks and glass slides. Routine sections are listed in Table 5 as well as additional sections that may be indicated depending on the particular case. The routine histologic stain is hematoxylin and eosin (H&E); however, numerous special stains and immunohistochemical stains can be performed on sections cut from the same paraffin blocks. It should be noted that even in cases of fetal maceration and
Autopsy: Pediatric
Table 7
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Ancillary Studies
Ancillary study
Specimen
Media
Toxicology on blood
Peripheral blood
Tissue viral culture
Tissue, sterile technique
Aerobic and anaerobic transport media Viral transport media
Rotavirus analysis
Fecal swab and feces
Sterile swab and sterile container
Insulin, C peptide analysis
Blood
Serum separator tube
Hemoglobin A1c
Blood
Serum separator tube
Sterile container with preservative (NaF tube) Toxicology screen Urine Sterile container Toxicology on tissue Tissue (e.g., liver and brain) Sterile container Toxicology on vitreous Vitreous Small sterile tube Toxicology on gastrointestinal contents Gastric contents, small and large Sterile containers, each submitted intestinal contents individually Hair analysis Pulled posterior vertex hair Submit hairs oriented as to root and tips (200 g) Carbon monoxide hemoglobin saturation Blood Tube with EDTA or NaF Serology (viral antibodies, cardiac enzymes, tryptase, hormones, and Blood Serum separator tube lipids) Chemistry (electrolytes, ketones, glucose, and beta-hydroxybutyrate) Vitreous Small sterile tube Urinalysis via test strip Urine Sterile container Cytogenetics and karyotyping 1 cm3 tissue¼skin, fascia lata, Fibroblast culture media or Ringer’s lactate lung, placenta, and cartilage Blood Blood in sodium heparin Molecular genetics and cardiac channelopathies Blood/blood spots; heart, liver, EDTA tube or filter paper, frozen tissue and spleen (5 g) DNA and paternity Blood EDTA tube Metabolic testing Fresh whole blood, blood spots; Filter paper bile and frozen tissue Electron microscopy 1 mm3 sections of organ/tissue Sterile container Hemoglobin electrophoresis Blood 2.5% Glutaraldehyde Microbiology blood culture Right atrium blood, sterile EDTA tube technique Microbiology exudate culture Exudate, wound, purulent fluid Aerobic and anaerobic culture broths Sterile culturette Microbiology tissue culture Tissue, sterile technique
Abbreviations: EDTA, ethylenediaminetetraacetic acid; NaF, sodium fluoride.
decomposition, the histologic examination can prove valuable.
placenta, and additional sections of any abnormalities (Popek, 2014).
Placenta
Ancillary Studies
In cases of fetal and neonatal deaths, the placenta should always be examined. The fetal (smooth) and maternal (16–20 cotyledons) surfaces are examined for integrity, color, lesions, and retroplacental clots. The cord length, diameter, insertion, and twisting are noted and the number of vessels (normal ¼ 2 arteries, 1 vein) determined. The membranes are examined for color, completeness, and insertion. The weight of the placenta is the disc weight minus the cord and membranes, or called the trimmed weight. The disc is then sectioned and the cut surface evaluated. The sections submitted for histology include: two sections of umbilical cord from separate areas, a membrane roll to include the area of membrane rupture, two sections of nonmarginal, normal appearing
With advances in science and medicine, new techniques and a better understanding of familiar procedures allow forensic pathologists to obtain more information from the autopsy than ever before (Collins and Cina, 2003; Conran and Stocker, 2014; Collins, 2011; Balikova, 2005). Historically, the common ancillary procedures used in the pediatric autopsy have been toxicology and microbiology. Toxicology specimens have routinely been urine for the drug and alcohol screen and peripheral blood (preferably femoral) for confirmation and quantification. Microbiology specimens have usually been blood, spleen, lung, and cerebrospinal fluid for bacterial cultures. The list of ancillary testing quickly expanded to include vitreous chemistry serology for enzymes, and analysis for
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Autopsy: Pediatric
inborn errors of metabolism. As scientists continue to study laboratory medicine, genetics, and molecular biology, new analyses and applications evolve (Ackerman, 2005; Ackerman, 2009). Today, autopsy specimens can be examined not only to determine cause and manner of death but also for public health initiatives, epidemiology, and consultation. Table 7 lists ancillary studies, specimens, and transport media that are utilized in autopsy and forensic pathology. A few points are worth mention regarding ancillary studies:
• • • • • •
• • • • •
•
• • •
The respective ancillary laboratory should be contacted ‘before’ submitting specimens. Blood for toxicology should be peripheral, preferably femoral, and placed into a container with preservative, i.e., sodium fluoride. Blood for microbiology culture should be taken from the right atrium. If blood is not available, spleen can be submitted for culture to evaluate sepsis. A prolonged postmortem interval over B15 h adversely affects the accuracy of microbiology culture results and interpretation. The time that microbiology specimens were obtained must be documented; specimens for culture should be transported to the laboratory as soon as possible. Tissues for anaerobic culture should be placed in anaerobic media and pressed into the media to insure an anaerobic environment. Vitreous should be placed in a small sterile tube to decrease head space should volatiles be analyzed. Tissue submitted for electron microscopy should be placed in 2.5% glutaraldehyde and then transferred to formalin after 24–48 h. Tissues for cytogenetic analysis must be procured in sterile fashion. Cerebrospinal fluid can be drawn by one of three methods: (1) a sterile needle inserted through the atlanto-occipital membrane and cisterna magna, (2) a lumbar puncture at L3-L4, or (3) from the lateral cerebral ventricle after removal of the calvarium, reflection of the dura, and delicate separation of the hemispheres. To obtain vitreous, a sterile 15- to 18-gauge needle is inserted through the lateral canthus 4–6 mm posterior and lateral to the junction between the cornea and sclera. In infants approximately 1 ml can be aspirated from each eye. Vitreous should be drawn slowly to prevent disruption of the retina and erroneous electrolyte results. Vitreous potassium can be used to estimate postmortem interval. The time of procurement must be recorded. If the ocular globes are to be removed and examined for retinal hemorrhages, vitreous should not be drawn.
Organ and Tissue Recovery The shortage of organs and tissues for life-saving and lifeenhancing transplantation continues as the candidate wait list grows. As much as 70% of potential organ and tissue donors fall under the jurisdiction of the Medical Examiner or Coroner in the United States (Wetli and Davis, 2014; Goldstein et al., 1997). However, the need is even more critical in the pediatric population where size-matched organs and tissues are required (Wetli and Davis, 2014). Studies have shown that organ donation does not interfere with criminal investigation and prosecution (Strama et al., 1994) and denial of organ donation, with its attendant loss of life of the potential recipient, is clearly not justified (Shafer et al., 1994). The National Association of Medical Examiners (NAME) position paper states that “the procurement of organs and/or tissues for transplantation can be accomplished in virtually all cases, without detriment to evidence collection, postmortem examination, determination of cause and manner of death, or the conducting of criminal or civil legal proceedings" (Pinckard et al., 2007). Essentially, the position of NAME is that there is rarely a reason for blanket denial, even in homicide cases (including child abuse) (Wetli and Davis, 2014). However, there may be ‘approvals with restrictions’ depending on the circumstances of any particular case (Pinckard et al., 2007).
See also: Autopsy Findings: Sudden Infant Death Syndrome − Pathological Findings and Autopsy Approach. Children: Infant Death Investigation. Children: Neglect. Children: Physical Abuse. Children: Sudden Natural Infant and Childhood Death. Domestic Violence. Falls from Height; Physical Findings − Pediatric. Head Trauma: Pediatric and Adult − Clinical Aspects. Injury, Fatal and Nonfatal: Blunt Force Injury. Neonaticide
References Ackerman, M.J., 2005. Cardiac causes of sudden unexpected death in children and their relationship to seizures and syncope: Genetic testing for cardiac electropathies. Seminars in Pediatric Neurology 12 (1), 52–58. Ackerman, M.J., 2009. State of postmortem genetic testing known as the cardiac channel molecular autopsy in the forensic evaluation of unexplained sudden cardiac death in the young. Pacing and Clinical Electrophysiology 32 (Suppl. 2), S86–S89. Balikova, M., 2005. Hair analysis for drugs of abuse. Plausibility of interpretation. Biomedical papers of the Medical Faculty of the University Palacký, Olomouc, Czechoslovakia 149 (2), 199–207. Burton, E.C., Mossa-Basha, M., 2012. To image or to autopsy? Annals of Internal Medicine 156, 158–159. Collins, K.A., 2011. Postmortem vitreous analysis. eMedicine Autopsy Textbook. Available at: http://emedicine.medscape.com/article/1966150-overview (accessed 25.03.14). Collins, K.A., Cina, S.J., 2003. Ancillary studies for the autopsy. In: Collins, K.A., Hutchins, G.M. (Eds.), Autopsy Performance and Reporting, second edition. Northfield: College of American Pathologists Press, pp. 229–238. (Chapter 24).
Autopsy: Pediatric Combes, A., Mokhtari, M., Couvelard, A., et al., 2004. Clinical and autopsy diagnoses in the intensive care unit: A prospective study. Archives of Internal Medicine 164, 389–392. Conran, R.M., 2010. Removal of the temporal bone, en bloc resection. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 42–43 (Chapter 20). Conran, R.M., Stocker, J.T., 2014. Ancillary studies and dissection techniques in the pediatric autopsy. In: Collins, K.A., Byard, R.W. (Eds.), Forensic Pathology of Infancy and Childhood. New York: Springer Publishing, pp. 1127–1156 (Chapter 37). Doberson, M.J., 2010. Posterior neck dissection. Spinal cord, anterior removal. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 28–29 (Chapter 13). Gilbert-Barness, E., 2005. Pediatric autopsy. In: Gilbert-Barness, E., Debich-Spicer, D.E. (Eds.), Handbook of Pediatric Autopsy Pathology. New Jersey: Humana Press, pp. 7–74 (Chapter 2). Goldstein, B., Shafer, T., Greer, D., Stephens, B.G., 1997. Medical examiner/coroner denial for organ donation in brain-dead victims of child abuse: Controversies and solutions. Clinical Intensive Care 8 (3), 136–141. Michiue, T., Ishikawa, T., Kawamoto, O., et al., 2013. Postmortem CT investigation of air/gas distribution in the lungs and gastrointestinal tracts of newborn infants: A serial case study with regard to still- and live birth. Forensic Science International 226 (1−3), 74–80. Miller, D.V., Kendall, A.M., 2010. Spinal cord, anterior removal. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 32–33. (Chapter 15). Newton, D., Coffin, C.M., Clark, E.B., Lowichik, A., 2004. How the pediatric autopsy yields valuable information in a vertically integrated health care system. Archives of Pathology & Laboratory Medicine 128, 1239–1246. Nimkin, K., Kleinman, P.K., 2001. Imaging of child abuse. Radiologic Clinics of North America 39 (4), 843–864. Ostendorf, A.L., Rothschild, M.A., Muller, A.M., Banaschak, S., 2013. Is the lung floating test a valuable tool or obsolete? A prospective study. International Journal of Legal Medicine 127 (2), 447–451. Pinckard, J.K., Wetli, C.V., Graham, M.A., 2007. National association of medical examiners position paper on the medical examiner release of organs and tissues
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for transplantation. American Journal of Forensic Medicine and Pathology 28, 202–207. Popek, E.J., 2014. Placental and maternal conditions in perinatal deaths. In: Collins, K.A., Byard, R.W. (Eds.), Forensic Pathology of Infancy and Childhood. New York, NY: Springer Publishing, pp. 109–168 (Chapter 5). Ross, K.F., 2010. Back (posterior trunk) and extremities cut-downs. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 12–13 (Chapter 5). Shafer, T.J., Schkade, L.L., Warner, H.E., et al., 1994. Impact of medical examiner/ coroner practices on organ recovery in the United States. JAMA 272, 1607–1613. Shojania, K.G., Burton, E.C., McDonald, K.M., Goldman, L., 2003. Changes in rates of autopsy-detected errors over time: A system review. JAMA 289, 2849–2856. Sinard, J.H., 2010. Eye enucleation, posterior approach. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 40–41 (Chapter 19). Strama, B.T., Hatcher, S.B., Shafer, T.J., 1994. Criminal Investigations and Prosecutions Not Adversely Affected by Organ Donations. Case Law Review. American Bar Association. Wetli, C.V., Davis, J.A., 2014. Pediatric organ and tissue donation. In: Collins, K.A., Byard, R.W. (Eds.), Forensic Pathology of Infancy and Childhood. New York, NY: Springer Publishing, pp. 1157–1172 (Chapter 38).
Further Reading Miller, D.V., 2010. Spinal cord in continuity with brain, anterior removal. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 36–37 (Chapter 17). Miller, D.V., Collins, K.A., 2010. Spinal cord in continuity with brain, posterior removal. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 38–39 (Chapter 18). Miller, D.V., Kendall, A.M., 2010. Spinal cord, posterior removal. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 34–35 (Chapter 16).
Abstract Pathology is a branch of medicine, and the autopsy is a medical procedure. However, like many medical procedures, performance of the autopsy varies depending upon the age of the patient. The overall death investigation including the scene and history gathered is distinctive for the pediatric death. Likewise, the autopsy equipment, autopsy performance, special autopsy dissections and techniques, and ancillary studies are modified for the pediatric decedent. This chapter will highlight distinctive aspects of the pediatric autopsy with focus on the gross examination and proper collection of specimens for pertinent laboratory analyses.
Glossary Early neonatal period The first week of life. Embryonic period Time from fertilization to the end of the eighth week of gestation. Extremely low birthweight infant Infant weighing o1000 g. Fetal death Death after 20 weeks gestational age. Some areas in the world use 22 weeks gestational age. Full term Child born between 37 and 42 weeks gestation. Infant A child from 1 month to 1 year of age. Intrapartum death Death which occurs during labor and delivery.
Late fetal death Death after 28 weeks gestation. Neonatal death Death during the first month, or 28 days, of life. Neonate A child from birth to 1 month, or 28 days, of age. Premature Born less than 37 weeks gestational age. Small for gestational age (SGA) o10th percentile. Stillbirth Fetus born with no signs of life after 28 weeks gestational age. Very low birthweight infant Infant weighing o1500 g.
Introduction
Scene Investigation
The autopsy has numerous roles in science and medicine. The gold standard for quality assessment – the autopsy has important clinical implications not only to discover discrepancies but also to confirm clinical diagnoses, assess effectiveness of treatment, and improve standard of care (Burton and Mossa-Basha, 2012; Shojania et al., 2003; Combes et al., 2004; Newton et al., 2004). In the forensic arena, the autopsy is the key tool in death investigation. It is important in certifying the cause and manner of death, estimating time of death, identification, trauma documentation, accident reconstruction, correlating physical findings with a given history, evidence and specimen collection, and epidemiology and public health initiatives. The forensic autopsy has both a medical and a legal role. When the decedent is a child, the approach to the death investigation differs from that of an adult in several ways including the scene investigation, collection of history, performance of the external and internal examination, and the ancillary studies performed.
Investigation of the scene of death or the incident which led to death is often crucial to the accuracy of the autopsy conclusions. Table 1 serves as a list of important details that should be known to the forensic pathologist before beginning the autopsy. Likewise, any history of the decedent should be gathered to include medications, diet, natural diseases, previous injuries or illnesses, family history, and social history. Table 2 provides a list of important investigative details relating to decedent’s history. It is imperative to obtain details of the scene investigation and the history before beginning the autopsy as such findings can prevent overlooking and/or overcalling certain physical findings.
Encyclopedia of Forensic and Legal Medicine, Volume 1
Gross Examination Before commencing with the pediatric forensic autopsy, the proper instruments must be available. Some of these are the same as for the adult autopsy, but many are
doi:10.1016/B978-0-12-800034-2.00037-9
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Table 1
Autopsy: Pediatric
Scene investigation
The scene location
Initial body examination
Exact body location (house, adult bed, sofa, and car) Time of examination Bed and bedding Environmental hygiene Infestation Environmental hazards (heater, chemicals, tools, pool, medications, and electrical wiring) Source of heating and cooling Temperature (indoors and outdoors) Weather Food in home Siblings and pets Drug paraphernalia Floor surface(s) Hot water heater temperature and water temperature
Body position and face position Time of examination Rigor, livor, and algor (temperature) Imprints, pallor, and signs of bed-sharing Changes of decomposition Purge and body fluids Animal or insect activity Hygiene Well-nourished and well-developed? Nearby objects, toys, pillows, and bedding Position(s)/arrangement of clothing on body Cardiopulmonary resuscitation attempted? Trauma
Table 2
Decedent’s history
When found, last seen alive Recent health history Birth and prenatal history Pediatric history Remote illnesses Recent illnesses History of trauma Feeding history Sleep history, location, bedding, and bed-sharing, Medications Sibling history Family medical history Family social history (drugs, tobacco, and alcohol) Department of social services history
Table 3
Pediatric autopsy instruments
Scale for weighing the body Digital scale for weighing organs, calibrated to 0.1 g String Ruler (short and long) Forceps (preferably without teeth to preserve tissue integrity) Scalpel Sterile and non-sterile scalpel blades Small hemostats, straight and curved Small-to-medium blunt scissors Small tapered scissors Large scissors for calvarium and bone-cutting scissors Knives for organ sectioning Small probe with rounded ends Sterile syringes and needles Magnifying glass
specialized for smaller sizes and weights of organs, tissues, and vessels. Recommended instruments are listed in Table 3. A complete gross examination of the body begins with photography and documentation. The body is initially examined as it is received, any clothing
Table 4
External examination
Weight (unclad, minus medical devices) Body length¼crown-heel Crown-rump length Head circumference Chest circumference Abdominal circumference Foot length Fontanels (anterior and posterior), sutures Scalp hair growth pattern Symmetry of eyes, irides, and pupils Position and formation of ears Hard and soft palates Teeth, gingiva, buccal mucosa, and tongue Palmar and solar creases Extremity development, symmetry, and contractures Digits Nail development Patency of nares Overall assessment of facies Patency of anus Genitalia, hymen, and circumcision Birth marks, scars, and pigmentation Maceration and decomposition
itemized and then removed, and evidence of medical treatment documented. The clothing should be carefully inspected and photographed. If present, the diaper should be inspected for urine or fecal material, evidence of poor hygiene, or infestation. The gross examination then proceeds with the body weight and measurements (Table 4). The body should be weighed unclad and devoid of medical devices on a scale appropriate for the size of the body. Standard pediatric measurements not usually taken on the older child or adult body are best assessed using a string which is then placed against a ruler. The crown-heel is the body length, measured from the top of the head to the bottom of the heel while in the extended supine position. The crown-rump length, which is usually two-third of the crown-heel, is
Autopsy: Pediatric
measured from the top of the head to the bottom of the buttocks when the hips are flexed. The head circumference is the maximum circumference of the head taken from the frontal prominence around the occipital prominence. The chest circumference is taken around the thorax at the level of the nipple. The abdominal circumference is measured around at the level of the umbilicus. Foot length, the best measurement to estimate gestational age, is from the heel to the tip of the great/ first toe. Other measurements, such as arm length and interpalpebral distance, although useful in pediatric autopsy pathology are not standard in the forensic autopsy (Gilbert-Barness, 2005). Some external features and/or assessments are unique to the pediatric postmortem examination and can correlate with underlying organic diseases or the cause of death. The anterior and posterior fontanels should be palpated for fullness or depression as in cases of meningitis and/or cerebral edema or dehydration, respectively. If apparent, suture lines of fetuses and infants can be evaluated for depression, widening, or irregularity with overlapping skull plates. The scalp hair and growth pattern should be documented including any areas of alopecia, dermatitis, or unusual whorls. Symmetry of the upper and lower extremities, number and formation of digits, nails, and creases on the soles and palms can be abnormal in malformations and deformations. The position and formation of the ears, eyes, and nose are important in several underlying intrauterine infections, deformations, prenatal toxic exposures, and chromosomal abnormalities. Patency of the external auditory meatus, nares, and anus should be evaluated with a small, blunt-tip probe. Visual and digital examination of the hard and soft palate for completeness is important in all age groups especially in cases of asphyxia and failureto-thrive. The location of the testes (within the scrotum), penis, vulva, vagina, perineum, and anus should be inspected for trauma, infection, hygiene, and/or congenital abnormality. Identifying marks are documented such as Mongolian spots, birth marks, and scars. The entire surface is inspected for traumatic injuries including the oral cavity, postauricular region, axillae, and anogenital area.
Radiographs Postmortem imaging studies include standard radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI). The use of such studies has several purposes including the assessment of skeletal development, nutritional status, organic diseases, pneumothorax, remote/recent/acute trauma as well as identification of air/gas in the respiratory and gastrointestinal systems of newborns (Michiue et al., 2013). The standard radiograph is the first and most common study used. The whole body ‘baby-gram’ is insufficient
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as it causes geometric distortion, varying exposures, and will not properly delineate features needed to assess the above conditions. Instead, a multiple-film, skeletal survey is recommended especially in cases of suspected child abuse. The survey consists of a series of images collimated to each body region. The series includes frontal and lateral views of the skull, frontal and lateral views of the spine, frontal views of the chest (ribs) and pelvis, and frontal views of the extremities, including the hands and feet (Nimkin and Kleinman, 2001). Any fractures identified by radiograph can be excised during the autopsy, re-radiographed focusing particularly on the area in question, and examined histologically. The skeletal survey is widely available, inexpensive, and has a high sensitivity for acute and healing fractures. This type of survey is the same as used with living suspected child abuse victims.
Internal Examination The internal examination begins with the standard ‘Y’incision on the anterior thoracoabdominal region. The chest plate is removed by separating the sternoclavicular joints. The organs are first examined in situ to assess specific locations, anatomic relations, distribution of the vasculature, and rotation of the intestines. Volume and appearance of body cavity fluids are described. The serosal surfaces are examined for adhesions, petechiae, or abnormal texture. The thickness of the abdominal panniculus is recorded. At this time, specimens are taken for ancillary studies such as blood cultures, serology, and toxicology (see below). Using blunt dissection, the neck organs can be exposed and the thymus removed. The neck organs can then be removed in continuity (en bloc) with the thoracic, abdominal, and pelvic organs to maintain anatomical relationships and vascular connections. The dissection proceeds and the organs are each weighed in the fresh state and compared to tabulated expected weights based on crown-heel length. When dissecting the heart, the cardiac ventricular wall thicknesses, interventricular septal thickness, and valve circumferences should be measured. The volume and description of urine and bile are documented. The volume and description of gastric, small intestinal, and large intestinal contents are also recorded (Table 5). Routine sections are taken for histologic preparation as well as any additional sections depending on the case history or gross examination (Table 6). Organ and tissue sections are also to be taken for any additional ancillary studies (Table 7). The scalp is reflected via an intermastoidal incision to expose the calvarium. The calvarium is carefully removed and the underlying dura examined. Next, the brain is removed and weighed. The pituitary is removed,
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Table 5
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Internal examination measurements
Abdominal panniculus Body cavity fluids Organ weights (fresh state) Heart valve circumferences Left and right ventricles, cardiac interventricular thicknesses Gastric contents Small intestinal contents Large intestinal contents Bile Urine
Table 6
Sections for histology
Routine sections Heart (right and left ventricles, interventricular septum) Lungs (one from each pulmonary lobe) Thymus Liver Spleen Pancreas (head and tail) Kidneys (right and left) Adrenal glands Costochondral junction Trachea Larynx Lymph node Cerebrum (cortex with white matter) Cerebellum with dentate nucleus Brainstem, pons Hippocampus Basal ganglia, thalamus, and internal capsule Pituitary Spinal cord (cervical, thoracic, and lumbar) Dura Discretionary sections (depending on the case) Cervix, uterus, and vagina Ovary and fallopian tube Prostate and testes Urinary bladder Ileum with ileocecal valve Esophagus Stomach Gastroesophageal junction Colon, appendix, and anus Breast Vertebrae Bony fractures Mucocutaneous and/or muscular trauma Normal bone and/or skin control and/or muscle control Eyes and optic nerve Peripheral nerve Skeletal muscle Umbilical cord and fetal/neonatal end Umbilical cord, placenta, and membranes Tongue
and the dura is stripped from the floor of the skull. The petrous ridge portion of the temporal bones can be resected for examination of the middle ears (Conran,
2010). Cultures of any exudate should be taken at this time with a culturette. The spinal cord may be examined, especially in cases of blunt head/neck/back trauma or rotational head injury. A posterior neck and back dissection allows visualization of the bony column and supporting musculature followed by removal of the cord (Doberson, 2010). The spinal cord can be removed by the posterior or anterior approach, with or without maintaining continuity with the brain (Miller and Kendall, 2010). The ocular globes and optic nerves can be removed and dissected in cases of intracranial trauma via the superior/ posterior (internal) approach through the orbital roofs (Sinard, 2010). The brain and globes should be fixed before sectioning unless a section of fresh brain is needed for toxicology. In addition to the ventral ‘Y’-incision, a dorsal ‘Y’incision contiguous with single incisions along the long axes of the upper and lower extremities may be performed. The skin and underlying soft tissues are reflected and the underlying musculature adequately examined for soft tissue trauma (Ross, 2010).
The ‘Float Test’ The lung float test, also known as the hydrostatic test, is one that has been postulated to determine whether or not a child was born dead (a stillborn fetus) or alive (Ostendorf et al., 2013). Variations of the test exist. If performed, most forensic pathologists tie a ligature around each bronchus, resect the lungs, and place each in water. If the lung(s) is aerated, it will float indicating that air/gas is present, a possible marker of postnatal breathing. However, cardiopulmonary resuscitation, other movements of the body, and decomposition can result in a false positive float test. A piece of liver is used as the control. If the liver floats, then the test is of no value. Certain entities such as congenital pneumonia and postmortem atelectasis, may cause lungs to sink, resulting in a false negative float test. Histologic examination of lung sections is also useful to assess aeration.
Sections for Microscopic Examination As the organs are removed, weighed, and dissected, routine sections are placed in cassettes for histologic preparation into paraffin blocks and glass slides. Routine sections are listed in Table 5 as well as additional sections that may be indicated depending on the particular case. The routine histologic stain is hematoxylin and eosin (H&E); however, numerous special stains and immunohistochemical stains can be performed on sections cut from the same paraffin blocks. It should be noted that even in cases of fetal maceration and
Autopsy: Pediatric
Table 7
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Ancillary Studies
Ancillary study
Specimen
Media
Toxicology on blood
Peripheral blood
Tissue viral culture
Tissue, sterile technique
Aerobic and anaerobic transport media Viral transport media
Rotavirus analysis
Fecal swab and feces
Sterile swab and sterile container
Insulin, C peptide analysis
Blood
Serum separator tube
Hemoglobin A1c
Blood
Serum separator tube
Sterile container with preservative (NaF tube) Toxicology screen Urine Sterile container Toxicology on tissue Tissue (e.g., liver and brain) Sterile container Toxicology on vitreous Vitreous Small sterile tube Toxicology on gastrointestinal contents Gastric contents, small and large Sterile containers, each submitted intestinal contents individually Hair analysis Pulled posterior vertex hair Submit hairs oriented as to root and tips (200 g) Carbon monoxide hemoglobin saturation Blood Tube with EDTA or NaF Serology (viral antibodies, cardiac enzymes, tryptase, hormones, and Blood Serum separator tube lipids) Chemistry (electrolytes, ketones, glucose, and beta-hydroxybutyrate) Vitreous Small sterile tube Urinalysis via test strip Urine Sterile container Cytogenetics and karyotyping 1 cm3 tissue¼skin, fascia lata, Fibroblast culture media or Ringer’s lactate lung, placenta, and cartilage Blood Blood in sodium heparin Molecular genetics and cardiac channelopathies Blood/blood spots; heart, liver, EDTA tube or filter paper, frozen tissue and spleen (5 g) DNA and paternity Blood EDTA tube Metabolic testing Fresh whole blood, blood spots; Filter paper bile and frozen tissue Electron microscopy 1 mm3 sections of organ/tissue Sterile container Hemoglobin electrophoresis Blood 2.5% Glutaraldehyde Microbiology blood culture Right atrium blood, sterile EDTA tube technique Microbiology exudate culture Exudate, wound, purulent fluid Aerobic and anaerobic culture broths Sterile culturette Microbiology tissue culture Tissue, sterile technique
Abbreviations: EDTA, ethylenediaminetetraacetic acid; NaF, sodium fluoride.
decomposition, the histologic examination can prove valuable.
placenta, and additional sections of any abnormalities (Popek, 2014).
Placenta
Ancillary Studies
In cases of fetal and neonatal deaths, the placenta should always be examined. The fetal (smooth) and maternal (16–20 cotyledons) surfaces are examined for integrity, color, lesions, and retroplacental clots. The cord length, diameter, insertion, and twisting are noted and the number of vessels (normal ¼ 2 arteries, 1 vein) determined. The membranes are examined for color, completeness, and insertion. The weight of the placenta is the disc weight minus the cord and membranes, or called the trimmed weight. The disc is then sectioned and the cut surface evaluated. The sections submitted for histology include: two sections of umbilical cord from separate areas, a membrane roll to include the area of membrane rupture, two sections of nonmarginal, normal appearing
With advances in science and medicine, new techniques and a better understanding of familiar procedures allow forensic pathologists to obtain more information from the autopsy than ever before (Collins and Cina, 2003; Conran and Stocker, 2014; Collins, 2011; Balikova, 2005). Historically, the common ancillary procedures used in the pediatric autopsy have been toxicology and microbiology. Toxicology specimens have routinely been urine for the drug and alcohol screen and peripheral blood (preferably femoral) for confirmation and quantification. Microbiology specimens have usually been blood, spleen, lung, and cerebrospinal fluid for bacterial cultures. The list of ancillary testing quickly expanded to include vitreous chemistry serology for enzymes, and analysis for
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inborn errors of metabolism. As scientists continue to study laboratory medicine, genetics, and molecular biology, new analyses and applications evolve (Ackerman, 2005; Ackerman, 2009). Today, autopsy specimens can be examined not only to determine cause and manner of death but also for public health initiatives, epidemiology, and consultation. Table 7 lists ancillary studies, specimens, and transport media that are utilized in autopsy and forensic pathology. A few points are worth mention regarding ancillary studies:
• • • • • •
• • • • •
•
• • •
The respective ancillary laboratory should be contacted ‘before’ submitting specimens. Blood for toxicology should be peripheral, preferably femoral, and placed into a container with preservative, i.e., sodium fluoride. Blood for microbiology culture should be taken from the right atrium. If blood is not available, spleen can be submitted for culture to evaluate sepsis. A prolonged postmortem interval over B15 h adversely affects the accuracy of microbiology culture results and interpretation. The time that microbiology specimens were obtained must be documented; specimens for culture should be transported to the laboratory as soon as possible. Tissues for anaerobic culture should be placed in anaerobic media and pressed into the media to insure an anaerobic environment. Vitreous should be placed in a small sterile tube to decrease head space should volatiles be analyzed. Tissue submitted for electron microscopy should be placed in 2.5% glutaraldehyde and then transferred to formalin after 24–48 h. Tissues for cytogenetic analysis must be procured in sterile fashion. Cerebrospinal fluid can be drawn by one of three methods: (1) a sterile needle inserted through the atlanto-occipital membrane and cisterna magna, (2) a lumbar puncture at L3-L4, or (3) from the lateral cerebral ventricle after removal of the calvarium, reflection of the dura, and delicate separation of the hemispheres. To obtain vitreous, a sterile 15- to 18-gauge needle is inserted through the lateral canthus 4–6 mm posterior and lateral to the junction between the cornea and sclera. In infants approximately 1 ml can be aspirated from each eye. Vitreous should be drawn slowly to prevent disruption of the retina and erroneous electrolyte results. Vitreous potassium can be used to estimate postmortem interval. The time of procurement must be recorded. If the ocular globes are to be removed and examined for retinal hemorrhages, vitreous should not be drawn.
Organ and Tissue Recovery The shortage of organs and tissues for life-saving and lifeenhancing transplantation continues as the candidate wait list grows. As much as 70% of potential organ and tissue donors fall under the jurisdiction of the Medical Examiner or Coroner in the United States (Wetli and Davis, 2014; Goldstein et al., 1997). However, the need is even more critical in the pediatric population where size-matched organs and tissues are required (Wetli and Davis, 2014). Studies have shown that organ donation does not interfere with criminal investigation and prosecution (Strama et al., 1994) and denial of organ donation, with its attendant loss of life of the potential recipient, is clearly not justified (Shafer et al., 1994). The National Association of Medical Examiners (NAME) position paper states that “the procurement of organs and/or tissues for transplantation can be accomplished in virtually all cases, without detriment to evidence collection, postmortem examination, determination of cause and manner of death, or the conducting of criminal or civil legal proceedings" (Pinckard et al., 2007). Essentially, the position of NAME is that there is rarely a reason for blanket denial, even in homicide cases (including child abuse) (Wetli and Davis, 2014). However, there may be ‘approvals with restrictions’ depending on the circumstances of any particular case (Pinckard et al., 2007).
See also: Autopsy Findings: Sudden Infant Death Syndrome − Pathological Findings and Autopsy Approach. Children: Infant Death Investigation. Children: Neglect. Children: Physical Abuse. Children: Sudden Natural Infant and Childhood Death. Domestic Violence. Falls from Height; Physical Findings − Pediatric. Head Trauma: Pediatric and Adult − Clinical Aspects. Injury, Fatal and Nonfatal: Blunt Force Injury. Neonaticide
References Ackerman, M.J., 2005. Cardiac causes of sudden unexpected death in children and their relationship to seizures and syncope: Genetic testing for cardiac electropathies. Seminars in Pediatric Neurology 12 (1), 52–58. Ackerman, M.J., 2009. State of postmortem genetic testing known as the cardiac channel molecular autopsy in the forensic evaluation of unexplained sudden cardiac death in the young. Pacing and Clinical Electrophysiology 32 (Suppl. 2), S86–S89. Balikova, M., 2005. Hair analysis for drugs of abuse. Plausibility of interpretation. Biomedical papers of the Medical Faculty of the University Palacký, Olomouc, Czechoslovakia 149 (2), 199–207. Burton, E.C., Mossa-Basha, M., 2012. To image or to autopsy? Annals of Internal Medicine 156, 158–159. Collins, K.A., 2011. Postmortem vitreous analysis. eMedicine Autopsy Textbook. Available at: http://emedicine.medscape.com/article/1966150-overview (accessed 25.03.14). Collins, K.A., Cina, S.J., 2003. Ancillary studies for the autopsy. In: Collins, K.A., Hutchins, G.M. (Eds.), Autopsy Performance and Reporting, second edition. Northfield: College of American Pathologists Press, pp. 229–238. (Chapter 24).
Autopsy: Pediatric Combes, A., Mokhtari, M., Couvelard, A., et al., 2004. Clinical and autopsy diagnoses in the intensive care unit: A prospective study. Archives of Internal Medicine 164, 389–392. Conran, R.M., 2010. Removal of the temporal bone, en bloc resection. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 42–43 (Chapter 20). Conran, R.M., Stocker, J.T., 2014. Ancillary studies and dissection techniques in the pediatric autopsy. In: Collins, K.A., Byard, R.W. (Eds.), Forensic Pathology of Infancy and Childhood. New York: Springer Publishing, pp. 1127–1156 (Chapter 37). Doberson, M.J., 2010. Posterior neck dissection. Spinal cord, anterior removal. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 28–29 (Chapter 13). Gilbert-Barness, E., 2005. Pediatric autopsy. In: Gilbert-Barness, E., Debich-Spicer, D.E. (Eds.), Handbook of Pediatric Autopsy Pathology. New Jersey: Humana Press, pp. 7–74 (Chapter 2). Goldstein, B., Shafer, T., Greer, D., Stephens, B.G., 1997. Medical examiner/coroner denial for organ donation in brain-dead victims of child abuse: Controversies and solutions. Clinical Intensive Care 8 (3), 136–141. Michiue, T., Ishikawa, T., Kawamoto, O., et al., 2013. Postmortem CT investigation of air/gas distribution in the lungs and gastrointestinal tracts of newborn infants: A serial case study with regard to still- and live birth. Forensic Science International 226 (1−3), 74–80. Miller, D.V., Kendall, A.M., 2010. Spinal cord, anterior removal. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 32–33. (Chapter 15). Newton, D., Coffin, C.M., Clark, E.B., Lowichik, A., 2004. How the pediatric autopsy yields valuable information in a vertically integrated health care system. Archives of Pathology & Laboratory Medicine 128, 1239–1246. Nimkin, K., Kleinman, P.K., 2001. Imaging of child abuse. Radiologic Clinics of North America 39 (4), 843–864. Ostendorf, A.L., Rothschild, M.A., Muller, A.M., Banaschak, S., 2013. Is the lung floating test a valuable tool or obsolete? A prospective study. International Journal of Legal Medicine 127 (2), 447–451. Pinckard, J.K., Wetli, C.V., Graham, M.A., 2007. National association of medical examiners position paper on the medical examiner release of organs and tissues
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for transplantation. American Journal of Forensic Medicine and Pathology 28, 202–207. Popek, E.J., 2014. Placental and maternal conditions in perinatal deaths. In: Collins, K.A., Byard, R.W. (Eds.), Forensic Pathology of Infancy and Childhood. New York, NY: Springer Publishing, pp. 109–168 (Chapter 5). Ross, K.F., 2010. Back (posterior trunk) and extremities cut-downs. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 12–13 (Chapter 5). Shafer, T.J., Schkade, L.L., Warner, H.E., et al., 1994. Impact of medical examiner/ coroner practices on organ recovery in the United States. JAMA 272, 1607–1613. Shojania, K.G., Burton, E.C., McDonald, K.M., Goldman, L., 2003. Changes in rates of autopsy-detected errors over time: A system review. JAMA 289, 2849–2856. Sinard, J.H., 2010. Eye enucleation, posterior approach. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 40–41 (Chapter 19). Strama, B.T., Hatcher, S.B., Shafer, T.J., 1994. Criminal Investigations and Prosecutions Not Adversely Affected by Organ Donations. Case Law Review. American Bar Association. Wetli, C.V., Davis, J.A., 2014. Pediatric organ and tissue donation. In: Collins, K.A., Byard, R.W. (Eds.), Forensic Pathology of Infancy and Childhood. New York, NY: Springer Publishing, pp. 1157–1172 (Chapter 38).
Further Reading Miller, D.V., 2010. Spinal cord in continuity with brain, anterior removal. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 36–37 (Chapter 17). Miller, D.V., Collins, K.A., 2010. Spinal cord in continuity with brain, posterior removal. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 38–39 (Chapter 18). Miller, D.V., Kendall, A.M., 2010. Spinal cord, posterior removal. In: Collins, K.A. (Ed.), Special Autopsy Dissections. Northfield: College of American Pathologists Press, pp. 34–35 (Chapter 16).