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Cleveland, OH, United States

Armstrong E.J.,Cuyahoga County Medical Examiners Office
American Journal of Forensic Medicine and Pathology | Year: 2016

Fatal asphyxia by choking whether by food or foreign material remains an uncommon occurrence affecting mainly those at the extremes of age and with variable and sometimes misleading clinical presentations. Prompt clinical recognition of impending airway obstruction afforded by complete physical examination and assessment is paramount for prevention of morbidity and mortality in these cases. In the elderly, a death initially presenting with sudden cardiorespiratory collapse may be erroneously certified as due to natural disease without performance of an autopsy. Fortunately, deaths subsequent to cardiorespiratory collapse, where results of the clinical work-up fail to identify an etiology and medical history is insufficient, are reportable, falling under the jurisdiction of the medical examiner/coroner. The performance of an autopsy in the evaluation of a sudden death arising after hospitalization in which the etiology remains unclear can provide valuable information to our clinical colleagues that they can apply tomore timely diagnosis and treatment. Furthermore, the forensic autopsy offers clarification and answers to questions of medicolegal importance. This is particularly true for choking deaths. Presented is a choking death after tooth aspiration whereby the forensic autopsy provided specific anatomic correlation to the clinical clues not recognized before death and provided the true cause of death. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.


Wiens A.L.,Office of the Chief Medical Examiner | Felo J.A.,Cuyahoga County Medical Examiners Office
Journal of Forensic Sciences | Year: 2015

Discoloration of the skin of the anterior and lateral neck may raise suspicion for blunt force injury, particularly cervical compression, in an unwitnessed death. We present a case of an elderly woman with an unwitnessed death at home which highlights an external examination finding of blue/purple discoloration of the skin of the neck and links this finding with those from internal examination at autopsy. Pertinent negatives include absence of conjunctival and mucosal petechiae, absence of cutaneous abrasions of the neck, and absence of contusions of the anterior neck musculature. This case illustrates a natural disease entity, spontaneous dissection of a thoracic aortic hematoma, masquerading as blunt force injury externally and highlights the importance of having an appropriate index of suspicion when triaging jurisdictional cases for postmortem examination to accurately determine cause and manner of death. © 2015 American Academy of Forensic Sciences.


Armstrong E.J.,Cuyahoga County Medical Examiners Office
American Journal of Forensic Medicine and Pathology | Year: 2013

Upon encountering a body submerged within or in close association with a watery environment, the temptation by the first responder may be to surmise that the death is probably an accidental drowning of some sort. The challenge, however, is to quickly move beyond such temptation, maintaining an open mind to other possibilities. Unearthing the circumstances surrounding a water-related death requires the collaborative efforts of groups of trained professionals including law enforcement officers, medicolegal death scene investigators, forensic scientists, and forensic pathologists. The forensic pathologist has the ultimate responsibility for the interpretation of all results arising from comprehensive autopsy and toxicological and other ancillary examinations within the context of all available investigative information, for the most accurate determination of cause and manner of death.A water-related death is presented in which investigation into the circumstances surrounding the death and ultimately comprehensive postmortem analysis lead to the discovery of multiorgan sarcoidosis and lack of supportive evidence of drowning. This in turn facilitated the proper classification of the manner of death as natural. Copyright © 2013 by Lippincott Williams & Wilkins.


Naso-Kaspar C.K.,Cuyahoga County Medical Examiners Office | Wyman J.F.,Cuyahoga County Medical Examiners Office | Clark C.R.,Auburn University | Glass L.R.,Ethos Laboratories | And 4 more authors.
Journal of Analytical Toxicology | Year: 2013

Forensic toxicologists consider detection of 6-acetylmorphine (6-AM) definitive evidence of heroin abuse. This study investigated the possibility that aspirin, when in solution with morphine, may acetylate morphine to produce acetylmorphine (AM). Morphine sulfateextended release tablets (15 mg) and aspirin (325 mg) tablets were incubated in 50 mL postmortem gastric contents or deionized water at 37°C. One-milliliter aliquots were taken at timed intervals, extracted by solid-phase extraction, derivatized and analyzed by the gas chromatograph with a mass selective detector. Both 3- and 6-AM were detected in samples containing morphine and aspirin in combination; no heroin was detected. Production of AM was pH dependent with optimal formation at pH ≥4. In gastric contents, concentrations of 3-AM exceeded that of 6-AM by ̃10-fold. Production of 3-AM in gastric contents was approximately twice as high as it was in water, while matrix did not appear to affect 6-AM production. Urine specimens (10,602) assayed at a pain management laboratory and postmortem cases (>6,000) were investigated for in vivo formation of AM. Three cases exhibited unexplained 6-AM results. These data indicate that in vivo formation of 6-AM from the co-administration of aspirin and morphine, if it happens, is quite rare. In instances where this is suspected, 3-AM should be monitored. © The Author (2013). Published by Oxford University Press. All rights reserved.

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