Autopsy procedure, report and death certification

1. Lecture outline
• Autopsy procedure
• Autopsy report/Filling Death certificates
• Forensic wounds/Gun short injury
• Poisoning/Toxicology

2. Autopsy
• An autopsy (post-mortem
examination, obduction,
necropsy, or autopsia
cadaverum)
• is a surgical procedure that
consists of a thorough
examination of a corpse by
dissection to determine the
cause, mode and manner of
death.

3. Autopsy is Greek word: Autopsia – To see for oneself.
Autos - Oneself.
Opsis - Eye
3000 BC – Ancient Egyptians; removal,
examination, mummification.
Giovanni Morgagni
• (1682 – 1771) Father of Anatomical Pathology. Wrote:
The seats and causes of Diseases Investigated by
Anatomy 1769.
• Rudolf Virchow 19th. Standardisation of autopsy
procedure.

4. Purpose for Autopsy
• Determine if death was natural or unnatural
• Injury source and extent on the corpse
• Manner of death must be determined
• Time since death
• Establish identity of the deceased
• Retain relevant organs
• If it is an infant, determine live birth and
viability

5. • Determine the cause of death.
• Confirm or disprove the diagnosis.
• Evaluate therapeutic strategy.
• Legal requirement/questions.

6. Types of Autopsy
• Hospital/Clinical autopsy.
• Coroner’s; Medico-legal; Forensic autopsy.
• Family autopsy.
• Anatomical/Academic autopsy.

7. Autopsy procedure
1. Biodata
2. Time of date/Date of death
3. History/Circumstances of death
4. External Examination
5. Internal Examination
6. Microscopic Examination (Histology)
7. Results of further Examinations such as Microbiology,
Toxicology and Serology
8. Autopsy summary
9. Discussion
10. Opinion
11. Cause of Death (WHO format)
12. Qualification and Signature of the Pathologist

8. CONSENT
• Informed consent.
• Role of attending Consultant.
• Delivery of body/notes in the morgue.
• Discussion with Pathologist.
• Arrangement of time schedule and
• Presence at autopsy.

9. CLINICAL HISTORY
• The Pathologist must study the clinical notes
but should not be biased.
• Map out the autopsy strategy in order to
answer clinical questions touching on
diagnosis and treatment modality.

10. External Examination
• Height(length), weight and general state of
wellbeing
• Comment on signs of disease
• Identifying features
• The presence of rigor mortis, hypostasis,
decomposition/autolysis or any other
important postmortem changes

11. Post mortem changes
• Pallor mortis. Pallor – Paleness; Mortis – Of
death.
– Generally immediately (15 – 120 mins) after death
due to loss of capillary (CVS) function, coupled with
gravitation of blood.
• Algor mortis. (Latin). Algor – cold(ness); Mortis –
of death. Death chill-Core temp.; rectal temp.
– 2 degrees Celcius in the first 1 hour, then
– 1 degree per hour until near ambient temp

12. • Livor mortis; Hypostasis. Livor – Bluish colour;
Mortis – Of death.
• Hypostasis – Sediment. Gravitation of blood
into dependent areas but sparing areas of
contact flattening.
• Rigor mortis (Latin).
– Rigor – Stiffness; Mortis – of death.
– Ca++ pump failure post mortem; gradient
dependent intracellular movement.

13. Rigor mortis

14. • Putrefaction. Usually after 36 hrs but could be
earlier.
• Degradation of animal protein.
• Production of amines: Putrecine; Cadeverine.
• Modulating factors:
– Temperature/Geographical location.
– Endogenous bacteria/Cause of death.
– Exogenous bacteria/Wounds/Orifices.
– Entomological agents and accessibility.

15. Putrefaction; Time Scale.
• 1-2 Days: Staining around abdomen.
• 2-3 Days: Extension to veins; marbling.
• 3-4 Days: Abdominal and scrotal distention with
facial swelling; formation of blisters.
• 4-7 Days: Abdomen becomes taught; gas.
• 7-12 Days: Tissue softening; Rupture.
• 2-3 Weeks: Liquefaction of soft tissue; Nails drop.

16. Putrefaction

17. • Eyes: petechiae, arcus senilis, pupils, iris , and
lens
• Mouth and lips
• External genitals and anus
• List and describe all external injuries, recent
and old

19. Livor mortis

20. Types of skin incision
• Y-shaped or V-shaped incision can be made
starting at the top of each shoulder and running
down the front of the chest
• I-shaped incision ie a single vertical incision is
made from the sternal notch at the base of the
neck.
• U-shaped incision is made at the tip of both
shoulders, down along the side of the chest
• This is typically used on women and during chest-
only autopsies.

22. Y-Incision

23. I-Incision

24. Demonstration of pneumothorax

25. Removal of the rib cage

26. Pleural effusion

27. Removal of the skull

36. Types of Evisceration
• Letulle whereby all the organs are removed as
one large mass also called en masse technique
• Ghon - en bloc method of organ removal
• Virchow - this procedure, the individual organs
are removed sequentially and dissected
immediately after removal.
• Rokitansky - in situ dissection, in part
combined with en bloc removal.

37. Internal Examination
• In this section one systematically describes
the major organ systems as well as the organ
cavities
• Weights of organs are usually stated before
the findings in the various organ systems
• Routinely the weight of organs is only
necessary for the following: heart, lungs, liver,
spleen, kidneys, and brain

38. Microscopic Examination
• Histology is often not needed in forensic
cases, especially in deaths from trauma;
however slides are made when indicated
• Microscopic slides are usually indicated in
hospital autopsies
• A list of tissue samples retained for histology,
and their findings should be included in the
report

39. Further Examinations
Indications for further examinations depend
on the type of case, circumstance, and
availability of test
Further investigations include:
1. Toxicology
2. Serology
3. Microbiology
 Results of further examinations could be
issued as supplementary report

40. Autopsy Summary
• This is a summary of the lesions displayed by
the autopsy
• It often entails listing major findings in order
of importance
• It has also be referred to as “Provisional
Anatomical Summary” or “Final Anatomical
Summary” as applicable

41. Example of Anatomical summary
ANATOMICAL PATHOLOGICAL SUMMARY
• MORBID OBESITY
• PETECHIEL HAERRHAGES
• DIFFLUENT SPLEEN
• CHRONIC PYELONEPHRITIS
• ATHEROSCLEROSIS GRADE IV
PROVISIONAL DIAGNOSIS
• PRIMARY DISEASE
Chronic Pyelonephritis
• CAUSE OF DEATH
Septicaemia

42. Discussion/Comment
• Findings in the light of the known history or
circumstance
• Possible instrument of trauma/injury/disease
and mechanism
• Explore multiple/alternative causations, if
applicable, and ranking of possibility if
possible
• Offer interpretation as possible; avoid
speculation!

43. • An opinion as to the definite or most likely
sequence of events leading to the death
• This should briefly describe the cause of death
in as simple language as possible as well as
stating the manner of death

44. WHO Death Certificate
I(a) Disease or condition directly
leading to death* Rupture of myocardium
I(b) Antecedent causes (morbid
conditions, if any, giving rise to the
above cause, stating the underlying
condition last
Acute myocardial infarction
I(c) Coronary Artery Thrombosis
I (d) Atherosclerotic CAD
II Other significant conditions
(contributing to the death)
Diabetes Mellitus, COPD, Smoking
* This means the disease, injury or
complication which caused death
NOT ONLY, for example, the mode of
dying such as “heart failure,
asthenia” etc

45. WHO Format for cause of death
CAUSE OF DEATH
I. a. Hypovolemic shock
b. Massive ascites
c. Severe malnutrition
II. Hypertensive heart disease

46. WHO reporting of death-case
demostration

49. Cause of death
I a. Tonsilar herniation
b. Exradural haemorrhage
c. Blunt force injury with skull fracture

50. This should be avoided while writing
death certificate
• CARDIAC FAILURE,
• KIDNEY FAILURE, DYSPHAGIA,
• SENILITY, DYSPNOEA, ASPHYXIA,
• HEPATIC FAILURE,
• CARDIOPULMONARY ATTACK
NB: THESE MUST BE QUALIFIED IF USED.

51. Death certificate

52. Forensic Wounds
• Wounds are cause by application of physical
forces
• Are divided into blunt force trauma and sharp
force trauma
• Forces that do not require movement are
motion also produce their effects
• Force wound can be kinetic or non-kinetic

53. Classification of wounds
Kinetic injury
• Blunt force injuries
– Abrasions
– Contusion
– Lacerations
• Sharp force injuries
– Incised
– Stab wounds
Non-kinetic
• Thermal heat or cold
• Chemical
• Electrical
• Eletromagnetic

54. • Abration – is the most superficial types of
injury
• It involves only the epidermis and should not
bleed
• It come in forms of bite marks, grooved or
pachmented as in hanging
• In accidents it can be described as brush rash
or gravel rash

55. Abrasion

57. • Contusion-involves rupture of blood vessel
and leakage of blood into surrounding soft
tissue
• Skin remains intake the affected areas appears
dark brown and in most cases does show the
objects used in inflicting the injury

58. Contusion/Bruises

59. • Lacerations- appear as ‘cuts, splits or tears’ in
the skin and are the result of a blunt force
compressing or stretching the skin;
• They may extend through the full thickness of
the skin and can bleed profusely.

60. Contusion/Laceration

61. Bruises

62. • Incised wounds- are caused by objects with a
sharp or cutting edge
• Most commonly a knife but examples include
an axe, shards of glass
• An incised injury is distinguished from a stab
wound by being longer on the skin surface
than it is deep

63. Incised wound of the scalp

64. Incised wounds of wrist (Hesitation cut)

65. • A stab wound is caused by a sharp implement
and is deeper than it is long on the skin surface
• Any weapon with a point or tip can cause a stab
wound
• The edge of the blade does not need to be
sharp.
• Stab-like wounds may also be caused by blunt
objects such as screwdrivers or car keys.

66. Stab wounds

67. Penetrating injury

68. Penetrating wounds

69. Firearms wounds
• Discharging a firearm will result in the
formation of smoke, flame and gases of
combustion.
• These exit the barrel, together with portions
of unburned, burning and burnt propellant
and other items such as wadding and plastic
containers for the pellets.

70. Wound ballistics
• When the bullet hits the biological target, it
transfers its energy to the body, resulting in
injuries
– Kinetic energy: the energy possessed by an object due
to its motion;
– a function of the object's mass (M) and velocity (V):
KE = 1/2 MV2
– The bullet's mass plays an important role in gunshot
wounds, the most critical variable is the bullet
velocity;
– doubling the velocity will quadruple the kinetic energy

71. Firearms of forensic interest can be generally classified as:
• Handguns (pistols and revolvers)
• Long guns (shotguns and rifles)
• Rifled: the barrel contains spiral lands and grooves into
the inside of the barrel that grips the bullet as it exits
the firearm, providing spin and stabilization along its
path
• Smoothbore: the barrel is not rifled; typically found in
shotguns
• Low velocity: usually fires at less than 1,000 ft/sec
• High velocity: usually fires at more than 1,000 ft/sec

72. Bullets
• During its travel, the bullet is subject to rotational
forces causing:
– Yawing: oscillation of the bullet along its longitudinal
axis
– Tumbling: bullet loses its gyroscopic stability,
presenting a continually changing surface to the
direction of motion
– Precession: rotation of the bullet around the center of
mass
– Nutation: circular movement of the tip of the bullet

73. • Types of gunshot wounds:
– Penetrating wounds: the bullet enters the body
but does not exit
– Perforating wounds: the bullet enters and exits
the body
– Re-entry wounds: the bullet passes through a
body segment, exits and re-enters the body
– Graze / tangential wounds: the bullet strikes the
skin at a shallow angle, producing a superficial
wound

74. Soot deposition, searing of the skin and contusion surrounding
the central defect.

75. Suicidal twelve-bore shotgun entrance wound,
with soot soiling.

76. Bullet Inlet and multiple exist wounds

77. Comparism between AK 47 and AK 74
Trajectory path in the target

79. Graze wound on the skin and rifle exist wound
on the thigh

80. • A round is one complete unit of ammunition.
• This includes the bullet, the cartridge case, the
powder, and the primer.

81. • Photograph shows .22
long-rifle round (left)
and M16 round (right).
(Full metal case [FMC] is
a synonym for full metal
jacket [FMJ], type of
bullet used in military.)

83. Toxicology
• Multidisciplinary field focusing on the diagnosis,
management and prevention of chemical agent
toxicities in living systems, including
– Acute or chronic poisoning, drug overdoses, industrial
accidents, environmental exposures, envenomations,
adverse drug reactions
• Due to a wide range of potential chemical entities
faced in practice, several analytical techniques
may be required to detect the toxin of interest

84. • Numerous analytical techniques are used to
identify the drug / toxin of interest across
multiple biological samples
– Immunochemical assays are typically used as initial
screening
– Thin layer chromatography, high performance liquid
chromatography and gas chromatography / mass
spectrometry are used for confirmation
• Wide variety of tissue samples can be tested
(urine, serum, saliva, hair, vitreous homour,
blood)

85. Average time of death after ingestion or inhalation of fatal dose of poison
Solid regions indicate interval in which most deaths occur. Shaded regions indicate
intervals in which death occurs occasionally but less commonly.

87. CO Poisoning
• LIVIDITY cherry-red
bright red colour of the
skin
• CO in the nostrial and
mouth

88. Drugs
• Drugs and alcohol influence lives in many ways.
• The heroin- and crack-dependent addict arrested
for robbery, the recreational cocaine user
suspended following drug screening at work, the
student arrested for driving under the influence
of drugs and alcohol, and the chronic alcoholic
dying in police custody because of unrecognized
alcohol withdrawal are all examples of how drug
abuse can have huge impacts on individuals.

89. Drugs
• On June 25, 2009, American singer Michael
Jackson died of acute propofol and
benzodiazepine intoxication at his home
• On August 28, 2009, the Los Angeles County
Coroner concluded that Jackson's death was a
homicide
• Murray was convicted of involuntary
manslaughter in November 2011, and was
released in 2013

91. • In 2009, Bassam Abu Sharif, Arafat's former
advisor, alleged that Mossad, the national
intelligence agency of Israel, had poisoned
Arafat by a lethal dose of thallium
• A rare chemical whose effects are difficult to
trace

92. We must turn to nature itself, to the observations
of the body in health and disease, to learn the truth.
— Hippocrates
Thank you for your attention