miércoles, 21 de enero de 2009

3.-AIR EMBOLISM IN FORENSIC PATHOLOGY. PROF. GARFIA.A

3.- AIR EMBOLISM AND DEATHS SCUBA DIVING IN SPAIN (SCUBA DIVING DEATHS IN SOUTH SPAIN).
PROF. GARFIA.A


Deaths associated with scuba diving have become more numerous in Spain due to the increase in popularity of this recreational sport; many people believe that diving sport is not a dangerous sport and anyone can practice it, irrespective of their present state of health or other influences that can affect the physiological conditions under the water (alcohol, drugs,etc.) To the best of my knowledge, it is not necessary to obtain a Medical Certificate to practice this sport in anyone of the numerous schools on the Spanish coast who have introduced this popular sport. When death occurs during the practice of this sport or professional diving, using scuba equipment, though criminality is rarely a factor, in Spain, a forensic autopsy to determine the cause and the manner of the death, in the event of a request for compensation, which may lead to a civil case. Decompression of a diver ascending to the surface is, by far, the most common accident as a source of injury and death. In the professional diving field there is an increased activity associated with the offshore oil industry -the most dangerous type of commercial employment in other countries such as Britain, Venezuela,USA, etc. Most of these companies make sure for insurance purposes that their divers are fit and have Medical Certificates on a yearly or six month basis since they are paid very high salaries. Hazards of scuba diving, are: drowning and those secondary to barotrauma - pressure changes associated with descent and ascent- which describes the mechanical damage from gas released into the tissues. The bends (caisson disease; decompression sickness), air embolism, acute pulmonary emphysema, pneumothorax and related conditions are some of the more common examples; carbon monoxide intoxication occurs rarely, Paul-Bert intoxication ( acute neurotoxicity due to oxygen hyperbaric 100% concentrated), Lorrain-Smith effect (cronic pneumotoxicity),hypoxy and caustications due to soda lime are complications due to inhalation of hyperbaric oxygen with scuba closed circuit. The bends (caisson disease, decompression sickness) is due to a rapid decompression and occurs if the diver remains for a prolonged period of time at depths at which rapid changes of ambient pression cause the formation of bubbles in his blood and tissues. Rapid decompression may result in embolism of gas bubbles in two different ways: 1) air that expands but cannot escape the lung may damage the lung tissue (barotrauma) and be forced into the pulmonary vessels. The diagnosis of a venous air embolism, regardless of its cause, relies largely on the macroscopic examination findings. The venous air embolism can be diagnosed much more reliably in the course of an early autopsy, in order to find the presence of air bubbles, or frothy blood, inside the right heart, arteria pulmonalis, afferent cardiac large veins and coronary veins, than by microscopic examination. It is said: the diagnosis of venous air embolism is macroscopic although, microscopically, the presence of air bubbles in pulmonary arteries can be recognized by their outlines within the blood colums. 2) gas dissolved in the blood will be released in the form of small bubbles. In this case (caisson disease-decompression sickness), the presence of a lot of bubbles in the systemic circulation (arterial air embolism) has far greater consecuences than their embolization to the pulmonary vessels. Evidence of arterial air embolism is not easy to demonstrate and relies, largely, on the microscopical findings. After a short survival time of a few hours, the air disappears out of the vascular areas and organs affected, by resorption. However, sometimes it is possible to find the embolized air in the microscopic sections of several organs, such as brain, lungs, spleen, liver and kidneys. In this work I show the microscopical findings, with special reference to air-embolism, found in five cases of death during the practice of sport scuba diving, in Spain. The differential diagnostic must include the formation of postmortem gas emphysema (putrefaction cadaveric phase), in different organs -specially, liver, lung and heart- where the putrefaction air bubbles can show striking similarities with the air bubbles embolisms. For these reasons the autopsy must be carried out as soon as possible, preferably, within 24 hours.





CASES REPORTS
CASE Nº 1.-
Prof.Garfia.A

A man 30 years old, proffessional diver and teacher in a school of scuba diving, made an immersion, by night, after a great intake of alcohol. He was accompanied by a pupil who talked to him to persuade him not to make the immersion, due to his high intake of alcohol. The man was under the water for one hour. After this time the pupil rescued him, cadaver. Autopsy findings were typical of drowning and gas bubbles were found in the right ventricle and the liver, squeezing under the water during the autopsy delivered small air bubbles. Microscopically, air bubbles were found in the gastric wall -muscularis mucosae-, in the brain and in the kidneys. The stomach shows a acute haemorrhagic gastritis which was attribuited to the high alcohol intake ( one bottle of gin), in the observation of the pupil witness.


CASE Nº 2.-
Prof.Garfia.A

A man, 26 years old, was found dead in the sea when he was practicing sport scuba diving in the South Spanish coast. He was under the water, approximately, 30 minutes and to 10-15 meters of profundity. The macroscopical autopsy demonstrate heavy aedematous lungs but few macroscopical signs of drowning death. The more important microscopical findings were found in the cerebellum cortical layer: multiple cortical microhaemorrhages. The lungs and the heart show air embolism ( see figs. 1 and 2 ) and pulmonary oedema and emphysema. The rest of the organs showed inespecific congestion.

CASE Nº 3
Prof.Garfia.A

Woman, 40 years old, doctor, with antecedents of hypertension and diabetes.Obesity (90 kg). She was a pupil of a scuba diving course. Two months before, during the practice of scuba diving she had an accidente very similar to the actual. In that moment the woman was under the water to 10-20 meters of profundity and suddenly she was unconscious. Members of the team brought her to the surface and she was admitted to the nearest Hospital. She was in the Intensive Care Unit for 2 days and was treated with hyperbaric oxygen (50%). In the Unit, she presented dysnea and chest pain. A diagnosis of demi-drowning and Hypoxemic Respiratory Failure was emitted. Actually, the situation was similar; a member of the team related that the woman gives the alarm signal and she was transported to the surface in 20 seconds ( the profundity was, in that moment, of 20 meters). Once in the boat she was unconscious and on arrival at the Hospital she was pronounced dead. Autopsy demonstrates intense pulmonary congestion and very important edema with blood-tinged froth, in the nose, mouth, and distal respiratory passages and also interstitial pulmonary emphysema and pneumothorax. During the microscopical investigation, air bubbles were found in the following organs: brain, meningeal vessels, liver, kidney and spleen. Lungs show acute pulmonary emphysema. The more important finding was located in the heart ( 460 gr), with hypertensive cardiomyopathy and a severe narrowing arteriolopathy affecting the papilar muscles of the left ventricle. Also in the liver, hepatocytes showed glycogen vacuolization of nuclei- a specific marker of diabetes mellitus.

CASE Nº 4
Prof.Garfia.A

A man, 22 years old;. no pathologic antecedents. He belonged to a diver team who were doing immersion in groups. During the last immersion one member of the team saw one diver went out of the group and notice that he had open arms and legs, which appeared to be seperated from his body. Once member of the team came over to chek his condition and found him to be unconscious; this diver checked was unconscious and he had not the mouthpiece located in position normal; the diver intend to put him the self-mouthpiece but due to the unconscious state of him he can not do it. that the joung man and his mouth piece was not located in the normal position, and he was unable to replace the selfmouth piece due to his unconscieous state. Together with his partner they managed to re-surface him in 15 minutes. The man was dead when he arrived on the surface. The partner to decided to transported him to the surface, in 15 seconds. The computer-clock marked a deep of 101 meters and the time neccesary to go the surface was of 15 minutes. The coast police commented that it is not allowed diving under 60 meters.
Autopsy demonstrated multiple air bubbles inside the vascular compartment - heart, coronary venous vessels, and meningeal vessels- and also multiple haemorrhagic petechials in over the pleural surface. Microscopical investigation (see Figs.4) demonstrated air bubbles inside the vascular compartment of cerebellum, liver, lung and myocardium. The rest of the organs show unspecific congestion.

CASE nº 5
Prof. Garfia.A

A professional choral fisherman, age 30 years, was working at the Spanish coast in the proximity of Cádiz. The Police was called from a ship, who later arrived at the Port with a corpse of a young man. The Forensic Medical external examination of the dead body shows an extensive blood tinged froth extended all over the face - mouth and proximal respiratory passages.Although this finding is also seen in pulmonary edema from any cause, such as drug overdose, severe head injuries and congestive heart failure. The assistant personnel on the ship told the Police that the man was 40 minutes under the water at a deep of 75 meters. After that time the personnel of the ship went to look for him, and finally found him dead. The autopsy demonstrated haemorrhage in the middle ears, bilaterally; lungs showed intense pulmonary congestion and multifocal edema, and the stomach contained a lot of air due to the fact that it was largely distended. Microscopical investigation demonstrated the presence of air bubbels inside the vascular net of the brain, lungs and kidneys (see Figs. Case 5).





Prof. Garfia.A
FORENSICPATHOLOGYFORUM.BLOGSPOT.COM
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Case nº 5. Air embolism. Scuba diving. Death. Cerebellum. 
Note the air bubbles inside the cortical layer and also inside the meningeal vessels. Prof.Garfia.A



Prof. Garfia.A
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Case nº 5. Air embolism.Scuba diving. Death. Cerebellum. 
Air bubbles inside the cortical cerebellum vessels. Prof.Garfia.A

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Case nº 5. Heart. Air embolism. Scuba diving. Death. Prof.Garfia.A



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Case nº 5. Heart. Air embolism. Scuba diving. Death.

Note the different morphological aspects of air bubbles. Prof.Garfia.A



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CASE Nº4. Lung. Scuba diving death.
Elastic pulmonary artery contains one air bubble. Prof.Garfia.A



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CASE Nº4. Lung. Scuba diving deathElastic pulmonary artery contains two air bubbles. Prof.Garfia.A



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CASE Nº4.-Heart. Scuba diving death. Air embolism. 
Note the compression of the myocardiocytes. Prof.Garfia.A

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Case nº4.-
Liver.Hematoxilin-Eosin. Sinusoids air embolism. Scuba diving. Death. Prof.Garfia.A




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CASE Nº 4- Scuba diving death. Liver. Air embolism in the sinusoids (german sausage aspect).
Prof. Garfia.A



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CASE nº4.-Scuba diving death. Liver. Reticuline stain Numerous air bubbles in a portal space. Prof.Garfia.A


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Case nº 3.- Liver. Central vein. Scuba diving air embolism. Note how the air bubble made a pressure tunnel inside the continuous blood colum. Prof. Garfia.A


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Case nº 3.- Liver. Central vein distended by air bubble. Prof.Garfia.A



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Case nº 3.- Liver. Air embolism.The portal vein branch appears distended by the air bubble.
Prof. Garfia.A


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Case nº 3.- Brain. Air bubbles in the white matter. 
Prof. Garfia.A




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Case nº 2.- Detail to show the compression of the myocardiocites around the gas bubble (star).
Prof. Garfia.A



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Case nº 2.- Air bubbles in the heart capillaries (stars). Prof.Garfia.A



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Case nº 1.- Lung. Acute pulmonary emphysema, pneumothorax and air embolism may be considered, togheter, as they are all different stages of the same phenomenon.The mechanism responsible for the development of these conditions, single or in combination, is excessive pressure in the lungs. 
Prof.Garfia.A



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Case nº 1.- Fig.1.- Air embolism and death during sport scuba diving. Gastric wall. Air bubbles inside vessels of the muscularis mucosae. Prof. Garfia.A


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Case nº 1.- Fig.2.- Gastric wall showing multiple haemorragic foci in the mucosa which was attributed to the high alcohol intake (toxic haemorrhagic gastritis). Prof.Garfia.A


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Case nº 1.- Kidney. Shows air bubbles in the capillaries located in the medulla. Prof.Garfia.A



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Case nº 1.-Kidney. 
To show an air buble inside a renal arteriole. Note how the pression of the air buble dilates the vascular lumen of the arteriole.
Prof.Garfia.A


jueves, 8 de enero de 2009

1.-PULMONARY EMBOLISM OF CARDIAC TISSUE DUE TO GUNSHOT WOUND TO THE THORAX.Prof.Garfia.A

1.-MARKERS OF VITAL REACTIONS IN FORENSIC HISTOPATHOLOGY:PULMONARY EMBOLISM OF CARDIAC TISSUE DUE TO GUNSHOT WOUND TO THE THORAX.
PROF. GARFIA.A


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FIG. 1.-PULMONARY EMBOLISM Of CARDIAC TISSUE DUE TO GUNSHOT WOUND TO THE THORAX. PROF.GARFIA.A



PROF. GARFIA.A
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FIG. 2.- PULMONARY EMBOLISM OF CARDIAC TISSUE DUE TO GUNSHOT WOUND TO THE THORAX. ARROWS SHOW THE CHARACTERISTICALLY CENTRALLY PLACED NUCLEI OF THE CARDIAC MYOCYTES. PROF.GARFIA.A

     Venous and arterial embolisms of endogenous tissue components and also foreing material must be considered, in Forensic Pathology, as marker of vital reactions. On the other hand, must be borne in mind that, during the putrefactive cadaveric phase can be produced embolization of clusters of hepatic cells due to the putrefactive gases which can propelled it from the liver or other compact organs into the veins of the pulmonary circulation. Lung capillaries functions as a sieve in the blood circulation and various material can be trapped there. Bone marrow embolism is very frequently founded after trauma, reanimation procedures and bone surgery, -specially after methalic prothesis implants, due to the great destruction of bone tissue during the surgical procedure. Pulmonary embolism of bone spicules is a very rare event and sometimes ocurrs after trauma ocurring in a septic bone lesion, or accompanying to the cerebral tissue embolism to the lungs due to gunshot wound to the head. However, embolism of cardiac muscle cells to the lungs is vey rare type of embolism of organ fragments. It has been previously described following the operation on an atrial septum defect in a child.

Case Report
A little girl 16 year old was admitted to Hospital because she had received a close range gunshot wound from a revolver 44 Magnum. She was pronounced death at the arrival in the Hospital. On postmortem examination was found one entrance wound gunshot located at the right shoulder and an exit wound gunshot located between the 9th and 10th left ribs, through the intercostal space. Internal examination demonstrated a rounded hole surrounded by hemorrhagic infiltration, 1.5 cm diameter, which connect with the interventricular septum and perforating it, obliquely, in the way to the posterior face of the left ventricle; here, can be found an exit wound, rounded, affecting left ventricle, posterior interventricular septum and a small part of the wall of the right ventricle. Microscopic lungs examination demonstrate the presence of a lot of emboli of cardiac tissue inside the alveolar pulmonary capillaries.