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Casadesús JM, Nieto-Moragas J, Serrando MT, Boadas-Vaello P, Carrera A, Aguirre F, Tubbs RS, Reina F. Pulmonary barotrauma in SCUBA diving-related fatalities: a histological and histomorphometric analysis. Forensic Sci Med Pathol 2023; 19:541-550. [PMID: 36705884 PMCID: PMC10752830 DOI: 10.1007/s12024-022-00567-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 01/28/2023]
Abstract
Arterial gas embolism following pulmonary barotrauma occurs in 13-24% of cases of diving deaths. The study aimed to evaluate the usefulness of a histomorphometric digital analysis in the detection of air space over-distension due to pulmonary barotrauma. The study was performed on lung parenchyma specimens of 12 divers: six had died due to arterial gas embolism following pulmonary barotrauma (mean age at death of 54 years, range of 41-61 years), and six had drowned in saltwater without a diagnosis of pulmonary barotrauma (mean age at death of 54 years, range of 41-66 years) (positive controls). For negative controls, six cases of non-SCUBA divers (mean age of death of 42 years, range of 23-55 years) who died of intracerebral haemorrhage were evaluated. No significant differences were observed in the characteristics of the air spaces between control groups (positive and negative). However, differences were observed in the area occupied by air spaces and the percentage of air space area when we compared the case group to the controls (p < 0.01); and there was a slight difference in the maximum and minimum diameters of air space (p < 0.05). The mean area occupied by air spaces and the mean percentage of air space were the most useful for discriminating pulmonary barotrauma from other causes of death (100% sensitivity and 91.7% specificity). Based on our study, inclusion of an increased pattern of air spaces as a possible diagnostic criterion for pulmonary barotrauma would be useful in discerning the cause of diving death.
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Affiliation(s)
- Josep M Casadesús
- Institute of Legal Medicine and Forensic Sciences of Catalonia (Division of Girona, Spain), Av. Ramón Folch, 4-6, Girona, 17001, Spain.
- Research Group On Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, University of Girona, Girona, Spain.
- Experimental Neurophysiology and Clinical Anatomy (NE&AC; 2017 SGR 01279), Department of Medical Sciences, University of Girona, Girona, Spain.
- Department of Medical Sciences, Faculty of Medicine, University of Girona (Spain), Av. Emili Grahit 77, Girona, 17003, Spain.
| | - Javier Nieto-Moragas
- Research Group On Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, University of Girona, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona (Spain), Av. Emili Grahit 77, Girona, 17003, Spain
- ICS-IAS Girona Clinical Laboratory, Av. Dr. Castany S/N, Salt, 17190, Spain
| | - Maria T Serrando
- Research Group On Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, University of Girona, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona (Spain), Av. Emili Grahit 77, Girona, 17003, Spain
- ICS-IAS Girona Clinical Laboratory, Av. Dr. Castany S/N, Salt, 17190, Spain
| | - Pere Boadas-Vaello
- Research Group On Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, University of Girona, Girona, Spain
- Experimental Neurophysiology and Clinical Anatomy (NE&AC; 2017 SGR 01279), Department of Medical Sciences, University of Girona, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona (Spain), Av. Emili Grahit 77, Girona, 17003, Spain
| | - Ana Carrera
- Research Group On Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, University of Girona, Girona, Spain
- Experimental Neurophysiology and Clinical Anatomy (NE&AC; 2017 SGR 01279), Department of Medical Sciences, University of Girona, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona (Spain), Av. Emili Grahit 77, Girona, 17003, Spain
| | - Fernando Aguirre
- Research Group On Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, University of Girona, Girona, Spain
- Special Group for Underwater Activities (GEAS), Spanish Civil Guard, C/Torroella S/N, Estartit, 17258, Spain
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - Francisco Reina
- Research Group On Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, University of Girona, Girona, Spain
- Experimental Neurophysiology and Clinical Anatomy (NE&AC; 2017 SGR 01279), Department of Medical Sciences, University of Girona, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona (Spain), Av. Emili Grahit 77, Girona, 17003, Spain
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Keller T, Desgraz B, Lossois M, Baccino E, Casadesus JM, Tuchtan L, Piercecchi MD, Klinguer P, Zarattin M, Gassend JL, Varlet V. Multicentric case series of scuba diving fatalities: The role of intracardiac gaseous carbon dioxide in the forensic diagnosis. Forensic Sci Int 2023; 352:111845. [PMID: 37757648 DOI: 10.1016/j.forsciint.2023.111845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023]
Abstract
Scuba diving fatalities post-mortem diagnosis presents a higher level of forensic complexity because of their occurrence in a non-natural human life environment. Scuba divers are equipped with diving gas to breathe underwater. It is essential for them to be fully trained in order to be able to manage their dive safely despite the varying increase of ambient pressure and temperature decrease. Throughout the dive, the inhaled diving gas is dissolved in the diver's tissues during the descent and if the decompression steps are not respected during the ascent, the balance between the dissolved gas and the tissues (including blood) is disrupted, leading to a gaseous release in the organism. Depending on the magnitude of this gaseous release, free gas can occur in blood and tissue. Venous or arterial gas embolism can also occur as a consequence of decompression sickness or barotraumatism. It can also induce drowsiness that consequently leads to drowning. As a result, the occurrence of gas in dead scuba divers is very complex to interpret, as is the difficulty to distinguish it from resuscitation maneuver artifacts or body decomposition. Although the literature is scarce in this domain, significant work has been done to provide a precise intracadaveric gas sampling method to enlighten the cause and circumstances of death during the dive. The aim of this study is to obtain higher statistical significance by collecting a number of cases to confirm the gas sampling protocol and analysis and gain more information about the cause of death and the events surrounding the fatality through the establishment of clear management guidelines.
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Affiliation(s)
- T Keller
- Swiss Human Institute of Forensic Taphonomy, University Centre of Legal Medicine Lausanne Geneva, Switzerland; Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - B Desgraz
- Universitary Centre of Hyperbaric Medicine (CURMedHyp), Lausanne, Geneva, Switzerland
| | - M Lossois
- Legal Medicine Department, Lapeyronie Hospital, Montpellier, France
| | - E Baccino
- Legal Medicine Department, Lapeyronie Hospital, Montpellier, France
| | - J M Casadesus
- Institute of Legal Medicine and Forensic Sciences of Catalonia, (Division of Girona, Spain), Spain; Research Group on Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, University of Girona, Girona, Spain
| | - L Tuchtan
- Legal Medicine Department, Marseille La Timone University Hospital, Marseille, France
| | - M D Piercecchi
- Legal Medicine Department, Marseille La Timone University Hospital, Marseille, France
| | - P Klinguer
- Forensic pathology unit, University Centre of Legal Medicine Lausanne Geneva, Switzerland; Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - M Zarattin
- Forensic pathology unit, University Centre of Legal Medicine Lausanne Geneva, Switzerland; Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - J L Gassend
- Swiss Human Institute of Forensic Taphonomy, University Centre of Legal Medicine Lausanne Geneva, Switzerland; Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Forensic pathology unit, University Centre of Legal Medicine Lausanne Geneva, Switzerland; Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - V Varlet
- Swiss Human Institute of Forensic Taphonomy, University Centre of Legal Medicine Lausanne Geneva, Switzerland; Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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Tarozzi I, Franceschetti L, Simonini G, Raddi S, Machado D, Bugelli V. Black box of diving accidents: Contribution of forensic underwater experts to three fatal cases. Forensic Sci Int 2023; 346:111642. [PMID: 36963130 DOI: 10.1016/j.forsciint.2023.111642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/04/2023] [Accepted: 03/08/2023] [Indexed: 03/17/2023]
Abstract
Diving is a popular activity, largely practiced worldwide. Diving fatalities are not rare events, with drowning being the most common cause of death, followed by cardiac-related natural causes, immersion pulmonary edema and arterial gas embolism. In such cases, positive signs of drowning are not specific, depending also on the time of submersion of corpses. Moreover, drowning can be the terminal event. Over the years, measures to perform appropriate post-mortem examination in cases of diving fatalities were suggested, including the execution of post-mortem CT-scan, the use of a decompression chamber and the adoption of specific autoptic techniques. Although a multidisciplinary approach in forensic investigations concerning diving fatalities is discussed, poor cases focus on how the analysis of diving computer records and equipment can contribute to determining the cause of death. The present study shows how the cooperation between a forensic underwater expert and a forensic pathologist played a crucial role in interpreting radiological findings, guiding the autopsy and confirming/denying circumstantial data emerging from the investigations. Technical analysis of dive computer records and diving equipment is a fundamental step in the definition of the cause of death in diving fatalities. All diving computer data, not only those related to maximum depth and ascent's profile, should be considered in detail, and the immersion graph carefully studied by both the forensic pathologist and the forensic underwater experts. The diving technical data can often play a crucial role in explaining any legal issue related to the circumstances of death, possibly leading the prosecutor to further investigation.
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Affiliation(s)
- Ilaria Tarozzi
- Modena Local Health Unit, Department of Legal Medicine and Risk Management, Modena, Italy
| | - Lorenzo Franceschetti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy; Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Luigi Mangiagalli, 37, 20133 Milano, Italy.
| | | | - Silvia Raddi
- Health Science Department, Forensic Pathology Section, University of Florence, Florence, Italy
| | - Davide Machado
- South-East Tuscany Local Health Unit, Department of Neuroradiology, Grosseto, Italy
| | - Valentina Bugelli
- South-East Tuscany Local Health Unit, Department of Legal Medicine, Grosseto, Italy
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Post-mortem computer tomography in ten cases of death while diving: a retrospective evaluation. Radiol Med 2022; 127:318-329. [PMID: 35050453 DOI: 10.1007/s11547-022-01448-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 12/31/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Self-contained underwater breathing apparatus (SCUBA) diving deaths have always been a challenge for forensic pathologists. Post-mortem computer tomography (PMCT) allows intracorporeal gas visualization, contributing to identify the cases in which the cause of death is arterial gas embolism (AGE). However, in the literature, it is indicated to perform the radiological examination within 24 h after death. MATERIALS AND METHODS In this retrospective study, 32 cases of death who had undergone PMCT 24-48 h after death/corpse finding between January 2011 and March 2021 were analyzed, including ten cases of SCUBA divers who died of AGE. All cases' radiological images were reviewed to localize the intracorporeal gas distribution alongside other findings that are usually related to SCUBA diving death. A semi-quantitative evaluation was also performed. RESULTS Most of the divers showed gas within the left heart and the arteries. In addition, the semi-quantitative evaluation revealed that the divers presented a higher mean amount of intraarterial gas compared to the fresh corpses. On the other hand, the putrefied corpses presented gas within the portal system and generalized subcutaneous emphysema with higher frequency and quantity than the divers and fresh corpses. CONCLUSION Our cases suggested that the PMCT, even when performed 24-48 h after death, remains a valuable tool to diagnose AGE in cases of SCUBA diving deaths. In addition, with the limit of the small sample size, our data showed that at least a medium quantity of intraarterial gas, when not associated with a high amount of gas within the portal system and subcutaneous emphysema, could be considered a diagnostic criterion of AGE.
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Wu W, Guo BB, Zhang JG, Wang RS, Ruan HB, Liu L. Forensic Identification of Diving Deaths. FA YI XUE ZA ZHI 2021; 37:683-686. [PMID: 35187921 DOI: 10.12116/j.issn.1004-5619.2020.400501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Investigation of the cause of death during diving is one of the contents of forensic pathology. In this article, relevant foreign literature is reviewed to summarize the techniques and methods used in the identification of diving deaths, such as accident reconstruction, diving monitoring data, postmortem CT examination and gas analysis (location and quantity) in the body of the corpse, in order to provide a reference for forensic identification of such cases.
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Affiliation(s)
- Wei Wu
- Hubei Chongxin Judicial Expertise Center, Wuhan 430415, China
| | - Bing-Bing Guo
- Hubei Chongxin Judicial Expertise Center, Wuhan 430415, China
| | - Jing-Guo Zhang
- Chaoyang District Sub-bureau, Public Security Bureau of Beijing, Beijing 100025, China
| | - Rong-Shuai Wang
- Hubei Chongxin Judicial Expertise Center, Wuhan 430415, China
| | - Hong-Bin Ruan
- Hubei Chongxin Judicial Expertise Center, Wuhan 430415, China
| | - Liang Liu
- Department of Forensic Medicine, Tongji Medical College Huazhong University of Science and Technology, Wuhan 430030, China
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López-de la Cruz Y, Quintero-Fleites YF, Nafeh-Abi-Rezk MS, Chávez-González E. Fisiología y anatomía quirúrgica de la arteria mamaria interna: ¿qué debe saberse durante su disección esqueletizada? CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Bradley LM, McDonald AG, Lantz PE. Fatal systemic (paradoxical) air embolism diagnosed by postmortem funduscopy. J Forensic Sci 2021; 66:2029-2034. [PMID: 34132391 DOI: 10.1111/1556-4029.14781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/14/2021] [Accepted: 05/20/2021] [Indexed: 11/27/2022]
Abstract
Air embolism is often unrecognized and underreported. Published case reports or case series describe only rare fundal examinations of retinal air emboli (RAE)-a distinctive sign of systemic air embolism. We report an infant, found unresponsive at home, who died in the emergency department after unsuccessful resuscitative efforts. Before the autopsy, diagnostic RAE were recognized and imaged during postmortem funduscopy. Postmortem radiography and an autopsy confirmed systemic (paradoxical) air embolism due to inflicted abdominal and thoracic blunt force injuries. While a few descriptions and illustrations of RAE occur in case reports, we found no published photographic images of RAE in infants, children, or adults. This case report describes and photographically documents classic RAE associated with fatal systemic (paradoxical) air embolism. Complementing postmortem radiography and judicious autopsy techniques, the detection of RAE can aid pathologists in diagnosing systemic air embolism.
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Affiliation(s)
- Lucy M Bradley
- Department of Pathology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Anna G McDonald
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Patrick E Lantz
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Abstract
Systemic arterial air embolism (SAAE) is a rare but potentially life-threatening condition that may occur when air enters into pulmonary veins or directly into the systemic circulation after pulmonary procedures (biopsy or resection) or penetrating trauma to the lung. While venous air embolism is commonly reported, arterial air embolism is rare. Even a minor injury to the chest along with positive-pressure ventilation can cause SAAE. Small amounts of air may cause neurological or cardiac symptoms depending on the affected arteries, while massive embolism can result in fatal cardiovascular collapse. We discuss the various causes of SAAE, including trauma, computed tomography-guided lung biopsy, and various intervention procedures such as mechanical circulatory support device implantation, coronary catheterization, and atrial fibrillation repair. SAAE diagnosis can be overlooked because its symptoms are not specific, and confirmation of the presence of air in the arterial system is difficult. Although computed tomography is the optimal imaging tool for diagnosis, patient instability and resuscitation often precludes its use. When imaging is performed, awareness of the causes of SAAE allows the radiologist to promptly diagnose the condition and relay findings to the clinicians so that treatment, namely hyperbaric oxygen therapy, may be started promptly.
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Casadesús JM, Aguirre F, Carrera A, Boadas-Vaello P, Serrando MT, Reina F. Diving-related fatalities: multidisciplinary, experience-based investigation. Forensic Sci Med Pathol 2019; 15:224-232. [DOI: 10.1007/s12024-019-00109-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2019] [Indexed: 10/27/2022]
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