Autopsy Findings in Asphyxia in Medical Bed Rails

Entrapment within an ottoman storage bed: an unusual accidental asphyxial death

Herein, we present an uncommon forensic case of death by asphyxia. The victim was a woman whose body at death scene investigation (DSI) was discovered beside an ottoman storage bed. According to the rescue team, who had moved the body before our arrival, the body was originally found in the prone position and stuck with the neck, thorax and arms within the bed. Examination of the body showed hypostasis that was mainly distributed to the face and the lower chest while sparing the neck and the upper chest. The face was markedly swollen, and the eyes were congested with blood. Dissection and histology revealed pulmonary oedema and emphysema of both lungs. Integrating circumstantial, radiology and autopsy data, it was established that the victim, while trapped between the mattress and the edge of the ottoman storage bed, died by mechanical asphyxia due to cervical-thoracic compression and postural asphyxia acting simultaneously.

The use of physical restraints in long-term care in Spain: a multi-center cross-sectional study

BACKGROUND

Physical restraint is a procedure used frequently in long-term care. It is a controversial practice because its use is associated with numerous complications and also affects freedom and individual autonomy. The objective of this study was to examine the use of physical restraint of long-term care residents with the ability to move voluntarily.

METHODS

We conducted a cross-sectional observational and correlational multi-center study. Nine centers agreed to participate. Of the 1,200 people present at the time of data collection, those without voluntary movement or in the facility for less than a month were excluded. Thus, the final sample was 920 residents. Data on the use of restraints was collected by direct observation. Information about the age, gender, length of stay, falls, mobility, cognition and functional status of residents was gathered by reviewing clinical records and interviewing nursing staff. A descriptive analysis of the data obtained was conducted. The generalized linear model was used, considering only the principal effects of each variable and using the logit link function. The model has been adjusted for clusters and for other possibly confounding factors. For all analyses, a confidence interval (CI) of 95% was estimated.

RESULTS

The prevalence of residents with at least one physical restraint was 84.9% (95% CI: 81.7-88.1), with variability between centers of 70.3 to 96.6% (p-value Kruskal Wallis test <0.001). Full-enclosure side rails were most often used (84.5; 95% CI: 81.1-87.9), but other types of restraints were also used frequently. Multivariate analysis showed that the degree of functional impairment increased the probability of the use of restraint. A significant association was also found between restraint use and the impaired cognitive status of residents.

CONCLUSIONS

The prevalence was higher than in studies from other countries. The results emphasize the need to improve the training of nursing staff in the care of residents with impairments in functional and cognitive status. The use of alternative devices and nurse consultants need to be evaluated, and the introduction of specific laws considered.

Autopsy practice in forensic pathology - evidence-based or experience-based? a review of autopsies performed on victims of traumatic asphyxia in a mass disaster

Current autopsy practice in forensic pathology is to a large extent based on experience and individual customary practices as opposed to evidence and consensus based practices. As a result there is the potential for substantial variation in how knowledge is applied in each case. In the present case series, we describe the variation observed in autopsy reports by five different pathologists of eight victims who died simultaneously from traumatic asphyxia due to compression during a human stampede. We observed that there was no mention of the availability of medical charts in five of the reports, of potentially confounding resuscitation efforts in three reports, of cardinal signs in seven reports and of associated injuries to a various degree in all reports. Further, there was mention of supplemental histological examination in two reports and of pre-autopsy radiograph in six reports. We inferred that reliance on experience and individual customary practices led to disparities between the autopsy reports as well as omissions of important information such as cardinal signs, and conclude that such reliance increases the potential for error in autopsy practice. We suggest that pre-autopsy data-gathering and the use of check lists specific to certain injury causes are likely to result in less deviation from evidence-based practices in forensic pathology. Pre-autopsy data-gathering and check lists will help ensure a higher degree of standardization in autopsy reports thus enhancing the quality and accuracy of the report as a legal document as well as rendering it more useful for data-gathering efforts.

First rib fractures in abused infants: a report of three cases

The authors describe 4 first rib fractures in 3 infants, highlighting the difficulty in detecting first rib fractures on skeletal survey. All 4 fractures were the result of physical abuse. A literature search does not find a case of first rib fracture in a healthy infant that is not the result of child abuse. The diagnosis of first rib fracture in an infant should prompt a thorough medical and social evaluation for child abuse.

Nursing home deficiency citations for physical restraints and restrictive side rails

This article examines whether nursing home facility-level characteristics are associated with the likelihood of receiving deficiency citations for physical restraints, including restrictive side rails. Data from the on-line survey certification of automated records were used to calculate odds ratios for facility-level characteristics associated with these deficiency citations. Repeat records from 2000 to 2007 were combined to produce longitudinal data. The results of this study show that restraint/side rail deficiency citations were negatively associated with higher staffing levels of registered nurses and licensed practical nurses (p ≤ .001) and higher Medicaid reimbursement rates (p ≤ .01). Citations were positively associated with greater nurse aide staffing (p ≤ .01) and higher quality-of-care deficiency citation percentiles (p ≤ .001). The extent of physical restraint and restrictive side rail misuse within nursing homes appears to vary according to various facility characteristics. It is less clear how internal processes within a facility bring about these observed patterns of variation.