Cervical Soft Tissue Emphysema in Hanging-A Prospective Autopsy Study*

Clinical use of Macklin-like radiological sign (Macklin effect): A systematic review

INTRODUCTION

Recent studies suggested that Macklin sign is a predictor of barotrauma in patients with acute respiratory distress syndrome (ARDS). We performed a systematic review to further characterize the clinical role of Macklin.

METHODS

PubMed, Scopus, Cochrane Central Register and Embase were searched for studies reporting data on Macklin. Studies without data on chest CT, pediatric studies, non-human and cadaver studies, case reports and series including <5 patients were excluded. The primary objective was to assess the number of patients with Macklin sign and barotrauma. Secondary objectives were: occurrence of Macklin in different populations, clinical use of Macklin, prognostic impact of Macklin.

RESULTS

Seven studies enrolling 979 patients were included. Macklin was present in 4-22% of COVID-19 patients. It was associated with barotrauma in 124/138 (89.8%) of cases. Macklin sign preceded barotrauma in 65/69 cases (94.2%) 3-8 days in advance. Four studies used Macklin as pathophysiological explanation for barotrauma, two studies as a predictor of barotrauma and one as a decision-making tool. Two studies suggested that Macklin is a strong predictor of barotrauma in ARDS patients and one study used Macklin sign to candidate high-risk ARDS patients to awake extracorporeal membrane oxygenation (ECMO). A possible correlation between Macklin and worse prognosis was suggested in two studies on COVID-19 and blunt chest trauma.

CONCLUSIONS

Increasing evidence suggests that Macklin sign anticipate barotrauma in patients with ARDS and there are initial reports on use of Macklin as a decision-making tool. Further studies investigating the role of Macklin sign in ARDS are justified.

Autopsy findings of suicidal hanging in Mugla, Turkey

Introduction: External and internal autopsy findings of suicidal hanging were evaluated retrospectively in Muğla, Turkey. The relations between macroscopic autopsy findings and age, gender, nature of the ligature, position of the knot, and the ligature marks were assessed. The aim of this study was to describe autopsy findings of the hangings and discuss the regional differences. Method: The reports of 175 hanging autopsies between 2013 to 2018 were evaluated retrospectively. Macroscopic external and internal findings were evaluated and compared statistically. Results: Among the 2534 autopsies, the cause of death was suicide by hanging in 175 cases (6.9%). The male-to-female ratio was 3:1, 76%(n = 133) of the cases were male, 24% (n = 42) were female, the mean age was 44.9(SD = 19.3) years. Suicide by hanging was most prevalent in the 25-44 age group and among men. Complete hanging was more common than incomplete hanging, and softer materials were more commonly used in incomplete hangings. Females utilized soft materials more than males. Males used atypical hanging more than females. Bilateral hemorrhage in the neck muscles was more common with typical hanging. There was a significant relationship between tongue protrusion and hemorrhage at the clavicular head of sternocleidomastoid muscle. Conclusion: In this study, which includes a large series, some regional and gender differences were observed. Careful and detailed macroscopic examination was important to diagnose antemortem vitality findings.

Massive subcutaneous emphysema mimicking anaphylaxis - pathological and radiological correlations

This report details the pathological and radiological findings in a rare case of massive subcutaneous emphysema. A 74-year-old male presented with sudden onset dyspnea and facial swelling following a fall. His symptoms were refractory to treatments for anaphylaxis, which was suspected clinically, and he quickly succumbed. Autopsy, including post mortem CT scan revealed the underlying etiology to be multiple rib fractures with rupture of the parietal pleura, bilateral pneumothoraxes and massive subcutaneous emphysema involving the face, torso and upper limbs. Multiple frothy air bubbles were observed throughout the mediastinal adipose tissues on internal examination. Our findings echo those of rare previous reports and show how subcutaneous emphysema may, in rare circumstances, mimic anaphylaxis.

Relevant findings on postmortem CT and postmortem MRI in hanging, ligature strangulation and manual strangulation and their additional value compared to autopsy - a systematic review

Several articles have described the use of postmortem computed tomography (CT) and postmortem magnetic resonance imaging (MRI) in forensic medicine. Although access to CT scanners and, particularly, access to MRI scanners, is still limited for several institutes, both modalities are being applied with increasing frequency in the forensic setting. Certainly, postmortem imaging can provide crucial information prior to autopsy, and this method has even been considered a replacement to autopsy in selected cases by some forensic institutes. However, the role of postmortem imaging has to be assessed individually according to various injury categories and causes of death. Therefore, this systematic review focuses on the role of postmortem CT and MRI in cases of hanging and ligature and manual strangulation. We assessed the most common and relevant findings on CT and MRI in cases of strangulation and compared the detectability of these findings among CT, MRI and autopsy. According to the available literature, mainly fractures of the hyoid bone or thyroid cartilage were investigated using postmortem CT. Compared to autopsy, CT demonstrated equivalent results concerning the detection of these fractures. A currently described "gas bubble sign" may even facilitate the detection of laryngeal fractures on CT. Regarding the detection of hemorrhages in the soft tissue of the neck, postmortem MRI is more suitable for the detection of this "vital sign" in strangulation. Compared to autopsy, postmortem MRI is almost equally accurate for the detection of hemorrhages in the neck. Another "vital sign", gas within the soft tissue in hanging, which is hardly detectable by conventional autopsy, can be clearly depicted by CT and MRI. The number of cases of manual and ligature strangulation that were investigated by means of postmortem CT and MRI is much smaller than the number of cases of hanging that were investigated by CT and MRI. Likewise, judicial hanging and the hangman's fracture on postmortem imaging were described in only a few cases. Based on the results of this systematic review, we discuss the additional value of CT and MRI in fatal strangulation compared to autopsy, and we reflect on where the literature is currently lacking.

Outcomes of patients admitted for hanging injuries with decreased consciousness but without cardiac arrest

OBJECTIVE

The objective of this study is to provide appropriate treatment of patients who showed decreased mentality but did not suffer cardiac arrest (CA) from hanging injury, from reviewing the characteristics and analyzing the outcomes in such patients.

METHODS

A retrospective review of victims with decreased mentality but without CA due to hanging presenting to 2 tertiary general hospitals between January 2005 and August 2011 was performed. Treatments and examinations were evaluated, and the outcomes were assessed by cerebral performance category at hospital discharge.

RESULTS

A total of 21 patients were included, and their initial Glasgow Coma Scale scores were between 3 and 11. No one received therapeutic hypothermia, but all regained consciousness spontaneously and were discharged with cerebral performance category 1. They received only conservative treatment such as respiratory care, fever control, and inotropic use. Computed tomography and magnetic resonance imaging studies revealed no definite abnormality if the patient did not show abnormal symptom and sign.

CONCLUSION

Unconscious patients without CA from hanging could recover consciousness through conservative treatment.