Unexpected out-of-hospital deaths in persons aged 85 years or older: an autopsy study of 1886 patients

PURPOSE

The aim of this study was to determine the causes of death in the very elderly.

METHODS

We reviewed 24,081 consecutive autopsies performed over 10 years (1989 to 1998) at the Institute of Forensic Medicine, Vienna, Austria. We focused on autopsies of people aged 85 years or older who died unexpectedly out of hospital.

RESULTS

The mean age of the 1886 patients (561 men and 1325 women) at the time of death was 88 +/- 3 years (range, 85 to 108 years). Thirty-one percent (n = 588) of those who died were described as having been previously healthy. Cardiovascular disease was the most common cause of death (n = 1465 [77%]). Thirteen percent (n = 246) died of respiratory illness, 5% (n = 94) of gastrointestinal disorders, and 3% (n = 53) of diseases of the central nervous system. Genitourinary and metabolic diseases were uncommon.

CONCLUSION

Although this out-of-hospital sample is not representative of the entire elderly population, postmortem examinations emphasize the importance of cardiovascular diseases in causing unexpected deaths in older persons.

[Pump-gun as a weapon. Type of injuries, prohibition of weapons]

Pumpguns are shotguns with pump action whose injuries and wound mechanisms have several special features: extremely high kinetic energy of the shot (2500 to 3500 J) frequent cases of "Krönlein shots" (exenteration of the brain) punchmark/imprint immediately adjacent to the entrance wound from the front of the pipe magazine exit wounds from buckshot may be similar to pellet entrance injuries from a distant shotgun discharge the use of various shotgun cartridges (plastic ammunition, slug bullet, various lead pellets) within the same weapon. The change in the Austrian gun law and the banning of the pumpgun in 1995 is also discussed in the article.

Injuries due to letter bombs

In Austria in late 1993 ten letter bombs were sent to outstanding persons who have been engaged in the care of foreigners. Four of these bombs detonated, when they were opened by the addressee. The remaining six bombs were discovered in time and could be deactivated by specialists. The construction of these bombs and the lesions sustained by the four victims will be discussed. The injuries mainly concerned the left hand, i.e., the hand used by right-handed persons to hold a letter when opening it. The way holding the letter was of crucial influence on the degree of injury, as with the same explosive charge (which can be assumed deducing from the investigation of the deactivated bombs) injuries varied considerably. They ranged from minor tissue-lesions to mutilated fingers and the risk of exsanguination.

Homicide by strangling or dumping with postmortem injuries after heroin poisoning?

During construction work, the corpse of a 33-year-old man, H.L., who had been missing for 2 years and 4 months, was found in the cellar of a house. Primary findings indicated an attack directed at the throat (hematomas of the soft tissue and broken larynx). The owner of the cellar claimed, however, that H.L. had died of overdose of heroin and that he had removed the body to avoid trouble with the authorities. Morphine poisoning was confirmed by chemical analysis. The case is interesting because of (a) the good condition of the corpse after over 2 years, (b) macroscopic and microscopic evidence of hematomas of the cervical soft tissue, (c) successful chemical analysis providing evidence despite a long time since death, and (d) considerations regarding the vitality of injury findings.

[Electroshock devices as weapon]

13 electric shock weapons were investigated. The authors measured the electrical output and observed the effects on corpses and test persons. The electric shock weapons produced only moderate pain and did not stop the disposing capacity. The electrocardiogram and the circulation parameters were not influenced. The electric shock weapons tested might have only a limited deterrent effect and might be able to cause fatal complications under circumstances. Drug use and heart disease might enhance the risk.

Fatal impalement injuries after falls at construction sites

Three fatal accidents suffered by men at construction sites are reported. The victims fell from a considerable height onto metal construction rods and died from impalement injuries. The particular features of wound morphology are discussed. The influence of alcohol and medicines is also considered as a contributory cause of the falls.

[6 cases of premeditated murder of adults by drowning]

Premeditated murder of adults by drowning is rare and hard to investigate. Six cases are reported. If the aim of the killer is homicide by drowning to begin with (primary drowning), it is usually difficult to prove as morphological findings are missing of may be insignificant and ambiguous. If, on the other hand, the killer opts for drowning only as a conclusion to a primarily differently planned assault (e.g. strangling), the finding patterns are different, and their interpretation is usually easier (secondary drowning).

'Oral hygiene'--a method of killing in a medical setting

'Oral hygiene' is a routine nursing care procedure used in the treatment of critically ill patients. In the course of their confessions the women accused of the homicides at the Lainz Hospital in Vienna admitted having applied another form of 'oral hygiene'. About 250 ml of tap water was administered per os into the airways of severely ill and comatose patients, and death occurred about one hour later. Pathophysiological investigations have shown that this procedure is a suitable method of killing comatose patients with pulmonary impairment. Possible findings and the problems of detection on the corpse are discussed.

Assault and homicide by chop blows: a series of 11 cases

In a series of robberies, 11 elderly women living alone were attacked by an assailant (HS) by means of chop blows directed primarily at the throat, but also at the head, neck, and thorax. 5 died of their injuries. 1 died immediately after the assault. The other 4 victims survived for between 7-38 days. As a result of the injuries incurred, the women were confused, physically weakened and confined to bed, and eventually died from pneumonia. Their death was thus casually related to the violence sustained. Extensive haematomas of the scalp and cervical soft tissue were present. In 3 cases there were injuries to the laryngeal skeleton and adjacent soft tissue. In 2 cases there were conjunctival haemorrhages. The other 6 attacks were not fatal. The blows led to transient unconsciousness, which often resulted in a state of confusion, sometimes mimicking cerebrovascular accidents (CVA). Of other injuries, craniofacial haematomas were the most common. These cases are reviewed in this paper.

[Serial homicide in the Vienna-Lainz hospital]

Report on many cases of murder (the indictment included 41 cases) in the Clinical Centre of Lainz in Vienna. Two of the accused nurses were sentenced to life imprisonment, the other two to 15 and 12 years respectively. The operating modes are presented: intravenous administration of flunitrazepam, so called "oral hygiene", which proved to be forced aspiration of water, and injection of insulin. Possibilities of preventive measures against murder in hospital are discussed.

Shots fired with silencers--a report on four cases and experimental testing

Four cases of homicide, in which silenced firearms were used, are reported and supplemented by data from experimental investigations regarding wound features, marks, traces, and ballistic behavior. Wound features are largely determined by the construction of the silencer. In one case, even a muzzle imprint was produced by a silenced weapon fired at contact range. In general, silencers are likely to result in a decrease in bullet energy and accelerated energy release in the target (tissue). In terms of wound morphology, silencers produced a reduction in or even a lack of the contact ring (ring of dirt). In close-range and contact wounds, any features indicative of shots fired at close range were missing (such as soot deposit and powder tattooing). It is also worth mentioning that biological matter may get into the silencer in shots fired at contact range.

Gunshot wounds caused by Fiocchi Anticrime cartridges (plastic bullets)

The Fiocchi Anticrime cartridge (caliber 12/70) used for shotguns contains 15 plastic bullets that have a total weight (mass) of 15.2 g and feature a V4 of 302 m/s and an E4 of 694.7 J. Hence the bullets, which are claimed to be harmless, are able to penetrate the skin at close range. This article presents four cases of injuries. According to our tests, the Fiocchi Anticrime cartridge may well cause fatal injuries within firing distances of up to approximately 4-5 m.

[Maltreatment by police officers?]

In January 1990 amnesty international stated a report concerning 128 cases of alleged torture by the police in Austria since december 1984. Our material consists of 31 cases, three case reports are given in detail. Problems of medical expertise are discussed. It may be difficult to rule out injuries which are caused by accident or self inflicted. Some methods of torture (certain kinds of asphyxia for example) may be impossible to trace.

[Unusual motor ability in gunshot injury of the heart caused by a shotgun]

In a case of shotgun-injury of the heart with complete rupture of both ventricles and lesion of the aorta the victim was able to move a few metres in approximately six seconds. Despite other opinions ability to move or act can be maintained in cases of severest injuries of the heart caused by missiles with high energy.

[Carotid and vertebral artery circulation in forearm choke holds in Doppler sonography]

By means of continuous wave doppler the effect of two choke holds (Carotid sleeper, Nami-juji-jime) on the carotid and vertebral arteries was investigated. For both choke holds, which are characterized by pressure on lateral parts of the neck, we found an obstruction up to a complete stop of flow. The degree of obstruction depended on the direction of force. The vertebral artery can be compressed between the subclavian artery and the foramina transversaria, therefore it was most effective to press on the lower neck. Tensing the neck muscles can reduce the effect of choking.

[Gunshot wounds of the head in soldiers wearing military helmets-- general aspects and experiments and observations on the biomechanics and wound morphology]

With respect to wound ballistics, the situation is different if the person wearing a military helmet suffers head injuries from a bullet. The mechanisms of injury were investigated in four experimental series and supplemented by a case history. The study showed surprising results: in the majority of cases, the helmet does not protect the wearer, but instead intensifies the damage caused by the bullet. The reasons for this phenomena are changes in the stability of the projectile and deformation of or damage to the bullet. All of these mechanisms result in the bullet striking the tissue with higher energy. In this investigation, Kevlar helmets were also tested, which are not penetrated by 9 X 19 mm parabellum bullets. Even so, however, severe injuries of the skull and brain can occur because the projectile causes intensified impressions on the skull under the helmet and, in addition, an acceleration of the head.

[A fatality caused by heparin overdose]

Because of suspected pulmonary embolism 550.000 I.U. of heparin were administered instead of 55.000 I.U. of heparin within 24 h to a 62 year old patient. The man died because of cerebral hemorrhage the following day. Autopsy findings are reported and difficulties in medical expertise are discussed.

[Mechanism of action of forearm strangulation technics]

Two cases of death caused by the use of choke holds are reported; four different types of choke holds used in combative sports were investigated. In experiments on corpses it was found that even relatively little expenditure of strength can impede the passage of fluid not only through the internal carotid artery but also through the vertebral artery, depending on the respective choke hold. Fractures of the larynx cannot be expected as often as after typical throttling. However, a quick loss in defense capacity was found experimentally, and this always occurred within 15 s. Pulse frequency and blood pressure were recorded. Injuries to the neck are minor and may not be typical.

[Periventricular fatty metamorphosis in neuroglia--a morphologic substrate in SIDS]

In 7 of 15 cases of sudden infant death syndrome (SIDS), distinct periventricular fatty metamorphosis of the neuroglia could be demonstrated by a histological staining technique. None of the six children (under 1 year of age) used as a control group whose cause of death was not SIDS showed this morphological change. Thin-layer chromatographic analysis of the lipids accumulated in the glial cells in SIDS established a high amount of esterified cholesterol whereas the content of esterified cholesterol in the control group was low. We presume that fatty metamorphosis of the neuroglia represents the morphological substrate of a metabolic disorder of the sensitive, immature glia of the periventricular white cerebral matter caused by various kinds of damage.

[Liver rupture in a newborn infant caused by hemangiomatosis of the liver]

When a court-ordered autopsy was carried out on a deceased 17-day-old child, multinodular hemangiomatosis of the liver was determined to be the cause of massive intra-abdominal bleeding. The physicians who had treated the child had suspected this disease because of the results of their sonographic investigations, but were unable to reach a final diagnosis. Also, the results of the autopsy excluded negligence by the obstetricians with certainty.

Poisoning with oral antiarrhythmic drugs

The incidence of poisoning with antiarrhythmic drugs (AAD) is low, but frequently cardiac disturbances cause a high mortality. Clinical and toxicological data on verapamil, quinidine, ajmaline, prajmaliumbitartrate, mexiletine and aprindine as collected by the Austrian Poison Information Center (PIC) are presented in this paper. The drug concentrations of verapamil, mexiletine and quinidine detected in post-mortem specimens are discussed and compared with correspondent data from literature. Clinical experiences with this kind of intoxication are rather poor and therapeutical principles are very inconsistent. To avoid life-threatening symptoms, gastric lavage has to be performed irrespective of the latency period, accompanied by continuous cardiac monitoring. Cardiocirculatory disorders respond well to sympathomimetic drugs. Immediate and adequate cardiopulmonary resuscitation decisively determines the therapeutical success in critical cases.

Forensic problems in Rett syndrome

A case of the Rett syndrome is presented, where the patient died without medical help at home because of extreme malnutrition. The forensic aspects of the case are discussed.

[Brain stem hemorrhage from capillary telangiectasis--a substrate of sudden death from natural causes]

Pontine haematomas because of capillary telangiectasis must be considered a rare condition. This report deals with autopsies of five such cases. In two of these there was rapid loss of consciousness and/or immediate death, as established by circumstantial evidence. These haematomas proved-- in the estimation of the authors--to be lethal. The two other cases had uremia, and the possibility is discussed that these haemorrhages could be a terminal, concomitant feature of this underlying disease. Whatever significance the brain-stem haemorrhages may have, however attention must be given to these morphological findings in cases of sudden natural death. For the forensic investigator it is also important to know that capillary telangiectasis could be the cause of an accident.

[History of the early acute R.D.S. and description of a method to improve immediate postmortem fixation of the lung (author's transl)]

A technique for immediate lung fixation on patients who die of ARDS is described. The advantages compared to the selective needle biopsy, the transthoracic circumscript fixation and the lung fixation organ removal are: 1. functional anatomical proportions are kept, 2. Artefact mainly caused by autolysis is avoided, 3. Simple performance and low costs. The results obtained with the described technique are presented. It is demonstrated that the changes in the initial shock phase correlate well with the pattern of its distribution. These changes are not uniform. Therefore we feel that the results with biopsy are somewhat doubtful.

[Suicides in hospitals of Vienna (author's transl)]

An analysis of the autopsies ordered by the Viennese Forensic and Health Authorities between 1967 and 1976 has shown that 2.3% of all suicides were committed in hospitals. Two thirds of the 77 examined cases were carried out by males. Thirty-five patients were in stationary psychiatric treatment; their average age was 50.7 years. In all other kinds of hospitals 42 (mostly male) patients committed suicide at an average age of 65.3 years. Preferred methods of performance were jump and fall from height (44.1%) and hanging (40.3%). Rare methods used were one case of abdominal incisions (harakiri), one self-strangulation, and one case of suffociation in plastic bags. The act was usually accomplished early in the morning or in the late afternoon. Among the suicidal patients who were hospitalized because of organic diseases those with malignant neoplasms [18] and cardiovascular diseases [12] were predominant. Also taking the suicides outside hospitals into consideration the numerical ratio between natural deaths due to cancer and the suicides of cancer patients is about 1:1,000. Amont the suicides in psychiatric institutions schizophrenics [11] and endogenous depressives [7] were the most numerous. In 4 cases the suicide was preceded by acts of injury or homicide.