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Forensic pathology is a branch of medicine that applies the principles and knowledge of the medical sciences to problems in the field of law The major duties of a medicolegal system in handling deaths falling under its jurisdiction are: • To determine the cause and manner of death • To identify the deceased if unknown • To determine the time of death and injury • To collect evidence from the body that can be used to prove or disprove an individual’s guilt or innocence and to confirm or deny the account of how the death occurred purchase zantac toronto antral gastritis diet chart. Definition of Death Because of advances in medical science purchase zantac 150 mg line gastritis diet 80, what was formerly not a problem has now become one—the definition of death buy discount zantac line definition de gastritis. In simpler times, death was defined as the permanent cessation of cardiac and/or respiratory function. Today, instrumentation can keep a heart beating and an individual breathing 1 2 Forensic Pathology in spite of the fact that if this machinery were turned off, heart and respiratory activity would cease. There is extensive literature on this subject, and the definition of brain death in adults and children is not necessarily the same. The only time that difficulty might arise is in the harvesting of organs and the moving of brain dead individuals. Thus, in most jurisdictions, if harvest- ing of organs is intended and family permission has been obtained, and if the case is to be a medical examiner’s or coroner’s case, prior to removal of the organs, permission must also be obtained from the medical examiner or coroner. This is because, once the individual is “dead,” he or she becomes a medicolegal case. Harvesting of organs at that time could then be interpreted as interfering with the duties of the medicolegal system and therefore could constitute a crime. Permission to harvest the organs after pronouncement of death is, for the most part, automatic in most medicolegal systems, because the importance of organ harvesting is recognized by medical examiner/cor- oner offices. If properly coordinated, the harvesting of organs can be per- formed without any interference to a subsequent medicolegal examination of the body, including homicides. The only time the authors have had problems has been when it was decided to pronounce an individual dead, to maintain the person on life support systems, and to transport the body outside the jurisdiction of the medical examiner’s office. Once the organs are harvested and the machines turned off, who then will perform the examination of the body? Because the body has been moved out of the legal jurisdiction where it was pronounced dead, does it have to be moved back to that jurisdiction or does the medi- colegal agency in the area where the organs are harvested take jurisdiction? Does this medicolegal agency have the legal right, since the individual “died” in another jurisdiction? Fortunately, such problems can usually be settled beforehand with conferences involving the agency harvesting the organs and other medicolegal entities. An individual may be pronounced dead, yet be maintained on a life support system for 2 to 3 days after pronouncement. This has sometimes resulted in confusion in the doc- umentation of the date of death. Delayed Deaths Most people realize that violent deaths (accidents, suicides, and homicides) fall under the jurisdiction of a medicolegal system. What they often fail to Medicolegal Investigative Systems 3 realize is that this jurisdiction is retained even if there is a long delay between injury and death, as long as the death was a result of injuries. Thus, if an individual suffers a head injury resulting in irreversible coma, is put in a nursing home, and dies 2 or 3 years later of pneumonia, this is still a medical examiner’s case because the medical condition was the result of trauma. In one case, an individual died of chronic renal failure within a few hours of admission to a hospital. The renal failure was due to chronic pyelonephritis, complicating paraplegia, which had in turn been caused by a gunshot wound to the spine 25 years prior. This case was not only still a medical examiner’s case, but was a homicide, since the event that started the chain of events that resulted in the death was a gunshot wound. In this case, there were no legal problems, because the perpetrator had died 10 years prior to the victim. Cause, Manner, and Mechanism of Death Two of the most important functions of the medical examiner’s or coroner’s office are the determination of the cause and manner of death. Clinicians, lawyers, and the lay public often have difficulty understanding the difference between cause of death, mechanism of death, and manner of death.

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They are often extremely difficult to solve because they frequently represent the purest form of stranger-to-stranger crime — that is generic zantac 300 mg overnight delivery chronic superficial gastritis definition, the victim and assailant are unknown to each other order cheap zantac on line gastritis symptoms heart attack. There is usually only one assailant purchase zantac 300mg visa gastritis diet bananas, so there is no one to “squeal” to the police. In rape-homicides, the cause of death is usually strangulation, stabbing, or blunt force injuries. In cases of rape-homicide, the medical examiner, in addition to deter- mining the cause of death, has to document evidence of sexual assault and collect trace evidence that can be used subsequently at a trial to convict the perpetrator. In rape-homicides, as in all homicides, the medical examiners’ involvement with the body should begin at the scene. This does not mean that they have to be present personally, but at least an investigator from their office should be present. The scene is not the place for examination of the body, either by a physician or an investigator. Manipulation of a body at the scene could result in destruction of trace evidence. Transport of the Body Prior to transporting the body from the scene, paper bags should be placed on the hands to preserve any trace evidence that might be clutched in them or beneath the fingernails. Paper bags should be used instead of plastic, because there will be condensation of moisture inside plastic bags as the body is shifted from cold to warm environments. In addition to covering the hands, the body should be wrapped in a clean white sheet or placed in a clean body bag. This serves two purposes: to prevent loss of trace evidence from the body in transporting it to the morgue, and to prevent the body from picking up debris from the vehicle transporting the body that might subsequently be confused with legitimate trace evidence. A number of author- ities are now attempting to lift fingerprints from the skin of a body in which there has been close contact between the assailant and victim. Rape-homi- cides are ideally suited for such attempts because of the physical contact necessary in such an assault. If attempts to recover fingerprints from the body are to be made, the skin should not be touched with the bare hand. Unfortunately, the procedures used in an attempt to recover fingerprints might involve fuming of the skin with various chemicals. Because of this, the forensic pathologist should examine the areas to be fumed prior to attempts to lift fingerprints. Prior to the autopsy, the medical examiner should be thoroughly knowl- edgeable as to the circumstances surrounding the death, as well as any special tests the police may deem necessary. An autopsy should never be conducted until the medical examiner fully understands the circumstances surrounding the death. Trace Evidence Recovery from the Hands The first part of the autopsy consists of examining the hands for foreign material clutched in the hands or present under the fingernails. The body should never be fingerprinted prior to examination of the hands by the medical examiner. Any material removed from the hands, as well as nail clippings, should be put in labeled containers. It is not uncommon to find hair clutched in the hands of rape-homicide victims who have been strangled or beaten about the head. Thus, it is necessary at the time of the examination to obtain head hair from the victim for a control.

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In case of radial artery or brachial artery dissection discount zantac 150 mg mastercard gastritis diet , the procedure can often still be continued because the catheter itself will serve to tamponade buy zantac without a prescription gastritis tips. Closure buy 150mg zantac free shipping chronic gastritis definition, however, should be documented, as with its initial recognition, with angiography using a 50/50 mix of saline and contrast material. Injection of contrast material is also useful to visualize tortuosity, which can pose major challenges not only distally but also for engagement of the ascending aorta. In these cases the catheter might need to guide the wire around the origin of the brachiocephalic artery rather than vice versa. For difficult cases, it is recommended not to lose position and to use an exchange-length 0. The use of diagnostic catheters designed for radial approaches and both coronary ostia (e. Once complete, the equipment is removed, including sheath, and a wristband with an inflatable balloon cuff is used to achieve hemostasis. To avoid thrombotic occlusion, the site is allowed to bleed back before the cuff is inflated to 2 cc over hemostasis level. Practices should have protocols that guide the deflation process and monitoring of the pulse and perfusion status. Also, the radial artery is not the best approach if larger sheath sizes are required (e. Presentation and management of complications from radial access are summarized in the postprocedural care section (see eFig. A meta-analysis of 12 studies with 5000 patients showed 33 that a radial approach was associated with a nearly 50% decrease in mortality and major bleeding risk. Percutaneous Brachial Artery Technique The brachial artery approach is similar to the femoral artery approach but rarely used, as replaced by the radial technique. Using the Seldinger method, a 4F to 6F sheath is placed into the brachial artery and flushed with 3000 to 5000 units of heparin. Proficient hemostasis after removal of the sheath is critical; the arm should be maintained straight on an arm board for 4 to 6 hours, with close observation of the radial and brachial pulses, access site, and upper arm size. The main advantage of the brachial artery for percutaneous access is the larger luminal size than the radial artery and accessibility when other access options have failed. This includes access for patients with severe peripheral arterial disease or such a degree of vascular tortuosity or body size that even with the use of extra-long coronary catheters, the coronary ostia cannot be reached. The percutaneous approach is easier than the cutdown of the brachial artery, which was in fact the first technique introduced for coronary artery catheterization by Sones and colleagues. Given the anatomic location, the access site is very close to the x-ray generator tube or image intensifier, depending on the angle. It may therefore lead to greater x-ray exposure and restriction of angiographic views. Venous Access With any concomitant procedure involving the femoral artery, the femoral vein is used most often for venous access. However, when the right-heart catheter is left in place after the procedure, the internal jugular approach is preferable (Videos 19. The internal jugular is preferred over the subclavian approach to lessen the risk for pneumothorax. Use of a micropuncture kit with a 21-gauge needle and introducer can minimize potential trauma from inadvertent puncture of the carotid artery or lung. When the jugular vein has been entered, the micropuncture assembly can be exchanged for any larger sheath (e. In addition, routine adjunctive use of portable vascular ultrasound probes can help to locate and verify the patency of the jugular vein. The femoral vein is located 1 cm medial to the femoral artery, which is the distance to be taken from the arterial pulse in the horizontal plane, and another 1 cm caudal in the vertical plane.

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