Case ReportPostmortem computed tomography evaluation of fatal gas embolism due to connection of an intravenous cannula to an oxygen supply
Introduction
Postmortem computed tomography (PMCT) is becoming common in the practice of forensic medicine [1], [2]. Imaging methods have revolutionized not only forensic diagnosis but also the documentation of evidence that can be applicable in court proceedings [3]. In addition, PMCT is a superior tool for finding air within the body, such as pneumothorax and gas embolism of the heart and great vessels [4], [5]. Traditional invasive autopsy may miss a cardiac gas embolus unless the conventional autopsy techniques are employed. However, traditional techniques can be supplemented with PMCT [6], [7], [8]. Here we report an unusual case of gas embolism, in which an intravenous catheter was accidentally misconnected to the oxygen supply. In the present case, PMCT demonstrated cardiac gas embolism accompanied by the presence of gas within the left subclavian and brachiocephalic veins, which seemed to be consistent with the route of gas ingress from an intravenous catheter in the left forearm, whereas subsequent autopsy was able to locate the presence of gas in the right ventricle. PMCT prior to autopsy appears to provide a useful guide to forensic pathologists when conducting careful examinations for gas embolism.
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Case history
An 84-year-old man who had suffered from chronic obstructive pulmonary disease (COPD) accompanied by moderate pneumonia and gastric cancer with liver metastasis was hospitalized because of fever, dyspnea and disorientation that had appeared on the previous day. He had been receiving oxygen therapy at home and chemotherapy as an outpatient. Physical examination indicated wheezing, and pulse oximetry demonstrated a subcutaneous oxygen saturation of 70%. After admission, he was supplied with
Radiological findings
Just before autopsy, which was undertaken two days after the deceased had been found, the entire body of the deceased was examined by CT scan at the Autopsy Imaging Facility, Gunma University Graduate School of Medicine. All scans were performed using a four-slice CT scanner (Asteion/TSX-021B/4A, Toshiba, Japan) with a slice thickness of 1 mm and settings of 120 kV and 225 mAs for the head and 120 kV and 100 mAs for the body. 3D transparent volume-rendered images were reconstructed on a CT
Autopsy findings
At autopsy, the body was 158 cm in height and 64.7 kg in weight. External examination revealed a puncture surrounded by bruising on the left forearm. Livor mortis was prominent in the back, while we did not obtain any information regarding a change of body position after death declaration. And rigor mortis persisted. There was no evidence of advanced postmortem change such as gaseous or putrefactive fluid-fluid skin blisters on any part of the body. In addition, there were no external signs of
Discussion
A cardiac gas embolus may be overlooked by conventional postmortem examination unless relevant information is available prior to forensic autopsy and a targeted research approach is implemented from the beginning. In general, the main method for diagnosis of gas embolism is radiographic inspection. Therefore, invasive autopsy techniques have been supplemented by PMCT. However, air within the vasculature is one of several artifacts that can be visualized by PMCT, and air in the heart is a
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