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By T. Gorok. Westwood College California.

Te annual risk of rupture over Recent data suggest a genetic basis for the arrhythmogenic 7 cm in size is 33% buy 150mg rulide with amex. Patients with tic aneurysm and reach the hospital have a 50% mortality aortic stenosis generic rulide 150 mg online, especially when acutely symptomatic generic 150 mg rulide with mastercard, can rate, with the overall mortality rate greater than 85%. Most cases of aortic ste- Aortic dissection is characterized by an intimal tear nosis are caused by either rheumatic heart disease or valve followed by a dissection of blood within the wall of the calcifcation, which can occur on trileafet or congenitally aorta, most commonly the tunica media. Rupture of this 4 Color Atlas of Forensic Medicine and Pathology dissecting aortic hematoma may lead to hemothoraces, sudden death. Aortic dissection because there is nothing accidental about this process and is a major cause of sudden death, mostly in patients over its use ofen adds confusion in forensic proceedings. Te 50 years of age with the underlying risk factor being essen- term “stroke” or “event” as an alternative is less confus- tial hypertension. Tromboembolic events with connective-tissue diseases such as Marfan syndrome can underlie ischemic cerebral events and are associated also make up a signifcantly afected patient population. Hypertension is a major risk factor for intrapa- iatrogenic trauma to the aortic intima. In younger patients renchymal hemorrhage and may lead to increased intra- and those with connective-tissue disease, microscopy may cranial pressure, herniation, and death. Rupture of an intracranial aneurysm is believed to Fragments of blood clot may break of and embolize to account for 0. Some hospital- 75% of the large pulmonary vessels results in a rise of based studies suggest that approximately 10% of patients the pulmonary artery pressure greater than 40 mmHg. It is not unusual to perform foren- and systemic venous pressures, with a decrease in car- sic autopsies where death was almost instantaneous and diac output resulting in sudden death. Te mechanism of death in such multiple small pulmonary emboli or in situ thrombus cases is cardiac arrhythmia, which is described in greater formation over time may present with increasing short- depth later. Most intracranial aneurysms (approximately ness of breath and right-sided heart failure. Because the 85%) are located in the anterior circulation, predomi- lungs have dual circulation, infarctions are less common nately on the circle of Willis. Atherosclerosis is an independent risk factor for mation can cause wall thickening, thrombosis, dis- the development of intracranial aneurysms. Mesenteric thrombosis may be history of subarachnoid hemorrhage shows that rupture associated with polyarteritis nodosum and other auto- ofen occurs when they reach a size over 7 mm. Te mechanism may be infltration, or edema the Cushing’s triad (hypertension, bradycardia, and formation, into the key respiratory/cardiac centers of abnormal respiration). Tonsillar and central malignancies may sometimes metastasize to the heart transtentorial herniation is associated with compression and interfere with the conducting system, causing a fatal of cardiovascular and respiratory centers in the medulla arrhythmia. Ruptured berry aneurysms are a or malignancies include erosion of large vessels or visci leading cause of sudden death in women during sexual with fatal hemorrhage. In certain ischemic or intracerebral hemorrhage, can lead to positions, the cyst will act like a ball valve and suddenly Sudden Natural Death in a Forensic Setting 5 block the fow of cerebral spinal fuid, resulting in acute when laryngeal edema flls the rich lymphatic supply of obstructive hydrocephalus. Increased mast cell tryptase levels in but develop symptoms when he or she lies down. Tis the patient’s serum can be detected that peak approxi- buildup of cerebral spinal fuid pressure can cause a fatal mately 15–60 minutes afer the onset of anaphylaxis and arrhythmia. Bacterial pneumonia with the combination then decline with a half-life of about 2 hours. Status asthmaticus is procedures but only if the patient presents in a timely defned as an acute attack of respiratory failure due to fashion. Sudden death in asthmatic Hypertension, lef ventricular hypertrophy, and car- patients is thought to be secondary to fatal arrhythmia, diomegaly are all independent risk factors for sudden occurring as a consequence of global hypoxia and right- death. Morbid obesity is a reasonable cause of death by Tere is a condition known as sudden unexpected itself due to stress on the heart. Te mechanism is unclear, three times the expected body weight has roughly three but this phenomenon occurs in up to 18% of patients times the vasculature with three times the blood vol- with epilepsy, presumably in those with subtherapeutic ume to pump. Autonomic dysfunction has devastating consequences on the heart, with death by been proposed as a mechanism. Hypoxia as a result of respira- cemia, and is characterized by severe bacteremia and tory compromise can result in ischemic cardiac events. Tis combination results Tis may be part of the fnal mechanism of death in in overwhelming shock and, if untreated, sudden death epileptic patients experiencing status epilepticus. Organisms other than Neisseria meningitidis, Another interesting point to remember is that there such as Escherichia coli, have been reported to produce is ofen very rapid rigor mortis formation in deaths this syndrome. Precipitants with prolonged muscle contractions from prolonged may include infection, dehydration, hypoxia, physical convulsions. Usually there are few pathologic fndings excretion, vaso-occlusion, or fat embolus following bone that explain the sudden death in epileptic patients. Tis acute hemolytic sickling crisis results in Autopsy fndings may include bite marks to the tongue severe hypoxemia with end organ failure. Tere sickle cell anemia have auto-infarcted spleens and are may be no fnding at all. Osteoporosis respiratory tract along with hypotension, resulting from aging, Cushing syndrome, steroid use, and other in respiratory and circulatory collapse. Death caused natural disease processes will make bones more fragile by anaphylaxis is primarily due to airway obstruction and allow fractures to occur more easily. Note the fatty streaks on the intimal surface from this individual in their early 20s. This discoloration may be helpful as a feature for identifcation when other modalities are not possible. This discoloration, superior to the arrow, occurred during childhood when the teeth were still forming. The second picture demonstrates non-formaldehyde-fxed brain in an individual who exsanguinated from a rup- tured aortic aneurysm. It also demon- strates the “purple head sign,” a common fnding in victims of sudden death, particularly cardiac death. The explana- tion for this fnding is not known in entirety but is attributed to uncontrolled terminal sympathetic nervous system discharges, which open free capillary sphincters and produce a gush of capillary blood. Note the purple dis- coloration of the pericardial sack due to underlying accu- mulation of blood. Note the two different examples with large blood clot encasing the heart after the pericardial sac was removed. This demonstrates a cardiac tamponade fol- lowing an acute ruptured myocardial infarction. Note the hemorrhage to the right ventricle wall with the ruptured site indicated by the probe.

This aperture assists accurate placement of mandibular angle implant and also facilitates positioning the posterior extensions of other implants to augment simultaneously the central mentum and the midlateral zones anteriorly cheap 150 mg rulide with visa. The author has already stated that integrity of the mental nerve and easy positioning of the implant beneath it can be assured through fiberoptic techniques generic 150 mg rulide with amex. To (a ) and location of an extended anatomic implant beneath the mental position a long cheap 150mg rulide otc, extended premandible implant, a tunnel or nerve (b) space must be created that is longer posteriorly than the length of the implant. The implant can then be inserted from the central incision far into one side and then be folded upon D ysesthesias and paresthesias in small or sometimes itself to be introduced into the opposite mandibular tunnel. The symptoms are usually temporary and subside protuberance are keys to accurate placement. Posterolateral implants are placed through a posterolateral Clinically, there appears to be a definite correlation incision. The posterolateral incision is transverse and is located between the occurrence of nerve symptoms and the degree of approximately 1. Appropriate space for placement is There is no correlation, however, with the size and shape of created by making a direct dissection onto bone and subperi- the implant. A curved elevator is implants contain specific notches designed to avoid pressure used to dissect around the posterior aspects of the ascending around the mental foramen. Secure closure of muscle and mucosa slow, gradual changes that take place in the soft tissue con- must be done with all intraoral facial implant incisions. The limited technical results of routine tissue repositioning and tightening techniques from tradi- tional facial aesthetic surgery may therefore be acceptable to 19 Preoperative Planning them, because they do produce some significant visible albeit limited postoperative improvements. Although there presently is an assortment of ever-evolving • Get the patient’s verbal description of his/her “ideal tools for measuring aesthetic skeletal parameters, precise scene ” appearance of facial change. The authors request their patients to mod- • Have older patients bring a variety of earlier personal ify photographs of themselves and bring them in, or to pro- photos. Most patients do have surgery is the critically essential step for achieving success- very precise ideas about the images of facial contours they ful results. Therefore, when they do not, it is easy to accurate and definitive communication with the patient, discover that their expectations cannot be met. In elective whose perceptions and expectations the surgeon must under- operations, surgeons must not undertake what they are not stand completely. For traditional surgery on aging patients, sure they can accomplish, especially when the patient’s own communication about their needs and wishes may be rela- visually described goals are poorly defined. They wish to have their prior youthful con- authors find computer imaging technology to be indispens- tours and facial features restored as completely as possible. Finally, by drawing the preoperative configurations definition, this is responsible for the patients postoperative of the pertinent regional and zonal anatomic landmarks on appearance. Multiple consultations with the patient are the patient’s face, the surgeon is provided with guidelines for important to precisely define the final desired outcome. On accurately performing the intraoperative surgical dissection the morning of surgery, quality time spent in marking, mea- and implant placement (Fig. Terino 20 Postoperative Care 21 Complications Postoperative care for facial implants is straightforward The major disadvantages of the use of alloplastic materials and uncomplicated. Prior to the start of surgery, 1 g of Ancef is given intravenously • P o ssibilities of severe infection, especially with porous by the anesthesiologist. Ten milligrams of Decadron are materials, which become infiltrated with fibrotic ingrowths also given intravenously during the surgery to control post- or bone sequestrum, which complicates ready removal operative edema. During the postoperative period, a 5-day • Contour abnormalities of an unattractive or even disfigur- diminishing course of steroid in the form of a Medrol dose ing nature when implants do not have the proper shape, pack is taken orally. Removal to excessive and inappropriate trauma during dissections of intraoral mucosal and external subcuticular sutures is to introduce or to remove the implant materials (Fig. It is highly recommended that the patient reclines at a 45° angle Complications from the intraoral approach include dyses- and in the supine position for at least 1 week. Vigorous thesias from damage to the infraorbital nerve or motor dys- physical activity is not permitted for 4 weeks. Nerve patients may engage in any and all types of exercise symptoms may be attributed to transection of small branches activities. One typical injury involves facial nerve branches to the frontalis and orbicularis oculi muscle. Both patients experienced complete recovery at 6–8 weeks following surgery 1028 E. Complete resolution almost always occurs by 6–10 weeks following surgery nerve bundle during dissection or pressure impingement on canthopexy techniques are used to minimize this possibility the nerve from an implant. Resection of skin and muscle flap should be con- These complications, however, are rare and almost nonex- servative, i. U se of traditional transverse incisions through the muscle Incisions that transact muscle fibers not only lead to inad- pillars of the zygomaticus produce traumatic transection, equate closure but also may create weakness and laxity of the resulting in transient and perhaps even permanent damage to mentalis muscle, thereby contributing to a potential for chin muscle function. Ptosis of the mentalis musculature and soft tissue D uring the subciliary dissection, the infraorbital nerve is mound of the central mentum is described in the literature as also intentionally avoided. An incision is made in the perios- one of the controversial aspects of alloplastic implants. Indeed, teum 3–4 mm anterior to the orbital rim along its lateral the possibility for deformities, such as central drooping an. A skin flap should never using the previously described vertical entrance wound and be used, because it always shrinks and predisposes to eyelid securely approximating the mentalis muscle pillars during clo- retraction and ectropion. The mentalis muscle can easily stretch to accommodate approach, however, there should be no trauma to the orbicu- the introduction easily of large, extended anatomic implants. Central implants except for large customized “square E xcessive muscle damage, with bleeding into lid tissues, front” implants almost always create a central mound defor- stimulates fibrosis and contracture within the middle lamella mity with an adjacent “anterior mandibular prejowl sulcus” of the lower eyelid, producing ectropion. Left : pre-correction, and right: 6 months after lateral canthopexy Conclusions facial images, as well as compensate for the deterioration, Plastic surgeons are now better prepared to fulfill the pri- sagging, and diminution of facial tissue mass that comes mary goal of facial cosmetic surgery. The use of implants on the facial skeleton represents volume and mass augmentation and alteration of facial form. Skoog T (1969) Useful techniques in face lifting presented at the Skeletal augmentation now represents a final phase for meeting of the American Association of Plastic Surgeons, San Francisco, April 1969 facial plastic surgery. Plast Reconstr Surg enable surgeons to dramatically or subtly alter inherited 58:80–88 1030 E. Clin Plast Surg 5:29–49 dimensional contour alterations combining alloplastic and soft tis- 6. T e ssier P (1971) The definitive plastic surgical treatment of the jawline lower third facial aesthetic unit. Art Facial Contouring severe facial deformities of craniofacial dysostosis: Crouzon’s and 153:165 Apert’s diseases. Sevin K, Askar I, Saray A, Yormuk E (2000) Exposure of high- means of esthetic unities. Rev Bras Cir 33(6):527–533 density porous polyethylene (Medpor) used for contour restoration 10. Facial Lipofilling Domenico De Fazio and Laura Barberi 1 Introduction cess, in which we see opposing phenomena of lipoatrophy and lipohypertrophy in adjacent zones.

Delay in instituting proper treatment may lead to involvement Umbilical infection in the newborn is a common problem order rulide 150 mg. Te etiologic factors include poor sanitary conditions and local application of unsterile dressings purchase cheap rulide line. It may present as: observation during the frst couple of days order rulide 150 mg on-line, needs only Slight purulent discharge from localized infection of saline irrigation or sulfacetamide drops (10%). Gonococcal ophthalmia is treated with (it is respon- Even septicemia and neonatal tetanus may well be sible for profuse purulent discharge) systemic penicillin regarded as forms of umbilical sepsis. If left untreated therapy (100,000–150,000 units/kg/day in 2 or 3 divided or inadequately treated, localized infection may be doses) and penicillin, gentamicin or chloramphenicol eye accompanied by formation of a pinkish, rounded, drops. Conjunctivitis caused by Chlamydia trichomatis (inclu- Prevention: It lies in aseptic care of the umbilicus, sion blenorrhea) needs treatment with 10% sulfacetamide including its cutting. Treatment: It consists of administering a broad- Pyoderma spectrum antibiotic and local application of triple-dye, Superfcial skin eruptions, usually caused by Staphylococ- gention violet paint or a powder/cream containing cus aureus and albus result from contaminated hands of bactracin and neomycin. No treat- needs cauterization by touching it with silver nitrate or ment other than local application of triple-dye is indicated. Systemic Infections Tese are identical despite varying causative agents 305 and may vary from inapparent or silent to fulminant, Neonatal Sepsis (Nns) depending on severity of infection, maturity and birth Sepsis is a serious neonatal problem. Loose motions, abdominal distention, fever or hypo- thermia (latter is more common and more dangerous), Etiopathogenesis failure to gain weight, pallor, jaundice, respiratory dis- Infection may be contracted antenatally, or during or after tress and skin eruptions are other prominent features. Te neonatal occurrence of convulsions, high-pitched cry, blank units must, therefore, have an ongoing review of the listless appearance, bulging anterior fontanel and neck causative organisms and their antibiotic sensitivity pattern retraction should arouse suspicion of its existence. Predisposing factors and etiologic Depending on involvement of various systems, there pathogens are listed in Box 17. One should take advantage of the clinical clues for probable etiologic diagnosis (Table 17. Diferential Predisposing factors and etiologic pathogens diagnosis is from conditions such as hypoglycemia, Box 17. Presence of two or more parameters means Instrumentation a positive sepsis screen. A repeat screen is indicated in Equipment (use of catheters, respirator, resuscitator, feeding case of a negative result after 12 hours; every 48 hours bottles, solutions for cold sterilization, incubator, face masks and white aprons, etc) in ventilated neonates. Grayish-black gangrenous lesions over skin Pseudomonas Handling by medical personnel, including doctors and Peripartum fu-like maternal illness, gastro- Listeria nurses, may. Lumbar puncture is of value if meningitis is sus- Maintenance of optimal body temperature, i. Nasal saline drops to clear nasal block, if any Other useful investigations include chest X-ray, blood Blood transfusion (packed cells) for anemia and shock; sugar, urine for routine and culture and serum bilirubin. In of accompanying meningitis, a third generation case of scleroma, endotoxic shock and meningitis, admini- cephalosporin (cefotaxime) + ampicillin/amikacin stration of hydrocortisone may be considered. Prolonged chemotherapy ampicillin + gentamicin/amikacin and the second line should be supplemented with vitamin K and other vitamin cefatoxime + amikacin. For resistant Staphylococcus, coamoxyclav or Close monitoring, timely institution of appropriate antimi- vancomycin is the best. In nosocomial septicemia (Staph- crobial therapy and intensive supportive care are the key ylococcus, Klebsiella, Pseudomonas), ceftazidime/cefap- factors in survival of the neonates with sepsis. Mortality is higher in: sensitivity report warrants a change in the antimicrobial Early-onset (within 72 hours of birth) septicemia therapy, it should be made. Presence of meningeal involvement Gram-negative septicemia Minimum duration of antimicrobial therapy Box 17. It is believed to be the outcome Sequelae of interaction between intestinal mucosal injury, luminal Tese include: bacteria, enteral feedings and immature host response. Congenital: It is due to transplacental transmission of the malarial parasite and is rare since placenta, as a rule, is supposed to act as a barrier to such a transfer. In a span of over two decades, we could diagnose it in only 50 instances, though we have all along been actively looking for it. Naturally-acquired malaria: It results following an actual bite of a previously infected female anopheles mosquito. Clinical Features Clinical manifestations include unexplained pyrexia with hepatosplenomegaly, anemia, slight jaundice, poor feed- Fig. Supportive treatment directed at controlling fever, raising hemoglobin level and maintaining water and electrolyte balance and nutrition is also warranted. On forcing the feed, refex Blood for transfusion must be tested for malarial para- spasm of masseters, pharyngeal muscles leads to trismus site. Spasms of Standard measures for control and eradication of limbs and generalized rigidity with opithotonos in exten- malaria. Refex laryngeal spasm may cause apnea and that of respiratory muscles the cyanosis. India umbilical stump following cutting of the cord with an stands declared as neonatal tetanus-free in 2015. Physiologic Unlike adults in whom it is clinically detectable with a serum Pathologic bilirubin of less than 2 mg/dL, in neonates it is apparent only z Increased production of bilirubin when serum bilirubin is less than 5 mg/dL. Serum bilirubin level at which jaundice z Drugs becomes clinically detectable is 5 mg/dL. In z Extrahepatic atresia of bile duct term infants, it appears on second or third day (between z Hereditary spherocytosis 30 and 72 hours) and reaches peak on 4th or 5th day. It z Neonatal hepatitis is generally mild, the serum bilirubin seldom exceeding z Drug-induced hemolytic anemia 12–15 mg%. Persistent jaundice during frst month In case of the preterm baby, physiological jaundice z Inspissated bile syndrome may appear little earlier (but always after 24 hours), may z Cretinism be relatively deeper (upto 15 mg/dL) and reaches peak on z Congenital hypertrophic pyloric stenosis. Nevertheless, the infant needs Te following points should be particularly noted: to be closely followed up for undue rise or persistence of Maternal and family history with special reference to maternal infections during pregnancy, drugs given hyperbilirubinemia. In the latter situation, he should be during pregnancy or labor, previous sibling(s) afected investigated for pathologic jaundice. Tis is termed as exaggerated General condition of the infant—whether healthy, physiologic jaundice or hyperbilirubinemia. Pathological Jaundice (Unconjugated Hyperbilirubinemia) Clinical Examination Te neonatal jaundice not conforming to time table or Gestational age, activity and general condition of the infant. Te cause may be insufcient lactation leading to inad- Clinical detection and grading of severity of jaundice equate feeding, dehydration and hemoconcentration. Laboratory Investigations Breast Milk Jaundice Serum bilirubin, both direct and indirect. Conjugated A small proportion of exclusively breastfed infants also tend (direct) bilirubin less than 0. Coombs test of mother as well as baby Occasionally, undue anxiety in the parents may warrant Blood culture temporary withdrawal of breastfeeding just for 2–3 days. Comparison of clinical features of physiological and pathological jaundice in Principles of Management neonates Phototherapy and exchange transfusion are the two major Parameter Physiological jaundice Pathological jaundice efective therapeutic modalities available today. Additional options include pharmacotherapy in the form of phenobar- Onset More than 24 hours of birth Less than 24 hours of birth bital, agar-agar, albumin infusion, n-mesoporphyrin and Serum Slow Rapid: 0. With light sources of this range, 311 Clinical methods of detection of neonatal Box 17. A small portion gets oxidized to Blanching Blanching the skin of tip of nose, sternum, abdomen, palms and soles biliverdin.

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