Medicine at East Carolina University, Medical ExaminerfortheStateof Concord, NH(TA), BrodySchoolof NM (EM),MayoClinic- Anatomical Author Affiliations: NewHampshire Page 206 • Volume 4 Issue 2 Medical Investigator, Albuquerque, TX (JL),NewMexicoOfficeofthe Office ofChiefMedicalExaminer, Downloaded NAME POSITION PAPER NC (MG),HarrisCountyInstitute Laboratory Medicine,Greenville, Pathology, Rochester, MN(RR). of ForensicSciences,Houston, James R.GillMDistheChief Department ofPathologyand National Association ofMedicalExaminers Acad ForensicPathol 2013 4(2):206-213 by Contact Dr. Gillat: a [email protected]. NAME Connecticut. member. © 2014

This National Association ofMedicalExaminersPosition Paper: and the wrong diagnosis may result in a wrongful perpetrator, the be may caregiver a physician, a als, the decedent may have been seen recently by profession- trained by even responses passionate elicit may group age this in death any reasons: in- many for pathologist challenging forensic a for most vestigations the among are micides, ho- particularly (TBI) children, injury infants/young among brain traumatic to due Fatalities and heat-related, opioid deaths(3-5). cocaine, of certification and papers on recommendations for the investigation position published previously has NAME (2-5). position papers standards and autopsy lication of pub- the is mission this fulfilling of method One of violent, suspicious andunusualdeaths” (1). tinuing improvement ofthemedicalinvestigation sional and technical information vital to the con- death investigators and disseminating the profes- of fostering the professional growth of physician (NAME) wasfoundedwith“the dual purposes The National Association of Medical Examiners INTRODUCTION KEYWORDS: inquiries thatmayfollowfromthepublicandcriminaljusticesystem. of multitude the support to reviewable independently is that examination documented oughly the productionofadetailorientedandthor- of suchinfantdeathsinvolves documentation deaths. of these in theinvestigation thatareimportant of documentation and The evaluation forms 3) and tests, laboratory ancillary 2) procedures, 1) describes paper this Specifically, trauma. head inflicted of, died apparently have or of, died have who infants of examination postmortem the during produced be to dataset the constitutes what on pathologist forensic postmortem examination, and ancillary studies. This paper provides recommendations for the an evaluation of all available data including information derived from the investigation, scene, upon dependent is death of manner and cause the both of certification correct The trauma. position paper for recommendations for the investigation of infant deaths due to inflicted head ABSTRACT: Evan MatshesMD,R.RossReichardMD James R.GillMD,Thomas Andrew MD,M.G.F. GillilandMD,JenniferLovePhD, Suspected HeadTrauma inInfantsand Young Children Recommendations forthePostmortem Assessment of article is Forensicpathology, Headtrauma,Infant,Homicide intended

The National a paneltocreate Examiners convened of Medical Association for personal use, but may be distributed ednl rveal ivsiain f pediatric of investigation reviewable pendently an inde- thorough, describe a facilitate to to protocol is autopsy aim paper’s this Similarly, diseases. of range broad a for look that nations to ensure consistency and comprehensive exami (7-13) deaths infant sudden and metabolic, diac, car for developed been have protocols Autopsy and record itforotherstoseeandevaluate ery attemptshouldbemadetoprotect, preserve, prisonment, orthe life and death of someone, ev- make thedifference between the freedom orim- itmay that so important is finding postmortem tions. Moritz stated,“Ifanegativepositive or As and potentially answer unanticipated future ques- data primary review to opportunity best the low) original forensic pathologist (and others who fol- the allows that dataset reviewable independently cause and manner of death, but also to produce an topsy is not only to aid in the determination of the au- the of goal the investigation, death thorough a to Complementary deaths. these of vestigation in- the for recommendations generate to panel a risk. at children other convened NAME such, As putting and families, of dissolution prosecution, by NAME members solely for scholarly purposes. ” (6). - -

HEAD TRAUMA POSITION PAPER Gill et al. • Page 207 purposes. scholarly for solely

- - members NAME Table 2. Table In by distributed be may but use, personal importance of the detection and documentation of other disease processes and injuries involving the torso and extremities is vital. DISCUSSION Initial Autopsy Investigation The initial autopsy investigation includes digital photography and full body radiologic imaging performed prior to the internal examination. Digital Photography Integral to the development of a dataset that fa- cilitates independent case review is high Unlike qual- color filmphotography. ity, photography, digital imaging allows the prosector immediately if to the know image is properly (14). Therefore, captured digital photography is the pre- ferred method for photographic documentation for these investigations. A core list mended of photographs is recom included in pho- are body the of surfaces external all general, tographed with close-up photographs of specific findings. Important internal images of injury and pertinent negative findings include subscalpular views, subdural/epidural/subarachnoid hemor rhage, skull, brain (external and representative cross sections), and eyes, nerves, and subcutaneous and skeletal injury. including the optic Plain Film Radiography As skeletal injury may not be detected during a standard autopsy, healed and healing fractures for - - - - - intended is article This member. describe any hemorrhage/injury including the layers involved (preretinal, retinal, subretinal), extent nerve sheath: describe the extent and location (subdural, subarachnoid, intradural, extraocular, orbital NAME , numerous, extensive), and distribution (posterior pole, equatorial, and peripherally, including whether a neuropathologist or ophthalmic pathologist consultation may be useful. neuropathologist or ophthalmic pathologist consultation by (few they abut the ora serrata). A Optic fat) of any hemorrhage. Retina:

C. A. B. Describe injury and hemorrhage of the anterior and posterior neck. Describe injury and hemorrhage of the anterior and negative findings. radiological skeletal survey with, as indicated, an internal of examination the musculoskeletal system to document A soft tissue or bone injury. and/or exclude [SAH]). subdural [SDH], or subarachnoid board-certified a with consult to ability the and cord spinal and dura, cranial brain, formalin-fixed the of Examination neuropathologist. documentation) and microscopically: optic nerves both grossly (with photographic Description of the eyes and

Photography Photography including overall full body external color images with close-ups of specific findings pertinent and 7. for correlation with the history and autopsy findings. Medical record review as available 6. 2. 3. Description (color, size, location) and photographic documentation of intracranial hemorrhage (epidural [EDH]), 4. 5. Specific Autopsy Reporting and Procedures for Suspected Pediatric Head Injury Deaths Head Injury Pediatric for Suspected Procedures and Reporting Autopsy Specific 1: Table 1. Downloaded The subsequent protocol describes a progression of relevant examinations and processes for the thorough description and documentation of per Infants die suddenly and myriad of unexpectedly reasons that span for the spectrum a from natural disease to inflicted injury. Infant/child hood deaths due to TBI may have no history or unexpect therefore, trauma; of evidence external ed and unexplained infant/childhood deaths are thoroughly evaluated at the outset as they may be homicides or due to rare natural disease. As thorough uniformly a undergo deaths these such, ini- the through documentation and investigation tial stages of the evaluation, documentation, and As pathologic evisceration. findings emerge dur prosection, and examination the of course the ing the necessity and/or utility of ancillary their and dissec- apparent, become will studies and tions selection can be tailored by the forensic patholo gist. tinent 1). findingsAlthough (Table the focus of the paper is on the central nervous system, the head injury deaths. NAME has already published already has NAME deaths. injury head general autopsy standards that are applicable to infants/children with apparent head This trauma. traumatic brain injury protocol is not meant to replace those preexisting standards but to pro- vide detailed techniques, procedures, and other recommendations for these investigations. Each a as meant not is protocol this and unique, is case follow- The judgment. professional for substitute ing protocol, however, may be considered prac- tice recommendations for these endorsed by the NAME Board of Directors. investigations Page 208 • Volume 4 Issue 2

Downloaded NAME POSITION PAPER by a NAME member. This wounds andinjurytoallowfor1:1reproduction(15). major of photograph one least at in included scale reference a and photograph each in visible be should number case *A tocol is provided in (ME/C) (16, 17). A pediatric skeletal survey pro- examiner/coroner medical the of attention the to come of that deaths evaluation infant/childhood the unexplained for necessary is survey etal with potential inflicted trauma. A radiologic skel- death a investigating when indicated are lesions, these of detection the in aid may which graphs, radio- body full Therefore, (16). missed be may o ms fatrs n hlrn Te s o CT/ of use The children. in fractures most for evaluation clinical the for choice the be to tinue con- radiographs film plain autopsy addition, forensic In setting. the in defined fully be to yet have modality each of weaknesses and strengths the time, current the at films, plain over injuries certain for results superior provide likely dures proce- these While hospitals. local with access arranged have or scanners in-house have offices Some lesions. three-di body of and visualization mensional unobstructed provide the to offer ability (MRI) imaging and resonance (CT) magnetic tomography computed Postmortem Advanced RadiologicTechniques radiologist maybeusefulinsomeinstances. pediatric a with consultation fractures, simulate may disease and subtle be may fractures diatric pe- some As radiographs. film plain examine to skeletal survey). Forensic pathologists are trained diologists are not available to define the pediatric 14. Thecervicalspineand/ornerveroots,asindicated 13. 12. 11. 10. 9. Exposedpericranialsurfacesfollowingusualreflectionofthescalp 8. Layeredsofttissueplanedissections(chestandabdomen,scalp) 7. 6. 5. 4. 3. 2. 1. Table 2:CorePhotographstobeObtainedinCaseswithHead Trauma orSuspectedHead Trauma* article External andinternalsurfacesoftheeyes Representative crosssectionsofthebrainandspinalcord Exterior surfacesofthebrainandspinalcord Epidural, subdural,andsubarachnoidhemorrhages Exposed ectocranialsurfacesfollowingpericranialmembraneremoval Arms andlegsincludingwrists,ankles,hands Genitals andperianalregion Chest, abdomen,andback Extended anteriorneck Both sidesoftheface Identification photo(face) is intended Table 3 (if board-certified ra- for personal use, but may be distributed - adjunct, the external and internal autopsy exami useful a be may currently CT/MRI postmortem While (18). modalities such for funding and ties facili of availability the to subject and thologist the forensicpa- remains atthediscretionof MRI 6. 5. 4. T 3. 2. 1. Table 3:PediatricRadiologicSkeletalSurvey by Four viewsofthelowerextremities Four viewsoftheupperextremities T Two viewsofthecervicalspine Three viewsoftheskull NAME wo viewsoftheribs wo viewsofthetrunk/torso d. c. b. a. d. c. b. a. b. a. b. a. b. a. c. b. a.

Right foot Left foot Right lowerextremity Left lowerextremity Right hand Left hand Right upperextremity Left upperextremity RPO (Rightposterioroblique) LPO (Leftposterioroblique) Lateral AP Lateral AP Lateral condyles andthemidfacialskeleton) T Anterior members owne’s (30%angleviewofthemandibular -Posterior (AP) solely for scholarly purposes.

- - HEAD TRAUMA POSITION PAPER Gill et al. • Page 209 purposes. scholarly for solely - - - - members NAME by distributed be may but use, personal Skull: documentation of the location, dimension, dimension, location, the of documentation Skull: type (e.g., linear, depressed, comminuted, dia- static) of fracture(s) is achieved through the nar and radiologic rative report, digital photography, images; some forensic pathologists may choose to supplement their reports with diagrams. Skull fractures may be subtle in the young population and therefore pediatric removal of the pericra nial membranous soft tissues along with the cra- nial dura allow them to be better identified and examined in detail. Microscopic be may sections and findings gross document and confirm help of the stage of healing. useful for assessment Hemorrhage: the type [epidural (EDH), subdural (SDH), or subarachnoid (SAH)], location, size, ap- through documented are adherence and color, propriate use of narrative description and digital The size of SDH photography. and EDH, for ex- ample, may be documented by volume, weight, The effects measurements. or three-dimensional of the hemorrhage on the brain (e.g., compres- sion, herniation, shift) are noted in the autopsy report. Microscopic sections help confirmdocument and gross findings and maybe useful for 22). assessment of the stage of healing (21, Brain: for optimal results, the brain and cranial dura should be fixed in formalin (usually for a minimum of 10-14 days). Forensic pathologists are trained to diagnose and describe brain traumatic injuries. As some neuropathologic diseas- es may be subtle or mimic trauma, consultation with a board-certified neuropathologist may be warranted. Express mail delivery services, gross photography, tissue retention, and microscopic initial the after even consultation for allow slides brain dissection. Pertinent positive and negative gross and microscopic findings include: hypox- ia-ischemia, contusion, contusion hematomas, diffuse axonal injury, presence/absence of brain swelling and herniation (type and extent), intra cerebral hemorrhage (location and extent), vas- cular malformations, congenital anomalies, and other focal lesions. Examination of the cerebral dura includes description of any pathology (e.g., subdural blood, surgical defects) and evaluation (opening) of the sinuses (e.g., thrombosis). Mi- croscopic examination of the dural - con postmortem from thrombus distinguish help sinus may gealed blood. - trau inflicted suspected for sections Microscopic matic brain injury include evaluations of pathol ogy identified grossly and sampling that allows processes, disease natural possible of assessment hypoxic-ischemic brain injury, and axonal injury. Hypoxic-ischemic brain injury traumatic in infants/children has a characteristic distribution for ------intended is article This member. NAME a by Downloaded Scalp/subscalpular: the number, location, size of and scalpular and subscalpular hemorrhages are best documented through a combination of the photograph(s) and narrative description(s). Correlation should be made hemorrhage between and medical intervention (i.e., prior sites of surgery). Other discrete di- from sutures areas cranial along as such occur, may of hemorrhage astasis due to marked brain swelling. The docu- mentation should convey the information neces- sary for users of the autopsy report to determine when hemorrhage is either due to a process secondary or a direct result of trauma. If concern for there facial injury not apparent externally, is a formal face dissection is possible (20). Detec tion of otherwise unknown or underappreciated impact sites of the face may change the context of the infant death from one of one with non-impact demonstrable impact. to Intraoral exami nations may reveal frenulum, inner cheek, and tongue injuries. Shaving of hair allows for better evaluation and documentation of scalp injuries. Careful examination of the ears includes looking inside and behind the ears. Head As the autopsy progresses, findings suspicious for inflicted traumatic brain injury (iTBI) may be detected. If so, the following specific exami- findings particular of documentation and nations are recommended. These are described by body region. Specialized Autopsy Investigations When Encountered Suspicious Findings are ference) in addition to length and search for trace evidence and sexual A weight be useful. may assault evidence collection, if indicated, is done inju- visualize better to body the washing to prior per is examination internal and external An ries. formed Autopsy per Perfor the NAME Forensic are followed when Standards which also mance describing an injury (e.g., type, shape, pattern) (15). location size, Depending on the age of the infant/young child, certain body measurements (e.g., head circum External and Internal Examination External and Internal nation nation remains the best method for the postmor tem diagnosis of injury (19). Since some infants may injuries from die ultimately who children or have a survival period in the hospital, antemor tem advanced imaging often has been obtained. Admission imaging and other hospital CT and and information valuable provide may scans MR reviewed. should be sought and Page 210 • Volume 4 Issue 2

Downloaded NAME POSITION PAPER by a NAME member. This unclear if this technically difficult dissection difficult yields anydiagnosticvalue. technically this if unclear is it but (26), attached still cord spinal the with brain lumbar). the of removal and recommended have thoracic, Some (cervical, levels all three at examined is cord spinal the cord: Spinal necessary todiagnoseorexcludedTAI. parasagittal (e.g., be internal capsule)may white, posteriorlimbof regions matter white lateral contra from samples addition, In useful. prove may cerebellum and brainstem, structures, gray Retention of representative cortical regions, deep (22). course variable potentially but predictable somewhat a in resulting individual), the of age process (e.g., size of hematoma, source of blood, this affect variables many SDH, a of healing of stages the for criteria are there Although ation. tissue healing is the best site for histologic evalu ongoing and blood sub/epidural between terface in- The EDH. and SDH in healing of stage the lular iron deposition may facilitate assessment of intracel for Evaluation processes. for subtle evaluate more and pathology gross assess to ful use- is dura cerebral the of evaluation Histologic der histologicsamplinganddiagnosis. hin- and evaluation gross the affect dramatically may example, for brains”), “respirator (so-called changes brain non-perfused Marked autopsy. at the clinical history and gross pathology identified on depending vary may however, stains, special of use and sampling Histologic brainstem, cerebellum. and structures, gray deep neocortex, of examination includes for processes disease evaluation natural Microscopic (23-25). reported been previously has processes other of variety a and trauma to due APPpatterns immunostaining of Assessment evaluated. be should sections ic dTAI,diagnose histolog- to (bilateral) additional traumatic axonal injury is present but insufficient if therefore, dTAI; of diagnosis the preclude to demonstrated been has sampling Limited ble 5. histologic sampling for dTAI is included in included is dTAI for sampling histologic be useful inselect instances. A may listoflocationsfor immunostain (APP) protein precursor amyloid with examination available, If sections. (H&E) eosin and hematoxylin routine includes children and infants in dTAI for sampling Histo- logic (23). brainstem the within isolated jury in- axonal traumatic have to reported been have hemispheric white matter, and brainstem. Infants cerebral callosum, corpus the including cations lo- multiple in injury axonal traumatic requires (dTAI) injury axonal traumatic diffuse of nosis in included his- is for sampling locations tologic of list A adults. in involved typically regions to addition in evaluation the in included be should regions those and injury, of article is intended for personal use, Diag - Table 4. but may be Ta distributed - - - - report. For retinal hemorrhages, the involved lay- autopsy the in documented is fat) orbital ocular, cation (subdural, subarachnoid, intradural, extra lo- the hemorrhage, sheath nerve optic For tion. examina microscopic to prior formalin in fixed are tissues soft periocular and eyes the removal, After (29). published been previously has eyes the of examination and removal for Atechnique ed traumaticbraininjuryisrecommended. eyes in instances of inflicted or suspected-inflict the of examination and removal the Therefore, hemorrhages. retinal diagnosed clinically refute or confirm may that measure assurance quality a as serves examination ocular the minimum, a Pending the publication of additional research, at iTBI (28). predictorof a as useful may be rhages indicated that theassessmentofretinalhemor study clinical prospective recent A umentation. menters of facts, are best to err on the side of doc- docu- independent the as pathologists, findings, certain exclude or confirm, diagnose, to chance only sometimes and best the often is autopsy an As findings. preserve and document to also but interpret, and diagnose to only not duty however, a have pathologists, Forensic paper. this of tation of retinal hemorrhages is beyond the scope the eyes also is possible at autopsy. The interpre A training. of examination microscopic and dissection gross and equipment additional require however,does (27), it endoscopy ophthalmic for needed that than expensive less is equipment the nondestructive and autopsy to prior retina the view to technique and noninvasive a is moscopy Ocular examination: monocular indirect ophthal 4. Posteriorlimboftheinternalcapsule 3. 2. 1. Axonal Injury(dTAI) Table 5:HistologicSamplingforDiffuse Traumatic 6. Pons 5. 4. Hippocampi(includingsubiculum) 3. 2. 1. Brain Injury Table 4: Histologic Sampling for Hypoxic-Ischemic by Midbrain, pons,andmedulla Parasagittal whitematter Posterior corpuscallosum(nearsplenium) Cerebellum Midbrain (inferiorcolliculus) Deep graystructures(basalganglia/thalamus) Border zone(i.e.,frontoparietalregion) NAME members solely for scholarly purposes. ------HEAD TRAUMA POSITION PAPER Gill et al. • Page 211 purposes. scholarly for solely ------members NAME by distributed be may but use, personal description of the stage of healing (i.e., bone cal bone (i.e., healing of stage the of description lus formation) is included in the autopsy report. Forensic pathologists are trained plain film radiographs to and bones. examine As some os- seous findings may be unusual normal anatomic variants, consulting with a board-certified foren- sic anthropologist may be useful. Other useful techniques and examinations include: stripping the parietal pleural lining to better visualize rib fractures, resecting the spinal column with the medial ribs for further evaluation for posterior rib fractures, and histologic sections of cutane ous/subcutaneous injuries (Prussian identify hemosiderin). blue can Ancillary Studies Depending upon the circumstances and autopsy findings, ancillary studies for vi- infectious (e.g., ral, bacterial cultures), hereditary, metabolic, or thrombophilic diseases may be indicated. Records Review of the medical records including ante mortem CT/MRI reports should be done as they may provide relevant clinical information. Re- such agencies other by generated reports of view as child protective services and law enforcement investigation findings also may guide the foren- these therefore and investigation pathologist’s sic should be requested. CONCLUSION The investigative value of each of the described studies is often unknown at the onset of the au- au- an during performed procedures Many topsy. topsy create irreversible changes to tissues and thus proactive documentation medical is use must pathologist forensic the critical. mately, Ulti- exam autopsy each conduct to how on judgment admonition the heed to wise be would but ination that “I would rather explain why I did an exami nation than why I did not.” In these instances, it may be stated that the examination was done in accordance with recommendations endorsed by the Board of Directors of the National Associa- tion of Medical Examiners. DISCLOSURES The opinions and conclusions of this paper have As- National the by approved and reviewed been sociation of Medical Examiners Board of Direc- tors and as such are endorsed by NAME. These opinions and positions are based on a consensus of the current literature, knowledge, and prevail ing theories on this topic. As Scientific knowl- edge and experience grow, NAME reserves the for - - - intended in situ in is article This in situ method that re- member. NAME a by Downloaded The NAME autopsy performance standards in- clude procedures and descriptions for trunk in- juries. A subcutaneous examination of the arms, legs, and back and buttocks may improve detec Trunk and Upper and Lower Extremities Trunk Of particular importance in pediatric other iTBI and rib of description and identification the are skeletal fractures. In addition to radiographs, an in situ skeletal examination may be further useful document to or exclude injury. An cal osseous and neural structures with formalin osseous and neural structures cal an is Another (37). fixation with- ganglia attached and cord spinal the moves In (38). tissues soft and bone surrounding the out this technique, the laminae are cut and the spi- nous processes removed. The lateral aspects of the cutting by removed then are arches neural the articulating facets and pedicles of the vertebrae. The freed sections of bone are removed and the attached. ganglia the with removed is cord spinal tion of occult subcutaneous and rhage (39). deep hemor examination may include exposure of the shaft and epiphyseal cartilages of the ribs, clavicles, long bones, and scapulae (40). Traumatized or abnormal structures may be removed for addi- tional analysis including gross (i.e., dry bone) or a possible, When (41-43). examination histologic Infants and children who die of inflicted injuries may have injuries of the anterior and posterior neck. In addition to the standard anterior dissection, neck a posterior neck dissection also may reveal internal injury. Injuries of the neck have been proposed to explain potential mechanisms of death and techniques have been described for the examination of the neck anterior intrinsic and spine structures/nerve posterior roots (30- 37). If the prosector is concerned structural for intrinsic spinal/nerve root injury, structures may be evaluated by various methods. then these cervi the of dissection is an en bloc One method Neck ers (preretinal, retinal, subretinal), extent (few, numerous, extensive), and distribution rior - (poste pole, equatorial, and peripherally, including whether they abut the ora serrata) are described. Special stains, such as Prussian blue to identify hemosiderin, may be useful in some instances. Collection of vitreous will disturb the retina and should be postponed until adequate examination of the retina, the optic nerve, and brain is done spe- the for analysis vitreous the of value the and appro- with Photography considered. is case cific priate lighting can aid in the documentation of ocular findings. Page 212 • Volume 4 Issue 2

Downloaded NAME POSITION PAPER by a NAME member. This REFERENCES any relevantconflictsofinterest. report not do staff publication and editors The rial review. to product of NAME and a as such, is was not subjected work This time. that before or at retired or years after publication unless reaffirmed, revised, five expire automatically Examiners Medical of tion papers endorsed by the National Association 4f70-9d03-7941bff5319d.pdf. All scientific posi- com/temp/ClientImages/NAME/2c26a527-f992- is https://netforum.avectra. approved at available and publically reviewed, are written, papers initiated, position The NAME opinions. which these by process update or revise to right

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article Site=NAME. com/eweb/DynamicPage.aspx?W 1998 Sep;51(9):689-94. investigation Sadler protocol c2001. problems, Byard Apr; 23(2):204-10. of neonatal Rinaldo 405. standards. Peterson [cited net]. National cardiac Lee autopsy Basso Am JClinPathol Moritz For and paper: National Panel and Davis Am JFor Committee National Association for Donoghue Med Pathol the Association Stephens 27(3):200-25. Arch. 2008Jan;452(1):11-8. fatty acid oxidation disorders. certification of cocaine-related deaths. ensic Pathol.2013Mar;3(1):77-83. certification of deaths related to opioid drugs. AH, Gallagher PJ. Post-mortem examination after examination Post-mortem PJ. Gallagher AH, mrcn olg o Mdcl oiooy Expert Toxicology Medical of College American h danss f etrltd ets National deaths: heat-related of diagnosis the acln (O: h Ascain c2005-2014 Association; The (MO): Marceline 2014 Jan 9]. Available from: GG, National Association of Medical Examiners National Medical GG, of Association recommendations for the investigation, diagnosis, is n vlaig n Rprig pod Deaths. Opioid Reporting and Evaluating on W Kos . udn nat et syndrome death infant Sudden H. Krous RW, , uk M Fre P e a. udlns for Guidelines al. et P, Fornes M, Burke C, Appendix I, International standardized autopsy standardized International I, Appendix W Te au o a hruh rtcl n the in protocol thorough a of value The DW. R Cascl itks n oesc pathology. forensic in mistakes Classical AR. surgery. investigation of sudden cardiac death. P, Yoon HR, Yu C, et al. Sudden and unexpected for sudden unexpected infant death; p. 319-33. death: a protocol for the postmortem diagnosis intended ensic MedPathol GF, Clark SC. Forensic autopsy performance autopsy Forensic SC. GF,Clark soito o Mdcl xmnr A Hoc Ad Examiners Medical of Association soitto o Mdcl xmnr [Inter- Examiners Medical of Associatation soito o Mdcl xmnr position Examiners Medical of Association G Jnzn M Krh , t l National al. et S, Karch JM, Jentzen BG, progress, and possibilities. London: Arnold; London: possibilities. and progress, ER, Graham MA, Jentzen JM, et al. Criteria al. et JM, Jentzen MA, Graham ER, Am JForensic Med Pathol on the Definition of Heat-Related Fatalities. . 2004Mar;25(1):1 f eia Eaies oiin ae on paper position Examiners Medical of f eia Eaies Psto paper. Position Examiners. Medical of f udn nat deaths. infant sudden of Histopathology . 1956Dec;26(12):1383-97. for personal . 1997Mar;18(1):11-4. ebCode=LoginRequired& 1-3. . 1998 Nov; 33(5):399- Nov; 1998 . Semin Perinatol use, https://netforum.avectra. but J ClinPathol. Am J Forensic 20 Sep; 2006 . may Virchows be . 1999 Acad distributed -

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by College of Collins J T are computed Molina implications. review computed Nolte 40(6):932-8. non-accidental C. Adamsbaum Am JRoentgenol infants, mortem McGraw Medical Examiners;2006.27p. standards. Marceline Peterson phy Oliver J For autopsy Ackerman Pathol LabMed.1997 tee the Bove ophthalmoscopy. victims examination T Judkins Exp Neur cidal Beta-amyloid Reichard Aug; 23(4):339-47. forensic diagnosis Geddes autopsies. JNeurotrauma.2003 dental Beta-amyloid Reichard T (IL): medicolegal Hirsch hematoma. Munro For infants Matshes 28(4):323-9. child sudden lines Gilliland nal imaging. inflicted Minns Lantz 25(1):29-32. echnical communication: rationale and technique for technique and rationale communication: echnical rauma ofthenervoussystem;p.994-1077. NAME rauma. 2007Sep;63(3):625-9. How to explore and report children with suspected with children report and explore to How . AcadForensic Pathol ensic Pathol.2011 Jul;1(1):82-91. CT scans reliable enough for courtroom testimony? courtroom for enough CTreliable scans perinatal and pediatric autopsy. Autopsy Commit- Autopsy autopsy. pediatric and perinatal f h Clee f mrcn Pathologists. American of College the of for postmortem protocol for ocular investigation of ensic MedPathol hre C hms c06 Catr 9 Pr 1, Part 19, Chapter c2006. Thomas; C Charles eiti mdclgl autopsies. medicolegal pediatric K, Mlady G, Zumwalt R, et al. Postmortem X-ray abuse. E Patc gieie fr uos pathology: autopsy for guidelines Practice KE. PE, Adams GG. Postmortem monocular indirect monocular Postmortem GG. PE, Adams WR. Considerations for gross autopsy photogra- A Jns A Tno , t l Peito of Prediction al. et A, Tandon PA, Jones RA, unexplained infant death and suspected physical physical suspected and death infant unexplained K. Special autopsy dissections. Northfield (IL): Northfield dissections. autopsy Special K. of abuse. , ert H Sria ptooy f subdural of pathology Surgical H. Merritt D, eta nros ytm nuy n pediatric in injury system nervous central DK, Nichols JJ, Dimaio VJ. The sensitivity of sensitivity The VJ. Dimaio JJ, Nichols DK, f h uiiy te hlegs ad h future the and challenges, the utility, the of i o nc tam, o ban trauma. brain not trauma, neck of die S Amrsmce V Siz n Fisher’s and Spitz V. Armbrustmacher CS, radiography after unexpected death in neonates, and children: should imaging be routine? be imaging should children: and of sudden unexplained death in the young. the in death unexplained sudden of F Vwe G, er W Elsn W The DW. Ellison TW, Beer GH, VowlesJF, R Ho I, icadn H, ok LB. Rorke HG, Mirchandani IG, Hood AR, brain injury in infants and children using reti- using children and infants in injury brain practice. W Eas M Pnkr J, t l Shaken al. et JK, Pinckard RM, Evans EW, GF, Clark SC. Forensic autopsy performance autopsy Forensic SC. GF,Clark ol. 2003Mar;62(3):237-47. EP, Pless JE, Pennington DJ, White SJ. Post- SJ. White DJ, Pennington EP,JE, Pless MG, Levin AV,Levin Guide- MG, RW,al. Enzenauer et R Wie L r, ldk L Dlnk D. Dolinak CL, Hladik 3rd, CL White RR, D. Dolinak CL, Hladik 3rd, CL White RR, members tomography (CT) scans in detecting trauma: detecting in scans (CT) tomography f ifs aoa ijr: mlctos for implications injury: axonal diffuse of American Pathologists;2010.50p. oorpy C) n frni atpy a autopsy: forensic and (CT) tomography Arch Neurol Psych J Tse D, rsol J Molecular DJ. Driscoll DJ, Tester MJ, investigation of death. 4th ed. Springfield ed. 4th death. of investigation Pediatrics Acad Forensic Pathol.2011 Jul;1(1):4-50. Am JForensic MedPathol f evu sse i ssetd infant suspected in system nervous of , een , ezu V Rey-Salmon V, Merzoug N, Mejean C, rcro poen tiig n nonhomi- in staining protein precursor rcro poen tiig f nonacci- of staining protein precursor trauma. J Forensic Sci. 2005 Nov; 50(6):1450-2. . 2002Jun;178(6):1517-21. Am JForensic MedPathol 1997 NeuropatholNeurobiol Appl . solely (MO): National Association of . 2001Jun;22(2):105-11. Apr; 121(4):368-76. . 2012Nov;130(5):e1227-34. Pediatr Radiol . 2011 Jul;1(1):52-81. for . 1934;35:65-78. scholarly Apr; 20(4):347-55. J Neuropathol 21 Jun; 2010 . 20 Dec; 2007 . purposes. . 2004 Mar; Acad Arch AJR Am

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members NAME by J Forensic Sci. 2009 J Forensic distributed be Radiographics. 2003 Jul-Aug; York: Humana Press; 2011. 136 p. Humana Press; 2011. York: may . Am J Roentgenol AJR 1986 May; but of Forensic Sciences; c2014. G51, Ganglia Thomas; 2006. p. 1325. PK, Marks SC, Blackbourne B. The metaphy- The B. Blackbourne SC, Marks PK, JEG, Love JC, Wolf DA, et al. Proceedings 1-45. use, correlation. scientific meeting. Colorado American Springs: study. study. JC, Derrick SM, Wiersema Skeletal JW. atlas of gan GJ, Baker AM, Morey MK, Boos SC. From investigation investigation of death. 4th ed. Springfield (IL): W, Spitz D. W, Investigation of deaths in childhood. JC, Sanchez LA. Recognition of skeletal fractures skeletal of Recognition LA. Sanchez JC, lesion in abused infants: a radiologic-histopatho- nerve root hemorrhage in cases of pediatric blunt archives of the AFIP. Child abuse: radiologic-patho- abuse: Child AFIP. the of archives Spitz W, Spitz D, editors. Spitz and Fisher’s medico- Fisher’s and Spitz editors. D, Spitz W, Spitz the American Academy of Forensic Sciences 66th infants: an autopsy technique. Peterson Peterson of annual Academy and p. 346. head injury; Spitz In: legal Charles C Love in Nov; 54(6):1443-6. Love child abuse. New Kleinman seal logic 146(5):895-905. Loner the logic 23(4):81

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Acta Acta Pathol Pathol Pathol Pathol intended is article This 2012 Jan; 57(1):113-9. . 2001 Jul; 124(Pt 7):1290-8. member. Neurosurgery. 1989 Apr; 24(4): Brain NAME study. study. a brain injury in infants. Brain. 2001 Jul; of inflicted head injury in children. I. Patterns I. children. in injury head inflicted of by J Forensic Sci. J Forensic of inflicted head injury children. in II. EW, EW, Joseph J. Pathologic evaluation of the P, Smith CR, Deck P, J, et Axonal al. injury and and lateral compartments and tongue. inter- chiropractic and surgical following spine JF, JF, Hackshaw AK, Vowles GH, et al. Neuro- JF, Vowles GH, Hackshaw AK, AK, et GH, al. Hackshaw Neuropa- Vowles JF, MN, Sonntag VK, Rekate HL, A. Murphy The VI. Autopsy VI. technique for neck examination. I. VI. Autopsy technique for neck examination. II. examination. neck for technique Autopsy VI. whiplash-shake whiplash-shake injury syndrome: a clinical and neuropathology of shaken baby syndrome. ertebral column and posterior compartment. Matshes cervical ventions. Geddes pathology of brain damage. Adams Anterior Annu. 1990; 25 Pt 2:331-49. Adams V Annu. 1991; 26 Pt 1:211-26. 124(Pt 7):1299-306. Hadley infant pathological 536-40. Shannon the . 1998 Jun; 95(6):625-31. Neuropathol Geddes Geddes thology Microscopic

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