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In one case buy generic toradol line lateral knee pain treatment, an individual had his head caved in with a baseball bat in front of a number of witnesses discount toradol online mastercard milwaukee pain treatment services. The brain showed virtually no subarachnoid hemorrhage and no contusions order toradol no prescription gallbladder pain treatment home remedies, though there were extensive lacerations. Absence of hemorrhage following lacerations to the brain has been reported as much as 1 h after injury, and is presumably due to prolonged spasm of vessels. This is due to subarachnoid hemorrhage causing scarring of the arachnoid villi, such that it impedes their ability to reabsorb cerebrospinal fluid. Subarachnoid hemorrhage can be produced postmortem secondary to decomposition, with lysis of blood cells, loss of vascular integrity, and leakage of blood into the subarachnoid space. In addition, minimal subarachnoid hemorrhage may be produced during the process of removing the brain. In this case, in the process of removing the skull cap, cerebral veins and the arachnoid are torn, with subsequent diffusion of blood into the subarachnoid space in the posterior aspect (dependent portion) of the cerebral hemispheres and cerebellum. While this hemorrhage is usually very minor, if the brain is not removed from the cranial cavity immediately but rather left to sit for a while, a considerable quantity of subarachnoid hemorrhage may accumulate. Trauma to the Skull and Brain: Craniocerebral Injuries 175 Vertebral Artery Injury (Laceration) Blunt trauma to the neck can cause severe injury to the vertebral arteries. The upper third of the cervical region is the area where the vertebral artery is most susceptible to trauma. In the most common form, there is a traumatically induced dissection in the vessel wall, along a length of vertebral artery, with rupture into the subarachnoid space at the base of the brain (Figure 6. The second type of injury also involves dissection but, instead of rupture of the vessel wall, there is thrombosis of the lumen with infarction of brain tissue. The remaining two cases had rupture, but death was too rapid for subarachnoid hemorrhage. The most common causes of vertebral artery trauma are blows to the neck, motor vehicle accidents, falls, and cervical spine manipulation. Injury of the vertebral artery should be suspected when an individual collapses and dies almost immediately after receiving a blow to Figuren 6. In cases caused by rupture of the artery, an autopsy reveals sub- arachnoid hemorrhage primarily concentrated on the ventral surface of the brain and around the brain stem. In rupture of the artery due to blunt trauma, Opeskin and Burke noted bruising and abrasions below and behind the ear in 50% of 18 cases. Demonstration of the vertebral artery injury is easiest by injection of radio-opaque dye into the vertebral arteries with radiological demonstration of the injury. Only after such demonstration should there be dissection of the neck, because dissection is extremely difficult and, if not done correctly, may produce artifactual defects in the vessels. Of 19 individuals with rupture and subarachnoid hemorrhage in the study of Opeskin and Burke, 14 died immediately and five in 10 h to 3 days. Of the four individuals who died secondary to vertebral artery thrombosis, symp- toms did not appear for 1 d to 4 weeks, with survival time of 3 days to 7 weeks. Traumatic Injury of the Carotid Artery This entity is probably more common than realized. In the neck, it may be found in association with hyperextension injury or spinal fracture. The injury was incurred in a low-speed motor vehicle collision and was due to deploy- ment of an airbag. Traumatic Dissection of Intracranial Arteries Dissection of intracranial arteries due to trauma is relatively uncommon. It is caused by Trauma to the Skull and Brain: Craniocerebral Injuries 177 subintimal dissection of the intracranial anterior circulation arteries. Unlike other areas of the body where dissection is in the media, here it occurs subintimal, with resultant occlusion of the lumen by mechanical effects and the production of infarction. Traumatic Brain Swelling and Edema Following significant head injury, whether clinically mild or severe, swelling of the brain can occur. Brain swelling may be focal, adjacent to an area of brain injury; or diffuse, involving one or both cerebral hemispheres. Brain swelling is due to an increase in intravascular cerebral blood volume second- ary to vasodilatation (congestive brain swelling), or an absolute increase in the water content of the brain tissue, or a combination of the two. An increase in tissue water content, or cerebral edema, is often incorrectly considered synonymous with brain swelling. If continued long enough, brain swelling caused by an increase in the intravascular cerebral blood volume progresses to cerebral edema, presumably due to increased vascular permeability. The magnitude of the brain swelling does not necessarily correspond to the sever- ity of the injury. Massive cerebral (congestive) swelling can occur within 20 minutes following head trauma. The secondary swelling may, in fact, cause a more serious mass effect than the hematoma. With severe brain injury, diffuse brain swelling of a severe degree may occur immediately without the individual regaining consciousness. Brain swelling, however, might not occur immediately after an injury, but rather develop minutes to hours later. It is usually diffuse and more often associated with the less severe forms of brain injury. Typically, the patient receives a concussion, regains consciousness, only to become stuporous and lapse into coma minutes to hours later. Until recently, it was felt that children were more susceptible than adults to developing diffuse swelling, even after minor trauma. If brain swelling develops to a severe degree and continues over a suffi- cient time, there can be herniation of the brain or secondary brain stem hemorrhage. A rapidly expanding intracranial mass or severe brain swelling 178 Forensic Pathology Figure 6. Herniation may be either symmetrical, due to brain swelling, or asym- metrical, due to a mass in one side of the brain or subdural space, e. In the case of diffuse brain swelling, there is usually symmetrical herniation of the cerebellar tonsils without brain stem hemorrhage. The brain stem and cerebellar tonsils are forced into the foramen magnum, with resultant dysfunction or even infarc- tion of the brain stem. The individual becomes unconscious and develops respiratory difficulty that proceeds to arrest and death. In some individuals with pro- longed survival, the authors have seen the upper spinal cord encased in necrotic cerebellar tissues shed into the cerebrospinal fluid. In dealing with an asymmetrical herniation caused by a subdural hematoma, in addition to ipsilateral cerebellar tonsil herniation, one often has a secondary brain stem hemorrhage (a Duret hemorrhage) involving the midbrain and pons. Transtentorial or uncal herniation is due to a rapidly expanding suprat- entorial mass lesion. It may be either unilateral or bilateral, though unilateral herniation is more common because rapidly expanding lesions are usually unilateral.

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Other symptoms of rupture l Have you ever had a sexually transmitted infection include feeling dizzy or faint or actually fainting buy 10mg toradol amex pain treatment drugs. What were the quately treated can cause scarring of the fallopian number of times and outcomes of your pregnancies? However safe toradol 10mg spine and nerve pain treatment center traverse city mi, women older than age 35 have a higher mortality rate from Previous Pregnancies ectopic pregnancy toradol 10mg visa tailbone pain treatment home remedy. The risk for spontaneous abortion is higher in women older than age 35 and in women with a history of three Weeks of Gestation or more prior spontaneous abortions. Among known pregnancies, the rate of spontaneous abortion is approximately 10% and usually occurs Is this related to age? An estimated 10% to 15% of clinically recognized pregnancies result in frst trimester loss. The patient Key Questions experiencing an ectopic pregnancy typically presents l How old are you? Chronic Health Conditions Age The risk for spontaneous abortion is higher in Knowing a woman’s age can help focus the differential women with systemic conditions, such as diabetes diagnosis. Pain Low back pain or abdominal pain that is dull, sharp, or Box 36-1 Risk Factors for Ectopic cramping may indicate spontaneous abortion or ecto- Pregnancy pic pregnancy. If there is pain associated with ectopic pregnancy, it will usually be described as “crampy,” • History of pelvic infammatory disease pelvic pressure, or “soreness” in the lower abdomen. Severe, sharp, and sudden pain in the lower • Infertility abdominal area may indicate rupture of the ectopic • In utero diethylstilbestrol exposure • Present use of intrauterine device pregnancy. Chapter 36 • Vaginal Bleeding 421 vascular, and less stable endometrium, predisposing Is this problem acute or chronic? Women Key Questions over age 40 years are more likely to have problems l Has this kind of vaginal bleeding occurred before? If a woman is postmenopausal, the origin of bleeding irregularities is often hormone therapy, endometrial Irregular Menses hyperplasia, or endometrial cancer (see section on In anovulatory cycles, the endometrium proliferates postmenopausal bleeding). Key Questions If the patient’s estrogen levels are fuctuating, she may l When did the bleeding begin? Acute Bleeding Symptom Analysis One episode of acute bleeding in a woman with Determine the amount of fow and its duration to estab- normally regular menstrual cycles suggests uterine lish if there is menorrhagia, metrorrhagia, or menome- fbroids or a complication of pregnancy, such as threat- trorrhagia. In a postmenopausal woman with an menses over the course of the cycle, which is estimated intact uterus, an episode of vaginal bleeding is indica- as saturating a sanitary pad or tampon hourly. Metror- tive of endometrial hyperplasia and is suspicious for rhagia is defned as bleeding at irregular intervals or endometrial cancer. When the menstruation has an unpredictable schedule and lasts for a prolonged time, Chronic Bleeding it is termed menometrorrhagia. Chronic midcycle spotting Patients may experience postcoital bleeding with can occur secondary to the normal midcycle drop in cervical infections, cervical polyps, or cervical estrogen levels and usually is not bothersome to the cancer. Accompanying dyspareunia may indicate patient because the amount of vaginal bleeding is very endometriosis. Pelvic Could this be caused by the patient’s birth control pressure or pain is suspicious for persistent corpus method? Uterine prolapse causes pelvic pressure, which is subjectively described as “something falling Key Questions out of the vagina. Throat and rectal cultures for gonorrhea and chla- of the cycle because of low estrogen level or in the last mydia should also be obtained. Long- Trauma to the perineum is more common in acting progestin contraceptives (Norplant) may cause children because the vulva has less subcutaneous fat. Irregular Menstrual Cycles Pediatric Vaginal Bleeding Anovulatory cycles are the most common cause of In the United States, the average age of menarche is irregular bleeding patterns among females beginning 12 years old. Vaginal bleeding before age 9 is abnormal (adolescent) or ending (perimenopausal) their men- and may indicate a foreign body, injury, or sexual strual cycles. Secondary sexual characteristics indicate sexual lescents will be anovulatory during the frst year of precocity. Regular ovulatory cycles are usually enlargement, galactorrhea, and a small amount of established by the second year of menses but may vaginal bleeding from maternal exogenous hormones. Menopause Symptoms Although uncommon, malignant genital tract tu- The hot fash is the most commonly experienced mors in girls can cause vaginal bleeding. It is a sensation of increased nosis and adenocarcinoma are the most common tumor upper body warmth that begins in the chest area and types. Sweating, which can be so profuse as to leave clothing wet, fol- Bleeding Problems lows the hot fash. Hot fashes often lead to disturbed A family history of bleeding problems or a positive sleep patterns, insomnia, and fatigue. Vaginal atrophy review of systems and physical examination indicating can cause vaginal dryness, dyspareunia, and atrophic the presence of petechiae or bruises suggests a bleed- vaginitis (see Chapter 37). Platelet counts or clotting studies are affect the urinary system, causing urinary frequency, indicated. Accompanying Symptoms Menopausal Syndrome Vulvovaginitis is the most common pediatric gyneco- The frequency of monthly ovulation becomes irregular logical problem. Vaginal discharge, vaginal itching, vul- at about 40 years of age, and this leads to intermittent var erythema, and lesions often accompany vulvovaginal symptoms of menopause. The time frame from onset Chapter 36 • Vaginal Bleeding 423 of symptoms to complete cessation of menstruation is be a symptom of atrophic vaginitis. The left in place at the time of the hysterectomy, the woman perimenopause phase can last up to 10 years. If meno- may not experience menopause until about 8 to pause is completed before age 40, it is considered 10 years after the surgery. The age of menopause is and nonfunctional over time, probably secondary to genetically determined and will be similar to those of altered blood fow resulting from the surgery. Menopause is vaginitis bleeding occurs from the slightest trauma; unrelated to age of menarche, pregnancies, or contra- even wiping the perineum with tissue after urination ceptive methods used. Hormone therapy for menopausal symptoms may Key Questions cause vaginal bleeding in women with an intact uterus. Regimens for women with an intact uterus include the l Do you still have a uterus? After a pattern of amenor- Age at Menopause rhea has been established, new bleeding should be The average age for a woman in the United States to go investigated. Menopause is defned Unopposed estrogen therapy in a woman with an as 1 year without menstrual cycles. However, a diagno- intact uterus predisposes her to endometrial cancer sis can be accurately made earlier by measuring the from a thick, built-up endometrium. Endo- bleeding that occurs after the establishment of meno- metrial hyperplasia can be diagnosed with endometrial pause. Vaginal bleeding after menopause warrants in- biopsy, ultrasonography, or dilation and curettage vestigation to rule out endometrial cancer.

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The depths of the laceration should be explored for the presence of foreign mate- rial that could have been deposited there by the weapon or surface that caused the laceration discount toradol 10 mg mastercard abdominal pain treatment guidelines. If the blow or impact that causes a laceration is delivered at an angle purchase toradol from india sciatic nerve pain treatment exercises, rather than perpendicular to the surface of the body buy discount toradol 10mg line pain management for shingles pain, one will find under- mining of the tissue on one side, which indicates the direction that the blow was delivered (Figure 4. The other side of the laceration, the side from which the blow was coming, will be abraded and beveled. While most lacerations have irregular, abraded, even contused margins, if an individual is struck with a heavy object having a relatively sharp edge along the impacting surface, the wound produced may greatly resemble an incised wound (Figure 4. Careful examination of the wound, however, will usually reveal at least some abrasion of the margin, plus bridging in the depths of the wound. Occasionally, a very dull knife may produce an incised wound with abraded margins. Again, careful observation of the edges and base of the wound with a dissecting microscope usually makes differentiation Blunt Trauma Wounds 105 A B Figure 4. Differentiation of a laceration from an incised wound of the head in a decomposed body is often not possible. An avulsion or avulsive injury to the outside of a body is a form of laceration where the force impacting the body does so at an oblique or tangential angle to the skin, ripping skin and soft tissue off the underlying fascia or bone. In a case of extreme avulsion, an extremity or even the head can be torn off the body. Internally, organs can be avulsed or torn off in part or in toto from their attachments. A variation of an avulsive laceration is one produced by shearing forces, where the skin shows no signs of injury but the underlying soft tissue has been avulsed from the underlying fascia or connective tissue, creating a pocket that may be filled with a large quantity of blood. This injury is occasionally encountered on the backs of the thighs of pedestrians struck by motor vehicles. As the hood of the car impacts the back of the thigh and lifts up the pedestrian, it imparts a shearing force to this region, avulsing the skin and subcutaneous tissue off the fascia and creating pockets where blood can accumulate. There are generally abrasions and contusions on the back of the hands, wrists, forearms, and arms (Figure 4. Lacerations are less common and may contain embedded fragments of the weapon in the wounds. When these occur, they generally involve the forearm, and are incurred in attempts to ward off a blunt object. Determination of Whether a Wound is Ante- or Postmortem At present, determination of whether a wound is either ante- or post- mortem is made by gross or microscopic examination of the wound. The presence of bleeding into the tissue is presumed evidence that the deceased was alive, or, at least, the heart was beating at the time the injury was incurred. The problem with this principle is that, on occasion, trauma to a recently dead body can cause bleeding into soft tissue. This phenom- enon may cause confusion to a forensic pathologist who is unaware of it. Much rarer is the postmortem contusion of the scalp previously men- tioned in this chapter. Another method of determining if an injury is antemortem is micro- scopic examination of the injury in search of an inflammatory reaction. The problem with this technique is that some tissues do not show an Blunt Trauma Wounds 109 inflammatory reaction unless the victim has survived for at least several hours after the injury. Techniques to identify antemortem injuries involving use of histochem- istry, enzymology and biochemistry have been developed. Analysis of enzyme activity in antemortem wounds has demonstrated a zone of decreased enzyme activity at the center of the wound, with increased enzyme activity at the periphery. The increased enzyme activity occurs over a specific time interval, with the interval different for different enzymes. The enzyme activity can be used to demonstrate that a wound was antemortem as well as to date it. Fractures of the Face Fractures of the mandible, maxilla, zygoma and zygomatic arch are pro- duced predominantly by assaults and motor vehicle accidents. Sagittal In dentoalveolar fractures, direct force applied anteriorly or laterally causes separation of a fragment of the mandible. The LeFort I fracture is a transverse fracture of the maxilla, above the apices of the teeth, through the nasal septum and maxillary sinuses, the palatine bone and the sphenoid bone. As it proceeds anteriorly, however, it curves upward near the zygomatic-maxillary suture, through the inferior orbit rim onto the orbital floor, through the medial orbital wall and across the nasal bones and septum. Fractures of the the Extremities Fractures of the bones of the extremities can be produced by either the direct or indirect application of force to the bone. With significant impact, however, there is crushing on the side of the bone to which the force is applied (the concave side), prior to the bone’s cracking. Fractures caused by direct application of force to a bone site can be divided into penetrating, focal or crush fractures, depending on the amount Blunt Trauma Wounds 111 of force applied to the bone and the size of the area to which it is applied. Because, for all practical purposes, this category is synonymous with gunshot wounds, penetrating fractures will not be discussed in this book. In focal fractures, a small force is applied to a small area and the resultant fracture is usually transverse. Overlying soft tissue injury is relatively minor, for example, an abrasion, contusion, or small laceration. In areas where two bones are adjacent to each other, such as in the forearm or calf region, typically only one bone is fractured. Focal fractures, produced by weapons such as a bat or pipe, are seen in forearms when an individual has tried to ward off blows from such instruments (Figure 4. In crush fractures, a large force is applied over a large area, with resultant extensive soft tissue injuries and, often, comminuted fractures of the bone. In the forearm and lower legs, there is usually fracture of both bones at the same level. Most crush fractures of the extremities involve the legs, with motor vehicle-pedestrian accidents the most common etiology. In severe impact injuries of the legs, a number of possible fracture pat- terns can be produced (transverse; oblique; spiral; segmental; comminuted; longitudinal split; tension wedge; compression wedge). In tension wedge fractures, the fractures begin opposite to the point of impact and radiate back through the bone at a 90º angle, giving rise to a wedge of bone whose point is directed in the direction of the force and whose base is at the point of impact. What appears to be an oblique fracture on X- ray may turn out to be a tensile wedge fracture on dissection. These are extremely rare and may be confused with the common tension wedge fracture. Fractures Caused by Indirect Application of Force Indirect fractures are produced by a force acting at a distance from the fracture site. In this regard, it should be noted that bone is weaker to tension (stretching) than compression. Angulation, rotation, and compression fractures In traction fractures, the bone is pulled apart by traction. An example would be violent contraction of the quadriceps muscle with resultant trans- verse fracture of the patella.

W. Charles. Johnson State College.