Mar 10, 2012

Autopsy: The Importance of the External Exam…

The external exam is a very important part of the adult autopsy and is sometimes overlooked by more inexperienced PA’s or pathology residents. Although in the hospital we know the patient died from a natural death and we have a chart with events leading up to the patients death and some of their medical history, the external findings on a patient can tell lots about what is going on with a patient inside.

I like to teach the residents and my students that there are 3 different components to the external exam.

#1 General death stuff

In hospital autopsies we know approximately what time our patients died and what position they were found in. 99.9% of the time my patients die in a hospital bed. We should still document post mortem changes such as rigor mortis, livor mortis and decomposition.

Lividity

This is an example of the normal pattern of livor mortis we see in hospital patients. Livor mortis is post mortem blood pooling- meaning the blood, after death, leaves the systemic circulation and pools to dependent areas. Because all of our patients die in a hospital bed, we should see this pattern of lividity on the back. Lividity starts setting in within 30-60 after death and lasts about 12-24 hours. This can be tested by pressing hard on the livid areas. If it is fresh, the skin will blanch. The skin will be a purplish color due to the fact the the blood is deoxygenated.

In comparison to the normal lividity pattern seen above in a patient with a natural death, this finding is much different. This is what is referred to as “cherry red lividity” and is seen in patients with carbon monoxide poisoning. This could be seen in accidental deaths from faulty heaters or suicides via exhaust pipe.

The post mortem and lividity patterns in this patient are weird as compared to the patient above. This is a huge indicator to me of how this patient died. When I see this external finding the first thing I think- sepsis. The skin discoloration is not just on the back, but on the entire body. This skin pattern represents what is called purpura fulminans. This happens in severe cases of sepsis. The 4 primary features of this syndrome are large purpuric skin lesions, fever, hypotension, and (DIC) disseminated intravascular coagulation. This patient was also noted to have these skin lesions premortem. Meningococcemia generally causes this, however other organisms including Staphylococcus aureus has been associated with purpura fulminans with accompanying toxic shock syndrome. This can also be seen in Streptococcus pneumonia sepsis.

Rigidity 

Rigor mortis. Post mortem stiffening. The degree of stiffening is due to the patients muscle mass. A young, muscular boy would have a strong rigor as compared to an elderly patient that is weak would have a more loose rigor. Rigor usually appears 2-4 hours after death. It becomes complete within 4-10 hours after death.  The time rigor kicks is dependent of the temperature in which the body was placed or found at death. The most accurate way to test rigor is by pulling on the jaw.

Decomposition

In hospital deaths, decomposition is rare. We know the time of death and patients are brought to the morgue refrigerator relatively quickly. Refrigeration greatly decreases the rate of decomposition and patients are usually brought to the funeral home or crematory within a couple days. When I see things like this, skin slippage which is the early stages of decomposition, it means the patient has some sort of underlying condition that is accelerating the decomposition- like sepsis. These changes can also be seen in ischemia.

Extreme extensive cases of decomposition such as these can be seen in medical examiner cases. Patients can get this decomposed in less than 24 hours given the time of year and the temperature in the conditions they were found in.

This stage of decomposition is referred to as marbling.

This is a more advanced stage of decomposition. Note the green-gray coloration of the skin and skin slippage.

This is a very extreme case of decomposition and an unfortuantly reality for summers in Philadelphia. Here you can see the patient is totally decomposed and covered with maggots. These cases can make certain individuals squeamish, but these patients still have to be autopsied to determine the cause of death. My very first autopsy I ever cut as a student was on a patient exactly like this. It is good for PA students and pathology residents to practice their cutting skills on a patient like this because they will not be having a viewing.

#2 Medical intervention

In hospital autopsies, we received our patients untouched from the floors. If the patient had any surgery or procedure the interventions would be evident to us during the external exam.

Here is a common finding we see on the external exam. PICC lines, central lines, single, double and triple lumen lines. These lines are put in place for administering medications, obtaining blood tests, etc.

ECMO

ECMO, which stands for Extracorporeal Membrane Oxygenation,  functions as a replacement for a critically ill patient’s heart and lungs. It’s used to support a patient who is awaiting surgery, or to give a patient’s vital organs time to recover from heart surgery or disease.

These patient’s have serious, but sometimes reversible, medical conditions that impair heart or lung function, or both. While a patient awaits treatment or recovers from treatment, the ECMO machine does the work for the heart and lungs, until these vital organs recover and can function well independently. ECMO maintains blood flow and oxygenation to the vital organs (liver, kidney, brain), so that the function of these organs are maintained while the heart or the lungs recover.

Intubation

Intubation is necessary when patients can no longer cough and clear secretions or breathe on their own. Endotracheal tubes can be connected to ventilator machines to provide artificial respiration. This can help when a patient is unconscious by maintaining a patent airway, especially during surgery. Internally these patients can have big, hyper-inflated lungs and soft brains.

Left ventricular assist device (LVAD)

A left ventricular assist device (LVAD) is an implantable mechanical pump that helps pump blood from the left ventricle to the rest of the body. LVADs are placed in patients who have weakened hearts or heart failure.

LVAD’s may be placed while a patient is awaiting a heart transplant or for the heart to become strong enough to effectively pump blood on its own. AN LVAD might be recommended for long-term treatment if the patient has heart failure and is not a good candidate for a heart transplant.

Ostomies

An ostomy (or stoma) is a surgical opening made in the skin as a way for waste products to leave the body. An ostomy can allow wastes to leave from the intestines (ileostomy or colostomy). Seeing one of these on external exam would indicate the patient had a previous bowel surgery. This could indicate a past history of cancer, infection, ischemia, inflammatory bowel disease or diverticulitis.

#3 General Health Stuff

What is the general health of the patient? Does the patient look their stated age? What is their weight? Are they obese? Cachectic? Do they have any scars indicating a previous surgery?

Here are some striking findings found on external exam. The skin is markedly jaundice (yellow). All of the subcutaneous hemorrhage is caused DIC or disseminated intravascular coagulation. You could see if this patient was just found down and this was a medical examiners case how these findings could be suspicious for a traumatic event. These findings tell us this patient was in end stage liver failure.

Here is a common external finding we see in the morgue. Stasis changes. Stasis dermatitis is caused by an increased intralumenal pressure in veins, usually due to stasis, and result in dilation and tortuosity of the vessels. When this condition affects superficial veins of the lower extremities, it can result in edema and trophic changes of the skin, as illustrated here.

Obesity

Unfortunately obesity is a common finding at autopsy. Being obese can have serious negative effects on your health. Obesity is an excess proportion of total body fat. A person is considered obese when his or her weight is 20% or more above normal weight. The most common measure of obesity is the body mass index or BMI. A person is considered overweight if his or her BMI is between 25 and 29.9; a person is considered obese if his or her BMI is over 30.

“Morbid obesity” means that a person is either 50%-100% over normal weight, more than 100 pounds over normal weight, and has BMI of 40 or higher.

Being obese increases your risk of diabetes, heart disease, stroke, arthritis and some cancers. At autopsy, I see what obesity can do to the body. Obese patients tend to have really large hearts to upkeep with the large body mass. This can cause hypertrophy of the heart muscle leading to arrhythmias and heart attacks. Many people do not realize this, but when you are obese extra fat grows around all of your internal organs and the liver can start getting large and fatty as well. These changes can effect the normal functions of the organs leading to serious problems and ultimately death.

Cachectic

Chachexia is physical wasting and loss of weight and muscle mass due to an underlying disease. Without any medical history on a patient like this, I would question if this person had HIV/AIDS, cancer, etc.

Clubbing

If you look at the list of things that can cause clubbing it’s pretty much every disease, disorder or tumor you could name. There are many genetic, idiopathic (which are both primary) and acquired (secondary) causes of clubbing. The most common causes tends to arise from pulmonary or cardiac issues leading to hypoxia.

Cyanosis

Cyanosis is a bluish color to the skin or mucus membranes that is usually due to a lack of oxygen in the blood. Cyanosis is usually due to heart and/or lung problems. This includes: pulmonary embolisms, COPD, drowning, high altitudes, choking, heart failure, congenital heart defects, drug overdose and toxins such as cyanide.

Pitting edema

Pitting edema can be demonstrated by applying pressure to the swollen area by depressing the skin with a finger. If the pressing causes an indentation as seen here that persists for some time after the release of the pressure, the edema is referred to as pitting edema. Edema can occur from a systemic process or a localized process. The most common systemic diseases associated with edema involve the heart, liver, and kidneys. In these diseases, edema occurs primarily because of the body’s retention of too much salt. The excess salt causes the body to retain water. This water then leaks into the interstitial tissue spaces, where it appears as edema. The most common local conditions that cause edema are varicose veins and thrombophlebitis of the deep veins of the legs. These conditions can cause venous insufficiency. The resulting increased back-pressure in the veins forces fluid stay in the extremities. The excess fluid then leaks into the interstitial tissue spaces, causing edema.

Rheumatoid Arthritis (RA)

I hate talking about complications of RA because my pop has it (his hand below). Rheumatoid arthritis can affect nearly every part of the body. The most common external manifestations of the disease can be seen in a patient’s hands. Internal complications include inflammation and scarring of lung tissue. A patient with RA is at increased risk of atherosclerosis. The blood vessels can also become inflamed leading to skin, nerve, heart, and brain problems. The outer surface of the heart and lungs can also become inflamed.

Marfanoid

Marfan syndrome is a genetic disorder. A mutation in the gene that controls how the body makes fibrillin causes Marfan syndrome. Fibrillin is a protein that plays a major role in your body’s connective tissue. Marfanoid characteristics include a tall, thin build with long arms, legs fingers and toes. Flat feet. The patients tend to be more flexible and are at higher risk of scoliosis. This condition effects all fibrillin of the body, so Marfan’s disease is not just confined to external findings.

The most serious complications of Marfan syndrome involve the heart and blood vessels. Marfan syndrome can affect the aorta, the main blood vessel that supplies oxygen-rich blood to the body. In Marfan syndrome, the aorta can stretch and grow weak. This puts the patient at risk for an aortic aneurysm and dissection.Marfan syndrome also can cause problems with the heart’s mitral valve called mitral valve prolapse. MVP is a condition in which the flaps of the mitral valve are floppy and don’t close tightly.

The lenses of the eye are also at risk of dislocation.

Scars

Scars can tell lots about a persons life. Scars can mean nothing and have nothing to do with the patient’s death. Scars can also point us in the right direction as to why the patient died.

Craniotomy

Craniotomy is a cut that opens the cranium. During this surgical procedure, a section of the skull, called a bone flap, is removed to access the brain underneath. The presence of this cut can indicate the patient had a tumor removed, a brain bleed , an aneurysm etc.  Other reasons for a craniotomy may include foreign objects (bullets), swelling of the brain, or infection.

Appendectomy

The appendix is a small, worm like projection that comes off a portion of the large intestine on the right side. It is usually surgically removed for acute appendicitis (inflammation) which can become an emergency situation. Cancer of the appendix is rare. Appendicitis is common and doesn’t really indicate an underlying disease.

Open cholecystectomy

This is a less common procedure and is seen more often in older patients (pre-laparoscopy). In open gallbladder removal surgery, a surgeon makes a large surgical cut  in the RUQ (right upper quadrant), just below the ribs. . The surgeon then removes the gallbladder by reaching in through the cut. This really does not tell us anything about why a patient died. Gallbladders are usually always removed for stones or inflammation of the gallbladder. It just tells me there will not be a gallbladder on the liver when I open the patient up. It’s less likely the gallbladder was removed for gallbladder cancer.

Laparoscopic cholecystectomy

The surgeon inserts a lighted scope attached to a video camera (laparoscope) into one incision. The surgeon then uses a video monitor as a guide while inserting surgical instruments into the other incisions to remove the gallbladder. This is the most common technique used today.

Sternotomy

A sternotomy is a vertical incisions made along the sternum, after which the sternum itself is divided, or “cracked”. This procedure provides access to the heart and lungs for surgical procedures. This is also referred to as “open heart surgery”. Seeing a scar like this indicates the patient had a serious surgery, usually for heart stuff like congenital defects, valve replacements or a heart transplant.

Pacemaker

A pacemaker is a small device that’s placed in the chest to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart to beat at a normal rate. The presence of this alone can indicate the patient died from heart disease. I hate pacemakers! I got shocked once excising it from an autopsy patient!

Previous amputations

Previous amputations with necrotic stumps are usually consistent with PVD (peripheral artery disease). Peripheral artery disease is caused by atherosclerosis, or “hardening of the arteries.”  This problem occurs when fatty material (plaque) builds up on the walls of the arteries. This causes the arteries to become narrower. The walls of the arteries also become stiffer and cannot dilate to allow blood flow. PVD can occur in adults with a history of high cholesterol or diabetes. Usually if a patient has crappy vessels in their legs, the rest of the arteries are just as diseased. This means these patients are also at risk for another ischemic event such as a stroke or an MI (heart attack).

Tattoos

Tattoos tell a story about a persons life. This tattoo for example shows that this person is awesome :)

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Disclaimer. All materials posted on my website are intended to showcase my love of pathology and art and the correlation between the two. In no way am I trying to exploit any patients or their specimens. All images and information should be used to educated people in the pathology field and enlighten others into my profession. Enjoy.