CAPÍTULO V: DISEÑO DE LA SOLUCIÓN
5. DISEÑO DE SALIDAS
5.1. Salidas Módulo Web
Dissection of the face is not an uncommon procedure during the forensic autopsy. It may be required in a variety of suspicious death investigations–particularly in those where facial injury has occurred or where human identification is an issue. At first glance, it may be thought that the dissection of the face will be associated with permanent disfigurement with consequent change in the visible identifying characteristics of the face. In practice, such a degree of disfigurement of the face is rarely the result of autopsy dissection. In situations where
complaints are made that the face has been altered as a result of the autopsy, examination of the allegation usually reveals that there was prior facial damage and disfigurement with alteration of the face before the autopsy commenced. In many forensic cases the family will not have seen the body of the deceased prior to the autopsy and as a result they can confuse the effects of the autopsy procedure with injuries that the deceased suffered prior to death.
The soft tissues of the face need to be examined carefully in a variety of autopsies including those performed for both clinical and forensic purposes.
In the clinical autopsy it may be necessary to dissect the soft tissues of the face in order to identify disease in structures such as the salivary glands, muscle and soft tissues. Skin pathology may need to be explored and where skin tumours have invaded the deeper structures, facial dissection may be required in order to determine the extent of direct tumour spread. Examination of the structures such as the lining of the mouth, including the tongue, the nose, the nasopharynx and the oropharynx will require a degree of facial dissection.
In the forensic autopsy soft tissue dissection of the face may be required in order to identify areas of soft tissue and bony trauma. Again oral structures may need to be dissected and the region of the lips, the nose and the eyes may require specific examination for injury. The forensic autopsy also often involves an examination of the subcutaneous tissues of the face in order to identify areas of bruising corresponding to regions of externally applied force. In forensic autopsy practice injuries to the face are a common feature of the pattern of trauma in cases of interpersonal violence.
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In addition to soft tissue dissection, examination of the bony tissues of the face may be required. Again in the clinical autopsy, pathology in the overlying soft tissues may have spread to involve the underlying bony tissues of the face. Specific areas of the facial skeleton of the skull may need to be dissected in some detail. Bone tumours involving the skull including the dental structures may require detailed dissection involving removal of portions of bone in order for the extent of the disease to be determined. Specific structures such as the sinuses and the deeper regions of the nose and orbits require special dissection techniques. In the forensic autopsy it may be necessary to examine the bony tissues of the face in order to determine the extent and nature of trauma to the face. Fine fractures of the facial skeleton may be difficult to determine on x-ray. For this reason facial dissection should be carried out in all autopsies where the deceased has suffered a facial injury.Gross trauma to the facial skeletal structures is a feature of many forensic autopsy subjects.
Firearm injuries to the face are particularly destructive of the facial skeleton and the exploration of these injuries can involve the dissection and removal of large portions of the mandible and the maxilla.
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In autopsies where the identification of the deceased person is unknown, it is necessary to make a detailed record of the mouth by means of detailed charts, photographs, radiographs and descriptions of dentition so that these can be used for comparison purposes. In many cases it may be possible to obtain this information by direct visual inspection of the inside of the mouth. However, in some cases it may be necessary to disarticulate the lower jaw (mandible) in order to expose the dental structures. In some cases it may also be necessary to remove the maxilla.The detailed dissection of the tissues and structures of the neck is linked to the examination of the soft tissues and hard tissues of the face. In practice, the dissection of the neck in the routine autopsy can be seen as a preliminary process to the more extensive procedures involved in facial dissection. Prior to the detailed dissection of the face it is often useful to have concluded
the remainder of the macroscopic autopsy. As with dissection of the neck, the prior removal of the thoracic organs and the brain allows the blood within the soft tissues of the head and face to be drained. This results in the soft tissues of the face becoming relatively free of blood allowing the pathologist to dissect the tissues with good visualisation of both soft and hard tissues.
External genitalia
In certain forensic autopsies dissection of both male or female genitalia may be required. In practice, however, it is female genitalia that most often require detailed dissection. Deaths from violence where a sexual assault has occurred require detailed assessment in order to reconstruct the circumstances in which interference with the external and internal genitalia took place.
If forensic specimens of vaginal contents are required for forensic biological assessment, such as vaginal swabs, these are best taken prior to the dissection of this area. It is preferable for such swabs to be taken prior to the internal examination of the body to reduce the risk of further contaminating the vulva and vagina with other body fluids.
Following the removal of the internal abdominal organs, the external and internal genitalia may be removed in continuity. It is essential that during the removal of the internal abdominal organs the pelvic organs are retained. This is best achieved using the modified Virchov dissection procedure which leaves the kidneys, aorta and pelvic contents in the body.
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To remove the internal and external female genitalia aligns the midline abdominal incision is extended at its inferior end down over the pubis on each side of the vulva. The incision can involve the most superior medial aspects of the proximal thighs and should be continued posteriorly so that the perineum and anus are included within the segment of skin to be excised. On completion of the skin insertion, the pubic symphysis may be opened by incising the cartilage. This allows for greater access to the floor of the pelvis through which the internal genitalia will be removed. From above, the uterus, rectum and bladder can be freed from their pelvic peritoneal attachments and passed through the floor of the pelvis beneath the inferior pubic rami. On removal of the dissection specimen it is possible to examine the vulva, vagina and uterus in detail and to identify the characteristics of any mucosal injury.The paediatric autopsy
Despite the difference in size, autopsies in the case of infants and young children are performed in a very similar manner. The same instruments are used in most instances.
However, smaller scissors and other surgical instruments may be required to dissect particular organs. It is important to obtain a set of scales capable of weighing organs of the relevant size to at least the nearest gram.
The external examination is performed in a similar manner to that of the adult. However, in the case of newborn infants it is important to document the presence of any congenital abnormalities. Body morphometry must be documented in detail as this may provide important information regarding the child’s development. The examination of the eyes, ears, nose and mouth must be carried out meticulously to check for features of congenital abnormality such as cleft palate or choanal atresia.
Opening of the body of an infant at autopsy is performed in a similar manner to the adult except that the lower portion of the abdominal incision is often extended on either side of the umbilicus to form an inverted “Y” shaped incision that extends down into both groins. This approach is usually restricted to autopsies on foetuses or small infants who have died in the
perinatal period. A variety of specialised autopsy techniques can be carried out in the infant particularly to assist in the detection of congenital anomalies. Removal of whole organs with post-removal fixation and examination allows for detailed dissection of these structures to be performed using an operating microscope. The collection of tissues and specimens for post-mortem microbiological analysis has particular relevance in the case of the infant autopsy as it is important to exclude infectious disease as a cause of the sudden and unexpected death.
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The sudden infant death syndrome (SIDS) is perhaps the most common cause of unexpected death in infants investigated by paediatric or forensic pathologists. Over the years this so-called “syndrome” has received considerable attention. The definition of SIDS has undergone considerable remodelling over the years but in essence it is still a “syndrome” based on exclusion, the key criteria of which is the absence of significant pathological features that might be expected to cause death. Perhaps the most critical point issue for forensic pathology is that this diagnosis can only be made when all significant natural disease has been excluded following a thorough post-mortem examination of the body.Despite this emphasis on the absence of significant pathology, there is a characteristic pattern to many of these deaths. The majority occur between the ages of two and five months and there is often a short medical history of a cold or a gastro-intestinal illness. Typically, the child is found dead in their cot in the morning. In the past, studies have shown that these deaths are more common in infants who have been bottle fed and whose mother smokes. While significant pathology is not identified at autopsy, a number of minor abnormalities may be detected being of a degree and type that would not be expected to ordinarily cause death.
In carrying out an autopsy in the case of a cot death, it is essential to rule out a homicide or a traumatic accident. Petechial haemorrhages may sometimes be seen at autopsy. However, these are not usually present to the degree that might be expected had the child been asphyxiated.
Careful examination of the whole body for signs of trauma of the type seen in a “child abuse”
or “battered baby syndrome” case must be made. Post-mortem radiology must be used to detect old or recent fractures. Features such as signs of neglect, bruises or burns of various ages and avulsion of hair must be considered as highly suspicious, particularly when these occur in infants who are too young to acquire these injuries themselves as a consequence of normal activity.