What are the steps to perform a post mortem examination on a road traffic accident victim?

Postmortem Examination of Road Traffic Accident Victims: Systematic Protocol

Perform postmortem computed tomography (PMCT) prior to conventional autopsy in all road traffic accident victims to precisely localize injuries, detect skeletal fractures and pneumothorax, and guide subsequent dissection technique. 1, 2, 3

Pre-Autopsy Imaging

PMCT Acquisition

• Obtain whole-body PMCT before any manipulation or opening of body cavities, as this significantly increases detection of bone fractures, skull injuries, spine fractures, clavicle/scapula fractures, and abnormal gas accumulations (pneumothorax) that may be missed on conventional autopsy alone 2, 3, 4
• PMCT is superior to standard autopsy for detecting skeletal injuries, cervical spine dislocations (including whiplash injuries), and air collections, providing objective documentation of injury patterns critical for accident reconstruction 3, 4, 5
• Consider PMCTA (CT angiography) by cardiac puncture if vascular injury such as aortic rupture is suspected based on mechanism or initial PMCT findings, as this can definitively diagnose traumatic vascular injuries when autopsy is refused or limited 6

Radiologist Consultation

• Have a radiologist evaluate PMCT images in addition to the forensic pathologist, as radiologists detect more skeletal injuries while pathologists identify more organ injuries; combined interpretation yields optimal results 4

External Examination and Sample Collection

Initial Documentation

• Photograph all external injuries, abrasions, contusions, and lacerations before any manipulation 7
• Document clothing, personal effects, and position of body as received 7

Critical Sample Collection Before Autopsy

• Collect blood in EDTA tubes (purple top) for DNA preservation at every autopsy before opening body cavities, as these samples are irreplaceable and may be needed for future genetic testing if underlying cardiac disease contributed to rapid decompensation or death 7, 1
• Obtain peripheral blood from the subclavian vein (preferred over jugular or femoral veins) for toxicology screening after disinfecting puncture sites with alcohol-based chlorhexidine or iodine solution 7
• Collect cardiac blood only if peripheral blood is unavailable 7
• Perform comprehensive toxicology screening on blood and body fluids in all cases, as substance use (alcohol, illicit drugs) frequently contributes to traffic accidents and may be legally relevant 7, 1
• Consider dried blood spots and buccal swabs as additional DNA sources for ease of storage and shipping 7

Internal Examination Protocol

Opening and Organ Sampling

• Disinfect skin before incisions to minimize contamination 7
• Open body cavities systematically, examining organs in situ before removal 7
• Use separate sterile instruments (scalpel and forceps) for each organ sample to prevent cross-contamination 7

Cardiac Examination (Critical in Young Victims)

• Perform standardized cardiac-specific examination even when traumatic injuries are obviously fatal, as underlying inherited cardiac disease may have made the victim more vulnerable to decompensation or may be legally relevant for family counseling 1
• Obtain standard histological examination with mapped, labeled blocks from representative transverse slices of both ventricles 1
• If victim is ≤40 years old, specifically evaluate for inherited cardiomyopathy, channelopathies, or structural cardiac abnormalities that may have contributed to the accident (e.g., syncope while driving) or rapid death after trauma 1, 8

Skeletal and Soft Tissue Examination

• Systematically examine all bones, correlating autopsy findings with PMCT results to ensure no fractures are missed 2, 3, 4
• Document skull fractures, spine injuries (particularly cervical spine for whiplash), rib fractures, and long bone fractures 2, 3, 5
• Examine solid organs (liver, spleen, kidneys) for lacerations and hemorrhage, as autopsy is superior to unenhanced PMCT for detecting organ injuries 3, 4

Vascular Examination

• Carefully examine the aorta for rupture, as this is better detected by autopsy or PMCTA than by unenhanced PMCT alone 4, 6
• If aortic rupture is suspected but not clearly visible, consider PMCTA findings if obtained 6

Microbiological Sampling (When Infection Suspected)

Timing and Technique

• Collect microbiological samples before heavy manipulation or opening cavities if infection is suspected as contributing to the accident (e.g., sudden collapse while driving) 7
• Disinfect puncture sites and sear external surfaces of organs before sampling 7
• Send samples to laboratory within 2 hours at room temperature or within 48 hours if refrigerated 7

Tissue Preservation for Future Testing

DNA and Metabolite Banking

• Preserve fresh frozen tissue from multiple organs (heart, liver, spleen) for potential future genetic or metabolic testing, as formalin-fixed tissue has lower success rates for genetic analysis 7
• Store specimens with documentation of collection date, time after death, and storage conditions 7
• Consider cerebrospinal fluid, bile, and skin tissue as sources of metabolites for metabolic diagnoses 7

Special Considerations for Young Victims

Genetic Testing Indications

• Consider postmortem genetic testing if the victim is ≤40 years old and autopsy reveals cardiomyopathy, absence of structural disease suggesting channelopathy, or minor cardiac abnormalities of uncertain significance 1
• Obtain informed consent from next of kin and first-degree relatives for genetic testing, as results may have implications for family members 7
• Refer first-degree relatives for cardiac evaluation with genetic counseling if inherited cardiac disease is identified 1, 8

Safety Measures

Personal Protection

• Use N-95 respirators, gowns, aprons, and face shields during autopsy 7
• Ensure adequate ventilation in autopsy room 7
• Follow protocols for blood-borne pathogen exposure and maintain hepatitis B immunization 7

Common Pitfalls to Avoid

• Do not skip PMCT imaging, as it significantly increases detection of skeletal injuries and pneumothorax that are critical for accident reconstruction and may be missed on autopsy alone 2, 3, 4
• Do not omit cardiac examination even when traumatic cause of death is obvious, as underlying cardiac disease may be legally relevant and important for family counseling 1
• Do not fail to collect and preserve DNA samples before autopsy, as these specimens are irreplaceable and may be essential for future genetic testing 7, 1
• Do not rely solely on autopsy for skeletal injury detection, as PMCT detects significantly more bone fractures, particularly in skull, spine, and extremities 2, 3, 4
• Do not neglect toxicology screening, as substance use is a frequent contributing factor in traffic accidents 7, 1