AUTOPSY

Gleaned from…
REFINING THE BASIC
AUTOPSY TECHNIQUE

Maria Cecilia F. Lim, MD, FPSP

Associate Professor
UP College of Medicine
Topics for Discussion:
• Getting the consent
• Pre-Autopsy
• Basic autopsy technique and
variations
• Ancillary procedures
• Special techniques
• Documentation
• The autopsy report
• Retention periods and storage
Getting the Consent
Getting the Consent
Some do’s:
• Send the best person to get the
consent
• Appeal for the deceased
• Appeal for the next of kin
• Appeal for the general public
• Be sympathetic
• Do assure confidentiality of results
Getting the Consent
Some Don’ts:
• Do not be “graphic”.
• Do not lie.
FAQ
• How extensive should the explanation of the
autopsy be?
– The purpose and scope of the autopsy should be
disclosed.
– The person should be given the opportunity to
place limitations.
• Can we keep the organs?
– Explicit authorization necessary.
• Do we need a separate consent for incisions
outside the brain and chest incisions?
FAQ
• Is the autopsy really forbidden by
religion?

• … In lieu of an autopsy, these

procedures may alleviate the need to
perform a complete autopsy in the
presence of religious objections
In lieu of…
• In-depth investigation of the scene,
environment, terminal circumstances,
and social and medical history of the
deceased

• Careful exclusion of criminal act

suspicion

• External examination
In lieu of…
• Radiographs or other imaging studies

• Toxicology or other analysis performed

on blood, urine, gastric samples, or
cerebrospinal fluid obtained
percutaneously
In lieu of…
• Endoscopic examination

• In situ or minimal procedure

examinations
Consent
• Should contain
– Explanation of the autopsy
– Removal and retention of organs
– Disposition of remains
Who will give the consent?
• Consent from the deceased prior to
death*

• An “attorney-in-fact” appointed as a
result of the decedent’s execution of a
durable power of attorney for health
care and authorized to consent to an
autopsy
Who will give the consent?
• Spouse (not legally separated or
divorced unless he or she has custody
of eldest child who is a minor)

• Adult child age 18 or older

• Adult grandchild
Who will give the consent?
• Parent

• Adult sibling

• Grandparents

• Adult uncles and aunts

Who will give the consent?
• Other adult relative

• Friend accepting responsibility for

disposition of the body

• Public official acting within his or her

legal authority
Pre-Autopsy
 Special Procedures
• Photography
• Fingerprinting
• Collection of rape kit
• Collection of insect specimens
on decomposed remains.
• Collection of gunshot residue.
Special Procedures
• Radiographs performed on:
– GSW
– Decomposed bodies
– Fire deaths
– Suspect child abuse
The Autopsy
External Examination
• Age, height, weight, sex, race, hair
color, eye color, state of nutrition,
muscular devt, teeth, congenital or
acquired abnormalities/deformities
• Presence of scars, pigmented skin
lesions and tattoos
• Anthropophagic markings
Evidence of Previous Medical
Treatment/Embalming
• Resuscitative attempts may
masquerade as traumatic injuries
preceding medical care.
Evidence of Injury
• Described in detail:
– Size, shape, pattern
– Correlate with internal exam (course,
direction, depth)
– Location in relation to fixed anatomic
landmarks
• Collect your specimens and store at 4 deg
Celsius:
– Blood : peripheral and central
*Sodium fluoride for tox
*EDTA for DNA
– Urine
– Bile
– Vitreous fluid
– Stomach
4 Types of
Evisceration Techniques
En Masse (Le Tulle)

• Organs are removed as a single bulky

aggregate.
• Adv:
– Complete preservation of relationships among
organs
– Speed
– Organs removed and stored for later dissection
• Disadv:
– Difficult to handle; require assistant
En Bloc (Ghon/Zenker)

• Maintain all connections between

physiologically related organs:
– thoracic pluck, coeliac pluck, urogenital pluck
• Adv:
– Preserve impt anatomic relations without unwieldy
mass of organs
• Disadv:
– Multiple organ system involvement complicates
the procedure
– Skill necessary to remove each block from the
body intact
Virchow’s
• All organs examined systematically.
• Brain  spinal cord  abdominal
cavity  thoracic cavity  organs
individually removed and sectioned
outside the body.
• Adv: systematic approach and
simplicity for beginning prosectors
• Disadv: destruction of anatomic
relationships.
Rokitansky (in situ)
• Basic principle: Disturb the connections
between organs as little as possible.
• Dissection occurs in situ with little
actual evisceration.
• If abnormality is found, regions
removed intact  combination of en
bloc and in situ
Rokitansky (in situ)
• Adv:
– Practical for single examiner
– Capability of preserving abnormal
anatomic relationships
• Disadv:
– Expertise necessary to recognize
abnormalities
 Histologic Sampling
• All grossly abnormal tissues
• All major organs
– Brain: cerebral cortex
hippocampus
basal ganglia with caudate & putamen
cerebellum with cortex & dentate nucleus
brain stem
Ancillary Studies
Microbiologic Studies
• Sample should be obtained as soon
after opening the body as possible,
prior to extensive manipulation
especially the intestines.
• Cultures should be collected within 15
hours after death.
• Samples:
– Blood from right atrium or IVC or
subclavian
– Tissues: spleen
The isolate is more likely
significant if
• The postmortem interval from death to
autopsy is shorter
• The more ante/postmortem cultures
yield the same organism
• The fewer the other organisms isolated
• Organisms isolated from postmortem
blood correspond to organisms causing
infection in tissue sections
Toxicology
• Drugs, alcohol, toxins
– Best: urine (antemortem samples if
possible)
– Blood from peripheral source (gray top)
– Tissues: Liver, kidney, skeletal muscle,
brain (100 gm)
• Electrolytes, Urea, Creatinine, Glucose,
Ketones
– Vitreous
Toxicology
• Stable after death:
– Hb, Hct
– Cholesterol
– TSH
– Cortisol
– Insulin and C peptide
– Place blood in marbled red top (serum
separator) tube
Radiographic Studies
• Ecopsy – echography-guided biopsy
• Postmortem angiography -
documentation of vascular
malformations (aneurysms, “leak”)
Rapid PAD
• Frozen section
• Cytology and Core Needle Biopsy
– Rosai – “Posthumous analysis”
Of limited value
• Cytogenetics
• Molecular studies
• Flow cytometry
DOCUMENTATION
Forms of Documentation

• Note-taking
• Photos
• Video
• Audio
Note-Taking
• Body diagrams
Photography
• Always label (case number, ruler)
• Bracket your shots
• Be careful of lighting
• Take shots of all pertinent findings
Guidelines for Ensuring
Admissibility of Digital Images
• Develop a departmental policy or
standardized procedure on digital
imaging including image security and
chain of custody.
• Preserve the original.
• Do not replace or overwrite the
original file with a new file.
THE AUTOPSY REPORT
List of Standardized First-Level
Headings
• Autopsy face sheet
• Historical summary
• Examination type, date, time, place,
assistants, attendees
• Presentation, clothing, personal effects,
associated items
• Evidence of medical intervention
• Postmortem changes
List of Standardized First-Level
Headings
• Postmortem imaging studies
• Features of identification
• External examination
• Internal examination
• Summary of injuries
• Ancillary procedures, lab results
• Block listing and histologic description
List of Standardized First-Level
Headings
• Findings and diagnosis
• Summary and comments
• Cause-of-death statement
• Amendments
 Retention of Records & Materials
• Wet stock tissue 3 yrs
• Wet tissue of whole organs 3 mos
• Paraffin blocks 20 yrs
• Reports indefinitely
• Slides indefinitely
• Gross photographs indefinitely
 Retention of Records & Materials
• Accession log records indefinitely
• Serum/CSF/urine 2 yrs
• Whole blood 6 mos
• Dried blood stain or
frozen tissue for DNA indefinitely
• Frozen tissue for tox 6 mos
On embalming
• It is always preferable to perform an
autopsy before embalming.
– Altered injuries and findings
– No specimen for tox, microbiology,
cytogenetic, biochemical or molecular
genetics studies
• Only of benefit in infectious diseases
(ex: HIV)