Excited Delirium and Sudden Death

The entity, Excited Delirium Syndrome, has been the focus of much discussion over the past 10 to 15 years.  Typically, this entity is used as the cause of death of highly agitated persons who are in police custody, who are not uncommonly restrained and or incapacitated by electrical devices.  Following a complete autopsy, the forensic pathologist cannot  define a specific anatomic cause of death, but frequently identifies psychostimulant intoxication, such as methamphetamine and cocaine, often in the presence of alcohol, as a contributing factor underlying causation of death.

Due to these individuals presenting in such an agitated and bizarre manner, police officers are often called to the scene.  The usual course of events is after the police have witnessed their behavior, there is an effort to restrain the individual using various methods of force, such as maximal restraints, baton strikes, chemical “pepper” sprays or electrical devices. Not uncommonly, during or after the use of such methods of restraint, the individual suddenly experience a cardiac arrhythmia, which culminates in sudden cardiac death.

Pathophysiologic process which leads to sudden death in Excited Delirium Syndrome

Excited Delirium Syndrome-2018

Child Abuse and the Lack of Intellectual Integrity

William A. Cox, M.D., FCAP Forensic Pathologist/Neuropathologist

October 18, 2017


Child Abuse and the Lack of Intellectual IntegrityAt this point in my career I have practiced Forensic Pathology for 43 years and Neuropathology for 41 years. Some of the most contentious cases I have had to deal with are those involving the death of a child in which non-accidental injury, child abuse, is believed to be the under lying causation of death. The determination of the cause of death in a child requires the forensic pathologist performing the postmortem examination to have a thorough understanding of the investigatorial information surrounding the circumstances, which led to the child’s death, as well as their past and present medical records. It is also essential the forensic pathologist approaches the clinical history, medical records and the findings of a very thorough autopsy in an unbiased and objective manner, free from all prejudice, and exercising eminent fairness in evaluating all facts of the case. It is equally important the forensic pathologist consider all literature related to the issues deemed responsible for the child’s death and not just the child abuse literature. It is important in the evaluation of alleged cases of child abuse that there be consideration of the non-CAC (child abuse community) peer- reviewed literature that challenges, if not refutes many of the unproven CAC teachings. Consensus statements from the American Academy of Pediatrics and the Society for Pediatric Radiology in-of-themselves do not create or validate science. Continue reading Child Abuse and the Lack of Intellectual Integrity

Rifled Weapons: A Forensic Analysis

Forensic Analysis of Rifled WeaponsThis blog article is a synopsis of our latest Forensic Science Newsletter ‘Rifled Weapons.’ If you wish to receive the full article and additional forensic pathology newsletters, please sign up using the form at the bottom of this page.


Rifled weapons include handguns, pistols and revolvers, and rifles.  These are weapons in which spiral grooves have been cut into the length of the interior or bore of the barrel (Fig. 1).  Rifling consist of ‘lands’ and ‘grooves’ (Fig. 2).  The ‘lands’ grip the bullet as it passes down the barrel, giving the bullet a rotation, which has a gyroscopic effect that increases the stability of the bullet’s trajectory and thus its accuracy (Fig. 3).  In contradistinction to rifled weapons, shotguns are smooth bored.  This is because rifling in a shotgun barrel would cause the shot to disperse to quickly in a 360 degree arc.

Continue reading Rifled Weapons: A Forensic Analysis

Effects of Alcohol on Traumatic Brain Injuries and Second Impact Syndrome

Traumatic brain injury scanINTRODUCTION

When a Forensic Pathologist and/or Neuropathologist evaluates a brain that has been subjected to traumatic brain injury (TBI), they tend to focus on the anatomic injuries, i.e., fractures of the calvarium or base of the skull; presents of epidural, subdural or subarachnoid hemorrhage; acute contusions, whether they be coup, contracoup or gliding; the presence of intraparenchymal hemorrhage; the presence of edema; and evidence of herniation to name a few of the anatomic injuries.

Continue reading Effects of Alcohol on Traumatic Brain Injuries and Second Impact Syndrome

Postmortem Hemorrhage: Examination by a Forensic Pathologist

Forensic Science Newsletter: February 2017

A recent case I was asked to review involved a victim who had been shot multiple times.  In the first two trials the jury was unable to reach a verdict whether the shooting of the victim was self defense or murder.  The prosecution decided to try the shooter a third time.  As a forensic pathologist, I was subsequently asked to review some of the trial testimony, police reports, autopsy reports and the scene and autopsy photographs.

In the autopsy, the Forensic Pathologist states there was 750 cc of blood in the right pleural cavity; 450 cc in the left pleural cavity; 30 cc in the pericardial sac; and 100 cc in the abdominal cavity.  At the time of the trials, the Prosecutor inquired of the Forensic Pathologist, the significance of the blood in the respective cavities and the pericardial sac.  Continue reading Postmortem Hemorrhage: Examination by a Forensic Pathologist

Injuries to the Vertebral Column and Spinal Cord: A Summary

Spinal Cord Injury: Forensic NeuropathologyThis article is a brief summary of the 19 page article entitled “Traumatic Spinal Cord Injuries,” published as a Forensic Science Newsletter on January 15, 2017.

General Information

The earliest known reference to traumatic lesions of the spinal cord are found in the Edwin Smith Surgical Papyrus.  During World War I, Riddoch, and later Head and Riddoch, gave what are now considered the classic descriptions of spinal transection in humans.  World War II marked the turning point in the understanding and management of spinal injuries. Continue reading Injuries to the Vertebral Column and Spinal Cord: A Summary

Traumatic Spinal Cord Injuries

Spine Injury Forensic X-RayForensic Science Newsletter: January 2017


In this Forensic Science Newsletter we will discuss traumatic spinal cord injuries.

Traumatic lesions of the spinal cord usually result from injuries which cause vertebral fractures.  The spinal cord may, however, be injured by vertebral dislocation without fracture or by penetrating wounds of the canal.

The common sites of injury are at levels of the upper cervical, the mid cervical, the lower cervical, the lower thoracic, and the upper lumbar vertebrae.  In approximately three-fourths of the cases of fracture of the cervical vertebrae, the spinal cord is injured.  Slightly more than half of the fractures of the thoracic spine and only about one-fourth of the fractures of the lumbar spine were associated with spinal cord injury.

Continue reading Traumatic Spinal Cord Injuries

Subconcussive Head Trauma


In this Forensic Science Newsletter we will discuss subconcussive head trauma, its definition, general information, clinical presentation, pathophysiology and biomarkers.


Subconcussive head trauma is head trauma that does not result in recognized concussion symptoms or signs.  It is due to blows to the head, which are below the threshold to cause or elicit any symptoms or sign of a concussion.

Read the full newsletter to learn more about Subconcussive Head Trauma.

Second Impact Syndrome: A Medical Catastrophe that need not occur

In our most recent Newsletter, “Second Impact Syndrome,” is discussed at length. You can also sign up here to receive our Forensic Science Newsletter by email.

Definition of Second Impact Syndrome (SIS)

Occurs when an athlete who has sustained a mild traumatic brain injury, usually a concussion, with or without loss of consciousness, suffers a second traumatic brain injury before the symptoms associated with the first have cleared. Such patients are at risk for developing intense cerebral vascular congestion followed by diffuse brain swelling, which typically occurs immediately after the second impact to the head or to the trunk, the latter imparting acceleration to the brain.

Concussion is defined as a trauma-induced alteration in mental status, usually characterized by confusion and amnesia that may or may not involve loss of consciousness, link “Mild Traumatic Brain Injury (Concussion) in Infants, Toddlers, Children and Adolescents.” Continue reading Second Impact Syndrome: A Medical Catastrophe that need not occur

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