10.3 Resuscitative, Therapeutic & Surgical Artifacts

ABMDI Registry Certification Diplomate

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1 Chapter 1: Medicolegal Authority, Systems & Inter-Agency Coordination

1.1 Medical Examiner vs. Coroner Systems & Statutory Authority 1.2 Statutory Reportable Deaths & Mandatory Referrals 1.3 Inter-Agency Coordination & Jurisdictional Boundaries 1.4 Establishing the Decedent Profile & Essential Case Information 1.5 Funeral Homes, Removal Services & Ancillary Agency Coordination

2 Chapter 2: Communication, Death Notification & Documentation

2.1 Death Notification Protocols & Family Interaction 2.2 Witness Interviewing & Information Gathering 2.3 Written Reports, Public Records & Professional Communication 2.4 Preparing Families for Identification Viewing & Explaining Procedures 2.5 Facilitating Family Requests & Releasing Investigative Findings

3 Chapter 3: Scene Response, Security & Documentation

3.1 Initial Notification, Scene Assessment & Safety 3.2 Scene Photography & Systematic Visual Documentation 3.3 Scene Sketching, Mapping & Evidence Spatial Analysis 3.4 Professionalism, Dignity of the Deceased & Scene Conduct

4 Chapter 4: Postmortem Changes, Decomposition & Postmortem Interval (PMI)

4.1 Algor Mortis & Body Cooling Dynamics 4.2 Rigor Mortis, Livor Mortis & Cadaveric Spasm 4.3 Decomposition Stages & Environmental Taphonomy 4.4 Forensic Entomology & Environmental Markers

5 Chapter 5: Evidence Preservation, Toxicology & Chain of Custody

5.1 Trace Evidence, Personal Effects & Body Packaging 5.2 Postmortem Toxicology Principles & Specimen Collection 5.3 Overdose Investigations & Pharmacological Indicators

6 Chapter 6: Forensic Identification, Anthropology & NamUs

6.1 Scientific Identification Modalities 6.2 Secondary Identification & Medical Hardware 6.3 Unidentified Decedents, Forensic Anthropology & NamUs

7 Chapter 7: Trauma Typology & Forensic Pathology Principles

7.1 Sharp Force Trauma & Wound Characteristics 7.2 Blunt Force Trauma Typology 7.3 Gunshot Wounds & Range of Fire 7.4 Asphyxial Deaths & Environmental Trauma

8 Chapter 8: Cause, Manner & Pediatric Death Investigation

8.1 Cause, Mechanism, and Manner of Death Certification 8.2 Sudden Unexpected Infant Death Investigation (SUIDI) 8.3 Pediatric Non-Accidental Trauma & Fatal Neglect

9 Chapter 9: Special Investigations, Mass Fatalities & Legal/Ethical Responsibilities

9.1 In-Custody, Institutional & Occupational Deaths 9.2 Mass Fatality Incidents & Disaster Response 9.3 Legal Standards, Expert Testimony & Investigator Ethics 9.4 Investigator Health, Wellness & Occupational Stress

10 Chapter 10: Systematic Body Assessment, Documentation & Medical Artifacts

10.1 Anatomical Terminology & Systematic Body Mapping 10.2 Body Examination Photography & Morgue Intake Documentation 10.3 Resuscitative, Therapeutic & Surgical Artifacts

11 Chapter 11: Completing the Investigation - Follow-Up, Pathology Liaison & Case Closure

11.1 Case Follow-Up, Required Forms & Records Acquisition 11.2 Interacting with Forensic Pathologists & the Autopsy Process 11.3 Evidence Release, Property Return & Final Disposition of Remains

12 Chapter 12: Forensic Science Foundations & Medical Knowledge

12.1 Forensic Science Disciplines & Crime Laboratory Coordination 12.2 Medical Terminology & Clinical Record Interpretation 12.3 Natural Disease Processes & Sudden Unexpected Natural Death

10.3 Resuscitative, Therapeutic & Surgical Artifacts

Key Takeaways Explain This Topic AI

All medical devices, lines, tubes, pads, and catheters are left in place for the pathologist; removing them destroys the ability to evaluate placement and any associated injury.

Anterior and anterolateral rib fractures and sternal fractures are common consequences of adult chest compressions, and mechanical compression devices increase both frequency and severity.

In infants, rib fractures from cardiopulmonary resuscitation are uncommon, and posterior rib fractures near the costovertebral junction are highly suspicious for inflicted squeezing injury rather than resuscitation.

Surgical wounds are distinguished from traumatic wounds by clean linear margins, approximation with sutures or staples, drain sites, and residual antiseptic skin staining.

Every artifact must be reconciled against the emergency medical services run sheet, which documents which interventions were actually performed, by whom, and when.

Last updated: September 2026

10.3 Resuscitative, Therapeutic & Surgical Artifacts

The ABMDI task list names Resuscitative Artifacts and Surgical Artifacts as separate scored components of physical assessment, immediately before postmortem changes and injury recognition. The reason is that the single most consequential error in body assessment runs in both directions: calling a therapeutic injury an assault, or dismissing a genuine injury as "probably from CPR."

1. The Governing Rule

Leave everything in place. Endotracheal tubes, intraosseous needles, central and peripheral lines, chest tubes, urinary catheters, gastric tubes, defibrillator pads, cervical collars, splints, and tourniquets remain on the body through transport and into the examination. The pathologist must evaluate whether the tube is in the trachea or the esophagus, whether the central line entered the vessel or the pleural space, and whether a puncture site is therapeutic or traumatic. A device removed by a well-meaning responder or investigator destroys that determination permanently.

2. Cardiopulmonary Resuscitation Artifacts in Adults

Artifact Mechanism Investigative significance

Anterior and anterolateral rib fractures, commonly ribs 2 through 6 Manual or mechanical chest compression Frequently reported in resuscitated adults; mechanical compression devices increase frequency and severity

• Costochondral separations Compression at the cartilage junction Easily mistaken for blunt impact
• Sternal fracture Direct compression force Common with prolonged or mechanical compressions

Anterior chest contusions and abrasions; rectangular device imprints Compression device pad or piston contact Pattern corresponds to the device footprint

Epicardial and anterior mediastinal hemorrhage Compression against the sternum Must be distinguished from traumatic cardiac injury

Hepatic and splenic lacerations Compression, especially with low hand placement Uncommon but real; must be distinguished from blunt abdominal trauma

Gastric distension, aspiration of gastric contents Bag-valve-mask ventilation Aspiration may be a resuscitation artifact rather than an antemortem event

Lip, gingival, and dental trauma Laryngoscopy and intubation attempts Mistaken for assault to the face

Rectangular erythema or burns on the chest wall Defibrillation pads and delivered shocks Correlates with documented defibrillation attempts

Puncture sites at the proximal tibia or proximal humerus Intraosseous access Frequently mistaken for injection sites

Punctures at the subclavian, internal jugular, or femoral sites, sometimes with local hemorrhage Central venous access Associated hemorrhage is expected and is not an assault finding

Small linear incision in the lateral chest wall Thoracostomy (chest tube) Sharp, deliberate, and clean-margined

Midline anterior neck incision or puncture Cricothyrotomy or needle airway Recognize before calling it a sharp-force neck injury

Timing clue: injuries inflicted during resuscitation occur when circulation is absent or minimal, so they typically show little or no vital reaction — minimal soft tissue hemorrhage relative to the fracture. That contrast is the pathologist's finding, but the investigator's job is to document what interventions were performed so the pathologist can make it.

3. The Infant Exception That Examinations Test

Resuscitation in infants is not a general explanation for rib fractures.

Rib fractures attributable to cardiopulmonary resuscitation in infants are uncommon , and when they do occur they are typically anterior or anterolateral , corresponding to two-thumb or two-finger compression over the sternum.

Posterior rib fractures near the costovertebral junction are produced by anteroposterior compression of the chest — the mechanics of an adult grasping an infant's thorax and squeezing — and are highly suspicious for inflicted injury . They are not a recognized consequence of standard resuscitation.

Classic metaphyseal lesions of the long bones and fractures of differing ages are likewise not resuscitation artifacts.

Any infant death with rib fractures requires a full skeletal survey , a careful resuscitation history, and immediate escalation.

The examination framing is straightforward: "CPR was performed" explains anterior chest findings in an infant; it does not explain posterior rib fractures.

4. Indwelling Devices and What They Tell You

Devices are not only artifacts; they are history.

Endotracheal tube: note depth marking and apparent position; esophageal placement is a critical finding for the pathologist.

Intravenous lines and infusion labels: document what was hanging. Administered fluids dilute blood drug concentrations, and administered drugs appear in toxicology results.

Cardiac monitor strips and automated external defibrillator data: the initial rhythm is frequently the most useful single prehospital data point.

Implanted cardiac devices: pacemakers and implantable defibrillators store terminal rhythm data and delivered therapies, and must be removed before cremation.

Insulin pumps, continuous glucose monitors, and intrathecal pumps: record device settings and reservoir contents; a pump reservoir is a toxicology specimen.

Dialysis access, ports, feeding tubes, tracheostomies: each documents a chronic disease course relevant to natural-cause certification.

5. Surgical Artifacts Versus Trauma

• Feature Surgical wound Traumatic wound
• Margins Clean, linear, deliberate Irregular, abraded, or with tissue bridging depending on mechanism
• Closure Sutures, staples, adhesive strips, or surgical glue Absent unless clinically treated

Associated findings Drains, packing, antiseptic staining of surrounding skin, shaved surgical field Trace evidence, clothing defects, patterned abrasion

Location Anatomically conventional approaches (sternotomy, Pfannenstiel, McBurney, laparotomy midline) Distribution follows the event, not anatomy

Vital reaction Consistent with the documented operative date Consistent with the event

Residual antiseptic staining — the orange-brown discoloration of povidone-iodine or the tinted film of a chlorhexidine preparation — is an underused clue that a region was surgically prepared. Healed surgical scars additionally serve as secondary identification features and as a medical history record.

6. Postmortem Handling and Environmental Artifacts

Not every mark was made by a person treating or harming the decedent.

Skin slip and blister formation from early decomposition, easily read as thermal or chemical injury.

Transport abrasions from dragging, gurney straps, or body pouch zippers, typically on prominences and often postmortem in appearance.

Postmortem insect and animal activity , especially at the eyelids, nares, lips, and any wound margin.

Pressure blanching and pattern impressions from bedding, clothing seams, or objects beneath dependent skin, which mimic patterned injury but blanch with the livor distribution.

Embalming artifacts in previously prepared remains: trocar tracks, injection sites, and sutured incisions.

Refrigeration and freezing artifacts , including skin discoloration and ice crystal effects.

7. Reconciliation: The Investigator's Actual Deliverable

The pathologist does not need the investigator to classify each mark. The pathologist needs an accurate account of what was done to this body, by whom, and when . ARTIFACT RECONCILIATION CHECKLIST

• [ ] Obtain the EMS run sheet and, where available, the monitor/AED download
• [ ] Record: who performed compressions, manual or mechanical device, duration
• [ ] Record: number of defibrillation attempts and pad placement
• [ ] Record: airway attempts, number and difficulty, device used
• [ ] Record: all vascular access sites attempted, including unsuccessful ones
• [ ] Record: all drugs and fluids administered, with times and volumes
• [ ] Record: any hospital procedures before death (chest tube, thoracotomy, surgery)
• [ ] Record: who moved the body, how, and over what surfaces
• [ ] Photograph every device IN PLACE before anything is disturbed
• [ ] Note unsuccessful attempts explicitly - they leave marks and no one reports them

The last line matters more than it appears. Unsuccessful intravenous attempts, an aborted intubation, or an intraosseous needle placed and withdrawn all leave findings that no one documents unless the investigator asks the specific question: "What did you try that didn't work?"