Performing Autopsy Protocols

1. Autopsy type — Hospital (clinical) autopsy, forensic/medicolegal autopsy, or limited/restricted autopsy? Default: hospital complete autopsy.
2. Authorization — Signed consent from legal next of kin (hospital) or jurisdiction authority (medicolegal)? Default: not yet obtained; flag [VERIFY].
3. Restrictions — Any organ systems excluded by consent? Retain brain? Default: no restrictions.
4. Clinical history — Terminal admission summary, past medical history, cause-of-death questions from clinical team? Default: request from medical records.
5. Infectious precautions — Known or suspected bloodborne pathogens, tuberculosis, prion disease, highly infectious agents? Default: standard precautions.
6. Medicolegal status — Has the medical examiner/coroner been notified and declined jurisdiction? Default: yes, ME/coroner declined.
7. Special studies — Are cultures, toxicology, cytogenetics, electron microscopy, or research tissue collection anticipated? Default: routine histology and toxicology.

Documents to Request

• Autopsy consent/authorization form
• Complete medical records (admission notes, operative reports, discharge summary)
• Imaging reports (CT, MRI, angiography)
• Laboratory results from terminal admission
• Medication administration record
• Clinical team's specific questions about cause of death
• Prior surgical pathology reports
• Medical examiner/coroner notification documentation
• Chain-of-custody forms if medicolegal

Step 1: External Examination

Perform a systematic external examination and documentation:

1. Identification: Verify decedent identity with wristband and toe tag. Photograph face for identification.
2. General description: Age, sex, race, height (cm), weight (kg), nutritional status, body habitus.
3. Clothing and personal effects: Document and inventory (especially medicolegal cases).
4. External findings:
   • Skin: Lividity pattern and fixation (indicates position at death), rigor mortis stage
   • Scars: Surgical scars (document location, length, orientation), traumatic scars
   • Therapeutic devices: IV sites, surgical drains, endotracheal tube, pacemaker
   • Injuries: Contusions, lacerations, abrasions, gunshot wounds (measure, describe, photograph)
   • Decomposition changes: Stage (fresh, bloat, active decay), insect activity
5. Eyes: Corneal clarity, petechiae (scleral, conjunctival), pupil size.
6. Oral cavity: Dentition, airway obstruction, mucosal lesions.
7. Photograph all significant findings per institutional protocol.

Step 2: Internal Examination — Evisceration and Organ Dissection

Follow a standardized evisceration technique (Virchow, Rokitansky, Ghon, or en-bloc per institutional protocol):

Organ System Review

Step 3: Ancillary Studies

Order and collect specimens for ancillary testing as indicated:

• Histology: Submit sections from each major organ per CAP AUT.07700 (minimum sections: heart x4, lung x4, liver x2, kidney x2, spleen x1, pancreas x1, plus any lesional tissue).
• Microbiology: Blood cultures (percutaneous and cardiac), lung tissue, CSF, urine, other fluids as indicated. Collect before evisceration when possible.
• Toxicology: Femoral blood (peripheral, not cardiac to avoid postmortem redistribution), urine, vitreous humor, liver tissue, gastric contents.
• Cytogenetics/molecular: Fresh tissue for karyotype, FISH, or molecular studies if hematologic malignancy or genetic disease suspected.
• Electron microscopy: Fix tissue in glutaraldehyde for renal disease, myocardial disease, or storage diseases.
• Neuropathology: If brain retention is authorized, fix in 10% formalin for 2-3 weeks before dissection.
• Photography: Document all significant gross findings before and during sectioning.

Step 4: Cause and Manner of Death Determination

Apply the WHO International Classification of Diseases (ICD) format for cause-of-death certification:

Part I (chain of causation):

• 1a. Immediate cause of death (e.g., pulmonary thromboembolism)
• 1b. Due to, or as a consequence of (e.g., deep vein thrombosis)
• 1c. Due to, or as a consequence of (e.g., immobilization following hip fracture)
• 1d. Due to, or as a consequence of (e.g., fall)

Part II (contributing conditions):

• Other significant conditions contributing to death but not in the causal chain (e.g., diabetes mellitus, coronary artery disease)

Manner of death (medicolegal only): Natural, accident, suicide, homicide, undetermined, or pending investigation.

Classification of discrepancies (Goldman criteria for hospital autopsies):

• Class I: Missed major diagnosis that would have changed therapy and potentially outcome
• Class II: Missed major diagnosis that would not have changed therapy (terminal event)
• Class III: Missed minor diagnosis related to terminal disease
• Class IV: Missed minor diagnosis not related to terminal disease

Step 5: Report Assembly and Finalization

Construct the autopsy report per CAP AUT checklist requirements:

1. Clinical summary: Relevant history, terminal course, clinical diagnoses, and clinical questions.
2. External examination: Complete description with measurements.
3. Internal examination: Organ-by-organ findings with weights and measurements.
4. Microscopic description: Section-by-section findings.
5. Ancillary results: Toxicology, cultures, special stains, molecular studies.
6. Final anatomic diagnoses: Numbered list in order of significance, with cause of death as first diagnosis.
7. Clinicopathologic correlation: Narrative synthesizing findings with clinical history.
8. Cause of death statement: Formatted per WHO ICD death certificate standard.

Turnaround time: Per CAP AUT.08850, preliminary report within 2 working days; final report within 30-60 calendar days.

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the identity verification documented with at least two identifiers?
2. Are all organ weights recorded and compared to expected normal ranges?
3. Does the cause-of-death statement follow WHO ICD chain-of-causation format?
4. Are clinicopathologic discrepancies classified per Goldman criteria?
5. Are all ancillary study results integrated into the final report or noted as pending?

Quality Audit

• Autopsy authorization/consent documented before procedure
• Medical examiner/coroner notification documented for reportable deaths
• External examination complete with photographs of significant findings
• All major organs weighed and compared to reference ranges
• Coronary arteries cross-sectioned at 3mm intervals with degree of stenosis documented
• Minimum histology sections submitted per CAP AUT.07700
• Toxicology specimens collected from appropriate sites (femoral blood, not cardiac)
• Microbiology cultures collected before evisceration when possible
• Cause-of-death statement follows WHO ICD chain-of-causation format
• Goldman classification applied for clinical-pathologic discrepancies
• Preliminary report issued within 2 working days
• Final report completed within 30-60 calendar days
• Chain of custody maintained for medicolegal cases
• Infectious precautions documented and appropriate PPE used

Guidelines

• Always verify decedent identity with two identifiers before beginning the external examination
• Collect toxicology specimens from femoral blood (not cardiac blood) to avoid postmortem redistribution artifacts
• Cross-section all three coronary arteries at 3mm intervals and document the degree and location of stenosis for every autopsy
• Weigh all major organs and compare to published reference ranges adjusted for age, sex, and body habitus
• Follow WHO ICD format for cause-of-death certification; the chain of causation must be logically consistent (each line causes the one above it)
• For hospital autopsies, always classify clinical-pathologic discrepancies using the Goldman system and report findings to the clinical team for quality improvement
• Issue a preliminary anatomic diagnosis within 2 working days to serve immediate clinical and family needs
• Maintain strict chain-of-custody documentation for all medicolegal cases; photograph, label, and store retained specimens per NAME or institutional standards