512854 9599 ‘Travis Medical Examiner 14:36:08 07-15-2 r) | @ E16 Robert G. Williams, D.D.S., PA Diplomate of the American Board of Forensic Odontology 1661 Preston Rd. #104 Dallas, Texas 75230 214-361-4151 July 5, 2016 Dr. Keith Pinckard Chief Medical Examiner Travis County Medical Examiner 1213 Sabine Street ‘Austin, Texas 78701 Re: Review of Dental Records of Travis County Case #ME16-01377 also known as Daisy Torres De. Pinckard: [AS per your request, have reviewed all ofthe material that you provided me for the review of the ant mortem records of Daisy Torres, DOB 01/16/15 and the post mortem records documented in your o ‘on case #ME16-01377, Materials Analyzed Ante Mortem Records Ante Mortem Dental Records furnished by you including: Two occlusal radiographs Taken on 03/29/16 Treatment Notes of Daisy Torres Dated from 7/21/2015 to0 3/29/2016 furnished by Gala Steele From Austin’s Children’s Dentistry Post Mortem Records: 31 Demal Radiographs 3 Dental Photographs Analysis Ante mortem records revealed two ocelusal radiographs taken on 3/29/2016 showing 8 partially erupt teeth, 4 upper. 4 lower anterior primary teeth. These teeth appear to be free of any dental disease and ental restorations. The postmortem radiographs and photographs show teeth #'s D.E,F,and G as havi had pulpotomies performed. These teeth also had been prepared to have Stainless Steel Crowns place subsequent to the completion of the dental pulpotomies. Opin ‘One can only speculate as to why any treatment was performed considering no indication of dental di or pathology was seen in the dental radiographs dated 03/29/16. Written records indicate that no dec: seen on the dental visit dated 07/21/2015, I is possible that the partially erupted teeth may have had congenital enamel defects but not necessarily requiring treatment with a child of this age No evidence that the child was in any type of pain was ever notated in the dental record and no pulp test was ever performed -01377 d e sy was tality512854 9599 Travis Medical Examiner 14:36:16 07-15-2016 38 . ® @® ME16-01377 Should any additional treatment become available, | will be happy to consider it als. Respectfully Submitted, by ine Robert G. Williams, D.DS,, D-ABFO Diplomate of the American Board of Forensic Odontology Fellow of the American Academy of Forensic Sciences Chief Forensic Odontologist, Center for Human Identification, Department of Forensic Anthropology, University of North Texas Forensic Odontologist, Travis County Medical Examiner Chief Forensic Odontologist. Southwestern Institute of Forensic Sciences Chief Forensic Odontologist, Webb County Medical Examiner128549964 Travis come 05:0227pm. 07-14-2016 20 c TRAVIS COUNTY OFFICE o ree na OF THE MEDICAL EXAMINER cer uEnCAN ne 1213 Satine Stesst PO Bo 74S Astin TN 7877 Fel (S1208541509 Fas, (S12) SSIS ‘wos eatiscountyes go medical evamuner MEDICAL EXAMINER REPORT | DAISY LYNN TORRES ME 16-01377 | ‘A postmortem examination was performed by J. Keith Pinckard, MD, PhD, Chief Medical Examiner, beginning at 0630 hours on March 30, 2016 at the Travis County Medical Examiner's Office, Austin, Texas. Other persons present: None. DECLARATION The death of DAISY LYNN TORRES was investigated by the Travis County Medical Examiner's Office under the statutory authority of the Travis County Medical Examiner. 1, J. Keith Pinckard MD, PhD, a board certified anatomic, clinical, and forensic pathologist licensed to practice medicine in the State of Texas, do declare that I personally poten fe supervised the tasks described in this Medical Examiner Report. It is only after carefil consideration of all the data available to me at the time this report was finalized that I attast the diagnoses and opinions stated herein, Numerous photographs were obtained along the course of the examination. I have personally reviewed those photographs and attest that they ae representative of findings reported inthis document. | Should you have questions after review of this material, please feel free to contact me at the ‘Travis County Medical Examiner's Office.512854 9964 Travis Co ME ‘TORRES, Daisy Lynn ‘ME 16-01377 05:02:38 pm 07-144 016 310s12854 996 Trav co ME 05:03:16 pm an0 TORRES, Daisy Lynn ME 16-01377 | Page 3 of 22 SUMMARY AND OPINION | | According to reports, this 14-month-old female with a reported history of dental caries (cavities) extending to the pulp chambers was to undergo a dental procedure under anesthesia. St intubated nasally and given diprivan (propofol), sevoflurane, and nitrous oxide, e procedure was begun. Approximately 40 minutes into the procedure, she was observed td have bradycardia (low heart rate), hypotension (low blood pressure), a'drop in end tidal dioxide, and an abnormal breathing pattem. Resuscitation attempts were begun and emergency medical services arrived approximately ten minutes later, at which point she had no palpable pulse and agonal irregular respirations. She was transported to the hospital where me died approximately five hours after the start of the dental procedure, Extemal examination demonstrated no evidence of injury. Four teeth exhibited signs of ea work (ie., drilling and/or pulpotomy) but no evidence of dental or oral pathology was grossly. A consultation from a forensic odontologist indicated no evidence of dental disease ( separate report). There were no anatomic findings in the oral cavity, such as abscesses, f example, that may have caused an infection. There were no injuries or any other associa findings to suggest that the dental procedure itself contributed to or caused the death, Internal examination demonstrated no gross evidence of natural disease or injury. me endotracheal tube was in the appropriate location; therefore, it is not likely that the cause af death was due to problems with the intubation or with maintaining ventilation through the tube. Microscopic examination of the internal organs did not reveal any evidence of disease that coul have caused or contributed to death, | Toxicology testing on blood taken at the hospital and of postmortem blood event Presence of nitrous oxide, sevoflurane, and propofol, at concentrations that are not elevat compared to those seen in patients undergoing anesthesia (see separate report). In other word the possibility of an “overdose” on the anesthetic agents is not likely. Testing of vitreous flui {fluid taken from the eye) demonstrated no abnormalities of electrolytes or glucose other than mildly elevated sodium concentration (see separate report). ] Given the absence of natural disease or injury to explain the death in this healthy child, it is mos likely that the cause of death is related to the anesthesia. A number of possibilities for the deat being anesthesia-related are considered below. Inhaled anesthetics such as sevoflurane have been shown to produce carbon ae anesthetic circuits in which the carbon dioxide absorbent has become desiccated, Jor monoxide is toxic and can cause death. Toxicology testing on both antemortem and postmortem blood samples did not show the presence of a significant carbon monoxide saturation; therefore this possibility is excluded.512856 9964 Travis co ME 05:03:33 pm. 07-14-7016 530 TORRES, Daisy Lynn : ME 16.01377 Page 4 of 22 Malignant hyperthermia is a rare disorder of skeletal muscle that can oceur when genetically susceplible individuals receive certain anesthetic agents. Features of that disorder include high body temperature and muscle damage. The clinical history in this patient is not consistent ih this disorder. At no time throughout the clinical course was the patient's body tempdrature clovated, and microscopic examination showed no pathologic abnormalities associated with this disorder (most notably in the skeletal muscle and kidneys). The possibility of anaphylaxis (allergy) in response to one of the anesthetics given we considered. Anaphylaxis occurs when a sensitized individual is exposed to the offendis allergen. An inappropriate immune response causes an inflammatory reaction that can lau rash, swelling of the face, tongue, larynx, and epiglottis, and hypotension, which can lead shock and death. Anaphylaxis in this ease is not likely for several reasons. Tryptase can be us as an indicator of anaphylaxis. The tryptase concentration was elevated as measured by 1 Gifferent laboratories (see separate reports); however, one laboratory differentiates total an mature trypiase. This laboratory measured the mature tryptase at <1 ng/ml and the total trypta at 25 ng/mL. Its the mature tryptase that is the primary species involved with anaphylaxis, the concentration of mature tryptase was very low in this case. Furthermore, the ratio of tatal mature tryptase is generally <10 in cases of anaphylaxis, whereas in this case the ratid. w approximately 25. It was the total tryptase that was elevated in this case, which represen increased mast cell burden more than mast cell activation (the key event in anaphylbni Furthermore, the clinical picture of anaphylaxis is generally hypotension and tachycardia (rapi heart rate), but the decedent exhibited hypotension and bradycardia (slowed heart rate), which not consistent with anaphylactic shock, Finally, there were none of the pathologic correlates of anaphylaxis identified at autopsy; namely, there was no rash or swelling of the face, tongu larynx, or epiglottis. There were also no microscopic changes suggestive of anaphylaxis, such ‘edema or mast-cell rich inflammation in the trachea. | es Reise Another possibility is the oculocardiac reflex, which is a reflex of the trigeminal and vagal nerves that can cause severe bradycardia or asystole (cardiac arrest) when the trigeminal nerve which runs within the subcutaneous tissues of the face, is stimulated. Indeed, the inciden this reflex has been demonstrated to be increased in pediatric strabismus surgery (surgery on ‘muscles of the eyes) when propofol has been given as an anesthetic. This reflex has be reported to be severe enough to cause death. Although speculative, it is conceivable that thi reflex may have occurred upon manipulation of the face during the dental procedure on thi Patient receiving propofol. Of course, there is no way to ascertain whether this occurred, as there ‘would be no anatomic correlate, However, it remains a possibility. Perhaps the most likely possibility for the cause of death in this case is a severe manifestation o the known physiologic responses to the anesthetics given. Propofol is well-known to cus. Severe, even fatal bradycardia. It also causes hypotension and decreased respiratory drive 01 apnea, which were all observed in this ease. Sevoflurane also causes respiratory depression Thus, the clinical picture observed in this case is exactly what has been described for|th Physiologic responses to propofol (and to some extent, sevoflurane). It may be that in this cas those responses were of a sufficient magnitude to cause death, not from an overdose, but rather {from a severe idiosyncratic reaction to the known effects of the anesthetics given. |512854 9964 Travsco me esonsepm. o7-14-por6 TORRES, Daisy Lymn : | ME 16-0137 Page 5 of 22 ‘The manner of death for intraoperative deaths is generally classified as natural if the de to.a known and recognized complication of an appropriate treatment for natural disease, Clini¢al diagnosis of natural disease, to include dental disease, is a matter of both objective data and subjective professional expert opinion, and in this case there are differing expert opini ‘between the dentist who treated the patient and the consulting forensic odontologist as to © ‘or not the disease process for which the dental procedure was being performed was - Iy ditional Present; therefore, the manner of death is classified as undetermined. Should ad ti information or evidence become available, the cause and/or manner of death may be amended. 613012854 964 Travis COME TORRES, Daisy Lynn ME 16-01377 Page 6 of 22, Body length (Inches, cm): Body weight (pounds, kg): Development: Stature: ‘Age: Anasarea: Edema localized: Dehydration: Stan: ‘Sealp hair color: Scalp hair length: Eyes: Iria Byes cornea: Byes sclera: Eyes conjunctiva: Facial hair: Facial haircolor: Maxillary dentition: Mandibular dentition: Condition of dentition: Neck: ‘Trachea midline: Chest development: 05:06:00pm, 07-1444 33s 26 18 Well-developed ‘Well-nourished ‘Appears to be stated age No No No Normal Blonde Short Bh yes preset Blue Testocent White Traslacent No Normally formed ‘Nomatly formed Norway formed Nove Does not apply ‘Natural; evidence of drilling/pulpotomy in four incisors Natural Good; no gros evidence of dental disease Unresarable Yes ‘Noxmal 16 770S12 asa ooe ‘Traveco ME 05:08:10 pm, 07-14-4016 a0 TORRES, Daisy Lynn ( ME 16-01377 Page 7 of 22 Chest symmetrical: Yer | Chest diameter: Appropriate Abdomen: Fa ‘Anus: Unvemarkable | Back: Unremarkable Spine: Normal Eaternal gentaia: Female Breast development: None Breast masses: Nove Right hand digits complete: Yes | Left hand digits complete: Yes Right (oot digits complete: Yes Left foot digits complete: Yes Extremities: Welldeveloped and symmetical ‘Muscle group atrophy: No Senile purpura: No iting edema: No Tattoos: None | Cosmet perc Enrlobes Sears: Nonesiz esd ooe Travis COME ‘TORRES, Daisy Lynn ME 16-01377 Page 8 of 22 Body temperature: Rigor mortis: [Livor mortis— color: Livor martis— fixation: Liver mortis — positio ‘State of preservation: Funerary Preparation(s): Organ/tisoue procurement: (Cool subsequent to refiigeration Fully fixed Purple Fully fixed Posterior [No decomposition None 05:04:16 pm. 07-14-3016 9150s128s4 9964 Travis co ME 05:08:28pm. 07-14-2016 10130 TORRES, Daisy Lynn \ ME 16-01377 Page 9 of 22 Evidence af medical intervention: 1. Orogastric ube 2. Endotracheal tube (uncuffed) in left naris, extending to distal trachea 3. Intravascular catheter in lft inguinal region 4. Needle punctures in right inguinal region and back: band Injuries related to resuscitative attempts: None512954 9964 Tras Co ME 05:0432pm. 07-14-2016, 11730 TORRES, DaisyLynn ( ME 16-01377 Page 10 of 22512854 9964 Travis CoE 05:04:38 pm. o7-14-pm16 TORRES, Daisy Lynn t ME 16-01377 Page 11 of 22 Gag Lae ‘Chest eavities examined: Yes ‘Abdominal cavity examin Yes See Evidence of Injury section: No | Organs in normal anatomic position: Yes Diaphragm: Intact Serosal surfaces: Smooth and glistening Body cavity adhesions: No Fluid accumulation present: Bilateral pleural effusions; approximately 100 ce serous fluid | bilaterally | Brain examined: Yes ‘See Evidence of Injury section: No ‘See Evidence of Medical Interventia No ‘See Postmortem Changes setion: No [Brain weight fresh (g): 1000 Facial skeleton: [No palpate fractures Calvarium: No fractures Skull base: ‘No fractures Dara mater: ‘Unremarkable and without masses Dural venous sinuses: Patent Leptomeninges: Thin and transparent ‘Epidural hemorrhages/hematomas: Absent ‘Subdural hemorrhageshematoma Absent Subarachnoid hemorrhages: Absent Cerebral hemispheres: Symmetrical Gyral and suleat patterns: Uaremarkable Gyral convotutions and sulci: ‘Mild widening or atening of gyri and no narrowing of sulci Uncal processes: ‘Unremarkable ‘Cerebellar tonsils: ‘Unremarkable | ee Ee 12790512654 9964 ‘Trawscome TORRES, Daisy Lynn ME 16-01377 Page 12 of 22 Cranial nerves: Basilar arterial vasculature: Cerebral cortex: White matter: Corpus Callosum: Deep gray matter structures: ‘Brainstem: Cerebellum: Other comments: Spinal cord examined: Spinal dura: Spinal cord: Other comments: He [Neck examined: ‘See Evidence of Injury section: ‘See Evidence of Medical Intervention: ‘See Postmortem Changes Section: Subeutaneous soft tissues: Strap muscles: Sugular veins: Carotid arteries: Tongue: Epiglotus: Hyoid bone: 0500451 pm. 7-1 016 Uaremarkable ‘Unromarkable Unremarkable Unremarkable ‘Unremarkable ‘Unremarkable Uoremarkable ‘Unremarkable \Unremarkable ‘Unremarkable Unremarkable (Unremarksble Unremarksble Unvemarkable Unremarlable 13/30512.654 9964 Travis come TORRES, Daisy Lynn ME 16-01377 Page 13 of 22 Larynx: Palatine tonsils: Other comments: Heart examined: See Evidence of Injury section: See Evidence of Medical Intervention: ‘See Postmortem Changes Section: Heart weight fresh (g): Right coronary ostlum position: Left coronary ostium position: Supply of the pasterior myocardium: Cardiae chamber ‘Tricuspid valve: Pulmonte valve: ‘Mitral valve: Aortic valve: Right ventricular myocardium: ‘Left ventricular myocardium: Atrial septum: ‘Ventricular septum: [Right ventricular free wall thickness (em): Left ventricular free wall thickness (em): Interventricular septal thickness (em): Other comments: Aorta examined: Orifices of the major vascular branches: 05:05:01 pm. 07-14-2016 ‘Unremarkable Not examined RICA aE 525 ‘Normal ‘Normal Right coronary artery ‘Varemarkable ‘Unremarkable Unremarkable ‘Uncemarkable ‘Uaremarkable ‘No fibrosis, erythema, pathologic infiltration of adipose tissue op reas of accentuated softening or induration ‘No fibrosis, erythema, or areas of accentuated softening or indut (Unremarkable nremarkable 02 os os Yes Patent 1a)30512054 9964 Traviecome TORRES, Daisy Lynn ME 16-0137 Page 14 of 22 ‘Aneurysm formation: Complex atherascler ‘Other aortic pathology: Other comments: Great vessels examined: Vena cava and major tributari ‘Lungs examined: See Evidence of Injury section: See Evidence of Medical Intervention: ‘See Postmortem Changes Section: & Right lung welght (g): Left tong weight (2): Upper and lower alrveays: 05:05:12 pm. Veni cava i 909 Unobsuced andthe macosa suries are soot and yellow Pulmonary parenchyma calor: Dark red-purple Palmonary congestion and edema: ‘Moderate amounts of blood and frothy uid Pulmonary trunk: Free of saddle embolus Pulmonary artery thrombi: Nove Pulmonary artery atherosclerosis: None Other comments: Liver examined: Yes See Evidence of Injury section: No See Evidence af Medical Intervention: No ‘Sce Postmortem Changes Section: No o71a-3016512858 9964 Travis Come os0523pm —o7-1-4or8 16/30 TORRES, Daisy Lynn ( ( ME 16-01377 Page 15 of 22 Liver weight (g): 300 Bile volume (ml 2 Hepatic parenchyma (color): Red-bown Hepatic parenchyma texture): Unvemarkable Hepatic vasculature: ‘Unremarkble and fice of thrombus Gaubbindder: Unveourkable Gallstones: No Tntrahepati biliary tree: Voremarkable Extrahepatic billary te Unremackable Other comment ‘Alimentary tract examined: Yes See Evidence of Injury sect No | See Evidence of Medical Intervention: No See Postmortem Changes Section: No Stomach contents volume (ml ° Stomach contents description: ‘Not applicable ‘Appendix: Yes ‘Esophagus | Course: Normal course without fistulae | Mucos Gray-white, smooth and without lesions | Other comments: | Stomach Mucosa: ‘Usual rug! folds | Pylorus: Patent and without emscular hypertrophy Other comments: z Se ‘Siu intestine Partially digested food512954 9964 Travsco me TORRES, Daisy Lynn, ME 16-01377 Page 16 of 22 Mucosa: Caliber and continuity: Other comments: Luminal contents: Mucosa: Caliber and continuity: Other comments: Genitourinary system examin« See Evidence of Injury section: ‘See Evidence of Medical Intervention: ‘See Postmortem Changes Section: Right kidney weight (g): Left kidney weight Kidney eapsules: Cortical surfaces: Cortices: Calyces, pelves, and ureters: Other comments: Urine volume (eal): 05:05:34 pm. 07-14-2016 Duodenal mucosa unremarkable; emai examined | Appropriate caliber without interruption of luminal continuity 1g bowel mucosa not Colon Formed stool Rectal mucosa unremarkable; remaining colonic mucosa not examined Appropriate caliber without interruption of luminal continuity Pancreas ‘Noa! uous ppeamnce ‘cenrrounivany sree Yes No No | No 303, 31 Thin, semitransparent Smooth "Normal thickness and well-dlineated from the medullary pyramids ‘Non-ilated and fee of stones and masses 179012050964 Travis CoME TORRES, Daisy Lynn ME 16-0137 Page 17 of 22 Urine description: ‘Not applicable Urinary bladder mucoss Gray-tan and smooth Other comments: Fensale Breast tissue: ‘Not applicable Uterus: ‘Unremarkable Uterine cervix: ‘Unremarkable Fallopian tubes: ‘Unremarkable Ovaries: ‘Unremarkable Vagina: Unremarkable Other comments: Ea ogc. °SRETICULOENDOTHELIAL SYSTEM, Reticuloendothelial system examined: Yes See Evidence of Injury section: No ‘See Evidence of Medical Intervention: No ‘See Postmortem Changes Section: No Spleen Spleen weight (g): 38.2 Spleen parenchyma: ‘Moderately firm Spleen eapsule: Intact Spleen white pulp: Prominent Other comments: Bowié Marrow Color: ‘Other comments: Regional adenopathy: Red-brown, homogencous and ample ‘Lymph nodes, No adenopathy 05:05:44 pm. o7-14-}016 19/20srzeseoose Travis coe Os05Sipm. ort dr6 TORRES, Daisy Lynn ( i ME 16-01377 Page 18 of 22 Other comments: i : oe Tania ‘Thymus weight: 209 | Parenchym “Tania, lobulated, and symmetric Other comments: REA ENDOCRINE SVS eo ee acheg Endocrine sytem examin Yes See Evidence of Tajury section: No See Evidence of Medical Tatervention: No ‘See Postmortem Changes Section: No Pitlinry gland Sie: Not examined Other comments: Thyroid gland ‘Thyroid plan position: Noma Thyroid plan size: Nona ‘Thyroid gland parenchyma: Normat Other comments: | Adrenal glands Adrenal gland size: Nona ‘Adrenal gland parenchyma: Other comments: ‘Musculoskeletal system examined: ‘See Evidence of Injury section: See Evidence of Medical Intervention: ‘Yellow cortices and gray medullae with the expected corticomedllary ratio 19/30512854 966 TravisCo ME 95:06:06 pm, 7-14-2016 20/20 TORRES, Daisy Lynn ( ME 16-01377 Page 19 of 22 See Postmortem ChangesSection: No Bony framework: ‘Unremarkable Supporting musculature: Unremarabie Subcutaneous sft tases: ‘Uaremarkable ae ReaD USADDTIONALCOMMENTS Eoin yelS ‘Anteroposterior radiographs of the body do not reveal the presence of fractures.s120se set ‘Trav CoME 05:06:13 pm. 7-14-2016, 2180 TORRES, Daisy Lynn ( ( ME 16-01377 Page 20 of 22 aa SLIDE KEY | A: Left lung B: Right lung C: Liver, spleen, thymus Kidney, adrenal gland E: Thyroid, trachea, pancreas F: Heart G: Skeletal muscle, heart H: Brain | “Unless otherwise indicated, sect is are stained only with hematoxylin and eosin (H&E). MICROSCOPIC DESCRIPTION Lung: vascular congestion; no specific pathologic alteration is identified. Liver: no specific pathologic alteration is identified. alteration is identified, Spleen: no specific patholo; ‘Thymus: no specific pathologic alteration is identified. | Kidney: no specific pathologic alteration is identified. Adrenal Gland: ‘no specific pathologic alteration is identified. Thyroid: no specific pathologic alteration is identified. ‘Trachea: no specific pathologic alteration is identified. Pancreas: no specific pathologic alteration is identified Heart: no specific pathologic alteration is identified. | Skeletal muscle: no specific pathologic alteration is identified. | Brain: no specific pathologic alteration is identified.