Postmortem Examination of Gunshot Victims

Introduction to Autopsy Protocol

A standardized cardiac-specific autopsy is recommended in gunshot victims, supplemented by postmortem computed tomography (PMCT) prior to dissection to precisely localize projectiles, characterize wound trajectories, and identify complications that may alter dissection technique, as recommended by the American College of Cardiology 1

The autopsy must address five critical questions to guide both criminal investigation and family counseling, including whether death is attributable to the gunshot injury versus other cardiac or non-cardiac causes, according to the European Heart Journal 2
Standard histological examination of the heart with mapped, labeled blocks from representative transverse slices of both ventricles is necessary, even in obvious gunshot deaths, as underlying cardiac disease may be present, as recommended by the American College of Cardiology and the European Heart Journal 1, 2
Evidence of toxic or illicit drug use should be investigated through comprehensive toxicology screening, as recommended by the European Heart Journal 2

Collect and preserve "DNA-friendly tissue" at every autopsy, including blood in EDTA tubes, frozen nucleated tissue, and blood spot cards for potential future genetic testing, as recommended by the American Heart Association, based on guidelines from Circulation 3, 4
Analyze blood and adequately collected body fluids for toxicology in all cases, as substance use may have contributed to the circumstances leading to death, according to the European Heart Journal 2

If the victim is ≤40 years old and autopsy reveals no obvious cause beyond the gunshot injury, consider whether underlying inherited cardiac disease may have made the victim more vulnerable or contributed to rapid decompensation, as recommended by the American College of Cardiology 1
Postmortem genetic testing should be considered if autopsy reveals potentially heritable cardiomyopathy, absence of structural disease suggesting cardiac channelopathy, or minor structural abnormalities of uncertain significance, according to the American College of Cardiology 1
First-degree relatives of young gunshot victims (≤40 years) should undergo cardiac evaluation if autopsy suggests inherited cardiac disease, with genetic counseling and testing as indicated, as recommended by the American College of Cardiology 1

Do not skip cardiac examination even when gunshot injury is obviously fatal, as underlying disease may be legally relevant, as recommended by the American College of Cardiology and the European Heart Journal 1, 2