Virtopsy and Quick-Tox: Establishing a multimodal workflow for postmortem forensic examination

Introduction Postmortem computed tomography (PMCT) has emerged as an increasingly important diagnostic tool in forensic medicine and has been used since 2015 to triage decedents delivered to the Zurich Institute of Forensic Medicine in order to more efficiently handle increasing caseloads. This retrospective study evaluated the use of quick toxicological screening methods (QT) in addition to PMCT for advanced postmortem triage. Methods All 128 triage and autopsy cases of the Zurich Institute of Forensic Medicine from the years 2019, 2021, and 2023 that received both PMCT and at least partial QT were analyzed using forensic radiology and toxicology reports as well as the final forensic report. QT included immunoassay for 10 substances, screening by untargeted liquid chromatography tandem mass spectrometry (LC-MS/MS), and blood alcohol analysis by headspace gas chromatography mass spectrometry (HD-GC-MS). Results Of all cases externally examined at the scene in 2023, 24% were further investigated and resolved with triage CT while 38.8% received an autopsy. Since 2015, this is a decline in autopsy numbers by 21.3% and a rise in triage CT by 88.1%, with an increase in external examinations by 16.2%. Of the cases receiving triage with CT and QT, 29.4% were further investigated with autopsy and 18.1% received standard toxicological analysis (STA). QT was able to identify intake of substances in 82.8% of cases and was positive in all 33 cases of intoxication. Cardiac, metabolic or infectious diseases were difficult to detect via triage with CT and QT. Conclusion QT is an important tool to confirm or exclude drug intake via triage, especially if there are signs of drug use at the scene or radiological signs indicating intoxication in PMCT. The combination of CT triage and QT may support workflow efficiency and informed decision-making within a forensic institution, particularly in high-caseload settings, by focusing investigations on the key forensic questions, ultimately benefitting the judicial authorities as well as the bereaved families.