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COUNTY OF EL PASO
OFFICE OF THE MEDICAL EXAMINER
AND FORENSIC LABORATORY

WEWEW Jim

 

Autopsy Report
Case 2017-0543

ROGELIO MARTINEZ

Cause of Death: Blunt Injuries of Head
Manner of Death: Undetermined

 

dlfnice Diazzc?alliery. MD.

Deputy Me cal Examiner for El Paso County. Texas

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AUTOPSY REPORT

MARTINEZ. ROGELIO
2017-0543

 

POSTMORTEM EXAMINATION
An autopsy is performed on the body of Rogelio Martinez at the El Paso County Office of the Medical
Examiner, State of Texas, on the 20th day of November. 2017 starting at 9:30 am. The body is
received within a body bag with a label bearing the decedent's name. Items of clothing and personal
effects are inventoried separately. The autopsy is conducted in the presence of Luis Ortega. Jose
Rivera and Carlos Fuentes of the US Border Patrol. Jesus Lowenberg of US Customs. Shannon
Enochs. John Bogovic and Gilberto Valencia of the FBI and Michael Lara of the El Paso Police
Department.

EXTERNAL EXAMINATION (EXCLUDING INJURIES)
The body is that of a well-developed. well-nourished (with a body mass index of 30.7 kg/mz). adult,
White. male who weighs 202 pounds. is 68 inches in length, and appears compatible with the reported
age of 36 years. The body is refrigerated. Rigor mortis is ?xed. Partially ?xed purple livor mortis
extends over the posterior surfaces of the body. except in areas exposed to pressure. The scalp hair
is straight. black and measures approximately inch in length over the crown. The irides are brown.
The corneae are clouded. The sclerae are white. and the conjunctivae are with edema. No petechial
hemorrhages are identi?ed on the sclerae, bulbar conjunctivae. facial skin. or oral mucosa. The nose
and ears are normally formed. The decedent is clean shaven. The oral cavity has natural teeth in
good repair. The neck is unremarkable. The thorax is well developed and symmetrical. The abdomen
is flat. The spine is normally formed. The external genitalia are those of a normal adult male. The
upper and lower extremities are well developed and symmetrical, without absence of digits. Identifying
marks include the dorsum of the right hand has an irregular 1 inch scar below the ?lsl ?nger. Evidence
of medical intervention includes an endotracheal tube. cervical collar. bilateral chest tubes, bilateral
femoral intravenous catheters, multiple cardiac patches. right wrist and left ankle hospital identification
bands. EKG patches. de?brillator patches. Foley catheter. bilateral hand intravenous catheters. right

middle finger oximeter and left arm blood pressure cuff.

fo

AUTOPSY REPORT

MARTINEZ. ROGELIO
2017-0543

 

EVIDENCE OF INJURY
BLUNT INJURIES OF HEAD:
Bilateral upper lids show red The right parietal scalp shows two lacerations: a 1 inch 

 

shaped laceration and a V4 inch linear laceration with associated small red abrasions that measure up
to 3/4 inch in greatest dimension. Behind the right ear is a purple discoloration. The right parietal skull
has a semi circular fracture with linear fractures radiating towards the frontal and temporal skull. The
right maxillary bone has a non displaced linear fracture from the right inferior orbital surface extending

to the edge of the nasal aperture of the maxilla.

BLUNT INJURIES OF TORSO:

The right shoulder shows a purple contusion that measures approximately 5 by 4 inches. Ribs 2
through 4 are fractured at the costochondral joint. The right clavicle has a comminuted fracture on the
lateral 1/3 with associated soft tissue hemorrhage. Each pleural cavity contains 100 mL of partially

coagulated red blood.

INTERNAL EXAMINATION (EXCLUDING INJURIES)

BOY CAVITIES:
No adhesions are in any of the body cavities. All body organs are in normal and anatomic position.

The serous surfaces are smooth and glistening.

HEAD (CENTRAL NERVOUS SYSTEM):
The brain weighs 1440 grams. The brain is preserved in formalin prior to further examination.
Complete examination of the brain will be detailed in a separate Forensic Neuropathoiogy

Examination report to follow.

NECK:
Examination of the soft tissues of the neck. including strap muscles and large vessels. reveals no

abnormalities. The hyoid bone and larynx are intact. The tongue is normal.

Lu

AUTOPSY REPORT

MARTINEZ, 
2017-0543

 

CARDIOVASCULAR SYSTEM:

The heart weighs 320 grams. The pericardial sac is free of significant ?uid or adhesions. The

 

pericardial surfaces are smooth and glistening. The coronary arteries arise normally and follow the
distribution of a right dominant pattern with no significant atherosclerosis. The chambers and valves
are proportionate. The valves are normally formed. thin and pliable, and free of vegetations and
degenerative changes. The myocardium is dark red-brown, ?rm, and free of focal or regional fibrosis,
erythema, pallor. or softening. The atrial and ventricular septa are intact, and the septa and free walls
are free of muscular bulges. The aorta arise normally and follow the usual course, with no significant
atherosclerosis. The ori?ces of the major aortic vascular branches are patent. The vena cava and its

major tributaries are patent and return to the heart in the usual distribution and are unremarkable.

RESPIRATORY SYSTEM:
The right and left lungs weigh 790 and 710 grams, respectively. The upper and lower ainivays are

 

unobstructed, and the mucosal surfaces are smooth and yellow-tan. The pleural surfaces are smooth.
glistening, and unremarkable. The pulmonary is light pink. and the cut surfaces exude
moderate amounts of blood and frothy ?uid. The pulmonary arteries are normally developed and

without thromboemboli and atherosis.

AND BILIARY SYSTEM:
The liver weighs 1700 grams. The hepatic capsule is smooth. glistening, and intact, and covers red?

 

brown The gallbladder contains 1 mL ofgreen watery bile without stones.

ALIMENTARY TRACT:

The esophagus is lined by gray?white, smooth mucosa. The gastric mucosa is unremarkable. and the
lumen contains 180 mL of partially digested food fragments. The serosa of the small bowel is smooth
and glistening. The small bowel contains partially digested food. There are no mucosal lesions of the
small and large bowel. The colon contains formed stool. The appendix is present. The pancreas has a

normal tan, lobulated appearance.

AUTOPSY REPORT

MARTINEZ. ROGELIO
2017?0543

 

GENITOURINARY TRACT:
The right and left kidneys weigh 150 and 160 grams. respectively. The renal capsules are smooth,

 

thin, semitransparent, and strip with ease from the underlying smooth, red-brown, and firm cortical
surfaces. The cortices are of normal thickness and are well delineated from the medullary pyramids.
The calyces. pelves, and ureters are non-dilated and free of stones. The urinary bladder contains 5
mL of clear, yellow urine; the mucosa is gray-tan and smooth. The bilaterally descended testes are of

normal size and consistency. The prostate is not enlarged.

RETICULOENDOTHELIAL SYSTEM:
The spleen weighs 170 grams and has a smooth intact capsule covering red-purple, moderately ?rm

 

The splenic white pulp is grossly indiscernible. The bone marrow of the rib is red-purple.

No regional node enlargement is noted.

ENDOCRINE SYSTEM:
The pituitary gland is of normal size. The thyroid gland is of normal position, size. and texture. The

adrenal glands have normal cut surfaces with yellow cortices and gray medullae.

RADIOGRAPHS
Full body radiographs are obtained.

OTHER LABORATORY TESTS

Femoral blood is submitted for toxicologic analysis.

PATHOLOGIC DIAGNOSES
I. Bunt injuries of head.
a. eyes, upper lids.
b. Lacerations and abrasions, scalp.
0. Fracture, skull and maxilla.
ll. Blunt injuries of torso.
a. Contusion, shoulder. right.

AUTOPSY REPORT

MARTINEZ. ROGELIO
2017-0543

 

b. Fractures, ribs and clavicle. right.

0. Segmental fractures of the anterior and posterior arches of the right first and second
ribs and non segmental fractures of the ipsilateral third through sixth ribs as per
thoracic CT scan 11/19/2017 CTDBOQOGDT.

d. Hemothoraces. 100ml right and 100ml left.

OPINION
This 36-year-old man, Rogelio Martinez, died of blunt injuries of head. According to reports the border
patrol agent suffered injuries in Van Horn. Texas. Autopsy revealed head injuries. Femoral blood
revealed butaibital 1.2 mcg/mL. The manner of death is undetermined.

Final: 2/6/2018

Phone: (215} 657-4900 Fax: (215) 657-2972
e-rnail: nms@nmslabs.com
Robert A. Middleberg. F-ABFT. DABCC-TC. Laboratory Director

NMS Labs 
3701 Welsh Road, PO Box 433A Willow Grove, PA 19090-0437

 

 

 

 

 

 

Corrected Report Patient Name MARTINEZ, ROGELIO
. Patient ID 17-0543
Report Issued 1204/2017 07.06 Chain 17363974
Last Report Issued 11f29/2017 15.10 Age 36 DOB 
To: 10233 Gender Mam
El Paso County Medical Examiner's Of?ce Workorder 

4505 Alberta Avenue
El Paso. TX 79905 P3991 0? 3
Positive Findings:
Qammund Been]; Minimums:
Butaibital 1.2 mcgimL 002 - Femoral Blood
See Detailed Findings section for additional information
Tes?ng Requested:
Analysis Code Description
8051B Postmortem. Basic. Blood (Forensic)
Specimens Received:
ID TubelContainer Volume! Collection Matrix Source Miscellaneous
Mass Datemme Information
001 Gray Top Tube 7.9 mL 11120001? 09:30 Femoral Blood
002 Homogenate Container Not Given 11i20/201? 09:30 Femoral Blood

All sample volumes/weights are approximations.
Specimens received on 11l22/2017.

NMS v.18.0

CONFIDENTIAL Workorder 17363974
Chain 17363974
Patient iD 17-0543

 

Page 2 of 3
Detailed Findings:
Rpt.
Analysis and Comments Result Units Limit Specimen Source Analysis By
Butalbital 1.2 0.20 002 - Femoral Blood 

Other than the above findings. examination of the specimen(s) submitted did not reveal any positive ?ndings of
toxicological significance by procedures outlined in the accompanying Analysis Summary.

Reference Comments:
1. Bulalbital - Femoral Blood:

Butalbital is a barbiturate derivative with an intermediate duration of action. Signs noted following its
administration include drowsiness. sedation and ataxia. The substance is often found in cembination with other
compounds. such as acetaminOphen. 88pirin. codeine. or caffeine. Typically these mixtures contain 50 mg of
butalbital.

The reported mean peak blood concentration following a single 100 mg dose of butalbital was 2.1 mcg/mL
(range, 1.7 - 2.6 mcgimL) at 2 heurs with a decline to 1.5 (range. 1.3 - 1.7 mcgimL] by 24 hours.

Concentrations of butalbital in 64 persons arrested for driving under the in?uence of drugs have been reported
at blood concentrations ranging from 0.1 - 28 (average 8.5 Two reported butalbital-related
deaths had blood concentrations of 13 and 26 

Sample Comments:
001 Patient ID modi?ed 12/0017. Previous value: 17-0545
001 Blood specimen required homogenization: 17363974-001
002 NMS Labs generated homogenized Blood sample: 17363974-002

Chain of custody documentation has been maintained for the analyses performed by NMS Labs.

Uniess alternate arrangements are made by you. the remainder of the submitted specimens will be discarded six (6)
weeks from the date of this report; and generated data will be discarded ?ve (5) years from the date the analyses were
performed.

Workorder 17363974 was electronically
signed on 12l04/20?l7 06:29 by:

if; 7 
Paul Miller.
Certifying Scientist

Analysis Summary and Reporting Limits:

All of the following tests were performed for this case. For each test, the compounds listed were included in the scope. The
Reporting Limit listed for each compound represents the lowest concentration of the compound that will be reported as being
positive. If the compound is listed as None Detected, it is not present above the Reporting Limit, Please refer to the Positive
Findings section of the report for those compounds that were identified as being present.

Acode 500118 - Barbiturates Confirmation. Blood (Forensic) - Femoral Blood

-Analysis by Gas Spectrometry

(GCIMS) for:
Amobarbital 0.20 mcgimL Butalbital 0.20 
Butabarbital 0.20 Pentobarbital 0.20 

NMS v.18.0

 CONFIDENTIAL Workorder 17363974
MS Chain 17363974

Patient ID 17-0543
Page 3 of 3
Summary and Reporting Limits:
Phenobarbital 0.20 Secobarbital 0.20 

Acode 8051 - Postmortem. Basic. Blood (Forensic) Femoral Blood

-Analysis by Enzyme-Linked Immunosorbent Assay (ELISA) for:

Amphetamines 20 ngImL Fentanyl IAcetyl Fentanyl 0.50 ng/mL
Barbiturates 0.040 Methadone I Metabolite 25 ngImL
Benzodiazepines 100 ngImL Methamphetamine I MDMA 20 ngImL
Buprenorphine I Metabolite 0.50 ngImL Opiates 20 ngImL
Cannabinoids 10 ngImL Oxycodone I Oxymorphone 10 ng/mL
Cocaine I Metabotltes 20 ngImL 10 ngImL

by Headspace Gas Chromatography (GC) for:

. . . .
Acetone 5.0 mgIdL lsopropanol 5.0 mgIdL
Ethanol 10 mgIdL Methanol 5.0 mgIdL

 

Forensic Neuropathology Consultation Report
Case 2017-0543

ROGELIO MARTINEZ

DR. DIAZ PERFORMED THE AUTOPSY ON 11/20/17
DR. DIAZ EXAMINED THE BRAIN ON 12/5/17
REPORT 02/06/2018

GROSS EXAMINATION:
Brain weight: 1440 gm.

The specimen consists ofthe brain and intracranial dura of an adult.

The intracraniat dura is not remarkable. All venous sinuses are patent.

The leptomeninges show thin, recent subarachnoid hemorrhage The cerebral gvri are of normal
size, configuration and consistency. There is no sign of herniation. The temporal lobes and orbital
surface of the left frontal lobe and cerebellum show petechial hemorrhages. The external aspects of the
brainstem are not remarkable. The arteries at the base of the brain follow a normal distribution and are
free of atherosclerosis, aneurysmatic dilatations or sites of occlusion. All cranial nerve stumps identified
are not remarkable.

Coronal sections of the cerebrum reveal cortical petechial hemorrhages on the cortex of the
temporal lobes, orbital surface of the left frontal lobe and left inferior parietal lobule. The white matter
of the right hemisphere of the cerebellum shows two hemorrhages measuring 0.5 and 0.8 cm in
diameter. There is no shift of the midline structures. Sections of the midbrain, pons, medulla oblongata
and cerebellum show no focal abnormalities. Myelination is normal for age. The substantia nigra is well
pigmented. The ventricular system and cerebral aqueduct are patent, and normal in size and
configuration. The ependymal lining is smooth and glistening.

PHOTOGRAPHS: YES

MICROSCOPIC EXAMINATION: NO
E, CD 45 and amyloid precursor protein stained sections:

1. Left superior frontal gyrus 5. Midbrain
2. Left basal ganglia 6. Pons

3. Right thalamus 7. Medulla

4. Right hippocampus 8. Cerebellum

Page 1 of2
OME NEUROPATHOLOGY CONSULTATION REPORT
Case 2017 0543 MARTINEZ, ROGELIO

Sections show subarachnoid hemorrhage with intact The white matter of the cerebellum
shows hemorrhage with Iysed The midbrain, pons and medulla show focal areas with
groups of swollen axons.

DIAGNOSIS:
I. ACUTE TRAUMATIC BRAIN INJURY.

 

MET 0:32, M?ij

Page 2 of 2
OME FORENSIC NEUROPATHOLOGY CONSULTATION REPORT
Case 2017 0543 MARTINEZ, ROGELIO