GLENN N. WAGNER. D.O. CHIEF MEDICAL EXAMINER (858) 694-2895 Name: Place of death: Date of death: Date of autopsy: - . If a k. (?lnunty at an Elmo STEVEN C. CAMPMAN, M.D. CHIEF DEPUTY MEDICAL EXAMINER (353) 694-2395 MEDICAL DEPARTMENT 5570 OVERLAND AVE. STE 101. SAN DIEGO, CA 921 23-1215 AUTOPSY REPORT GEORGE S. SLOSS 2018?1247 Scripps Memorial Hospital Age: 62 Years La Jolla, CA 92037 Sex: Male May 19, 2018; 1524 Hours May 21,2018; 0939 Hours CAUSE OF DEATH: BLUNT HEAD TRAUMA MANNER OF DEATH: HOMICIDE AUTOPSY SUMMARY: I. Blunt head trauma. Clinical history of: A. 1 2. 3. 4. Scalp contusion. Skull fractures. Subdural hematoma, status post craniectomy and evacuation. Subarachnoid hemorrhage, cerebrocortical contusions, hemorrhages, and herniation status post craniectomy and evacuation. Autopsy evidence of: Facial soft tissue hemorrhages. Skull fractures. Organizing subdural hemorrhage. Subarachnoid hemorrhage. Cerebrocortical contusions and hemorrhages. Cerebral edema with: a. Transcalvarial, uncal, cerebellar tonsillar. and subfalcine herniation. b. Multifocal acute infarction. AUTOPSY REPORT GEORGE SLOSS 2018-4247 ll. Acute bronchopneumonia. Hypertensive cardiovascular disease. A. Cardiomegaly (430 grams) with four chamber dilatation and left ventricular hypertrophy. B. Mild arterionephrosclerosis. IV. Hepatic steatosis. OPINION: According to the investigative information and available medical records, Mr. George Sloss was a 62-year~old man who lived in Solana Beach. On 05/13/2018, he was visiting his ?ancee at her home when their friend knocked on the door. The three of them reportedly got into an argument and the friend punched Mr. Sloss in the face and he fell backwards and struck his head on a wooden table, losing consciousness. The friend continued to kick Mr. Sloss and also reportediy assaulted his ?ancee. The friend fled the scene and 9-1-3 was called. Paramedics arrived and transported him to Scripps Memorial La Jolla Emergency Department (ED), Upon arrival to the ED, he had an altered mental status but was conscious and moving his extremities. Physical examination showed a ?contusion to the right occipital skull area? and bleeding in the right external auditory canal. A computed tomography (CT) scan of the head showed extensive subgaleal ?uid, right temporal bone skull fracture, hairline frontal bone fracture, a 15 mm right convexity subdural hematoma, 4 mm left tentorial subdurai hematoma, scattered subarachnoid hemorrhage, bifrontel and temporal hemorrhagic contusions, right uncal herniation, teftward subfalcine herniation, and left shift of septum peiiucidum. He underwent a hemicraniectomy decompression with evacuation of subdural hematoma, right frontal intracerebrai hemorrhage, right temporal intracerebral hemorrhage, and partial right frontal and temporal iobectomies on 05/1312018. He underwent placement of intracranial pressure monitor and intracranial Licox oxygenation monitor on 05/14/2018. The autopsy demonstrated evidence of head injury including skull fractures, bleeding AUTOPSY REPORT -3- GEORGE SLOSS 2018-1247 around the brain (subdural hemorrhages), bleeding upon the brain (subarachnoid hemorrhages), bruising of the brain (cerebrocortical contusions), and bleeding within the brain hemorrhages). There was also evidence of prior surgical intervention with removal of part of the skull (craniectomy). The bleeding into his brain was found to be a serious and predictable secondary complication of the cerebrocortical contusions (contusion hematomas; delayed traumatic intracerebral hemorrhages Natural disease included enlargement (cardiomegaly) and dilation of his heart with thickening of the heart?s main pumping chamber (left ventricular hypertrophy) and microscopic changes (arterionephrosclerosis) in his kidneys, Consistent with long term high blood pressure (hypertension). The lungs had features of infection (acute bronchopneumonia). Pneumonia is a common complication of severely ill, bed-ridden individuals. His liver showed fatty changes (steatosis), consistent with his history of alcohol abuse. Toxicological testing performed on antemortem blood detected alcohol Based on the autopsy ?ndings and the circumstances surrounding the death, as currently understood, the cause of death is blunt head trauma, and the manner of death is homicide. VIVIAN S. SNYDER, D.O. Forensic Pathology Fellow SUPERVISING PATHOLOGIST: BRANKICA PAUNOVIC, MD. Deputy Medical Examiner Date signed: AUTOPSY REPORT -4- GEORGE SLOSS 2018-1247 IDENTIFICATION: The body is received in a white body pouch, sealed with red tag number ?4466397?. The body is identi?ed by a yellow Medical Examiner?s identi?cation band bearing the decedent?s name and case number secured to the right ankle. A second blue Medical Examiner?s identi?cation band bearing the decedent's name, case number, and a weight of 219 (as received) is secured to the right ankle. A white hospital identi?cation band is around the right wrist, bearing the decedent?s name. A yellow and white hospital identi?cation band is around the right wrist, bearing the decedent?s name. A hospital identi?cation tag is attached to the left great toe, bearing the decedent?s name. WITNESSES: Robert Pizzuti, Brande Sliverthorn, and Norman Hubbert from the San Diego County Sheriffs Department are in attendance. Assisting is Forensic Autopsy Specialist Fabian King, Sr. CLOTHING: The body is unclad when initially viewed; no clothing accompanies the body. EVIDENCE OF MEDICAL THERAPY: 1. Several layers of white gauze are around the head. 2. Two intracranial pressure monitors are in the left frontal scalp; two 0.3 cm diameter Burr holes are in the left frontal and parietal bones. 3. An 11-1/2 inch healing curvilinear stapled incision is in the right frontOparietal scalp; the adjacent skin has focal super?cial ulceration and crust formation. 4. A craniectomy site is in the right side of the skull and involves portions of the right frontal, parietal, and temporal bones. The dura in this region is absent. A piece of blood - soaked material overlies the brain where the dura is absent. An intravascular catheter is in the right antecubital fossa. Gauze and tape overlie a puncture in the anterolateral right forearm. An intravascular catheter is in the posterior right hand. An intravascular catheter is in the anterior upper left arm. Gauze and tape overlie a scabbed puncture in the left antecubital fossa. An intravascular catheter and a suture are in the anterior left wrist. A Foley catheter is in the penis; a collecting device is attached. 4490905'9?9" EXTERNAL EXAMINATION Injuries are described in a separate section below. GENERAL: The body is that of a normally developed and well-nourished light- complexioned man appearing consistent with the listed age of 62 years. The length is 70 inches, and the weight is 219 pounds as received. The body is well preserved, cold, and has not been embalmed. Rigidity is fully deveIOped in the jaw and extremities. Lividity is pink-purple, blanching, and in a posterior distribution. AUTOPSY REPORT -5- GEORGE SLOSS 2018-1247 HEAD: See OF MEDICAL The right side of the head is soft. The scalp is partially shaved, on the vertex of the head; wavy gray hair measures up to 2- 3/4 inches on the sides of the head. The facial hair consists of a moustache and beard up to 3/16 inch long. The ears are normally formed and without drainage. The earlobes are creased. The irides are hazel, the corneas clear, and the bulbar and palpebral conjunctivae have scattered petechiae. The conjunctivae are edematous. The sclerae are white. The nose is intact, and the nares are clean and unobstructed. The lips are normally formed. The teeth are natural and in good condition. NECK: The neck is symmetrical and without injury. CHEST AND ABDOMEN: The chest is normally formed, symmetrical, and without palpable masses. The abdomen is mildly obese and soft. No masses are palpable. EXTERNAL GENITALIA: The external genitalia are those of a normal adult man with both testes palpable in the scrotum. BACK: The back is straight and symmetrical. The anus is atraumatic. ARMS: The arms are normally formed. No track marks or ventral wrist scars are noted. The hands are edematous. The ?ngernails are short and dirty. LEGS: The legs are normally formed and have no edema, amputations, or deformity. The toenails are short and dirty. BODY MARKINGS (SCARS AND TATTOOS): Scars: 1. A 7/16 1/2 inch scar is on the tip of the nose. 2. A 3/4 1/2 inch oval scar is on the anterolateral right upper arm. 3. A 1-1/4 inch long scar is on the anterior left shoulder. 4. Multiple irregular scars are on the forearms and hands, up to 3/4 inch in greatest dimension. Tattoos: None. EVIDENCEQF INJURY BLUNT 1. are focal (overlying the right mandible and the left pre-auricular area) within the subcutaneous soft tissues and muscles of the face. AUTOPSY REPORT ?6r GEORGE SLOSS 2018-1247 2. Full-thickness are in the right frontal, temporal, and parietal scalp, galea, and temporalis muscle, and in the occipital scalp and galea. 3. A 3.5 3.0 cm full-thickness scalp and galeal is in the left posterior parietal scalp. 4. A linear fracture is in the right temporal and occipital bones, and extends into the middle cranial fossa. The calvarial portion of the fracture partially extends into and splits the right-sided lambdoid suture (sutural diastasis). 5. Subdural hemorrhage is nearly diffuse and is most prominent overlying the base of the brain (up to 0.5 cm thick overlying the right anterior and middle cranial fossae; approximately 20-50 ml) and the right parasagittal convexity. 6. Dense subarachnoid hemorrhage overlies the frontal poles, inferior frontal lobes, and temporal tips (right greater than left). 7. Subarachnoid hemorrhage is thin and patchy overlying the convexities and the cerebellum, and is in association with congested leptomeningeal vasculature. 8. Cerebrocortical contusions and super?cial lacerations are patchy but extensive in the orbitofrontal gyri. The frontal lobe contusions extend from the frontal poles to the level of the genu of the corpus callosum. 9. The bilateral frontal and right temporal lobe contusions are associated with dense hemorrhages(right frontal lobe) and 1.3 0.8 0.2 cm (right temporal lobe). OTHER INJURIES: 1. A 1/2 inch diameter purple-green is in the right upper chest. 2. A 1 1/2 inch faint green is in the left upper chest. 3. A 1-1/2 1/2 inch faint green is in the midline abdomen. These injuries above, having been described, will not be repeated. INTERNAL EXAMINATION BODY CAVITIES: The abdominal fat layer measures up to 3.0 cm in thickness. Approximately 100 ml of serosanguinous ?uid is in the right pleural cavity; approximately 200 ml of serosanguinous ?uid is in the left pleural cavity. The body cavities otherwise have no hemorrhage or abnormal ?uid. The serosal surfaces are smooth, glistening, and without adhesions. The organs are normally located. The diaphragm is intact. The body cavities have no internal injuries. CARDIOVASCULAR SYSTEM: The heart weighs 430 grams and is enlarged. It has a globular shape with a smooth, glistening epicardium. The coronary arteries have a normal origin and distribution with right dominance. The coronary arteries have patchy minimal atherosclerotic stenosis. AUTOPSY REPORT -7- GEORGE SLOSS 2018-1247 The myocardium is red-brown, ?rm, and uniform without focal ?brosis, softening, or hyperemia. The atria and ventricles are dilated (atria ventricles). The left ventricle is hypertrophied. The right ventricle, left ventricle, and interventricular septum measure 0.4 cm, 1.8 cm, and 2.0 cm, respectively. The endocardium is intact, smooth, and glistening. The cardiac valve lea?ets are of normal number, pliable, intact, and free of vegetations. The mitral valve has mild myxoid degenerative changes with early interchordal hooding. The atrial and ventricular septa are free of defects. The aorta follows its usual course and has mild atherosclerotic changes. There are no vascular anomalies or The vena cavae and pulmonary arteries are without thrombus or embolus. RESPIRATORY SYSTEM: The right and left lungs weigh 720 and 950 grams, respectively, and have the usual lobation. The pleura are smooth and glistening; the lungs have mild anthracotic pigment. The lungs are congested and edematous and have patchy consolidation, most prominent in the lower lobe of the left lung. The is dark red-purple and exudes moderate amounts of ?uid. The lungs have no hemorrhage, infarct, tumor, gross ?brosis, or enlargement of airspaces. The bronchi contain no foreign material and have unremarkable mucosa. HEPATOBILIARY SYSTEM: The liver weighs 3000 grams and is enlarged. The intact capsule is smooth and glistening. The is orange-brown and ?brotic without mass or hemorrhage. The gallbladder contains an estimated 30 ml of dark brown, sludgy bile and no stones. Its mucosa is uniform and the wall is not thickened. The pancreas has a normal size, shape, and lobulated structure. The is pink- tan, ?rm, and uniform. SYSTEM: The spleen weighs 550 grams and is enlarged. The capsule is smooth and intact. The is dark purple, ?rm, and uniform. There is no enlargement of the nodes in the neck, chest, or abdomen. ENDOCRINE SYSTEM: The thyroid gland is not enlarged, and the lobes are symmetrical. The is uniform, ?rm, and red-brown. The adrenal glands have the usual size and shape. The cortices are thin, uniform, and yellow and there is no hemorrhage or tumor. The pituitary gland is not enlarged. AUTOPSY REPORT -8- GEORGE SLOSS 2018-1247 GASTROINTESTINAL SYSTEM: The esophagus and gastroesophageal junction are unremarkable. The stomach contains approximately 25 ml of thin, tan-brown ?uid without visible pills or pill residue. The gastric and duodenal mucosae are intact and unremarkable. The small and large intestines and appendix are unremarkable to inspection and palpation. SYSTEM: The right and left kidneys weigh 210 and 220 grams, respectively, and have a normal shape and position. The cortical surfaces are smooth. The kidneys have the usual corticomedullary structure without tumors or The pelves and ureters are not dilated or thickened. The urine collecting device contains approximately 10 ml of urine. The mucosa is intact, and the bladder wall is not hypertrophied. The prostate gland is enlarged and nodular, and has patchy yellow discoloration and multiple brown stones (ranging 0.1 0.3 cm in diameter). The testes are without hemorrhage or tumor. NECK: A 3.0 1.0 0.2 cm hemorrhage is in the left anterolateral aspect of the tongue. A 1.0 0.5 0.2 cm hemorrhage is in the right anterolateral aspect of the tongue. The strap muscles and other anterior neck soft tissues have no hemorrhage. The hyoid bone and the cartilaginous structures of the larynx and trachea are normally formed and without fracture. The ainrvay is unobstructed, lined by smooth, pink?tan mucosa, and contains no foreign material. The cervical vertebrae have no displacement, hypermobility, or crepitus. MUSCULOSKELETAL SYSTEM: The musculoskeletal system is well developed and free of deformity. There are no fractures of the clavicles, sternum, ribs, vertebrae, or pelvis. The ribs are not brittle. The skeletal muscle is dark red and ?rm. HEAD: See OF The calvarium and base of the skull are normally con?gured. CENTRAL NERVOUS SYSTEM: The brain and dura mater are ?xed in formalin for neuropathologic evaluation. Formalin ?xed brain weight: 1470 grams. See OF The smooth pachymeninges have no masses. Epidural blood is patchy along the midline convexity dura. Brown granular material is in association with sutures adjacent to the superior sagittal sinus. The leptomeninges are thin and delicate and have congested vasculature. The gyri are ?attened and the sulci are narrowed. The hemispheres are asymmetric; the right hemisphere is larger/fuller than the left. Much of the right parietal lobe is soft, has dusky brown-red discoloration, congested AUTOPSY REPORT -9- GEORGE SLOSS 2018-1247 super?cial cortical vasculature, and is in association with the previously described craniectomy site. The posterior parietal lobe has a sharp demarcation where it herniated through the craniectomy site (transcalvarial herniation). The lateral aspects of the right temporal, parietal, and occipital lobes are soft, friable, and necrotic (where the brain was in contact with the inferior portion of the craniectomy site). The unci and cerebellar tonsils are herniated. The superficial cortical vasculature has no thromboses or vascular malformations. The vessels at the base of the brain are normally configured and have no or atherosclerotic lesions. The cranial nerve roots are symmetric and normally distributed. The cerebral hemispheres have a cortical gray ribbon of normal thickness. The gray-white matter junctions are subtly indistinct in portions of the right parietal lobe. The right hemisphere is edematous and there is right to left shift with subfalcine herniation of the left cingulate gyrus and compression of the right lateral ventricle. The lateral aspects of the right parietal, temporal, and occipital lobes are soft, fragmented, and have gray to dark brown discoloration. An acute infarct characterized by softening and red-pink discoloration is in the right superior and middle temporal gyri, at the level of the thalamus. Herniation contusions are in the right inferolateral temporal and occipital lobes. The internal capsule, basal ganglia, thalamus, hippocampi, mammillary bodies, superior cerebellar vermis, cerebellar hemispheres, mesencephalon, pons, medulla, and the proximal cervical spinal cord are of normal configuration. The substantia nigra and the locus ceruleus are normally pigmented. The brain is without neoplasm, cyst, or abscess. SPECIMENS RETAINED TOXICOLOGY: Samples of central and peripheral blood, vitreous humor, gastric contents, urine, and liver are retained for toxicology. HISTOLOGY: Representative sections of organs and tissues are retained. Sections of the brain (17), dura (4), heart (2), lungs (7), liver (1), and kidney (1) are submitted for histology. Cassette summary: Cassette 1: Right lung Cassette 2: Left lung, upper lobe Cassette 3: Left lung, lower lobe Cassette 4: Liver; kidney Cassette 5: Heart Brain cassette summary: AUTOPSY REPORT Cassette A: Cassette B: Cassette C: Cassette D: Cassette E: Cassette F: Cassette G: Cassette H: Cassette I: Cassette 3: Cassette K: Cassette L: Cassette M: Cassette N: Cassette 0: Cassette P: Cassette Q: Cassette R: Cassette 8: -10- GEORGE SLOSS 2018-1247 Frontal lobe contusion Frontal lobe contusion Right frontal lobe hemorrhage Right temporal lobe contusion Right occipital lobe contusion Right temporal lobe infarct Splenium of corpus callosum Splenium of corpus callosum Left frontal border zone Right parietal border zone Left posterior hippocampus Left anterior basal ganglia Right posterior basal ganglia/internal capsule Cerebellum Midbrain Pons Medulla Dura mater Dura mater PHOTOGRAPHS: Facial identi?cation photographs, overall external photographs, and photographs of injuries and other selected ?ndings are taken. RADIOGRAPHS: Postmortem radiographs of the head, neck, and upper torso show skull fractures and evidence of surgical intervention in the head. EVIDENCE: Oral swabs and ?ngerprints (major case prints) are taken by SDSO. A blood sample is turned over to SDSO. AUTOPSY REPORT ?1 1- GEORGE SLOSS 2018-1247 MICROSCOPIC EXAMINATION HEART: The epicardium, myocardium, and endocardium are appropriately con?gured. Interstitial ?brosis is mild and patchy. Some of the myo?bers are hypertrophic and have enlarged nuclei. The myocardium does not have signi?cant in?ammation, myocyte necrosis, or hemorrhage. No myo?ber disarray is within the interventricular septum. LUNGS: The basic pulmonary architecture is retained. In one of the sections from the right lung, vascular congestion and intra-alveolar extravasation of blood are markedly prominent. Sections of the lower lobe of the left lung show broad swaths of alveoli containing sheets of neutrophils, ?brin, and fungal forms. The ainivays are appropriately con?gured and have mild acute and chronic in?ammation (including an increased eosinophil population). Some of the airspaces are dilated. Pigmented macrophages are scattered in the alveoli. Many of the alveoli contain eosinophilic proteinaceous material. LIVER: The basic hepatic architecture is retained. Macrovesicular steatosis is mild to moderate. The portal tracts are expanded by chronic in?ammatory cells and ?brous tissue. There is early portal-portal bridging. Lobular in?ammation is characterized by scattered small aggregates of acute and chronic in?ammatory cells, with focal hepatocyte necrosis. KIDNEYS: The basic renal architecture is retained. Hyaline-type arteriolosclerosis is mild. The glomeruli are normocellular and are without signi?cant sclerosis or in?ammation. The tubules have foamy changes and are without in?ammation. The interstitium is without ?brosis or in?ammation. The vasculature is congested. DURA MATER AND BRAIN: Organizing subdural hemorrhage is characterized by variably prominent layers of ?brocellular tissue on the subdural side of the dura mater. In some places, extravasated blood is layering between the strands and/or adherent to the strands. Extravasation of blood into the subarachnoid space is variably prominent. The macroscopically identi?ed ?cerebrocortical contusions" in the left frontal lobe, right temporal lobe, and right occipital lobe are composed of numerous linear streak-like (predominantly perivascular) hemorrhages in the cortex that are perpendicular to the gray- white junction, as well as larger con?uent hemorrhages in the cortex and white matter. Some of the large hemorrhages extend through the pial surface and are contiguous with blood in the subarachnoid space. The adjacent to the cerebrocortical contusions has variably severe features of acute infarction including pallor and vacuolization of the neuropil and subcortical white AUTOPSY REPORT -12- GEORGE SLOSS 2018-1247 matter, hyperangulated neurons with hypereosinophilic cytoplasm and pyknotic nuclei, axons, and endothelial hyperplasia. These features are most severe in the occipital lobe. The occipital lobe section also has foci of neutrophil in?ltration admixed with karyorrhectic debris. A section of the right frontal lobe hemorrhage shows extravasation of blood in the white matter. The immediately adjacent is necrotic and has axons, slit-like hemorrhages, and perivascular hemorrhages. Asection"o?themacroscopically identi?ed acute infarct?in?the?fght superior a ?er middle temporal gyri shows features of acute infarction including panlaminar neuronal ischemic change (shrunken, hyperangulated neurons with hypereosinophilic cytoplasm and pyknotic nuclei), vascular congestion, endothelial hyperplasia, scattered neutrophils and apoptotic debris, and vacuolization of the neuropil. The subcortical white matter has ischemic changes including geographic areas of pallor (washed out appearance) and vacuolization, and axons. A section of the frontal border zone shows pallor and rarefaction, with axons, and small hemorrhages; the overlying cortex is preserved. The parietal border zone has neuropil vacuolization and scattered neurons with acute ischemic change. The long white matter tracts are appropriately con?gured and without hemorrhages. The basal ganglia and hippocampus, cerebellum, are appropriately con?gured. Some of the neurons of the dentate nucleus have ischemic change. D: 5/21/18 T: 5/22/18 Rev. 7/11/18 @uurrtg of ?rm ginger GLENN D-o- MEDICAL DEPARTMENT CHIEF MEDICAL EXAMINER 69,259, 5570 OVERLAND Ave. STE: 101. SAN DIEGO. CA 92123-1215 ht! nl . ov/me TOXICOLOGY REPORT Name: SLOSS, George Medical Examiner Number: 2018-01247 Date of Death: 5/19/2018 Time ofDeath: 1524 Pathologist: Vivian Snyder, D.O. Brankica Paunovic, M.D. Specimens Received: Blood 2, Liver, Vitreous, Urine Date Specimens Received: 5/22/2018 STEVEN C. CAMPMAN, MD. DEPUTY MEDICAL EXAMINER (858)694-2695 Gastric, Subdural Blood, Antemortem Blood (Serum), Central Blood, Peripheral Blood 1, Peripheral Test Name (Method of Analysis: Alcohol Analvsis (GC/FID-Headspace) Antemortem Blood (Serum) Specimen Tested Result Alcohol (Ethanol) 0.06 Acetone, Isopropanol, Methanol Not Detected Drugs of Abuse Screen Antemortem Blood (Serum) Amphetamines Not Detected Benzodiazepines Not Detected Buprenorphine Not Detected Cannabinoids Not Detected Carisoprodol Not Detected Cocaine metabolites Not Detected Fentanyl Not Detected Methadone Not Detected Opiates Not Detected Oxycodone Not?Detected (PCP) Not Detected Zolpidem Not Detected A ntemortem Blood (Serum) was collected on 5/l 3/2018 at 2244 hours Unless otherwise requested, all specimens will be destroyed six (6) months after the closure of the case by the Medical Examiner End Results Approved and Signed: 06/06/2018 Iain M. McIntyre, Forensic Toxicology Laboratory Manager 2018-01247 An American Board of Forensic Toxicology (ABF T) Accredited Laboratory Pagel of