Imaging protocols for the autopsy service in a time of pandemic emergency minimizing the contagion of SARS-CoV-2 expert government agents

Objective: To contribute to the construction of parameters of biosafety in order to protect government agents in the exercise of their investigative functions in the context of a pandemic, as well as to resolve clinical, pathological and possibly legal issues. Methodology: The development of an exploratory review study with a qualitative approach was defined. The methodological design was carried out on the platforms: PubMed and SciELO through the descriptors: Human identification, Radiology, Virtópsia and Autopsy. The exclusion criteria include articles with duplicate information or that do not have information related to the objectives of the study. For inclusion, materials published in Portuguese, English or Spanish were used and at the end 76 articles were obtained. Results and discussion: Conventional autopsy is the most common method for post-mortem investigation in humans. However, with the evolution of imaging methods and the current pandemic threatening the health of government agents, Virtópsia has shown itself to be the most promising way to remedy the dichotomy of occupational risk and legal benefit. Final considerations: In this article, the main advances in Forensic Radiology in the last 11 years were described, with regard to the use of ante and post mortem radiographs in the identification process. Among the various radiological techniques treated, the following stand out: radiographic techniques produced by radiology professionals with different assessments in the radiological area. The images produced are security methods with invasive manipulation and use of all PPE, suitable for the pandemic moment.


Introduction
In December 2019, the World Health Organization (WHO) reports an outbreak of pneumonia, for reasons initially unknown, in the city of Wuhan, capital of the province of Hubei-China. On January 7, 2020, Chinese scientists isolated a new coronavirus, with symptoms of severe acute respiratory syndrome (Htun et al., 2021;Hui et al., 2021).
Between the months of January 2020 and January 2021, the pandemic has already affected almost one hundred million people and caused the death of around one million worldwide. In view of the high number of deaths, governments do not have biosafety protocols for the proper management of cadavers for the purpose of identification, establishment of the underlying or contributory disease for death (Garrido & Almeida 2020;Jabal et al., 2021).
Those killed by COVID-19 are not classified as violent death, as a rule they do not need to be referred to the Institute of Forensic Medicine. That is, the health authorities are responsible for handling it, and they must provide their employees with adequate training and stay in removing and fighting the proliferation of the virus. However, Death Verification Services (SVO), triggered in cases where the attending physician was unable to declare the cause of death and, in an emergency manner, IMLs are being used (Finegan et al., 2020;Da Silva et al., 2020).
It cannot be omitted that within the national and international recommendations on combating the proliferation of the virus, it includes the minimization of the handling of cadavers, which includes the considerable decrease or even the nonperformance of autopsies in this epidemic context. In the case of contaminated corpses, external examinations must be adopted: anthropometric, thanatological and traumatological, by means of photographs of the entire body and their eventual reconstitution by computer (in the places where these tools exist) (De Lima & Júnio, 2020;Rabay et al., 2020). In addition to internal examinations: x-rays and computed tomography and the removal of tissue, blood and secretions samples by guided biopsy or by means of puncture and aspiration. Other imaging options that can be used within the identification of cadavers is the method of intraoral radiography, extra oral (dental radiology) and intraoral scanning, today used as a digital possibility that is used to replace the plaster model of the dental arch of living beings (Hartmann, 2020). SARS-CoV-2, on the aspects of biosafety, is a pathogen belonging to the same risk group as the agents that cause HIV-AIDS and tuberculosis. Normally, infectious causes are not of medical-legal interest, but SARS-CoV-2 has high mortality rates and its symptoms, in some cases, are mild, which causes the concern of victims of violent death to be carriers of the virus. This is the greatest justification for knowing the national and international recommendations, as well as the establishment of biosafety protocols for imaging exams, in order to minimize the risk of biological exposure (Carvalho & Silva, 2020;Júnior, 2020;Valentin et al., 2020).
In principle, the limitations regarding the handling of cadavers must comply with the legal order of each country and, although, at the moment, we do not have scientific evidence regarding this form of transmission of SARS-CoV-2, care is taken due to direct contact. With the corpse fluids by means of aerosols and splashes at the autopsy, highlighting the need to use personal protective equipment; need for diagnostic tests for the presence of the virus in the corpse before the autopsy, limited by the availability of laboratory tests (Fineschi et al., 2020;Khoo et al., 2020).
This article seeks to contribute to the construction of parameters of biosafety in order to protect government Agents of Expertise, among them: coroners, pathologists, radiologists and professionals of radiological techniques, in the exercise of their investigative functions in a pandemic context, as well as, resolve clinical, pathological and eventually legal questions. Such problem is fundamental to the valuation of forensic radiology as an investigative science and virtópsia as a digital necroscopic technique. And in its specific objective it is analyzing the framework and terminological and technological between the virtópsia and the autopsy, in order to evidence the effectiveness of the techniques of virtual necroscopes in the investigation of violent and non-violent deaths of contaminated corpses, with the intention of evidencing the real efficiency of Forensic Radiology as a complementary expert method of great significance for the construction of a report within the criminal and legal expertise, thus strengthening the team of the General Department of Technical Scientific Police and the Judiciary.

Methodology
In order to achieve the proposed object, it was defined to develop an exploratory review study with a qualitative approach with a focus on the core precepts of the main thinkers in the object's concentration field, as well as in the literature of related areas that also demonstrate depth and commitment to the theme exposed.The methodological design was performed using the platforms: PubMed and SciELO, in order to summarize materials that endorse the proposed theme, the following descriptors were used:Human identification; Radiology; Virtópsia; Autopsy.
The selection of content was carried out through screening by inclusion and exclusion criteria. The exclusion criteria involved articles with duplicate information, or that were not related to the objectives of the study. For inclusion, we selected materials published in Portuguese, English or Spanish, with full access for free and published between 2010 and 2021. First, the titles were analyzed, right after the abstracts, and in sequence the article in its entirety, including content that contemplated the proposed theme. In short, after a critical reading, only 76were selected.

Correlation between macroscopic findings in conventional autopsy and virtopsy
The main objective of forensic radiology is to assist forensic medicine in the documentation, analysis and elucidation of scientific and / or legal issues that arise due to conflicts of interest for the protection of life. In the post-mortem, it seeks to identify the cause of death, estimate the lesions in degree, gender and extent of damage. In ant-mortem, on the other hand, it concentrates a large part of its efforts on the discovery of foreign bodies for the purpose of security and combating drug trafficking andalso, on anthropological and paleonradiological analyzes (Asriet al., 2021;Biswas et al., 2021;Marques et al., 2021).
The macroscopic findings in suspected COVID-19 corpses vary in blocks of studies that are also of interest to virtopsy. Taking into account that the inability to visualize certain pathologies in the virtual autopsy, where the comparability of the normal with the abnormal is essential for its verification, it can be suppressed by the artificial and mechanical return of Research, Society and Development, v. 10, n. 6, e28810615860, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i6.15860 4 the organ functioning (Curado et al., 2020).

Lungs
The lungs, in most cases, are heavier than normal, fissured and edematous, often with bronchopneumonia superimposed on focal consolidation areas, more aggressively in the lower lobes, but usually without a focus pattern in the lobes. Pulmonary thromboembolism was a relatively frequent finding, however, deep venous thrombosis was even more prevalent (Sakr et al., 2021). Table 1. The average lung volume and the increase in lung volume during post-mortem ventilation at different pressures.

Mean lung volume (in l)
Mean lung volume increase (in l)

Heart
In the heart, most of the findings come from pre-existing cardiovascular diseases, especially cardiomegaly and atherosclerosis. In the same way that occurs in the lungs, the detection of some pathologies requires the proper functioning of the vessels, since the main characteristic of cardiovascular diseases is partial or total obstruction and complications due to these changes. It is concluded that post-mortem angiotomographyis the best tool in these cases (Boland et al., 2020).
Many post-mortem radiological findings in the lungs are false negatives due to the lack of physiology in the organ, since a good part of the pulmonary pathologies are detected due to the difference in tissue density in this region. Therefore, in this case, mechanical ventilation is an accessible possibility to overcome this limitation (Willer et al., 2018;Bradley et al., 2020).

External documentation
Photogrammetry is the science of making surface measurements using simple photographs. The three-dimensional photogrammetry technique, known as stereophotogrammetry, is a more advanced technique, in which two or more photographs, in different positions, of a given object are made to offer measures that allow reconstructing the object photographed in three dimensions (Fonstad et al., 2013;Nesbit et al., 2018).  Source: The authors (2021).

Dental photogrammetry
Identity is an inherent right to the Human Being, thus being something inalienable. In this way, human forensic identification is a process through which the identity of a person is determined, being extremely important with respect to Forensic Medicine. Identifying a corpse implies looking for the physical and anthropological signs that allow it to safely establish its civilian personality (Cordner & Tidball-Binz, 2017).
There are many methods used in the identification of human remains, currently most are based on the comparison between ante-mortem data provided and post-mortem constructed in imaging laboratories. Although dermatoglyphics, papiloscopy, that is, the fingerprint analysis technique is considered the most accurate, it is not all cases that it can be used, especially when the bodies were mutilated, decomposed, burned, fragmented and now contaminated by SARS-CoV-2 (Joshi & Dwivedi, 2015;De Boer et al., 2018;Li et al., 2020).
Documentation of intra-oral and extra-oral photos widely used in dental radiology consists of taking ante-mortem photographs of the patient for dental treatments. Thus providing a database for the various dental radiology clinics, with photos of the frontal face, profile, upper and lower occlusal, anterior, right and left occlusion. In addition to these digital photos, some radiographs such as Teleradiography/Cephalometric Frontal and Profile, Panoramic, Periapicals and Hand and Wrist for bone age are registered with the documentation (Manigandan et al., 2015;Viner & Robson, 2017). Intra-oral radiographs can provide important evidence for identifying individuals when used in Forensic Radiology due to the large amount of information recorded on the radiographic film or digital image in DICON -Digital Imaging and Communications in Medicine. Characteristics found in anatomy, such as crown size and shape, pulp anatomy, position and shape of the crest of the alveolar bone, are very important. The factors of the changes caused by caries and the restorations made by dentists are also evaluated (Pandit & Boland, 2015).
This dental treatment presents results with unique and individual characteristics that, in most cases, are clearly visible on periapical radiographs. Thus, the identification technique consists essentially of a comparison between radiographs taken in life (ante-mortem), filed in software from dental radiology clinics, in orthodontic folders sent to patients and or dental offices, with those obtained after death (post-mortem) produced in specific laboratories for analysis (Cho et al., 2018).

Internal documentation
This method was developed in Switzerland in 2000, at the Institute of Forensic Medicine and Diagnostic Radiology at the University of Bern, known as PROJECT VIRTOPSY (Virtual Autopsy). Today, USP has become a pioneer in this project here in Brazil, creating criteria for the use of Scientific Radiology in solving crimes (Nissan, 2012;Bolliger & Thali, 2015).

Forensic identification
Throughout the twentieth century, mainly from the second half of the 1980s, with the great advance of information technology and the emergence of computerized radiology, there was a refinement and improvement of the radiological Research, Society and Development, v. 10, n. 6, e28810615860, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i6.15860 8 technique, thus offering greater accuracy in the identifications (Cnudde & Boone, 2013).
The use of radiological images in the identification processes consists in the comparison between the radiographs obtained ante-mortem and those produced post-mortem, which are providers of a large number of information of the individual, becoming a fundamental tool in the processes related to the establishment of an identity (Ruder et al., 2012).
The radiographs most frequently used in the search for a personal identity are those of the skull, face, long bones and teeth (Manigandan et al., 2015). The radiological images, in an identification process, have a value equivalent to fingerprints and dental exams (Wood & Kogon, 2010). One of the radiological methods of image acquisition useful in human identification is Computed Tomography (CT), which can be obtained in the traditional way, in two-dimensional and three-dimensional images (Guillet et al., 2014). The tomographic film displays the name, sex and age of the patient, in addition, performed antemortem, CT provides information that can be used to produce a post-mortem replica, considering that craniometric points can be accurately located .
Another useful tool in the individual identification process is facial reconstruction, which is a method that allows for the recognition by family members of certain remains without identification (Gupta et al., 2015).
When it comes to the facial reconstruction technique, some studies have opted for the use of Magnetic Resonance Imaging (MRI), because it has higher quality in the formation of the image and visualization of soft tissues (Bettoni et al., 2020).
Another alternative technique about human identification through the use of imagery can be used, such as the superimposition of images, or the skull-photo-comparative method, which consists of individual identification by photographic demonstration, using the superposition of individual photo negatives. Taken ante-mortem on those of the skull skeleton (Krishan et al., 2016).
With the evolution of Radiological Technologies, virtual autopsy has arrived and has been contributing enormously to research in the field of forensic pathology. Fast, non-invasive method that also protects family members from suffering, less traumatic than manual autopsy, when it comes to preserving the integrity of the body. It has 100% accuracy in identifying lesions of various types (Chen, 2017).
With this study, it can be concluded that human identification is something extremely relevant not only in the legal sphere, but also in the social sphere and, for that, Radiology, as well as Medical Imaging, contribute spectacularly to the identity determination and legitimize the it causes death of a person, constituting a safe, reliable, fast and practical method, in addition to being cheap, when compared to other methods such as DNA. However, no character taken in isolation has absolute value, as it is the set of signs and their convergence that allows for the positive identification and closing of a cadaveric report, but we cannot fail to mention the participation of this specialty in all social and investigative spheres (Zerbini & Saldiva, 2014;Savadjiev et al., 2019).

Post-Mortem X-rays
The birth of Forensic Radiology in the world accompanies the discovery of X-rays by the German physicist Wilhelm Conrad Roentgen . In 1896, a year after its discovery, the first criminal case occurred in the USA in which the use of X-rays was essential. The radiological examination of the jaw of the victim killed by a firearm demonstrated the authorship of the murder, due to the presence of the lead projectile in the exposed structure (Tchanque-Fossuoet al., 2011;Panchbhai, 2015).
The discovery of X-rays was a turning point for modern medicine (Widder, 2014). The countless accidents and deaths surrounding irresponsible exposures were useful for the advancement of research on the effects of the interaction of radiation with matter. Even with all the progress, at the first moment, the exams were seen as manifestations of the supernatural Research, Society and Development, v. 10, n. 6, e28810615860, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i6.15860 (Kalmbach, 2013).
In Brazil, it is not known for sure the first researchers to perform the radiology exam, since both chronologically already worked together. For this reason, it is almost impossible to determine precisely the first scientist to inaugurate the method on national soil, although the reports are varied, ranging from Professor Alfredo Brito in Bahia, through researcher Silvia Ramos in São Paulo, and finally at doctor Francisco Pereira Neves in Rio de Janeiro (Matushita, 2011).
Currently, x-rays are used as a primary imaging method at the Institutes of Forensic Medicine. The choice of this method, in the first analysis, does not go beyond technical criteria, since x-rays are the gold standard in the detection of fractures and foreign bodies because it is more economically viable and easy to handle. However, this method does not have a satisfactory range of findings effective in detecting anatomopathological findings due to SARS-CoV-2 (Morais et al., 2011;Lima et al., 2020).

Post-Mortem Computed Tomography -TCPM
CT, in turn, is the worldwide chosen method for opening three-dimensional documentation, due to the best cost, biosafety, quality and dynamism. The combination of both methods can develop dynamic ways of estimating the weight, morphological and even microscopic changes of the dead (Dos Santos et al., 2014).
The first study carried out on human cadavers took place in 1977, in which six cases of skull injuries by firearms were described 36. In 2003, researchers at the University of Bern, Switzerland, combined modern imaging methods, such as CT, MRI and photogrammetry to minimally invasive whole body necropsy (Ghosh, 2015).
Post-mortem CT helps a lot in the diagnosis of death from natural causes, with excellent results in cases of craniofacial trauma and firearm trajectory, besides presenting advantages in the detection of small fractures, injuries by firearms, foreign bodies and gases (Grabherr et al., 2014).

These are nonspecific signs of TCPM
Livor mortis can be seen inside the body in the lungs: on chest CT, the internal livor mortis appears as ground-glass opacity in the dependent lower lobes. Gas bubbles are very common after death due to systemic embolism after major open trauma, artificial respiration or due to the onset of the gas period (Christe et al., 2010;Panda et al., 2015).

They are specific signs of TCPM
Intracranial bleeding is hyper-attenuating both in radiology and in the postmortem image. Signs of strangulation are hemorrhages in the soft tissues of the neck, such as skin, subcutaneous tissue, platysma muscle and lymph nodes. The fluid in the airways with mosaic pulmonary densities and emphysema (aqueous), typical for drowning (Islam et al., 2018).
It is concluded that the postmortem image is a new radiological subspecialty and, unlike diagnostic radiology, standards have not yet been established. In addition to the clinical and postmortem radiology differ significantly in several aspects: the imaging parameters can be adjusted to maximize the quality of the image and the indications in forensic medicine are usually different from those in clinical radiology (Flach et al., 2014).

Post-Mortem Magnetic Resonance -RMPM
MRI can be instrumental in replacing a conventional autopsy in children and neonates, especially for religious families or not, but who deny the authorization of the more invasive exam. Thayyil et al., (2013) demonstrated that 41% of minimally invasive necropsies performed by MRI do not require conventional necropsy.
RMPM is good for visualizing soft tissue injuries in cases of hemorrhage, subcutaneous hematomas, brain and lung Research, Society andDevelopment, v. 10, n. 6, e28810615860, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i6.15860 injuries. In addition to presenting disadvantages in terms of variations due to the corpse temperature at less than 10º C, where we found a decrease in the contrast in the relationship between fat and muscle and an increase in contrast in the relationship between water and fat and water and muscle (Sehba et al., 2011;Thayyil et al., 2013;Cordeiro et al., 2019).

Biosafety and infection control
Biosafety is the set of actions aimed at prevention, protection of the worker and / or patient, minimization of risks inherent to the activities of research, production, teaching, technological and operational development and extends to environmental protection and quality (Balthazar et al., 2017;Lacy et al., 2020).
Within the forensic radiology sector, walls and benches must be made in such a way that they are easy to clean, without sharp angles and recesses, thus avoiding the accumulation of dust. The benches in the material processing area are cleaned using sodium hypochlorite solutions, with 70% alcohol or with iodized alcohol. The floor of the entire unit, in addition to the walls and ceiling, are washed daily (Da Silva et al., 2016;Karus et al., 2018).
The handling of newly sterilized instruments requires the use of protective gloves and a disposable apron. Personnel must wear other personal protective equipment (appropriate clothing, hat or cap, mask, goggles or face shield and gloves) (Loveday et al., 2014;Chughtai et al., 2018;Livingston et al., 2020).

Conclusion
It is concluded that the application of the image investigation techniques demonstrated in this article, evidence the need for hyper specialized training of radiology professionals.
Thus, the forensic expert in radiological techniques has broad participation and expertise in the handling and adaptation of varied radiological resources to scientifically assist in criminal justice, criminal body examinations, anthropological, dental, judicial and or private. This article brings a new perspective of the importance in this Pandemic moment and the direct participation of the professionals of the radiological techniques in the differential diagnosis of SARS-COV-2 (Ante-mortem) and in the closing of the cadaveric report (Post-mortem). The narrative comes to affirm Forensic Radiology as an investigative and multidisciplinary science. The insertion of this science in academic disciplines is necessary, given the range of knowledge necessary for its safe performance. This knowledge in the training matrix and / or specializing will be a divider for hiring in the specific area, being important for the teacher teacher to have these titles or prerequisite for the exercise of differentiated Forensic activity. It is relatively high to raise the banner of this multidisciplinary professional ready to serve society. It is very important to look responsibly at the use of radiation in its various radiological specialties.And that includes Ports, Airports, Industries, Prisons, Agribusiness, Anthropological and Dental, we have full knowledge of biosafety for each job highlighted here. Finally, the view of the researchers in the article presented, it is a Quantum change to protocols suggested by these scientists that will contribute to good Radiological practices in the challenges of a good diagnosis!