Cardiopulmonary resuscitation-related injuries and homicidal blunt abdominal trauma in children

Defendants accused of inflicting fatal abdominal injuries to children occasionally raise the defense that the injuries were caused by cardiopulmonary resuscitation (CPR). The purpose of this study is to answer the question: Does closed chest CPR result in fatal blunt abdominal injuries that can be mistaken for homicidal assault? To that end, a retrospective study was conducted of all homicidal blunt abdominal injuries in children 10 years and younger from the Dade, Broward, and Palm Beach Medical Examiner's Offices from 1981 through 1997. These were compared to cases of children who died of natural causes during the same time period in Broward County who had CPR (control group 1) and to children who died of nonvehicular accidental blunt abdominal trauma (control group 2). Children with life-threatening head injuries were excluded. Medical examiner records, autopsy reports, documenting photographs, and clinical records were reviewed. The data analyzed included subject demographics, whether CPR was performed and by whom, and autopsy findings. Thirty-three child homicides with fatal abdominal injuries were reviewed. Twenty-four (73%) of the homicides received CPR. There was no difference in the nature and severity of injuries between the 24 children who received CPR and the 9 who did not. Three hundred and twenty-four cases of pediatric natural deaths were reviewed, all of which had CPR. No traumatic abdominal injuries were found in any of the children who died of natural causes. Only four children who died of natural causes had evidence of extraabdominal trauma related to CPR. No cases of nonvehicular accidental blunt abdominal trauma were identified during the 17-year period, although there were nonvehicular accidental fatalities due to extraabdominal injuries. The likelihood of CPR-related primary abdominal trauma in child homicides is very low.     

Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario,Canada, 1990-1995

Child death due to repeated episodes of physical assault or neglect has been termed the child abuse-maltreatment syndrome (CAMS). We characterized the injuries in a series of fatally abused or maltreated child to delineate objective diagnostic criteria for the CAMS for use by clinicians and pathologists. All deaths (age <17 years) investigated by the Office of the Chief Coroner for Ontario, Canada during the time period 1990-1995 were reviewed. Cases of CAMS were defined as death due to lethal recent injury or malnutrition in the presence of significant old (healing or healed) injuries indicative of repeated episode of inflicted trauma. The nature and frequency of the various injuries was determined. The frequency of the shaken baby syndrome, and the types and frequency of ano-genital injuries were also studied. Twenty-one cases of fatal CAMS were found in the study period. Most cases had significant recent head injury with intra-cranial hemorrhage (71%). Other significant recent injuries commonly observed included blunt injuries of the skin and soft tissues (67%), blunt abdominal trauma with visceral injuries (14%), and fractures (18%). Eight cases (38%) fulfilled accepted criteria for the shaken baby syndrome. Many children with fatal head injuries had evidence of older head trauma (38% of all cases). A significant minority of cases had evidence of malnutrition due to neglect (10%) or ongoing ano-genital injuries (10%). Most cases of child homicides due to repeated episodes of abuse or maltreatment involve head trauma including shaken baby syndrome. Fractures of long bone and ribs, the classical markers of child abuse, were relatively infrequent compared with head injury. A proportion of cases had ano-genital injuries due to repeated sexual abuse or punitive maltreatment. All clinicians and pathologists must recognize the wide spectrum of injuries in child abuse to ultimate protect the victim or other children in an at-risk situation.     

A case of traumatic osteomyelitis in a victim of child abuse

A premature black female infant born at 31 weeks gestation with history of 4 weeks in the newborn intensive care unit was discharged healthy to the care of her mother and was lost to follow-up. At age 4 months the infant was found dead in bed. There was no history of trauma and no external injuries were noted. There was no attempt at resuscitation. Coroner's autopsy showed acute bronchopneumonia, 3 partially healed skull fractures, a chronic subdural hematoma, chronic intracerebral hemorrhage, retinal hemorrhages, multiple healing rib fractures, a fractured fibula, and a partially healed fracture of the distal right radius. The fracture of the right radius showed a medullary abscess of the bone surrounded by scar tissue and containing pus and granulation tissue. We believe this inflicted fracture became secondarily infected by a hematogenous route. The final diagnosis of the cause of death was pneumonia secondary to multiple blunt force trauma, and the manner of death was diagnosed as homicidal. This is believed to be the first reported case of osteomyelitis in a context of child abuse.     

Sudden death due to delayed rupture of hepatic subcapsular hematoma following blunt abdominal trauma

Blunt abdominal trauma can cause sudden, unexpected death due to injuries to internal organs. Rupture of a hepatic subcapsular hematoma is a relatively rare cause of sudden death following minor blunt abdominal trauma. Death may be delayed several days to weeks. The autopsy is an invaluable diagnostic tool that can be utilized to uncover sudden deaths due to abdominal trauma. The case of an alcoholic who died of a ruptured hepatic subcapsular hematoma is presented. The death investigation revealed that the victim had sustained blunt abdominal trauma during a fall a few days prior to death.     

A Unique Type of Birth Trauma Mistaken for Abuse

Pediatric abusive head trauma is a challenging subject across many disciplines. Of particular importance is the identification of mimics of abuse, so cause and manner of death can be properly assigned. We present the case of suspected child abuse involving an infant who presented unresponsive to the hospital with hypoglycemia, hypothermia, and bilateral parietal fractures. An autopsy revealed fractures associated with organizing scalp hemorrhage and gross leptomeningeal congestion and hemorrhage. The fractures were circular with external displacement, rounded margins, and subperiosteal new bone formation indicative of healing. Birth records revealed vacuum assist and cesarean section delivery. Although vacuum extraction‐related injuries are typically cephalohematomas and/or linear fractures, the outbending and circular morphology of the fractures are consistent with vacuum extraction. Moreover, microscopic neuropathological examination revealed hemorrhagic purulent leptomeningitis. This unique case demonstrates the importance of considering birth trauma in the determination of cause and manner of death of an infant.     

钝力性心脏外伤38例尸检病理学研究

本文研究表明钝力作为原始致伤因素作用于胸部通过压、拉、剪切、旋转等可引起钝力性心脏外伤包括心脏震荡、心脏挫裂伤、心脏玻裂、心脏断离等原发性心脏外伤和继发性乃至迟发性心脏外伤，诸如外伤性心脏炎、冠脉血管炎、血栓形成、外伤性心肌梗塞、外伤性冠状动脉瘤、外伤性室壁瘤、迟发性外伤性心脏破裂等。致命性的心脏震荡，除急性冠循环障碍和心失常外，还可有心脏传导系统和神经组织损伤，尤其心肌肌膜爆裂（ｓａｒｃｏｌｅｍｍａｂｕｒｓｔ）及相应的原纤维膨出畸形变可以作为心脏震荡性外伤的形态学指证。外伤性心肌梗塞和迟发性外伤性心脏破裂以突然发生在外伤后的一定间隔期为特征，应予特殊注意．     

Fatal acute intracranial injury, subdural hematoma, and retinal hemorrhages caused by stairway fall

We describe an infant with an acute subdural hematoma, a fatal head injury, and severe hemorrhagic retinopathy caused by a stairway fall. His cerebral and ocular findings are considered diagnostic of abusive head trauma by many authors. Our literature search of serious injuries or fatalities from stairway or low-height falls involving young children yielded 19 articles of primary data. These articles are discrepant, making the classification of a young child's death following a reported short fall problematic. This case report contradicts the prevalent belief of many physicians dealing with suspected child abuse that low-height falls by young children are without exception benign occurrences and cannot cause fatal intracranial injuries and severe retinal hemorrhages. The irreparable harm to a caregiver facing an erroneous allegation of child abuse requires physicians to thoroughly investigate and correctly classify pediatric accidental head injuries.     

Can computed tomography replace or supplement autopsy?

Postmortem computed tomography (PMCT) has been integrated into the practice of many forensic pathologists. To evaluate the utility of PMCT in supplementing and/or supplanting medicolegal autopsy, we conducted a prospective double-blind comparison of abnormal findings reported by the autopsy pathologist with those reported by a radiologist reviewing the PMCT. We reviewed 890 cases: 167 with blunt force injury (BFI), 63 with pediatric trauma (under 5 years), 203 firearm injuries, and 457 drug poisoning deaths. Autopsy and radiology reports were coded using the Abbreviated Injury Scale and abnormal findings and cause of death (COD) were compared for congruence in consensus conferences with novel pathologists and radiologists. Overall sensitivity for recognizing abnormal findings was 71% for PMCT and 74.6% for autopsy. Sensitivities for PMCT/autopsy were 74%/73.1% for BFI, 61.5%/71.4% for pediatric trauma, 84.9%/83.7% for firearm injuries, and 56.5%/66.4% for drug poisoning deaths. COD assigned by reviewing PMCT/autopsy was correct in 88%/95.8% of BFI cases, 99%/99.5% of firearm fatalities, 82.5%/98.5% of pediatric trauma deaths, and 84%/100% of drug poisoning deaths of individuals younger than 50. Both autopsy and PMCT were imperfect in recognizing injuries. However, both methods identified the most important findings and are sufficient to establish COD in cases of BFI, pediatric trauma, firearm injuries and drug poisoning in individuals younger than 50. Ideally, all forensic pathologists would have access to a CT scanner and a consulting radiologist. This would allow a flexible approach that meets the diagnostic needs of each case and best serves decedents' families and other stakeholders.     

Abusive Pediatric Thoracolumbar Fracture Due to Forced Hyperextension: Case Report,Biomechanical Considerations,and Review of the Literature

Pediatric thoracolumbar fractures are rare due to the physiological differences which afford greater resilience to the immature spine. Most pediatric thoracolumbar fractures occur as the result of high energy trauma, such as motor vehicle accidents, and modes of reasonable accidental injuries are limited by age and developmental capabilities of the child. These fractures can occur as the result of inflicted blunt force trauma and child abuse, and in most cases, the mechanism of injury to the spine is not known. We report the death of a 29-month-old man due to blunt force trauma to the back and forced hyperextension of the thoracolumbar spine causing fracture of the fourth lumbar (L4) vertebral body. A complete forensic examination revealed a previous healing fracture of the anterior aspect of the L4 vertebral body, with acute disruption of the anterior longitudinal ligament overlying the fracture site, complete fracture of the vertebral body, and fatal retroperitoneal hemorrhage. We present a review of the biomechanical considerations of the pediatric spine, a survey of pediatric spinal fractures, and a review of the literature on pediatric abusive thoracolumbar fractures. In this case, there was never a provided explanation for how the injury occurred; however, understanding the biomechanics of the pediatric spine allowed for the determination of the mechanism, force required to produce this specific pattern of abusive spinal injury, and the manner of death.     

Flail Chest Following Failed Cardiopulmonary Resuscitation

Following the death of a woman with blunt force chest trauma, the question was asked how common was the finding at autopsy of a flail chest in decedents after failed cardiopulmonary resuscitation. It was suggested in court that this was an uncommon occurrence. To address this issue, autopsy cases in adults (>18 years) with rib fractures attributable to cardiopulmonary resuscitation were taken from the files of Forensic Science SA over a 7‐year period from 2008 to 2014. Flail chest injuries were defined as those arising from fractures at two sites in at least three consecutive ribs. From 236 cases with rib fractures attributed to resuscitation, a total of 43 flail chest injuries were found in 35 cases (14.8%). The majority occurred in the 60‐79‐year‐old age group. These data suggest that flail chest injuries are a more common sequelae of cardiopulmonary resuscitation than has been previously appreciated in autopsy cases, particularly in the elderly.     

Nonfracture-associated fatal fat embolism in a case of child abuse

Fatal fat embolism is usually thought of as a sequel to long-bone fracture, although cases secondary to soft tissue injury and atraumatic conditions have been infrequently reported. In this case of a two-year-old child-abuse victim who sustained multiple blunt traumatic injuries without skeletal fractures, pulmonary and systemic (brain and kidney) fat emboli were identified. At autopsy, all thoracic and abdominal viscera were intact; cranial contents exhibited only diffuse symmetrical petechial hemorrhages of the white matter. Because of the severe and widespread nature of soft tissue hemorrhage, and the absence of a grossly discernible cause of death, fat embolism was suspected. Using a combination of frozen section with oil red O staining and formalin-fixed osmium stained tissues, the immediate cause of death was determined to be diffuse fat embolism. Review of the literature reveals a pathophysiologic basis for fat embolism in the absence of fracture, both as a consequence of an acute increase in local pressure at the site of trauma and an alteration of the emulsification of blood lipids during shock. In light of these findings, we present this case to remind the forensic science community to consider fat embolism as the cause of death in cases of blunt-force injury without fracture.     

Suicide by blunt force trauma

Suicide by self-inflicted blunt force injury is rare. The authors report a case of a 48-year-old man who initially appeared to have died of a homicidal beating. The pertinent autopsy findings consisted of blunt force closed head injury combined with numerous cutaneous abrasions and contusions of the entire body. Further inquiries confirmed a medical history of paranoid schizophrenia and a previous attempt at suicide. This case represents an extreme example of severe blunt trauma sustained during fatal self-mutilation and masquerading as a homicide. It also underscores the importance of correlating a thorough background investigation with autopsy findings in determining the appropriate manner of death.     

Cardiac Ventricular Laceration Due to Child Abuse: Abusive Ventricular Laceration

Traumatic cardiac ventricular ruptures in children are rare. Only a single case of left ventricular rupture due to child abuse has been reported. We report a child who sustained a fatal left ventricular apical rupture. It appeared to have resulted from hydrostatic forces resulting from abusive blunt thoracic injury. That he was being abused was previously missed when he was presented to the emergency department with facial pyoderma. It was not noted that he also had lip and oral mucosal injury, sites not affected by staph toxins. As a result, his underlying, abusive and secondarily infected, facial flow type scald burn was not appreciated. Within a week thereafter his fatal injury occurred, accompanied by extensive and obvious associated abusive injuries. Postmortem high‐detail whole body computed tomography scanning aided the autopsy. Although rare, ventricular rupture from abusive blunt thoracic injury can occur.     

Patterns of Trauma Induced by Motorboat and Ferry Propellers as Illustrated by Three Known Cases from Rhode Island*

Abstract: Understanding patterns of trauma is important to determining cause and manner of death. A thorough evaluation of taphonomy, trauma, and bone fracture mechanisms is necessary to reconstruct the circumstances of the death. This study examines the skeletal trauma caused by boat propeller strikes in terms of wound characteristics and location based on three cases from Rhode Island. These case studies review the traumatic characteristics caused by propeller injuries and highlight the anatomic regions most likely to sustain skeletal trauma. With this information, investigators may be able to identify propeller trauma even in severely decomposed remains. The discussion of boat propeller trauma also raises issues regarding how forensic anthropologists and forensic pathologists classify trauma (specifically blunt force vs. sharp) and highlights semantic issues arising in trauma classification. The study also discusses why these propeller cases should be classified as blunt trauma rather than sharp or chop/hack trauma. Ultimately, the authors urge consistency and communication between pathologist and forensic anthropologists performing trauma analyses.     

Commotio cordis: A case report of a fatal blow

Commotio cordis secondary to a blunt blow to the chest wall can result in ventricular fibrillation and sudden death in children. While it is commonly reported in adolescents during sporting activities, it may result from non-accidental trauma especially in infants and younger children. We report a case of a 6-month-old baby boy who presented to the emergency department in cardiac arrest. The patient's hospital records, postmortem imaging, and the autopsy results were reviewed. External examination of the infant did not reveal any evidence of trauma. Postmortem imaging revealed multiple healing posterior rib fractures and a metaphyseal corner fracture, both considered fractures highly specific for physical abuse. The autopsy revealed a structurally normal heart with no microscopic abnormalities. The infant's father confessed to hitting the child on the chest after which the child became unresponsive. Given the constellation of postmortem imaging and autopsy findings in addition to the father's confession, the child's death was ruled as a homicide secondary to commotio cordis. Since there are no structural and microscopic abnormalities in the heart autopsy in cases of commotio cordis, timely on-scene investigation and a thorough investigation regarding the mechanism of injury are required to make this diagnosis. Early identification of non-accidental trauma is crucial and can prevent further abuse in other siblings.     

Neck injuries caused by automatic two-point seat belts: an analysis of four cases

Although seat belts significantly reduce the extent and severity of injuries sustained by motor vehicle occupants, seat belts are known to be associated with chest and abdominal trauma. Less commonly understood are severe neck injuries caused by the use of two-point automatic shoulder harnesses without concurrent use of a manual lap belt. Such injuries may include cervical spine fractures, craniocervical dislocations and rarely decapitation. Recognizing patterned injuries caused by seat belts and the ability to correlate autopsy findings with the circumstances surrounding the death will allow for correct interpretation of seat-belt related trauma. The four cases described detail fatal neck injuries as a result of improper seat belt use in which an automatic two-point shoulder harness was used without a manual lap restraint. In two of the cases, the victims were decapitated.     

Fatal Injury Caused by a Ram (Ovis Aries) Attack

Animal‐inflicted injuries to humans are a major public health problem around the world resulting in great morbidity, money loss, and mortality. They are related to wild and domestic animals alike. Animals can cause injuries by various mechanisms—biting, stinging, crushing, goring, stomping, butting, kicking, pecking, etc. We present a case of a ram's attack with fatal consequences. A 4‐year‐old, 120 kg jezersko‐sol?ava breed ram with prior history of aggressive behavior inflicted multiple injuries to his 83‐year‐old owner, who died in the hospital a few hours later due to severe blunt force injuries sustained in the attack. The autopsy revealed the cause of death to be multiple injuries of the thorax and the head. Sheep, even though they are not considered aggressive or large farm animals such as cattle and horses, can inflict serious injuries with devastating results.     

Rupture of liver cell adenoma with fatal massive hemoperitoneum resulting from minor road accident

Blunt abdominal trauma can cause rapid death resulting from serious injuries of internal organs. The liver is commonly involved and may show tearing, usually in its upper surface, resulting in hemoperitoneum eventually leading to death. Minor trauma implies serious liver damage only when previous pathologic changes causing enlargement of the organ are present. The case of a 25-year-old woman who died as a consequence of a minor road accident is reported. At autopsy, the body showed no external injuries, the only relevant finding being a massive hemoperitoneum from the rupture of an unusually large liver cell adenoma. Liver cell adenomas carry a serious risk of spontaneous rupture, which may result in the death of the patient. The occurrence of the rupture after a minor blunt abdominal trauma is highly unusual.     

Death Due to Isolated Jejunal Tear Following Blunt Abdominal Trauma

Small intestinal injury following blunt abdominal trauma has been widely reported. Isolated jejunal tear which is caused by blunt abdominal trauma is rare and is most often seen in road traffic accidents. Here, we report a case of isolated jejunal tear in a 24‐year‐old male truck driver. He was admitted to a tertiary care hospital in a South Indian Metropolitan city with complaints of acute abdominal pain and tiredness following alleged accidental blunt trauma sustained to abdomen due to steering wheel impact. An isolated jejunal tear and adjacent mesenteric contusion and tear were missed by the treating physician even after preliminary investigations, and thus, the conservative management was instituted. The condition deteriorated gradually, and he succumbed to death. The autopsy revealed transverse tear of jejunum almost involving whole of its circumference on the antimesenteric border and peritonitis. Proper use of radio‐diagnostic techniques and timely undertaken explorative laparotomy would have saved the life.     

Fall from height--surprising autopsy diagnosis in primarily unclear initial situations

External post-mortem examination and first police assessments are often not consistent with subsequent autopsy results. This is all the more surprising the more serious the injuries found at autopsy are. Such discrepancies result especially from an absence of gross external injuries, as demonstrated by four examples. A 42-year-old, externally uninjured male was found at night time in a helpless condition in the street and died in spite of resuscitation. Autopsy showed severe polytrauma with traumatic brain injury and lesions of the thoracic and abdominal organs. A jump from the third floor was identified as the cause. At dawn, a twenty-year-old male was found dead on the grounds of the adjacent house. Because of the blood-covered head the police assumed a traumatic head injury by strike impact. The external examination revealed only abrasions on the forehead and to a minor extent on the back. At autopsy a midfacial fracture, a trauma of the thorax and abdomen and fractures of the spine and pelvis were detected. Afterwards investigations showed that the man, intoxicated by alcohol, had fallen from the flat roof of a multistoried house. A 77-year-old man was found unconscious on his terrace at day time; a cerebral seizure was assumed. He was transferred to emergency care where he died. The corpse was externally inconspicuous. Autopsy revealed serious traumatic injuries of the brain, thorax, abdomen and pelvis, which could be explained by a fall from the balcony. A 47-year-old homeless person without any external injuries was found dead in a barn. An alcohol intoxication was assumed. At autopsy severe injuries of the brain and cervical spine were found which were the result of a fall from a height of 5 m. Conclusion: On the basis of an external post-mortem examination alone gross blunt force trauma cannot be reliably excluded.