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.     

Left Diaphragm Laceration Due to Cardiopulmonary Resuscitation

External cardiac massage is the essential life‐saving gesture for the management of any cardiac arrest. Since the 1960s, many recommendations have been published to improve the effectiveness of chest compressions alongside the development of automated systems intended to maximize the chances of survival. The use of these manual and/or instrumental techniques can cause secondary injuries, of which rib fractures are the most commonly observed by forensic pathologists. However, a comprehensive review of the literature seldom highlights reports of injuries to the abdomen, even less so to the diaphragm. In this observation, an iatrogenic left diaphragmatic laceration for the first time is described, as a result of manual and instrumental cardiopulmonary resuscitation, in a victim from an intrathoracic wound caused by a bladed weapon.     

Complete Cardiac Rupture Associated with Closed Chest Cardiac Massage: Case Report and Review of the Literature

Chest skeletal injuries are the most frequent complications of external chest massage (ECM) during cardiopulmonary resuscitation, but heart and great vessels lacerations that are indeed very rare. We report the case of a 35‐year‐old workman who collapsed and underwent ECM by his co‐workers for almost 30 min. At autopsy, no external injuries, fractures or bruises of the ribs or sternum, were observed. A hemopericardium with a rupture of the heart was found, with no signs of pre‐existent cardiac disease. Bruises of thoracic aortic wall, lung petechiae, a contusion of the liver, and bruises of lumbar muscles were found. The cause of death was due to sudden cardiac death with an extensive cardiac rupture. This is an unusual report of massive heart damage without any skeletal or muscle chest injuries, secondary to cardiopulmonary resuscitation. This kind of cardiac lesions may be considered when thoracic–abdominal trauma, or medical history, is unclear.     

Characterization and Comparison of Injuries Caused by Accidental and Non‐accidental Blunt Force Trauma in Dogs and Cats

Motor vehicle accidents (MVA) are often difficult to distinguish from non‐accidental injury (NAI). This retrospective case–control study compared animals with known MVA trauma against those with known NAI. Medical records of 426 dogs and cats treated after MVA and 50 after NAI were evaluated. Injuries significantly associated with MVA were pelvic fractures, pneumothorax, pulmonary contusion, abrasions, and degloving wounds. Injuries associated with NAI were fractures of the skull, teeth, vertebrae, and ribs, scleral hemorrhage, damage to claws, and evidence of older fractures. Odds ratios are reported for these injuries. MVA rib fractures were found to occur in clusters on one side of the body, with cranial ribs more likely to fracture, while NAI rib fractures were found to occur bilaterally with no cranial–caudal pattern. Establishing evidence‐based patterns of injury may help clinicians differentiate causes of trauma and may aid in the documentation and prosecution of animal abuse.     

Patterns of Ecchymoses Caused by Manner of Death and Collateral Injuries Sustained in Bruising Incidents: Decedent Injuries,Profiles, Comparisons,and Clinicopathologic Significance

Abstract: We investigated how ecchymoses could be used to predict other injuries, or help establish the cause of death. Ecchymoses, fractures, lacerations, abrasions, and other data were recorded. Eleven percent of decedents had ecchymoses. Motor vehicle accident by car (MVA‐C) was the most common cause of ecchymoses and showed the most collateral injuries. Decedents of natural causes were more likely to have ecchymoses without collateral injuries. There appeared to be two groups of decedents with ecchymoses: one group is younger, comprised of victims of MVA‐C and homicides, with more injuries related to ecchymoses than others; another is an older group of victims of other accidents, natural causes, and suicide. There were no indeterminate causes of death among decedents with ecchymoses. Therefore, ecchymoses may be a surrogate marker to direct the pathologist to continue to seek a cause of death should be seen, even if the case, otherwise, appears to be indeterminate.     

Characteristics of child abuse by anteroposterior manual compression versus cardiopulmonary resuscitation: case reports

Lethal and sublethal injuries to infants caused by anteroposterior manual compression can be accompanied by lateral rib fractures, hemorrhage into the viscera, and when severe, rupture of large vessels and solid organs. Abusers may claim that these injuries were sustained in an attempt to perform cardiopulmonary resuscitation (CPR). The difference between injuries caused by CPR and injuries caused by inflicted anteroposterior compression is examined in one sublethal and two lethal cases.     

Causes and Mechanisms of Death in Fatal Water Buffalo Attacks

Deaths due to buffalo attack have not been well described. A 72‐year‐old man was trampled by a water buffalo (Bubalus bubalis) while attempting to move the animal within an enclosed area at an abattoir. At autopsy, there were numerous injuries involving the chest, head, neck, and left upper arm. Blunt force injury had resulted in multiple rib fractures with a flail chest and fracture/dislocation of the mid‐cervical vertebrae caused either by physical crushing by the animal against the walls of the enclosure or by stomping. There was also evidence of crush asphyxia with bilateral conjunctival hemorrhages and petechial hemorrhages. In addition, there was a deep degloving injury of the upper left arm compatible with goring by one of the buffalo horns. While large animal attacks may result in death from multiple injuries, careful dissection and examination of specific injuries at autopsy may clarify the complex interaction of lethal mechanisms.     

Can Neck Contusions in Unexplained Pediatric Deaths be Explained by Cardiopulmonary Resuscitation?

The distribution of cutaneous contusions in infants may raise the possibility of maltreatment. Neck contusions are particularly problematic since they seldom occur outside the setting of abuse, while cardiopulmonary resuscitation (CPR)‐related maneuvers may involve the neck. To address the role of CPR in neck findings, we examined 260 consecutive pediatric autopsies in which CPR was attempted. No neck contusions were identified in manners of death classified as natural, undetermined, or suicide. Contusions were present in two of 80 deaths classified as accident and had obvious accidental causes. About 26% of deaths classified as homicide had neck contusions with no explanation provided by the caregiver (p < 0.0001). In conclusion, neck contusions in deceased children with no apparent explanation should be regarded as suspicious for abuse and investigated accordingly. CPR is not a plausible explanation for neck contusions in children.     

Enhancing the Visibility of Injuries with Narrow‐Banded Beams of Light within the Visible Light Spectrum

The use of narrow‐banded visible light sources in improving the visibility of injuries has been hardly investigated, and studies examining the extent of this improvement are lacking. In this study, narrow‐banded beams of light within the visible light spectrum were used to explore their ability in improving the visibility of external injuries. The beams of light were induced by four crime‐lites^® providing narrow‐banded beams of light between 400 and 550 nm. The visibility of the injuries was assessed through specific long‐pass filters supplied with the set of crime‐lites^®. Forty‐three percent of the examined injuries improved in visibility by using the narrow‐banded visible light. In addition, injuries were visualized that were not visible or just barely visible to the naked eye. The improvements in visibility were particularly marked with the use of crime‐lites^® “violet” and “blue” covering the spectrum between 400–430 and 430–470 nm. The simple noninvasive method showed a great potential contribution in injury examination.     

Microscopic Pattern of Bone Fractures as an Indicator of Blast Trauma: A Pilot Study

The assessment of fractures is a key issue in forensic anthropology; however, very few studies deal with the features of fractures due to explosion in comparison with other traumatic injuries. This study focuses on fractures resulting from blast trauma and two types of blunt force trauma (manual compression and running over), applied to corpses of pigs; 163 osteons were examined within forty fractures by the transmission light microscopy. Blast lesions showed a higher percentage of fracture lines through the Haversian canal, whereas in other types of trauma, the fractures went across the inner lamellae. Significant differences between samples hit by blast energy and those runover or manually compressed were observed (p < 0.05). The frequency of pattern A is significantly higher in exploded bones than in runover and compressed. Microscopic analysis of the fracture line may provide information about the type of trauma, especially for what concerns blast trauma.     

Determining Bruise Etiology in Muscle Tissue Using Finite Element Analysis

Bruising, the result of capillary failure, is a common physical exam finding due to blunt trauma and, depending on location and severity, a potential indicator of abuse. Despite its clinical relevance, few studies have investigated the etiology of capillary failure. The goal of this study was to determine whether capillaries primarily fail under shear stress or hydraulic‐induced tensile stress. An arteriole bifurcating into four capillaries was modeled using ANSYS 14.0 ^®. The capillaries were embedded in muscle tissue and a pressure of 20.4 kPa was applied. Any tensile stress exceeding 8.4 × 10⁴ Pa was considered failure. Results showed that failure occurred directly under the impact zone and where capillaries bifurcated, rather than along the line of greatest shear stress, indicating that internal tensile stress is likely the primary mode of capillary failure in bruising. These results are supported by the concept that bruising can occur via blunt trauma in which no shearing lacerations occur.     

The Use of Forensic Tests to Distinguish Blowfly Artifacts from Human Blood,Semen, and Saliva

This study investigated whether routinely used forensic tests can distinguish 3‐day‐old or 2‐week‐old fly artifacts, produced after feeding on human blood, semen, or saliva, from the biological fluid. Hemastix^®, Hemident^?, and Hemascein^? were unable to distinguish blood from artifacts. Hemastix^® returned false positives from negative controls. ABAcard^® Hematrace^® and Hexagon OBTI could distinguish blood from 3‐day‐old artifacts, but not 2‐week‐old artifacts. Phadebas^® and SALIgAE^® were unable to distinguish saliva from artifacts. RSID^?‐Saliva was able to distinguish saliva from 3‐day‐old artifacts, but not 2‐week‐old artifacts. Semen tests Seminal Acid Phosphatase, RSID^?‐Semen, and ABAcard^® p30 were all able to distinguish semen from 3‐day‐old artifacts, but not 2‐week‐old artifacts. The tests investigated cannot be relied upon to distinguish artifacts from biological fluids. However, if an artifact is identified by its morphology, a positive result may indicate which biological fluid the fly consumed, and this knowledge may prove useful for investigators searching for DNA.     

Recognition of Skeletal Fractures in Infants: An Autopsy Technique

Abstract:  Complete recognition and documentation of injury pattern is crucial in the diagnosis of child abuse. Skeletal fractures regarded as highly specific to nonaccidental injury in infants include posterior rib, scapular, metaphyseal, and spinous process fractures. These injuries are often occult, especially when acute, to standard radiologic and autopsy procedures. The presented autopsy technique requires incising and reflecting skeletal muscles to expose the bones and costal osseous joints in situ , increasing the opportunity to recognize skeletal injury. Fractured or atypical appearing bones are removed and processed for complete evaluation. The bones are processed by macerating the soft tissue in a water soap bath at an elevated temperature. To aid in reconstruction of the decedent, long bones are replaced with wooden dowels and the chest cavity is packed with the organ bag. The technique is invasive and recommended for cases in which the pathologist has reasonable suspicion of acute or remote trauma.     

Fatal and Nonfatal Rip Saw Injuries

This paper deals with a fatal stab wound suffered by a 29-year-old man and nonfatal injuries of 35-year-old and 67-year-old saw operators. Rip saw is a machine that is specially designed for making a rip cut, a cut made parallel to the direction of the wood grain. Rip-saw-related injuries mostly occur when a person is struck by the cutting material, which usually involves splinters of irregular shape and diameter. When the splinter strikes the body diagonally, the injuries may include abrasions, lacerations, and cut wounds; in situations where the victim is struck directly, the most common injuries are oval- or star-shaped stab wounds with a varying width of abrasions around the wounds. Therefore, such injuries may come across as injuries produced by a knife-like instrument, which is an added difficulty in the interpretation of such injuries.     

A Comparison of Chemical Enhancements for the Detection of Latent Blood,,

Luminol, Bluestar^®, and Hemascein^® were tested to compare detection sensitivities to latent blood. Untreated, EDTA‐treated human blood, and a catalytically similar blood substitute were diluted (neat to 1:1,000,000) and pipetted onto a variety of substrates. Luminol and Bluestar^® performed similarly on all surfaces and fabrics. Hemascein^® yielded poor results on wood surfaces, but performed well in the detection of latent blood on fabrics. Results from untreated, EDTA‐treated, and synthetic blood results indicate that EDTA‐treated blood is similar or slightly less sensitive than untreated blood at all dilutions and on all substrates, and the synthetic blood is less sensitive than real blood, but consistent in detection threshold and thus is useful as a training aid. Additionally, some foods and household chemicals that have previously been shown to cross‐react were tested with Bluestar^®, Hemascein^®, and luminol. Hemascein^® cross‐reacted with many substances, while both luminol reagents were more discriminating.     

The pathological features and circumstances of death of lethal crush/traumatic asphyxia in adults--a 25-year study

A 25-year retrospective study of cases of crush/traumatic asphyxia autopsied at Forensic Science SA, Adelaide, Australia from 1980 to 2004 was undertaken. A total of 79 cases of crush asphyxia was found consisting of 63 males (80%) and 16 females (20%). The age range of the males was 19-86 years (mean=41.8 years) and of the females was 19-75 years (mean=38.6 years). In 18 cases the exact circumstances of death were unclear, leaving 61 cases in which details of the fatal episode were available. Major categories included vehicle crashes (N=37), industrial accidents (N=9), farm accidents (N=6) and entrapment beneath vehicles (N=5). Forty of the 79 victims (51%) had only very minor bruises and abrasions; 28 (35%) had evidence of chest compression with rib and sternal fractures and large areas of soft tissue bruising of the chest; 7 cases (9%) had other significant injuries or findings that had contributed to death. All of these victims had signs of crush asphyxia in the form of intense purple congestion and swelling of the face and neck, and/or petechial hemorrhages of the skin of the face and/or conjunctivae. The pattern of pathological findings of crush asphyxia was not influenced by the presence or absence of concomitant serious or lethal injuries. In 4 cases (5%) where the circumstances of the lethal episode were those of crush asphyxia there were no characteristic pathological findings. This study has shown that a high percentage of crush asphyxias may be caused by vehicle accidents. It has also demonstrated that on occasion fatal crush asphyxia may have to be a diagnosis of exclusion, made only when there are characteristic death scene findings, and no evidence of lethal natural diseases or injuries at autopsy, with negative toxicological screening.     

The Effects of Different Maceration Techniques on Nuclear DNA Amplification Using Human Bone

Abstract: Forensic anthropologists routinely macerate human bone for the purposes of identity and trauma analysis, but the heat and chemical treatments used can destroy genetic evidence. As a follow‐up to a previous study on nuclear DNA recovery that used pig ribs, this study utilizes human skeletal remains treated with various bone maceration techniques for nuclear DNA amplification using the standard Combined DNA Index System (CODIS) markers. DNA was extracted from 18 samples of human lower leg bones subjected to nine chemical and heat maceration techniques. Genotyping was carried out using the AmpF?STR^® COfiler^® and AmpF?STR^® Profiler Plus^® ID kits. Results showed that heat treatments via microwave or Biz/Na₂CO₃ in sub‐boiling water efficiently macerate bone and produce amplifiable nuclear DNA for genetic analysis. Long‐term use of chemicals such as hydrogen peroxide is discouraged as it results in poor bone quality and has deleterious effects on DNA amplification.     

The Accuracy and Applicability of 3D Modeling and Printing Blunt Force Cranial Injuries

The purpose of this study was to determine the factors affecting the accuracy of 3D models and 3D prints of cranial blunt force trauma, to evaluate the applicability and limitations of modeling such injuries. Three types of cranial blunt force lesions were documented (hinge, depressed, and comminuted) using three forms of surface scanning (laser, structured light scanner, and photogrammetry) at two different quality settings (standard and high). 3D printed models of the lesions were produced using two different materials (a gypsum‐like composite powder called VisiJet^® PXL and an acrylic engineered composite plastic called VisiJet^® M3 in crystal colour). The results of these analyzes indicate the prints in this study exhibit some statistically significant differences from the actual bone lesions, but details of the lesions can be reproduced to within 2 mm accuracy.     

An Accelerated Analytical Process for the Development of STR Profiles for Casework Samples

Significant efforts are being devoted to the development of methods enabling rapid generation of short tandem repeat (STR) profiles in order to reduce turnaround times for the delivery of human identification results from biological evidence. Some of the proposed solutions are still costly and low throughput. This study describes the optimization of an analytical process enabling the generation of complete STR profiles (single‐source or mixed profiles) for human identification in approximately 5 h. This accelerated process uses currently available reagents and standard laboratory equipment. It includes a 30‐min lysis step, a 27‐min DNA extraction using the Promega Maxwell^®16 System, DNA quantification in <1 h using the Qiagen Investigator^® Quantiplex HYres kit, fast amplification (<26 min) of the loci included in AmpF?STR^® Identifiler^®, and analysis of the profiles on the 3500‐series Genetic Analyzer. This combination of fast individual steps produces high‐quality profiling results and offers a cost‐effective alternative approach to rapid DNA analysis.     

Breaking point? An analysis of fatal stab wounds to the torso in Ireland between 2011 and 2018, examining the extent of rib fractures

This study examines the pattern of rib injuries occurring in cases of fatal torso stab wounds in Ireland between 2011 and 2018. It has been suggested by previous studies that rib fractures are not commonly sustained in stab wounds to the torso. We wanted to ascertain whether this was the case, as our data suggested that rib fractures were frequent, and where a rib is fractured there is a higher chance of organ injury and death, making this an important area of study. One hundred and forty seven cases of fatal stab wounds from an eight-year period were retrospectively reviewed. Fatal stab wounds to other body areas, were excluded; leaving a total of 104 cases with stab wounds to the torso. We found that 69.2% of cases had rib injuries, a figure significantly higher than previously reported. Our data suggests that stab wounds to the torso often fracture ribs, putting the underlying organs at increased risk of injury and perhaps contributing to fatality. The amount of force needed to cause a rib fracture can be difficult to quantify and indeed from the high percentage of rib fractures sustained in our data it appears that the ribs may be fractured regardless of the amount of force used; this is borne out by the finding that self-inflicted injuries also caused rib fractures. Our study shows that other factors, such as anatomical positioning and wound depth may have a greater bearing than force in terms of whether a rib fracture is sustained.