Fatal splenic rupture following Heimlich maneuver: case report and literature review

The most effective resuscitative procedure in choking by foreign bodies is the Heimlich maneuver, described for the first time by Henry Heimlich (1974) and recognized by the US Surgeon General (1985) as the "only method that should be used for the treatment of choking from foreign body airway obstruction." If performed correctly, this lifesaving maneuver is associated with rare complications, of which the most frequent are rib fractures and gastric or esophagus perforations. Other rare traumatic injuries such as pneumomediastinum, aortic valve cusp rupture, diaphragmatic herniation, jejunum perforation, hepatic rupture, or mesenteric laceration have been described.However, we are unaware of previous reports of splenic rupture after Heimlich maneuver. We present an interesting case of fatal hemoperitoneum due to a hilar laceration of the spleen following a correctly performed Heimlich maneuver.     

The seromuscular tear and other intestinal lesions in the seatbelt syndrome: a clinical and pathologic study of 29 cases

The authors describe the clinical and pathologic findings in 29 patients with injuries from motor vehicle accidents. The seromuscular tear (SMT), the hallmark intestinal injury of the seatbelt syndrome, is an unambiguous lesion similar in all segments of bowel and is caused by a tear that separates the inner muscularis from the submucosa. It is characterized by (1) a wedge that strips the submucosa from the inner circular muscle; (2) a bending retraction of the torn muscularis toward the uninvolved bowel wall; (3) mucosal-submucosal fold effacement, causing the mucosa-submucosa bridge spanning the tear to become paper thin; and (4) the vulnerability of this bridge to ischemia that in 35% of the tears studied culminated in incipient or frank perforations and/or gangrene. Large SMTs, particularly the circumferential degloving type, are most prone to develop these complications. These findings militate against the idea that the SMT is a trivial lesion. The SMT occurred in 90% of patients in this report and accounted for 65% of all intestinal lesions. Seventy-three percent of the tears developed in the colon, and one third of all SMTs occurred in the sigmoid colon. Two thirds of all intestinal and mesenteric injuries clustered in three sites: the ileocecal region, the sigmoid colon, and the jejunum. Perforations were the principal lesion in the jejunum and SMTs at the other two locations. Ninety percent of patients experienced two or more intestinal lesions. This suggests the simultaneous action of different traumatic mechanisms on the bowel and its mesenteries in seatbelted persons who are in motor vehicle accidents.     

Commode Cardia—Death by Valsalva Maneuver: A Case Series

The Valsalva maneuver is used in clinical medicine for the diagnosis and/or treatment of various cardiovascular conditions. It can also be used in activities of daily living, such as defecation. Due to the cardiovascular effects produced during the Valsalva maneuver, it may be contraindicated in certain medical conditions and could be a trigger of sudden cardiac death. The incidence and prevalence of death following Valsalva maneuver in the presence of underlying cardiovascular disease, or “commode cardia,” has not been examined. In 2012, the Wayne County Medical Examiner's Office (Detroit, MI) investigated 21 deaths that occurred on the toilet, fourteen of which were due to cardiovascular disease. In another 31 deaths in the bathroom due to cardiovascular disease, the possibility that the decedent defecated immediately prior to death could not be excluded. Hence, the incidence of commode cardia in this population ranges from 2.3 to 7.4% of all cardiovascular‐related deaths.     

Sudden death in children due to mesenteric defect and mesenteric cyst.

Two cases of sudden death in young female children due to small intestinal volvulus are reported, which involved a mesenteric defect and a mesenteric cyst. Death due to small intestinal volvulus is uncommon, especially when complicated by either a mesenteric defect or cyst.     

An alleged assault by police

A case is presented of self-inflicted injuries alleged to have been sustained during an assault by police. A summary is given of the factors in this case differentiating between self-inflicted injuries and those due to an assault. The desirability of taking photographs of injuries in cases of alleged assault and the importance of keeping an open mind when assessing injuries are emphasised. The need for greater awareness in the medical and legal professions of the advantages of a forensic medical opinion in the assessment of injuries is mentioned.     

An Autopsy Case of Acute Massive Hematochezia Caused by Superior Mesenteric Vein Thrombosis: A First Report in Forensic Medicine

Superior mesenteric vein thrombosis (SMVT) is an uncommon cause of intestinal ischemia and massive gastrointestinal bleeding. This report describes a man with alcoholic liver cirrhosis, who died of massive hematochezia due to SMVT. A medicolegal autopsy disclosed a thrombus at the superior mesenteric vein and hemorrhagic infarction of the bowel wall, an area also within the territory of the superior mesenteric vein. Liver cirrhosis, an enlarged spleen, and esophageal varices without rupture were also observed, but ulcers and variceal bleeding were not. Other organs showed no significant findings. His blood alcohol level was 0.14% w/v. Thus, this man died from severe hematochezia associated with SMVT due to liver cirrhosis and alcohol dehydration, which can lead to coagulopathy and rapid progress of thrombus formation. This is the first report on an alternate cause for massive gastrointestinal hemorrhage with a cirrhotic patient in a forensic autopsy.     

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.     

Comparison of injuries sustained by drivers and pillion passengers in fatal head-on motorcycle collision accidents

This study aimed to compare injuries sustained by motorcycle drivers with those sustained by pillion passengers in fatal head-on motorcycle collision accidents. We examined 84 cases of fatal head-on motorcycle collision accidents, causing 79 deaths of drivers and 19 deaths of pillion passengers, using medical and medico-legal examination records. The distribution of superficial injuries, characteristic injuries, injury severity as well as fatal causes was evaluated and compared using χ(2) tests. The results revealed a significant difference in the distribution of superficial injuries between drivers and passengers. The proportions of injuries in the hand and perineum regions were significantly higher in drivers than passengers. Some characteristic superficial injuries on the palms, chest, abdomen as well as the perineum areas were observed in drivers, while none of these characteristic injuries were observed in pillion passengers. Drivers were found to have suffered more severe chest and abdomen injuries than passengers. In addition, there was a higher incidence of fatalities involving run-over injuries for drivers compared with pillion passengers. The proportion of fatal injuries related to tumbling was higher for passengers than for drivers. Overall, our results revealed a difference in injury severity, superficial injury distribution and characteristic injuries between drivers and passengers. Few characteristic injuries were found in pillion passengers. These findings could help to guide medico-legal examinations, particularly in identifying drivers among victims involved in traffic accidents.     

The forensic evaluation of dental injuries in Istanbul, Turkey

When a person is wounded in Turkey, he first attends hospital for treatment. The hospital is responsible for a report describing his injuries and their treatment and prognosis. The patient is then scanned by a specialist in forensic medicine who provides a final official report. In that report the lesions, the prognosis (including whether the injuries are life threatening or not) and the projected days away from daily activity are shown. In this study 18,317 cases which were examined in the second and the third Specialization Board of the Council of Forensic Medicine during 1996 were analyzed. Among them 112 cases were dental injuries. Dental injuries are reviewed according to their sex, causation, detail of injury, and they are compared to other studies.     

The sensitivity and specificity of control surface injuries in aircraft accident fatalities

Among the important determinations that aircraft crash investigators try to make is which occupant of an aircraft was attempting to control the aircraft at the time of the crash. The presence or absence of certain injuries of the extremities is used to help make this determination. These "control surface injuries" reportedly occur when crash forces are applied to a pilot's hands and feet through the aircraft's controls. We sought to clarify the significance of these injuries and the frequency with which their presence indicates that the decedent was the person that might have been trying to control the aircraft, questions that are frequently asked of the examining pathologist. We studied sequential fatalities of airplane and helicopter crashes in which autopsies were performed by the Office of the Armed Forces Medical Examiner, excluding those that were known to have been incapacitated before the crash and those that were known to have attempted to escape from the aircraft, collecting 100 "qualified" crash decedents. The incidence of control surface injuries was determined for both pilots and passengers. The sensitivity and specificity of control surface injuries were calculated by classifying the decedents into a 4-cell diagnostic matrix. The positive and negative predictive values for control surface injuries were also calculated. Injuries that met the published definitions of control surface injuries had high incidences in passengers, as well as pilots, giving the term control surface injury a diagnostically unacceptable sensitivity and specificity for indicating "a pilot attempting to control an aircraft." We offer caveats and refinements to the definition of these injuries that help to increase the sensitivity and specificity of this term.     

Patterns of injuries in domestic violence in a romanian population

In Romania, the quantification of traumatic injuries is achieved in medical- legal services; therefore, each domestic violence (DV) victim needs a medical-legal certificate to prove in a court of law the presence of traumatic injuries. In this study, we aimed to determine the pattern of traumatic injuries in DV. A total of 219 consecutive DV cases were included. For each victim, a detailed medical-legal examination was performed, including specialized consults, if needed. Results were analyzed statistically using the SPSS software. Traumatic injuries in DV cases were usually located in the head, face, and neck areas and had a low severity index. Severe lesions were found in less than 10% and no sexual aggression was found. The severity increases with age and is higher for males than females. The pattern of DV-associated injuries we have encountered is similar to the one found in other similar studies. Knowing this pattern may be useful in clinical practice to detect cases of DV.     

Bimodal distribution of violent assaults

The aim of the present study was to investigate the relationship between the number of injuries inflicted on victim during violent assault and other variables, characterizing the offender and the assault. The study is based on all the cases that were processed at the City Court of Tallinn, Estonia in 1986 and 1996. The number of assault-related injuries caused to the victim in Tallinn, Estonia, for 1986 and 1996 revealed bimodal distribution. About 2/3 of the assaults resulted in 1-5 injuries, in 1/3 of the cases the number of inflicted injuries was 10 or higher, with only a relatively small number of injuries in between. This distribution pattern was stable over the 10-year interval between the observations and was invariant to alcohol intoxication, consequences, and reasons for the assault. Comparison of the offenders' criminal record during the 15-year follow-up period showed that recidivism was more common among those who had committed a multi-injury assault as their first offence. The evident distribution of assaults into few- and multi-injury groups and the fact that the number of injuries caused during the first offence is a more reliable criterion for predicting the further criminal record of the offender than the consequences of the assault suggest that there are two discrete types of behaviour determined by a set of variables characteristic of the offender's psychology.     

Peculiar circular and C-shaped injuries on a body from the sea

A case where a body with unusual circular injuries was found in the sea is presented. The victim was a 60-year-old woman who had been depressed and had attempted suicide before. She was missing for 6 days before the corpse was found. The body had several almost perfectly circular injuries and C-shaped incision injuries with almost circular flaps of skin. We concluded that the cause of the peculiar circular injuries might be bite marks of Isistius spp. (I. brasiliensis and/or I. plutodus), commonly known as cookie-cutter shark because of its very unusual feeding style.     

腹部穿透创致腹腔积血的法医学鉴定

在法医学鉴定中,当暴力所致的原发损害与医疗过失行为造成的继发损害并存时,应区别“不可避免的”继发损害和“可以避免的”继发损害,并将原发损害与“不可避免的”继发损害一起,作为损伤程度鉴定的依据,而不能将“可以避免的”继发损害也作为损伤程度鉴定的依据。《人体重伤鉴定标准》第七十二条规定了外伤后腹部积血的鉴定原则,如何应用该条款评定损伤程度,需对原发损害与继发损害加以区别,同时,有必要对这一条款进行必要的修改。     

Criteria for homicide and suicide on victims of extended suicide due to sharp force injury

This report is about the findings in association with the extended suicides of nine victims killed by sharp force. All victims were killed by sharp force. The perpetrators were predominantly the parents, the victims their children. Regarding the criteria for differentiating self-inflicted injuries from injuries inflicted by another person, the victims' injuries presented patterns usually found solely in suicides. Thus eight of nine cases presented tentative and hesitation injuries, in three of five cases areas of injury covered by clothing had been exposed beforehand. Despite extremely narrow intercostal spaces in children, injuries to the bones in thoracic stabbing were avoided more often than not (four of seven cases). Only the criterion "defence injury" occurred nearly as often as in homicide victims (three of nine cases). The psychopathology of extended suicide can explain this pattern. The perpetrator's motive is characterised by his pseudoaltruistic belief to save the loved ones from a world that is in his opinion unacceptable. A fusion or integration of the victim into the perpetrator's own self is based on an identity problem. Physical interrelation of forces between perpetrator and victim restricts the victim in his defence and presents an important prerequisite for acquiring the patterns of described injuries.     

Morphologic changes in spinal cord of patients with spinal injuries who died in hospital

Morphologic changes in the spine have been investigated in patients with spinal injuries who died in hospital. The incidence of injuries has been evaluated as 9.3% of mechanical injuries. Purposeful search for possible injuries increased the rate of detection of injuries of the spine and the cord. Spinal cord can be impaired without involving the osseous formations and spinal ligaments. Edema of the cord tissue develops during the early period of injury and prevents the detection of injuries, persisting for a long time after the injury. Edemas are detected even in subjects who died at the site of accident.     

Technical communication: rationale and technique for examination of nervous system in suspected infant victims of abuse

Most victims of fatal child abuse are under the age of 2 years and have a fairly typical pattern of injuries that involve the brain and spinal cord. Documenting these injuries in a systematic fashion is of paramount importance in establishing the cause and manner of death. Although the importance of recognizing these injuries is widely understood, there are few guidelines for the optimal examination of the central nervous system to document these changes. A standard procedure for postmortem dissection of the brain and spinal cord that preserves the anatomy of the cervicomedullary junction is outlined. Changes in the cervicomedullary junction and spinal cord are an underappreciated marker for shaking injury in children. This technique, along with examination of the eyes and optic nerves, will optimally identify the injuries associated with shaking injuries. A standard series of histologic sections are also outlined to document the corresponding microscopic changes.     

ILO standards and compensation for employment injuries in Nigeria

In 2010, Nigeria enacted the Employees’ Compensation Act (ECA) to provide compensation for employment injuries. This work assesses the Act with a view to evaluate the extent of Nigeria’s compliance with the social security minimum standards of compensation for employment injuries set by the International Labour Organisation (ILO). It finds that whilst the ECA 2010 is in substantial conformity with ILO standards, there are core challenges of applicability, adaptability and administration. The work recommends that progressive realisation of the standards and process consideration is imperative for realistic attainment of the philosophy of a compensation scheme for employment injuries in Nigeria.     

Forensic Epidemiologic and Biomechanical Analysis of a Pelvic Cavity Blowout Injury Associated with Ejection from a Personal Watercraft (Jet‐Ski)

Jet‐propelled personal watercraft (PWC) or jet‐skis have become increasingly popular. The means of propulsion of PWC, which is a jet of water forced out of small nozzle at the rear of the craft, combined with a high risk of falling off of the seat and into close proximity with the water jet stream, raise the potential for a unique type of injury mechanism. The most serious injuries associated with PWC falls are those that occur when the perineum passes in close proximity to the jet nozzle and the high‐pressure water stream enters the vaginal or rectal orifice. We describe the forensic investigation into a case of an anovaginal “blowout” injury in a passenger who was ejected from the rear seat position of a PWC and subsequently suffered life‐threatening injuries to the pelvic organs. The investigation included a biomechanical analysis of the injury mechanism, a summary of prior published reports of internal pelvic injuries resulting from PWC falls as well as other water sports and activities, and a comparison of the severity of the injuries resulting from differing mechanisms using the New Injury Severity Score (NISS). The mean (±standard deviation [SD]) NISS values for reported PWC injuries [not including the NISS of 38 in this case study] were 11.2 (±9.5), while the mean value for reported water‐skiing falls was half that of the PWC group at 5.6 (±5.2). It was concluded that the analyzed injuries were unique to a PWC ejection versus other previously described non‐PWC‐associated water sport injuries. It is recommended that PWC manufacturers help consumers understand the potential risks to passengers with highly visible warnings and reduce injury risk with revised seat design, and/or passenger seat “deadman” switches.     

Ankle joint injuries as a reconstruction parameter in car-to-pedestrian accidents

The study has assessed the usefulness of ankle joint injuries for deducing about the presumable location of a pedestrian in relation to a motor vehicle at the moment of collision. A statistically significant correlation was found between the direction of impact and the mechanism of ankle joint injuries. Such injuries were found in 113 of 317 pedestrian, fatal victims of road traffic accidents (36%). In the cases of impacts on the medial surface of the lower limb, the injuries associated with the supination mechanism were six times more frequent than the injuries associated with the pronation mechanism, while in the group of impacts on the limbs from the lateral side those connected with the pronation mechanism were four times more frequent. In victims hit from the back, the injuries connected with the plantarflexion mechanism were found almost four times more frequent than the dorsiflexion mechanism and in victims hit from the front in three of the five damaged joints the dorsiflexion component was observed (without any plantarflexion case). Less frequent "pronation injuries" in the limbs hit from the medial side and "supination injuries" in the limbs hit from the lateral side as well as "dorsiflexion injuries" in victims hit from the back predominantly occurred in impacts to the pelvic area, i.e. resulting from collisions with a van or lorry. Injuries of upper ankle joints are, thus, useful for reconstructing the presumable location of the pedestrian in relation to the vehicle at the moment of collision, especially, when the vehicle involved in the accident is known.