Medico-Legal Update

(1)Meera Th., (2)Nabachandra H.

(1)Senior Tutor,
(2)Professor, Department of Forensic Medicine,
Regional Institute of Medical Sciences, Imphal – 795004.

Abstract

Objective: The objective of the study was to find out the pattern of blunt thoracoabdominal trauma in Manipur as regards the sex ratio, the type of blunt trauma, survival period and cause of death of victims. It also aims at studying the injury severity scores (ISS) of these cases so as to assess what kind of injuries is incompatible with life and what are some of the frequent injury complications and was there any preventable deaths in these cases?

Material and method: Materials for the present study were collected from the 125 cases of blunt thoracoabdominal trauma which were brought for medicolegal autopsy at the mortuary of Forensic Medicine Department of Regional Institute of Medical Sciences, Imphal during the period from October 2001 to July 2003, and these cases were comprehensively studied.

Result: Males outnumbered females in the ratio of 3.8 : 1. The commonest age group of the victims was 21-30 years (20.80%). Vehicular accident was the leading cause of blunt thoracoabdominal trauma (86.40%) followed by assault by blunt weapon (8%). 12.80% of the victims no associated external injuries to the thoracoabdominal region. 59 victims (47.2%) died at the spot. 15 cases (12.0%) died within 1 hour and 13 victims (10.04%) survived less than 2 hours. Only 2 victims (1.60%) survived up to more than 1 week. The commonest cause of death was haemorrhagic shock (as a result of intra thoracic and abdominal bleeding) combined with head injury in 61 (48.80%) cases followed by haemorrhagic shock alone in (44%) of the cases. Peritonitis was the cause of death in 2 (1.60%) cases. It was found that in victims with low ISS (21-30 and 31- 40 ISS score ranges) survival was more as compared to the victims with high ISS (51-60, 61-70 and 71-75 ISS score ranges). The spot-death victims had a mean ISS score of 61.73 and cases who died within 1 hour showed 48.33 as the mean ISS. Mean ISS was low in those victims who survived more than 1 week i.e.27.50.

Kewords: Blunttrauma, thoracoabdominal injuries, survival period and injury severity score (ISS).

INTRODUCTION

The road traffic accident has always been a leading cause of blunt trauma throughout the world. At the same time, blunt weapons are some of the most easily available weapons during an unanticipated fight or assault. The thoraco-abdominal region, because of its dimension and anatomical position, is a major site of impact in any form of blunt trauma viz. road traffic accidents, the fall from heights, landslides, physical assaults, etc. Subsequent to blunt trauma, the thoracic and abdominal walls may show abrasions or bruises; but the abdominal wall usually escapes gross injury by transmitting the force of violence to more resistant organs inside the abdominal cavity, which get injured1. Contusions or lacerations of the lungs and the heart may be produced by blows from a blunt weapon or by compression of the chest even without fracturing any bone of the thorax or showing marks of external injury2. So, there is always a possibility of fatal thoracoabdominal injuries to be unnoticed leading to their late detection and fatal outcome. Moreover, injuries to the chest and abdomen are commonly associated with injuries to other parts of the body, namely the head, spine, limbs, etc. Hence, the presence of intra-thoracic and intra-abdominal injuries may be overlooked or discovered later. Early detection of the injury and prompt treatment are necessary in saving the lives of many of these victims.

The Injury Severity Score (ISS), which was first formulated by Baker et al.3 from the Abbreviated Injury Scale (AIS), is an anatomical scoring system that gives an overall score for cases with multiple injuries. Thus, a postmortem study of injury severity score in blunt thoracoabdominal trauma was carried out as the autopsy of injured persons dead on the spot can point out what kind of injuries is incompatible with life as well as with their severity. The autopsy of injured persons who survived trauma can also point to the most frequent injury complications, clinical diagnosis and preventable deaths4.

MATERIAL AND METHODS

Materials for the present study were collected from the 125 cases of blunt thoracoabdominal trauma which were brought for medicolegal autopsy at the mortuary of Forensic Medicine Department of Regional Institute of Medical Sciences, Imphal during the period from October 2001 to July 2003, and these cases were comprehensively studied.

The criteria used for selection of cases for this study were as follows: A) All the cases showing fatal thoracic injuries with or without external injuries were considered for this study. B) All the cases showing fatal thoracic and/ or abdominal injuries with any associated body injuries, both of which having jointly contributed towards the death were also included. C) All those cases of thoracic and/ or abdominal injuries with or without any associated body injuries, which were hospitalized following trauma and subsequently succumbed to their injuries, were also included in the study. Decomposed bodies and those cases where the nature of sustenance of injury was not known were not included in the study.

For the establishment of injury severity score, the injuries are ranked on a scale of 1 to 6 as follows as per AIS (Abbreviated Injury Scale)

AIS Score	Injury
1	Minor
2	Moderate
3	Serious
4	Severe
5	Critical
6	Unsurvivable

Each injury is assigned an Abbreviated Injury Scale (AIS) score and is allocated to one of six body regions i.e.

1. Head or Neck injuries – include any injury of the cervical spine, cervical spinal cord, skull, brain and ears.
2. Face injuries – include mouth, eye, nose and facial bone injuries.
3. Chest injuries – include injuries to all of the internal chest cavity organs, the diaphragm, thoracic spine and rib cage.
4. Abdominal injuries- include injuries to all the internal abdominal organs, pelvis and the lumbar spine.
5. Extremities injuries- include all sprains, fractures, amputations and dislocations. 3 External injuries- include all contusions, abrasions, and lacerations independent of their location.

For the calculation of the ISS, only the highest AIS score in each body region is used. The 3 most severely injured body regions have their score squared and added together to produce the ISS score which ranges from 1 to 75. If a victim has any injury with an AIS value of 6, the ISS is assigned a value of 75.

RESULTS

Out of the 125 cases of blunt thoracoabdominal trauma studied, males comprised 79.20% of cases; and the male: female ratio was 3.8 : 1. Male victims in the age group of 21-30 years (20.80%) followed by the age group of 31-40 years (18.40%) were the commonest victims (Table-1). As shown in Table-2, it was observed that vehicular accident was the commonest cause accounting for 86.40% of the cases. Other causes of blunt trauma included assault by blunt weapon in 10 cases (8.00%) and 3 (2.40%) victims who were hit by fall of heavy objects viz. boulder.

In the present study, 87.20% of the cases showed associated external injuries on the thoracoabdominal region while the remaining 12.80% did not show any external injuries (Table-3). But all the victims showed some amount of injuries in the form of abrasions, bruises and lacerations on the face and limbs.

59 victims (47.20%) of blunt thoracoabdominal organ trauma died at the spot. 15 cases died within 1 hour. 6 of out these 15 cases (12.00%) were declared brought dead when they reached the hospital since they died on the way. It took almost 45 to 50 minutes for them to reach the hospital from the site of the incident and they were declared brought dead when they reached the hospital. 10.04% of the cases survived less than 2 hours. Only 2 victims (1.60%) survived up to more than 1 week as shown in Table–4.

The commonest cause of death observed was haemorrhagic shock (as a result of intra thoracic and abdominal bleeding) combined with head injury in 61 (48.80%) cases followed by haemorrhagic shock alone in (44%) of the cases. Cardiac tamponade was the cause of death in 3 (2.40%) cases and peritonitis combined with head injury in 4 (3.20%) cases. Peritonitis alone was the cause of death in 2 (1.60%) of the cases with intestinal lacerations (Table – 5 ).

It was observed that in victims with low ISS (21-30 and 31-40 ISS score ranges) survival was more as compared to the victims with high ISS (51-60, 61-70 and 71-75 ISS score ranges). The spot-death victims had a mean ISS score of 61.73 and cases who died within 1 hour showed 48.33 as the mean ISS. Mean ISS was low in those victims who survived more than 1 week i.e.27.50 (Table- 6).

DISCUSSION

Males outnumbered females in a ratio of 3.8 : 1, which is in concurrence with the findings observed by several workers5,6,7,8. This male dominance is explainable by the fact that males are more exposed to hazards of roads, industry and violence as they are the working and earning members in majority of families.

In the present study of thoracoabdominal trauma victims, it was observed that the majority of the cases were in the age group of 21-30 years (23.20%) followed by the age group of 31-40 years (22.40%). Similar findings were reported by workers like Chandra J. and Dogra T.D.5, Chandulal R.9, Sinha S.N et al.10. The large number of cases in this age group can be explained by the fact that this age group is the most active period in life, and young persons in this age group are at the peak of their creativity and have the tendency to take unwarranted risk, thereby subjecting themselves to the danger of accidents and injuries.

In the present series, majority of blunt thoracoabdominal injuries were due to vehicular accidents (86.40%). This finding is also in agreement with those observed by numerous workers10,11,12,13. Ameh E.Z. et al.14 also observed that the commonest cause of blunt abdominal trauma was vehicular accident (57%). This could be explained by poor maintenance of roads as well automobiles and gross indiscipline by drivers, unlicensed drivers, over-speeding, reckless driving as well as reckless movement on the roads by pedestrians.

Mason J.K.15 observed that minor abrasions and bruises to ragged lacerations and degloving injuries in all the pedestrians with face, arms and legs being injured on every occasion. In the present study too, since the majority of the victims (86.40%) were victims of traffic accidents, the external injuries were seen on the face, limbs and thoracoabdominal region even though 12.80% of the victims did not show any associated injury of the region.

On the spot emergency medical care and rapid transportation from the incident site to the hospital is emphasized by the fact that 6 of out these 15 cases died within hour were declared brought dead since it took almost 45 to 50 minutes for them to reach the hospital from the site of the incident. However, Daly K.E. and Thomas P.R.16 observed that majority of deaths due to multiple injuries (70%) occurred before arrival at a hospital.

The finding of Haemorrhagic shock combined with head injury as the commonest cause of death (48.80%) in the present study is in agreement with the findings observed by Brainard B.J. et al.17and Segers P. et al.8. This could be explained by the fact that thoracoabdominal trauma is often accompanied with head injuries.

Cases of peritonitis combined with trivial head injury died within 1 to 7 days of hospitalization while they were being treated for head injuries. But the presence of intestinal and stomach injuries were overlooked as it was associated with the head injury. Moreover, the possibility of any intraabdominal injury was sidelined since there were no associated external injuries of the region in 2 of these 4 cases. Similar observation was made by Daffner R.H. et al.21.

Only 2 (22.22%) cases died of peritonitis following intestinal injuries. In these two cases, no surgical intervention was made and they could have been saved by a prompt treatment. Sahdev P. et al.19 also opined that out of the 177 autopsies of road traffic accidents, 23% of the deaths were preventable. Similar observations were made by Nikolic S. et al.4.

Anderson S. et al.22 analysed 390 trauma cases (95% Blunt) with ISS (Injury Severity Score) greater than 12 and identified 61 missed injuries (Abbreviated Injury Scale, AIS>1) in 54 victims (13.8%) of which three were abdominal injuries. Further Brainard B.J. et al.17 observed an average injury severity score (ISS) of 20.5 among all the cases. It was observed in the present study that the spot death victims had a mean ISS of 61.73. The victims who survived for less than 1 hour had a mean ISS of 48.33, while mean ISS for those victims who survived for more than 1 week was 27.50, thereby showing that victims with low ISS survived longer than victims with higher ISS values. This is in agreement with the findings observed by Nikolic S. et al.4. These variations in survival period with ISS can be of value in the management of thoracoabdominal trauma cases.

CONCLUSION

Thoracoabdominal organ injuries may occur without any external injury in the region, so any victim with a history of forceful impact on the area without any visible external injury should be promptly and thoroughly examined to find out any serious damage in the internal organs. A timely diagnosis and surgical treatment would help in diminishing the morbidity and mortality rates in these cases. All the victims of head injury with coma and developing shock soon after must be considered as having intrathoracic or abdominal injury until confirmed otherwise.

The relationship between ISS and survival period can be of immense value in the management of thoracoabdominal trauma cases. Simultaneously, from the medicolegal point of view, it can also find out whether death was due to trauma; whether it was the consequence or complication of injury; what could be the cause and nature of death; whether it was preventable; whether there were possible malpractice or negligence, etc4.

REFERENCE

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TABLE – 1. SHOWING AGE AND SEX WISE DISTRIBUTION OF CASES

Sl.No.	Age Group in Years	Males		Females		Total	P.C (%)
		No.	P.C(%)	No.	P.C(%)
1.	0-10	2	1.60	4	3.20	6	4.80
2.	11-20	13	10.40	4	3.20	17	13.60
3.	21-30	26	20.80	3	2.40	29	23.20
4.	31-40	23	18.40	5	4.00	28	22.40
5.	41-50	15	12.00	6	4.80	21	16.80
6.	51-60	13	10.40	3	2.40	16	12.80
7.	61-70	6	4.80	0	0	6	4.80
8.	71-80	1	0.80	1	0.80	2	1.60
	Total	99	79.20	26	20.80	125	100.00

TABLE – 2. SHOWING THE TYPES OF BLUNT THORACOABDOMINAL TRAUMA

Sl. No.	Type Of Trauma	No.	P.C (%)
1.	Vehicular Accident	108	86.40
2.	Assault by Blunt Weapon	10	8.00
3.	Hit by fall of heavy objects (boulders)	3	2.40
4.	Fall from Height	3	2.40
5.	Kick by Horse	1	0.80
	Total	125	100.00

TABLE-3. SHOWING THE RELATIONSHIP BETWEEN BLUNT THORACOABDOMINAL ORGAN INJURIES AND ASSOCIATED EXTERNAL INJURIES IN THE REGION

Sl.No.	Thoracoabdominal organ injuries	No.	P.C (%)
1.	With associated external injuries	109	87.20
2.	Without associated external injuries	16	12.80
	Total	125	100.00

TABLE – 4. SHOWING SURVIVAL PERIOD OF VICTIMS

SURVIVAL PERIOD
	Spot	< 1	>1-2	>2- 6	> 6-12	>12-24	>1- 7	>1- 2
No. of cases	59	Hr 15	Hrs 13	Hrs 19	Hrs 5	Hrs 3	Days 9	Wks 2	Total 125
P.C.	47.20	12.00	10.04	15.20	4.00	2.40	7.20	1.60	100.00

TABLE – 5: SHOWING THE CAUSES OF DEATH IN 125 CASES OF BLUNT THORACOABDOMINAL TRAUMA

Sl. No.	Causes of death	No.	P.C
1	Haemorrhagic sock + Head Injury	61	48.80
2	Haemorrhagic shock	55	44.00
3	Cardiac tamponade	3	2.40
4	Peritonitis + Head injury	4	3.20
5	Peritonitis	2	1.60

TABLE-6. SHOWING SURVIVAL PERIOD IN RELATION TO INJURY SEVERITY SCORE

Sl. No.	ISS SURVIVAL PERIOD
1.	0-10	Spot 0	< 1 Hr 0	>1-2 Hrs 0	>2-6 Hrs 0	>6-12 Hrs0	>12-24 Hrs 0	>1-7 Days 1	>1-2 Wks 0
2.	11-20	1	0	1	1	0	0	1	0
3.	21-30	3	2	1	4	1	1	4	2
4.	31-40	7	1	2	8	4	2	0	0
5.	41-50	4	7	8	5	0	0	3	0
6.	51-60	8	2	1	1	0	0	0	0
7.	61-70	4	0	0	0	0	0	0	0
8.	71-80	32	3	0	0	0	0	0	0
	Total	59	15	13	19	5	3	9	2
	Mean ISS	61.73	48.33	39.38	35.42	33.60	32.33	30.22	27.50

Dr Th. Meera,
Senior Tutor, Department of Forensic Medicine,
Regional Institute of Medical Sciences
Imphal – 795004
E-mail: [email protected]