Forensic Sci Med Pathol (2012) 8:73–75 DOI 10.1007/s12024-011-9226-9
IMAGES IN FORENSICS
Blunt head trauma or extensive tension pneumothorax? C. Buschmann • J. C. Hunsaker III A. Correns • M. Tsokos
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Accepted: 27 January 2011 / Published online: 13 February 2011 Ó Springer Science+Business Media, LLC 2011
Case report The emergency medical squad and police found a 60-yearold alcoholic dead in his unlocked apartment. On first inspection at the death scene, lividity of the supine body was pronounced in the head and neck area (Fig. 1), the eyelids (within the livid area) were discolored blue and markedly swollen, and bloody purge trickled from the nose (Fig. 2). Ostensibly subacute, partially scabbed skin lesions on the arms, hands and kneecaps were identified, and a brownish, scabbed, 1 cm-long wound was present on the back of the head, which was suggestive of a possible physical argument and battery. Despite the absence of other injuries or indications of a struggle at the death scene, investigators postulated that fatal blunt head trauma due to a physical attack had occurred. The man had been last seen 4 days earlier when he fell down while intoxicated without obvious injury. At forensic external examination, a generalized parchment-like, crepitant cutaneous emphysema invested the entire body, notably including a prominently distended pneumatoscrotum. Autopsy revealed the cause of death to be an extensive tension pneumothorax, which was characterized by the following: (a) collapsed lungs; (b) depression
C. Buschmann (&) A. Correns M. Tsokos Institute of Legal Medicine and Forensic Sciences, University Medical Centre Charite´—University of Berlin, Turmstr. 21, Building N, 10559 Berlin, Germany e-mail:
[email protected] URL: http://remed.charite.de J. C. Hunsaker III Kentucky Justice and Public Safety Cabinet, Central Laboratory Facility, University of Kentucky, 100 Sower Boulevard, Ste 202, Frankfort, KY, USA
Fig. 1 Death Scene
Fig. 2 Bloated face by skin emphysema, particularly of the orbits, and traces of bloody purge from the nose due to gravity-dependent craniofacial hyperemia
of the diaphragm; (c) pneumomediastinum; and (d) pneumopericardium, which was attributed to (e) a fractured 7th rib in the right posterior axillary line; the sharp-edged bone
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craniofacial congestion due to both tension pneumothorax and the slight head-down position after death. Toxicological examination revealed cannabis and benzodiazepine abuse 1–2 days before death, but no acute intoxication.
Discussion
Fig. 3 Fracture of the 7th rib in the right posterior axillary line with sharp-edged bone fragments protruding into the chest cavity
Fig. 4 Stab injury of the right lung with subpleural entrapped gas bubbles
ends protruded into the chest cavity (Fig. 3), corresponding to an 0.2 9 0.3 cm superficial puncture of the right lung (Fig. 4). The subcutaneous tissue superjacent to the rib fracture was discretely hyperemic; the overlying skin was intact. There were no cutaneous petechial hemorrhages. The bloody fluid exuding from the nose was ascribed to
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Generalized subcutaneous emphysema at postmortem examination included differential diagnostic considerations of putrefaction, infection or pneumothorax. Putrefaction could be excluded initially since the body presented no signs of decomposition; gas gangrene from clostridial myonecrosis or mixed local soft tissue infections with subsequent skin emphysema [1] could be excluded after autopsy. The remaining issue to be elucidated was whether the orbital swelling was either from blunt impact trauma or due to skin emphysema produced by tension pneumothorax. As there were no injuries to the face, a traumatic origin was ruled out. The swelling of the eye socket was most likely to be caused by generalized skin emphysema in combination with increasing upper body congestion (tension pneumothorax), and exacerbated by the slight headdown position at death [2] with development of dependent lividity of the orbits. It was hypothesized that the man must have fallen backwards onto a rounded edge, which caused planar blunt impact with rib fracture and superficial penetrating lung injury, resulting in bronchopleural fistula. In view of the degree of tension pneumothorax at autopsy, investigators opined that the time interval between the fall and death was at least several hours. Delayed (tension) pneumothoraces up to 2 days after trauma are described in the literature [3]. In cases of polytrauma, the incidence of tension pneumothorax is up to 5%, and skin emphysema is a universal sequela [4]. In contrast to pneumothorax per se, tension pneumothorax is caused by a communication between the pleural space and atmosphere with valve effect, so that—during inspiration—air infuses the pleural space, becomes entrapped, and accumulates. Death occurs by pressure-induced displacement of the mediastinum and heart to the contralateral side. Of note is the absence of petechiae in the head and neck area despite upper body congestion by tension pneumothorax, prolonged duration of the agonal phase, and slight head-down dependent position.
References 1. Tsokos M, Schalinski S, Paulsen F, Sperhake JP, Pu¨schel K, Sobottka I. Pathology of fatal traumatic and nontraumatic clostridial gas gangrene: a histopathological, immunohistochemical, and
Forensic Sci Med Pathol (2012) 8:73–75 ultrastructural study of six autopsy cases. Int J Legal Med. 2008;122:35–41. 2. Scha¨fer AT. Death in a head-down position. In: Tsokos M, editor. Forensic pathology reviews, vol. 3. Totowa: Humana Press Inc; 2008. p. 137–54.
75 3. Lu MS, Huang YK, Liu YH, Liu HP, Kao CL. Delayed pneumothorax complicating minor rib fracture after chest trauma. Am J Emerg Med. 2008;26:551–4. 4. Leigh-Smith S, Harris T. Tension pneumothorax–time for a rethink? Emerg Med J. 2005;22:8–16.
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