EFFECTS OF INJURIES

Prof. Dr Slobodan Savi

Serious bodily injury may

lead to:
INSTANTANEOUS DEATH
destruction of vital organs
explosion
heavy vehicles (train)

traffic accident - passenger in the car

destruction of the head

 DELAYED VIOLENT DEATH

- from various posttraumatic effects

delay may be

short (torrential haemorrhage)

longer (hours, days, weeks, years)
- important for clinicians

HAEMORRHAGE
external

- through the wounds

- via natural passages
internal - into

- body cavities
- organs

external haemorrhage through the wounds

incisions
stab wounds

external haemorrhage through the wounds

firearm injury trajectory through the trunk

external haemorrhage
firearm injury trajectory through the head

external
haemorrhage
through the wounds

via natural passages

internal haemorrhage - retroperitoneal bleeding

rupture of the abdominal aorta

DANGEROUS EFFECTS OF BLEEDING:

actual blood loss

- type, number and size of injured blood

vessels
fatal blood loss - exsanguination
a completely severed artery may bleed

less than one that is only partly

transected due to retraction

 rate of loss compensation

(vasoconstriction, increased heart rate)

decompensation leads to shock

previous health condition

 the amount of activity after injury with

resultant bleeding
- hard to estimate retrospectively
- depends on numerous factors

A male who committed suicide in the presence of a few

witnesses - he cut his throat, pulled out all neck organs with
his hand, then walked across the home yard, lighted a
cigarette and then collapsed and died.

when an injury penetrates the pericardial sac,

bleeding can escape into the pleural cavity, or
even abdomen if the diaphragm is cut
exsanguination

 a stab wound of the heart, usually fatal,

may be associated with unexpectedly long

survival period (a victim may be able to
walk or run, to defend himself or to attack)
a

homicide in which the victim was

stabbed through the heart, yet ran more
than a quarter of mile before collapsing

DANGEROUS EFFECTS OF BLEEDING:

space-occupying and compressive effect

- cardiac tamponade heart compression

haemopericardium (cardiac tamponade)

blood accumulates in the pericardial sac, presses the
heart and prevents the filling by blood during diastole

EXAMPLE 1 - A 25-year-old male during a quarrel

sustained a fist blow to the left temple. He suddenly lost
consciousness and fell down. After about 3 minutes, he
completely recovered. Police took him to a small
ambulance station, where one general practitioner
examined him and diagnosed only a slight haematoma
and swelling in the left temporal region. The doctor
decided that the patient might be discharged and taken
by police. About 6 hours later the same patient was
again taken to the same ambulance station, but in deep
coma, the left pupil was widened, without reaction to the
light stimulus. The patient died very soon after the
second admission.
DIAGNOSIS ?

extradural haemorrhage brain compression

classical clinical picture with
a lucid or latent interval (up to 24 hours)

multifocal subdural hemorrhage

fatal child abuse
autopsy finding

MRI appearance

intraventricular brain haemorrhage

EXAMPLE 2 A 18-year-old male was admitted

to hospital giving anamnestic data that he had
sustained a hard fist blow into the upper right
part of abdomen, just below the right costal
arch. With examination neither external skin
injury on the abdominal wall nor clinical
manifestations of haemorrhage were noticed.
He was discharged from the hospital, but about
3 hours later he suddenly collapsed at home. He
was urgently transported to the same hospital,
and on the second admission he was in the
state of irreversible haemorrhagic shock, with
extremely pail skin and visible mucous
membranes. He died a few minutes after
admission.
DIAGNOSIS ?

liver
subcapsular
haematoma

delayed
intraperitoneal
bleeding
"bleeding in two
periods

BLEEDING WITH DELAYED CLINICAL

MANIFESTATIONS
As the injured person may be completely without
clinical disturbances during the latent interval, may
be discharged from the care of a doctor, and later
suddenly deteriorate and die out of hospital.

This sequence may be the cause of legal actions for

medical negligence against doctors who fail to
anticipate the late development of an extradural
haemorrhage or delayed bleeding from ruptured
subcapsular haematoma.

INFECTION
modern medical services

decreased risk of infection

local infection - aerobic or anaerobic

bacteria
- suppurated wounds and burns, gaseous
gangrene

spreading of infection in vicinity

abdominal stab wound peritonitis

peritonitis

local infection

suppurated
burns

post-traumatic purulent meningitis

Phlegmona basis oris

after tooth extraction

 infection is not necessarily related to the

site of injury

severe craniocerebral injury

hypostatic pneumonia

general infection sepsis after criminal abortion

and resultant hysterectomy - septic shock
jaundice and purpura

bilateral adrenal hemorrhages

splenomegaly bilateral and adrenal hemorrhages

kidneys
bilateral cortical necrosis

brain multiple hemorrhages - DIC

EXAMPLE 3 A 60-year-old female was injured

as a pedestrian. She sustained fractures of the
right femur, tibia and fibula. The whole right leg
was immobilised on admission to hospital.
Otherwise she was in rather good condition,
without signs of lesion of vital organs. On the
10th day after injuring, when she was moved
from bed in order to be transported for control
roentgenography, she suddenly got severe
dyspnoea and retrosternal pain, she was pale
and cold sweated in the face. Her condition
deteriorated progressively, with facial cyanosis,
signs of shock and insufficiency of the right
side of the heart, and rapid fatal outcome.
DIAGNOSIS ?

pulmonary thromboembolism riding embolus

source - phlebothrombosis in the iliac veins

EMBOLISM
an embolus - a foreign bolus which migrates
through the vascular system, causing damage
when it lodges at some place in circulation
solid
liquid
gaseous

PULMONARY THROMBOEMBOLISM
phlebothrombosis - predisposing factors Virchows triad:
lesion of the blood vessel
increased blood coagulability
disturbance of circulation slowed blood flow

ORIGIN OF PHLEBOTHROMBOSIS:
natural

heart failure, pregnancy, malignancies...

traumatic

This can make the establishing of

relationship of death to an injurious event
difficult in the medicolegal expertise!

TRAUMATIC TISSUE DAMAGE

(fractures or soft-tissue damage):
(a) an increase in the coagulability of the
blood
(b) local venous thrombosis in the contused
muscles or around the fractured bones
(c) immobilization, venous stasis, decreased
venous blood flow in the legs

thrombosis in deep veins: legs / pelvic veins

phlebothrombosis in the iliac veins

 usually develops silently

fatal episode of pulmonary embolism is

often first clinical manifestation

a few days to two weeks after trauma
after sudden body movements (sudden

standing up, coughing, defecation)

large thromboemboli
- impact in the right
heart, pulmonary
trunk and its
branches

rapid death
(cor pulmonale acutum)

smaller emboli - peripheral arterial branches (lung infarcts)

at autopsy the source of the embolus must be sought
(preparation of the posterior part of the legs)

EXAMPLE 4 A 70-year-old male was injured

as a pedestrian in a traffic accident. He
sustained bilateral comminuted fractures of
tibia and fibula, an oblique fracture of the left
femur, fractures of the left iliac and pubic
bone, as well as widespread skin bruising on
the lateral side of the left leg and the medial
side of the right leg. On admission to hospital
he was in the state of traumatic shock, which
was successfully treated with urgent therapy.
He was conscious, without signs of lesions of
the brain, thoracic and abdominal organs.

The multiple bone fractures were treated

conservatively, using leg traction. On the 3th
day after the accident, he showed progressive
worsening of consciousness to the deep
coma, with severe respiratory insufficiency,
and petechial haemorrhages in conjunctivae
and skin of both axillary regions. He died very
soon, despite all resuscitative measures.
DIAGNOSIS ?

FAT EMBOLISM
fat embolism occurs to some degree in

almost every injury

subcutaneous tissue

involving

bone

or

- fractures of long bones

- contusions of subcutaneous adipose tissue
fat emboli are transported to the pulmonary

arterial branches - a small amount has no

clinical significance

 a large amount of fet emboli - pulmonary fat

embolism:
- sudden death - cor pulmonale acutum
- delayed death - respiratory failure
(ARDS, pneumonia)
if

fat globules penetrate the pulmonary

vascular bed or pass through patent foramen
ovale - they embolize vital organs: brain,
kidneys, myocardium and skin (systemic fat
embolism)
BOTH FORMS MAY BE FATAL

pedestrian multiple bone fractures

contusions of subcutaneous adipose tissue
cause of death was fat embolism

CLINICAL MANIFESTATION
Fat Embolism Syndrome FES after a latent interval
(several hours or a few days) triad of:

1.

respiratory disturbances (dyspnea, tachypnea,

lung oedema, ARDS)

2.

cerebral symptoms (unconsciousness, focal

neurological disorders)

3.

petechial haemorrhages of the skin (axillary folds,

chest) and conjunctiva

CLINICAL FINDINGS - small infarctions and

haemorrhages - petechiae in the skin (especially in
axillary region) and retina

fat embolism
petechial haemorrhages of the
skin in axillary fold

clinical
and
autopsy
finding

autopsy findings - spotty hemorrhages in the

white matter of the brain

autopsy findings - spotty haemorrhages in the white

matter of the brain (cerebrum, cerebellum, brainstem)

autopsy findings - spotty haemorrhages

in the white matter of the cerebellum

autopsy findings - spotty haemorrhages

in the white matter of the brain stem

microscopic findings (HE staining) around the

obstructed blood vessel a small area of tissue
necrosis with surrounding bleeding

microscopical examination - special fat staining

(Sudan III) red stained fat emboli
in capillaries of the brain

fat emboli in capillaries of the brain

fat emboli in capillaries of the lung

fat emboli in
capillaries of the lung

fat emboli in
capillaries of
kidney glomeruli

CLINICAL PROBLEM fat embolism, even

fatal, usually remains clinically
unrecognised and therefore undiagnosed
our research on the autopsy material in

12 cases of fatal fat embolism, positively

proved by autopsy and microscopic
examination, only in one case a clinical
diagnosis of suspicious fat embolism was
written in the medical records, while in
other 11 cases diagnosis was cerebral
contusion (contusio cerebri)

autopsy diagnosis - FATAL SYSTEMIC FAT EMBOLISM

discharge list

pedestrian - fatal
outcome 4 days
after injuring

negative CT scan
of the head

AIR EMBOLISM
cardiac embolism
considerable volume of air gains access

to the venous system and is carried to the

heart where it fills the right atrium and
ventricle with frothy bubbles

an air lock causes ciculatory failure

opening of the large

veins in the neck
(cut throat, surgical
operations)

suction effect
due to negative
pressure

open skull fracture

with opening of dural
sinuses

suction effect
due to negative
pressure
homicidal incisions
with an axe

skull fracture

opening of the sinus sagitalis superior

 positive pressure - injection of air (old form

of abortion, transfusion bottles)

gaseous embolism - rapid decompression

of divers or high-altitude flyers allows

bubbles of nitrogen gas to appear from
the plasma in any blood vessel in the
body.
special autopsy technique - air embolism

tape IX - after S-299/03

AMNIOTIC FLUID EMBOLISM

complication of childbirth or abortion -

escape of amniotic fluid into the maternal

circulation

fatal by - an allergic response

- producing DIC
fluid, fetal squames, lanugo, vernix lipoid

and meconium can be found in pulmonary

arteries (microscopically)

FOREIGN BODY EMBOLISM

in drug addicts drugs are mixed with a

variety of materials (talc) - this material is

insoluble, when gains entry to the veins,
reaches and ends in the lungs - foreign
body
granulomas
with
typical
multinuclear giant cells

foreign body granulomas

with typical multinuclear giant cells

FOREIGN BODY EMBOLISM

projectile - transported by blood flow far

away from the initial wound track

Homicide A father in law killed his son in law

firing one bullet from the pistol. One gunshot
injury with the entrance wound in the precordial
region the bullet had to be found out.

homicide gunshot
injury
the entrance wound
in the precordial
region

trajectory through the

anterior wall of the
right ventricle

trajectory through the

cavity of the right
ventricle

penetration into aorta

above the aortic
valve
superficial intimal
laesion of the aortic
arch

the bullet was found in

the popliteal artery
5cm below the medial
line of the popliteal
fossa

ADULT (ACUTE) RESPIRATORY DISTRESS SYNDROME

ARDS
a complication of many traumatic incidents (blunt

injuries to the chest, aspiration of gastric contents,

inhalation of irritant gases, infections, shock, etc.)
the lungs become edematous
clinically

- dyspnea, hypoxaemia, progressive

respiratory insufficiency - marked ventilatory failure
due to poor gas exchange

at autopsy bulky, firm and edematous lungs

histologically - edema, hyaline membranes

immediately fatal / later fibrosis

RENAL FAILURE
extensive muscle damage burns
tubules may be blocked with casts of myoglobin
or disintegrated erythrocytes
haemoglobinuric nephrosis

SUPRARENAL HAEMORRHAGE
haemorrhage into the adrenal glands,

sometimes bilateral

a few days after severe trauma (2 to 21 days)

the bleeding in the medulla - causing sudden

collapse and rapid death due to adrenal

insufficiency

a part of a general response to stress,

neurologically mediated via the sympathetic

nervous system

diffuse bilateral adrenal haemorrhage

in Waterhouse-Friderichsens syndrome

EXAMPLE 5 A 15-year-old boy was injured

jumping from a rock into the river. He
sustained compressive fracture of the 7th
cervical vertebra, with contusion of the spinal
cord and resultant quadriplegia. In the
beginning he was treated conservatively (neck
traction). On the 8th day after injuring he got a
severe maelena and he manifested clinical and
laboratory signs of gross haemorrhage
(severe anaemia). Firstly partial and later total
gastrectomy had to be done, but in spite of all
therapeutic measures, he died due to
exsanguination.
DIAGNOSIS ?

acute haemorrhagic erosive gastritis

multiple small erosions exsanguination

STRESS ULCERATIONS
injuries accompanied with haemorrhagic shock,

severe craniocerebral trauma (Cushing ulcer),

spinal cord trauma, burns (Curling ulcer),
hypothermia, uraemia, sepsis, etc.

Stomach and duodenum:

- one or several bigger ulcers

- multiple small erosions (acute erosive gastritis)
- aggravation of the pre-existing peptic ulcer
the greatest danger - massive and sometimes

fatal bleeding - the onset of bleeding usually

several days after the trauma

scanty gastric erosions

acute haemorrhagic erosive gastritis

multiple small erosions exsanguination

exacerbation of chronic peptic ulcer

perforation of duodenal ulcer

PROBLEMS IN MEDICOLEGAL EXPERTISE

REGARDING EFFECTS OF INJURIES
CONSEQUENCE is an effect which is
essentially involved in the clinical course of
one injury, that is, something that happens
in all cases of such injury
COMPLICATION - is an effect which is not
essentially involved in the clinical course of
one injury, that is, something that may
happen, but is not obligatory

injury

incised skin wound

brain contusion

bone fracture

consequence

complication

injury

consequence

incised skin wound

bleeding

brain contusion

gliosis

bone fracture

callus

complication

Q
injury

consequence

complication

incised skin wound

bleeding

infection

brain contusion

gliosis

abscess

bone fracture

callus

osteomyelitis

 appearance of complications depends on:

- the nature of primary injury

- individual factors (age, constitution,
health condition)
- other factors (medical treatment)
CLINICAL IMPORTANCE of complications

- prolong and aggravate treating process

MEDICOLEGAL IMPORTANCE:
(1) Complication as a possible
cause of death
when an injured person dies after trauma

question: if there is the cause-effect

relationship between actual death and
previous trauma

profound legal implications both for civil

compensation and criminal legal

responsibility

the fatal outcome may be caused:

directly by severe trauma
by complication of injury

thromboembolism, fat embolism, purulent

meningitis, pneumonia, sepsis
even when primary injury is not fatal per se
(e.g., fracture of the femur complicated with
vein thrombosis and fatal pulmonary
thromboembolism)

 as long as a direct chain of events can be

traced from the injury to the death, then

injury must be considered to be the basic
cause of death
the determination of this direct chain of

events may be difficult, especially when

the outliving period is extremely long

EXAMPLE: The victim suffered a fractured

spine, with resultant paraplegia, paralysed
urinary bladder and recurring ascending
urinary infection leading to death 15 years
after traumatic event, in renal failure from
bilateral pyelonephritis. In this case there is
direct chain of events, so that the basic
(indirect) cause of death is the primary injury
to spinal cord, in spite of very long outliving
period, since the immediate (direct) cause of
death is renal failure which occurred as a
complication of the primary injury.

(2) Complication as a possible

cause of invalidity
in non-fatal injuries, a matter of civilian law
(appropriate financial compensation to the
injured and disabled person)
the task of medicolegal expert - to estimate
the extent of harmful effects of injury and
its complication

(3) Possible accusation of medical stuff for

medical malpractice and negligence
In some situations when the cause of death
is related to the complication of injury, the
accused perpetrator and his attorney try to
prove that this complication was the
consequence of inadeaquate medical
treatment and not the result of nature of the
sustained injury.

Especially when the injured patient was in

apparently good condition after injuring
until the moment of sudden death (single
femur fracture, with silently developed
deep venous thrombosis, and sudden and
fatal
attack
of
pulmonary
thromboembolism).

the task of medicolegal expert - to determine

if the fatal complication occurred only due to
the nature of injury, or due to inadequate
medical treatment, answering the following
questions:
if the doctor had adequately anticipated

possibility
of
(observation)

certain

complication

if the adequate preventive measures had been

applied in order to avoid this complication

(anticoagulative
therapy
in
pulmonary
thromboembolism)

 if

appropriate diagnostic method were

applied to reveal certain complication
(ECHO for subcapsular liver haematoma)

if

appropriate therapeutic method were

applied
in
treating
of
developed
complication (adequate antibiotics on the
basis of antibiogram)

if the doctor in any way could directly or

indirectly cause this complication (wound

infection due to use of non-sterile surgical
instruments)

the successful medicolegal expertise in such

cases must be based on:

(a) appropriate medical records

(b) adequately performed medicolegal autopsy

Adequacy of the applied medical procedures

can be only proved in the court if the medical
documentation is appropriate!

VITAL REACTIONS
important medicolegal issue - whether the

found injuries have been sustained during

the life or after death (ante-mortem or
post-mortem injury)

cases

in which the dead body of

previously killed individual is injured by
the murderer in order to hide the traces of
the crime, to destroy the corpse (e.g., by
burning) or to simulate the suicide (e.g.,
hanging of the dead body)

decapitation - running over by a train

Is it really a suicide or maybe something else?

Differentiation between ante-mortem and

post-mortem injuries
VITAL REACTIONS
reactions of the whole body or parts of the
body, which certainly or probably indicate
that an injury occurred during the life

ABSOLUTE VITAL REACTIONS

occur exclusively during the life, owing to
preserved circulation and respiration as
vital functions of the human body
1. exsanguination (fatal blood loss)
2. thrombosis
3. all kinds of embolism
4. inflammation
5. aspiration (blood, soot)
6. deglutition (swallowing)

exsanguination
(fatal blood loss)

lack of livores

exsanguination - lack of livores

thrombosis of the
left common
carotid artery

consequent
infarction of the
left cerebral
hemisphere

all kinds of embolism

fat emboli in
capillaries of the lung

pulmonary thromboembolism the source is

thrombosis in deep leg veins

fire - a carbonized (charred) body

Was the person alive in the fire ?

fire - a carbonized (charred) body

aspiration
of soot

absolute
vital
reaction

aspiration
of soot

absolute
vital
reaction

combustion of
laryngeal and
tracheal mucosa
due to inhalation
of hot air
in the fire
absolute vital
reaction

combustion of
laryngeal and
tracheal mucosa
due to inhalation
of hot air
in the fire
absolute vital
reaction

60-year-old man fire in the flat

carbon monoxide intoxication (HbCO 80%)

traces of soot
around the nose
and mouth

deglutition
(swallowing) of soot
in the oesophagus

deglutition
(swallowing) of soot
in the oesophagus

aspiration of blood

absolute vital
reaction

aspiration of blood

absolute vital reaction

a 17-year-old girl
committed suicide
using her
grandfathers pistol
the entrance wound
in the left temporal
region

the exit wound in the

right temporal region

direction of the bullets trajectory

the bullets trajectory through the brain

multiple fractures of
the skull base

resultant massive
aspiration of blood in the
lungs

aspiration of blood

absolute vital reaction

slashes of the neck:

exsanguination
aspiration of blood
air embolism

all are absolute vital

reactions

RELATIVE VITAL REACTIONS

occur during the life, but in some extent
may also appear after death
1. bleeding
2. bruise
3. abrasion with exuded tissue fluid
4. skin contusion

combination of bruise and abrasion

5. retraction of the tissue - gaping of a stab
wound

POST-MORTEM BLEEDING
due to passive leakage of blood
dependent parts, scalp wounds, pleural and peritoneal
cavity (up to 1000 ccm from the cut aorta)

throttling
brusies and abrasions

bruises of subcutaneous soft tissue

bruises
fist fight

bruise 6 days after sustaining

changing of colour of the skin bruise

changing of colour of the skin bruise may occur

only during the life absolute VR

changing of colour of the skin bruise absolute VR

2 days

3 days

bone fractures with bleeding in the adjacent soft

tissue as sign of vitality

rib fractures due to cardiac massage in agony

slight vital reaction
little or no bleeding at the site of fractures

post-mortem injuries - animals

lack of
bruises as a
vital reaction

POST-MORTEM BRUISES
hypostatic purpura (vibices)

skin abrasion

retraction of the tissue - gaping of a stab wound

Thats all for today.

Thank you for your attention!

purulent (pjurulnt)
suppurate (spjureit)
Immobilization (imoubilaizein)

SLIDES
1.
hemoptoja dva slajda iz prirodne smrti (broj 6 i 9)
2.
ubodine, suicid S-208/92 sa odecom - external haemorrhage
3.
ubodine, suicid S-208/92 bez odece - external haemorrhage
4.
ubistvo dve sekotine vrata sa krvarenjem S-870/71
5.
ubistvo, les external haemorrhage
6.
ubistvo, les u krupnijem planu, external haemorrhage
7.
ubistvo, krv na krevetu external haemorrhage
8.
S-648/81 les, bio u histoloskoj kolekciji, external haemorrhage
9.
S-648/81 krv na krevetu, bio u histoloskoj kolekciji, external haemorrhage
10. les i krv oko njega, stolica pored lesa, bio u histoloskoj kolekciji, external haemorrhage
11.
krvni izliv haemothorax L-512/66
12. krvni izliv haemopericardium S-987/74
13. krvni izliv haemoperitoneum L-523/65
14. extradural haemorrhage S-140/88
15. extradural haemorrhage S-786/90
16. subcapsular spleen haematoma S-295/88
17. histological collection 127 purulent meningitis
18. histological collection 171 posttraumatic myocardial abscess
19. histological collection 172 renal abscess with groups of bacteria
20. histological collection 241 purulent bronchopneumonia
21. fat embolism 13 Swedish collection I
22. fat embolism 14 Swedish collection I
23. fat embolism 15 Swedish collection I
24. fat embolism 1 Swedish collection I
25. fat embolism 2 Swedish collection I
26. fat embolism 11 Swedish collection I
27. fat embolism 17 Swedish collection I
28. fat embolism 19 Swedish collection I

29.
30.
31.
32.
33.
34.
35.
36.
37.

ARDS hyaline membranes (HE) 3 Swedish collection II

ARDS hyaline membranes (PTAH) 4 Swedish collection II
ARDS hyaline membranes and pneumonia (PTAH) 5 Swedish collection II
haemoglobinuric nephrosis 186 from histological collection
dekapitacija (suicid) S-507/71
karbonifikacija - pogodna
histological collection aspiration of blood 44
histological collection aspiration of soot 357
histological collection - aspiration of brain tissue 47

PHOTOS
od dr Nikolica makroskopski nalaz kod masne embolije kozne petehije, tackasta krvarenja u velikom mozgu i
mozdanom mostu S-45/2000 L-42/69
- aspiracija gara

tromboembolija