CASE REPORT

Accidental Fatal Lung Injury by Compressed Air A Case Report Anand Parashuram Rayamane, MD, PGDMLE, PGDHR* and Pradeepkumar MV, MDÞ

Abstract: Compressed air is being used extensively as a source of energy at industries and in daily life. A variety of fatal injuries are caused by improper and ignorant use of compressed air equipments. Many types of injuries due to compressed air are reported in the literature such as colorectal injury, orbital injury, surgical emphysema, and so on. Most of these injuries are accidental in nature. It is documented that 40 pounds per square inch pressure causes fatal injuries to the ear, eyes, lungs, stomach, and intestine. Openings of body are vulnerable to injuries by compressed air. Death due to compressed air injuries is rarely reported. Many cases are treated successfully by conservative or surgical management. Extensive survey of literature revealed no reports of fatal injury to the upper respiratory tract and lungs caused by compressed air. Here, we are reporting a fatal event of accidental death after insertion of compressed air pipe into the mouth. The postmortem findings are corroborated with the history and discussed in detail. Key Words: compressed air, lung injury, autopsy (Am J Forensic Med Pathol 2015;36: 1Y2)

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ompressed air has been used in the industry and daily living for variety of purposes such as inflating tires, operating air power tools and paint guns, and so on. However, ignorant and improper use of compressed air equipment leads to disastrous fatal events. Colorectal injuries and orbital injuries are among the rarely reported injuries due to compressed air. Subcutaneous emphysema is also seen in a few cases when the air enters a damaged skin. Death due to compressed air injuries is rarely reported as many cases are treated successfully by conservative or surgical management. Technical search found that 40 pounds of air pressure released from the nozzle of an air gun passing 4 inches from the ear can cause rupture of the ear drum and/or cerebral hemorrhage resulting in death. The same pressure passing this distance from the eyes or mouth can cause blindness or rupture of the lungs, stomach, or intestines. It has been estimated that only 4 pounds of direct air pressure will rupture the bowel.1 Here, we are reporting an autopsy case of accidental death after insertion of compressed air pipe into the mouth.

CASE REPORT History of the Case The deceased, a 29-year-old young man, on the fateful day after finishing the bore-well work, was cleaning dirt on his clothes Manuscript received April 7, 2014; accepted June 9, 2014. From the *Department of Forensic Medicine, Mysore Medical College and Research Institute, Mysore, Karnataka, India; and †RajaRajeswari Medical College and Hospital Bangalore, Karnataka, India. The authors report no conflicts of interest. Reprints: Anand Parashuram Rayamane, MD, PGDMLE, PGDHR, Department of Forensic Medicine, Mysore Medical College and Research Institute, Mysore, Karnataka 570001, India. E-mail: [email protected]. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0195-7910/15/3601Y0001 DOI: 10.1097/PAF.0000000000000109

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with the air pipe when, accidentally, the pipe was brought very close to the mouth. Suddenly, he collapsed and died on the spot. The said pipe is the small air pipe fitted adjacent to the main air pipe, which is used to release the pressure from the main air pipe of the bore well. Investigation revealed that the air pressure in small pipe is between 100 and 200 pounds per square inch.

Postmortem Findings The deceased was moderately nourished. External appearances were unremarkable. No external injuries were noted over the body. On dissection, the mucosal surfaces of the larynx, trachea, and bronchi were denuded mucosa, congested and stained with grayish material (Fig. 1). The right lung weighed 500 g, and the left lung weighed 400 g. Lungs were firm, edematous, and congested. Cut section showed reddish granular appearance with multiple areas of hemorrhage. Other viscera showed no significant findings. Both lungs and trachea were subjected for histopathological examination.

Microscopic Findings The trachea showed denudation of the respiratory mucosa and congested blood vessels with foci of hemorrhage. Patchy anthracotic pigmentation was present. Both lungs showed areas of alveolar damage with diffuse hemorrhage and edema. Alveolar capillaries showed extensive congestion and anthracotic pigmentation perivascularly as well as in the alveolar interstitial region and alveoli (Fig. 2). Section from hila showed hemorrhage in the bronchial lumen with congestion and hemorrhage in the bronchial wall (Fig. 3).

Cause of Death On the basis of investigative information, postmortem findings, and histopathological examination, the cause of death was opined as ‘‘respiratory failure due to diffuse alveolar damage.’’

DISCUSSION A compressed air injury is generally an accidental industrial mishap and occurs rarely because of a prank or practical jokes or playing with the dangerous compressed air pipe for fun.2 Compressed airYrelated injuries rarely results in death of the person, as most of the cases are caused by mild impact with the pressured pipe, which is effectively treated. Most reported cases are due to the air hose being held at a distance from the anus for fun and the air is forced into the anus through the clothes causing colorectal injuries. These minor injuries were treated successfully by means of conservative or surgical treatment.2Y6 In cases of compressed air injury, air accumulates in the body cavities with minimal tissue inflammation.7 In cases of compressed air jet injuries through the anus, death is caused by any of the following mechanisms: acute air embolism, acute fat embolism, acute respiratory insufficiency due to enhanced intra-abdominal pressure and chest compression, or acute heart failure due to insufficient preload and peritoneal shock.8 Kampmann and Kijewski9 reported a case of compressed air inserted into the anus causing multiple perforations of the large www.amjforensicmedicine.com

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FIGURE 1. In situ dissection of the upper airway tract showing grayish congested denuded tracheal mucosa.

intestine, resulting in death. In their experimental work, they showed that clothing does offer protection against the high-pressure air and colon perforations are caused only if the distance between the anal opening and the tip of the air pipe is very close. In another case, a 7-year-old girl sustained accidental injury after injection of pressurized air from the air pipe used to fill air into bicycle tire. She presented with generalized subcutaneous emphysema along with pneumomediastinum, pneumothorax, pneumoperitoneum, pneumoretroperitoneum, and pneumorrhachis.10 Literature search also revealed a case of distal esophageal rupture due to compressed air11 and many cases of orbital injuries caused by compressed air.12Y15 In our case, an ignorant act of the deceased to clean his shirt with ease after a heavy work through the forced air from the air pipe led to fatal injury to the respiratory tract causing death. Injury to the upper respiratory tract or upper gastrointestinal tract is rare as compressed air itself push face backward avoiding injuries through oral or nasal orifice. As per history given by fellow workers, the deceased kept the air pipe into his mouth, which led to fatal lung injury causing instantaneous death. Compressed air pipe pressure was between 100 and 200 pounds per square inch, which is 10 times greater than fatal pressure required to cause injury to the lungs.

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FIGURE 3. Hematoxylin-and-eosinYstained low-power view of the bronchial wall showing hemorrhage into the bronchial lumen and congestion and hemorrhage in the bronchial wall.

CONCLUSIONS Compressed air injuries are rarely encountered by autopsy surgeon; thorough autopsy with ancillary investigation helps to conclude the cause of death. Educate the employees regarding personal safety measures to be taken during the handling of compressed air equipments. REFERENCES 1. Available at: http://www.usmra.com/repository/category/ compressed_air/Compressed_Air_1008.pdf. Accessed March 31, 2014. 2. Suh HH, Kim YJ, Kim SK. Colorectal injury by compressed airVa report of 2 cases. J Korean Med Sci. 1996;11(2):179Y182. 3. Zunzunegui RG, Werner AM, Gamblin TC, et al. Colorectal blowout from compressed air: case report. J Trauma. 2002;52(4):793Y795. 4. Stone GW. Rupture of the bowel caused by compressed air. Lancet. 1904;2:216. 5. Andrews EW. Pneumatic rupture of the intestine: a new type of industrial accident surgery. Gynecol Obstet. 1911;12:63Y64. 6. Mehmet E, Muhammed Rasit O, Sedat K, et al. A rare case of colorectal injury with compressed air. J Med Cases. 2013;4(3):159Y160. 7. Ahmadreza A. Pressurised air injection causing subcutaneous emphysema in a pediatric patient. J Foot Ankle Surg. 2008;47:66Y68. 8. Weber M, Kolbus F, Dressler J, et al. Survived ileocecal blowout from compressed air. Int J Legal Med. 2011;125(2):283Y287. 9. Kampmann H, Kijewski H. Perforation of the large intestine caused by compressed air. Experimental studies reconstructing compressed air insufflations. Arch Kriminol. 1983;171(5Y6):173Y181. 10. Poovazhagi V, Thangavelu S, Shanthi S. Pressurized air injury in a child. Indian Pediatr. 2011;48(8):647Y648. 11. Curci MR, Dibbins AW, Grimes CK. Compressed air injury to the esophagus: case report. J Trauma. 1989;29(12):1713Y1715. 12. Li T, Mafee MF, Edward DP. Bilateral orbital emphysema from compressed air injury. Am J Ophthalmol. 1999;128:103Y104. 13. Hitchings R, McGill JI. Compressed air injury of the eye. Br J Ophthalmol. 1970;54:634Y635.

FIGURE 2. Hematoxylin-and-eosinYstained low-power view of the lung showing diffuse alveolar damage with alveolar hemorrhage, edema, and congestion.

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14. Yuksel M, Yuksel KZ, Ozdemir G, et al. Bilateral orbital emphysema and pneumocephalus as a result of accidental compressed air exposure. Emerg Radiol. 2007;13:195Y198. 15. Caesar R, Gajus M, Davies R. Compressed air injury of the orbit in the absence of external trauma. Eye. 2003;17:661Y662.

* 2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Accidental fatal lung injury by compressed air: a case report.

Compressed air is being used extensively as a source of energy at industries and in daily life. A variety of fatal injuries are caused by improper and...
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