Case report
Fatal hemothorax due to homicidal blunt trauma to carotid artery in the neck
Medicine, Science and the Law 2014, Vol. 54(3) 174–176 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025802413502332 msl.sagepub.com
C Behera1, Karthik Krishna1, SR Singh1 and Sanjeev Lalwani1
Abstract A 30-year-old man was found dead in a pool of blood inside his office room in the morning. Autopsy revealed a small contusion at the lower anterior part of neck, laceration on the left common carotid artery, hemothorax and a laceration over the nose with underlying fracture. On investigation, it was found that on the previous night the victim had been assaulted by his domestic help with an iron rod over head and neck. The blunt trauma to the neck resulted in laceration on the left common carotid artery and subsequently bled, causing fatal hemothorax. The authors report this case owing to the rarity of such patterns of injury leading to fatal outcomes, which may be overlooked due to the simple nature of external injuries. Keywords blunt force, carotid artery, hemothorax, homicidal, neck injury
Introduction Injury to the carotid artery in the neck due to blunt force trauma occurs in situations like road traffic accident, fall from height, etc.1–3 The consequences of blunt trauma carotid are intimal tear, occlusion, contusion, transection and dissection.1,4–6 The patient usually presents with neurological symptomology consequent to cerebral ischemia.4,7 Hemothorax consequent upon blunt trauma to the carotid in the neck causing immediate fatality is not found in available scientific literature. We hereby report an autopsy case where the victim died due to fatal hemothorax caused by homicidal blunt injury inflicted on his neck.
Case report A 30-year-old male adult was found in a pool of blood, inside his resting room in the early morning hours, at a transport office. The victim was first seen by a driver working in the same office. The cables of the receiver of three landline telephone were found to be cut. A preliminary investigation was conducted by the police and the body shifted to the mortuary for autopsy. At the crime scene, blood stains were found on the wall, doors, floor and furniture. Later investigation by the police revealed that the victim was working as a manager in the transport office and was allegedly assaulted by his domestic help. The victim was reclining over the office chair when the accused assaulted him by an iron rod on his face and neck. The police recovered the alleged weapon
of offence, which was an iron rod-Axle type, length 53.5 cm, circumference 5.5 cm at middle and 4 kg in weight with blunt edges.
Autopsy finding The body was that of a 30-year-old man, heavily built. The clothes were blood stained. Rigor mortis was present all over the body. Postmortem lividity was faintly present on the back except at pressure areas. Dried blood stains were present over the face, right ear and lower limbs. Multiple reddish colored contusions were present on the inner aspect of lips, elbow region and fingers. A lacerated wound was present over the nose with fracture of underlying bone. A reddish colored contusion of size 4 3 cm was present on the midline of lower one-third of the neck (Figure 1). On dissection of the neck, hematoma was present on the lower one-third of neck on left lateral and posterior aspect of trachea, up to its bifurcation. The large hematoma that extravasated had raised the pretracheal fascia, trickling along into the pleural cavities (Figure 2). The left common carotid artery was torn, just below the cricoid cartilage surrounded by
1
All India Institute of Medical Sciences, New Delhi, India
Corresponding author: C Behera, All India Institute of Medical Sciences, Room No. 303, 2nd Floor, New Delhi 110029, India. Email: [email protected]
Downloaded from msl.sagepub.com at UNIV OF GEORGIA LIBRARIES on June 25, 2015
Behera et al.
175
Figure 1. Contusion present on lower one-third of neck.
Figure 2. Hematoma underneath pre-tracheal fascia showing the pathway of extravasated blood up to bifurcation of trachea.
Figure 3. Site of arterial tearing for the left common carotid artery.
Figure 4. Hematoma surrounding the torn left common carotid artery.
injuries were fresh in duration and antemortem in nature. hematoma (Figure 3). On gross examination, hematoma could be seen surrounding the left common carotid artery up to its origin from the arch of aorta (Figure 4). The chest cavity contained about 1.5 l of fluid and clotted blood. Both the lungs were found to be collapsed. Stomach contained about 100 ml of fluid and clotted blood. Solid organs such as liver, spleen and kidney were pale on cut sections. The coronary arteries were patent. Histopathology of the left common carotid artery, right brachiocephalic artery and right subclavian artery showed no preexisting pathology. Histopathology examination of abdominal aorta showed mild atherosclerotic changes. The cause of death was hemorrhagic shock as a result carotid injury caused by blunt force to the neck. All
Discussion The neck region is protected from trauma by the spine posteriorly, head superiorly and chest inferiorly, the anterior and lateral aspects are still prone to external trauma.8 Trauma to the neck are often life-threatening as multiple organ systems, namely airway, vascular, neurological and gastrointestinal are involved. Vascular injuries in the neck involving the carotid artery leading to immediate fatal hemothorax are rarely reported. Tanizaki and Hayashi 9 reported a case of massive hemothorax due to blunt trauma to transverse cervical artery in a fall from height incidence; however, the victim had survived after surgical intervention. Kaplan 1 reported a case of delayed fatal
Downloaded from msl.sagepub.com at UNIV OF GEORGIA LIBRARIES on June 25, 2015
176
Medicine, Science and the Law 54(3)
hemothorax due to traumatic carotid dissection due to occult neck trauma in a case of accidental sledding. Silvernail et al.10 reported three patients presenting with carotid artery injury produced by blunt nonpenetrating trauma to neck; however, the cases were non-fatal and the complications in the victims were not due to hemorrhage in the thorax. Seamon et al.6 reported a case where stab injury to the neck resulted in massive hemothorax due to transection of thyrocervical trunk; however, the patient survived. In our case, the victim was in sitting position, while he was struck multiple times with the iron rod on to his head, neck and face. One such blow had landed on the front aspect of lower one-third of neck, leading to laceration of left common carotid artery. The extravasated blood had seeped underneath the damaged pre-tracheal fascia of the visceral space in the neck, into the chest cavity, causing massive hemothorax and death. At autopsy, external examination of neck revealed contusion, but on dissection there was hematoma surrounding the damaged artery. The hematoma was tracked along the damaged left common carotid artery, crossing the bifurcation of trachea into the chest cavity causing hemothorax. Histopathology of large vessels of neck revealed no pre-existing pathology. Although, in our case, the victim was brought dead to hospital due to considerable time-lag, it is important to mention that if immediate medical attention would have been made available, there was a possibility of survival. The authors could thus establish the pattern of injury, the cause of death in this case and highlight the fact that blunt trauma to the neck could result in carotid injuries with subsequent fatal hemothorax.
Declaration of conflicting interests The authors declare that there is no conflict of interest.
References 1. Kaplan JA. Delayed fatal hemothorax due to traumatic carotid dissection: a case report of a previously unreported cause of death. J Forensic Sci 1994; 39: 552–556. 2. Ballard JL, Bunt TJ, Fitzpatrick B, et al. Bilateral traumatic internal carotid artery dissections: case report. J Vasc Surg 1992; 15: 431–435. 3. Mann CI, Dietrich RB, Schrader MT, et al. Post traumatic carotid artery dissection in children: evaluation with MR angiography. AJR 1993; 160: 134–136. 4. Pozzati E, Giuliani G, Poppi M, et al. Blunt traumatic carotid dissection with delayed symptoms. Stroke 1989; 20: 412–416. 5. Zelenock GB, Kazmers A, Whitehouse MA, et al. Extracranial internal carotid dissections. Arch Surg 1982; 117: 425–432. 6. Seamon MJ, Choudry R, Santora T, et al. Thyrocervical trunk transection: a rare cause of massive hemothorax. J Trauma 2007; 62: 1534. 7. Mokri D. Traumatic and spontaneous extracranial internal carotid artery dissection. J Neurol 1990; 237: 356–361. 8. Levy DB and Gruber BS. Neck trauma. Emedicine, http://emedicine.medscape.com/article/827223-overview (last accessed 30 October 2012). 9. Tanizaki S and Hayashi H. Massive hemothorax after blunt transverse cervical artery injury. J Emerg Med 2012; 43: e397–399. 10. Silvernail WI , Croutcher DL, Byrd BR, et al. Carotid artery injury produced by blunt neck trauma. South Med J 1975; 68: 310–313.
Downloaded from msl.sagepub.com at UNIV OF GEORGIA LIBRARIES on June 25, 2015
Fatal hemothorax due to homicidal blunt trauma to carotid artery in the neck
Medicine, Science and the Law 2014, Vol. 54(3) 174–176 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025802413502332 msl.sagepub.com
C Behera1, Karthik Krishna1, SR Singh1 and Sanjeev Lalwani1
Abstract A 30-year-old man was found dead in a pool of blood inside his office room in the morning. Autopsy revealed a small contusion at the lower anterior part of neck, laceration on the left common carotid artery, hemothorax and a laceration over the nose with underlying fracture. On investigation, it was found that on the previous night the victim had been assaulted by his domestic help with an iron rod over head and neck. The blunt trauma to the neck resulted in laceration on the left common carotid artery and subsequently bled, causing fatal hemothorax. The authors report this case owing to the rarity of such patterns of injury leading to fatal outcomes, which may be overlooked due to the simple nature of external injuries. Keywords blunt force, carotid artery, hemothorax, homicidal, neck injury
Introduction Injury to the carotid artery in the neck due to blunt force trauma occurs in situations like road traffic accident, fall from height, etc.1–3 The consequences of blunt trauma carotid are intimal tear, occlusion, contusion, transection and dissection.1,4–6 The patient usually presents with neurological symptomology consequent to cerebral ischemia.4,7 Hemothorax consequent upon blunt trauma to the carotid in the neck causing immediate fatality is not found in available scientific literature. We hereby report an autopsy case where the victim died due to fatal hemothorax caused by homicidal blunt injury inflicted on his neck.
Case report A 30-year-old male adult was found in a pool of blood, inside his resting room in the early morning hours, at a transport office. The victim was first seen by a driver working in the same office. The cables of the receiver of three landline telephone were found to be cut. A preliminary investigation was conducted by the police and the body shifted to the mortuary for autopsy. At the crime scene, blood stains were found on the wall, doors, floor and furniture. Later investigation by the police revealed that the victim was working as a manager in the transport office and was allegedly assaulted by his domestic help. The victim was reclining over the office chair when the accused assaulted him by an iron rod on his face and neck. The police recovered the alleged weapon
of offence, which was an iron rod-Axle type, length 53.5 cm, circumference 5.5 cm at middle and 4 kg in weight with blunt edges.
Autopsy finding The body was that of a 30-year-old man, heavily built. The clothes were blood stained. Rigor mortis was present all over the body. Postmortem lividity was faintly present on the back except at pressure areas. Dried blood stains were present over the face, right ear and lower limbs. Multiple reddish colored contusions were present on the inner aspect of lips, elbow region and fingers. A lacerated wound was present over the nose with fracture of underlying bone. A reddish colored contusion of size 4 3 cm was present on the midline of lower one-third of the neck (Figure 1). On dissection of the neck, hematoma was present on the lower one-third of neck on left lateral and posterior aspect of trachea, up to its bifurcation. The large hematoma that extravasated had raised the pretracheal fascia, trickling along into the pleural cavities (Figure 2). The left common carotid artery was torn, just below the cricoid cartilage surrounded by
1
All India Institute of Medical Sciences, New Delhi, India
Corresponding author: C Behera, All India Institute of Medical Sciences, Room No. 303, 2nd Floor, New Delhi 110029, India. Email: [email protected]
Downloaded from msl.sagepub.com at UNIV OF GEORGIA LIBRARIES on June 25, 2015
Behera et al.
175
Figure 1. Contusion present on lower one-third of neck.
Figure 2. Hematoma underneath pre-tracheal fascia showing the pathway of extravasated blood up to bifurcation of trachea.
Figure 3. Site of arterial tearing for the left common carotid artery.
Figure 4. Hematoma surrounding the torn left common carotid artery.
injuries were fresh in duration and antemortem in nature. hematoma (Figure 3). On gross examination, hematoma could be seen surrounding the left common carotid artery up to its origin from the arch of aorta (Figure 4). The chest cavity contained about 1.5 l of fluid and clotted blood. Both the lungs were found to be collapsed. Stomach contained about 100 ml of fluid and clotted blood. Solid organs such as liver, spleen and kidney were pale on cut sections. The coronary arteries were patent. Histopathology of the left common carotid artery, right brachiocephalic artery and right subclavian artery showed no preexisting pathology. Histopathology examination of abdominal aorta showed mild atherosclerotic changes. The cause of death was hemorrhagic shock as a result carotid injury caused by blunt force to the neck. All
Discussion The neck region is protected from trauma by the spine posteriorly, head superiorly and chest inferiorly, the anterior and lateral aspects are still prone to external trauma.8 Trauma to the neck are often life-threatening as multiple organ systems, namely airway, vascular, neurological and gastrointestinal are involved. Vascular injuries in the neck involving the carotid artery leading to immediate fatal hemothorax are rarely reported. Tanizaki and Hayashi 9 reported a case of massive hemothorax due to blunt trauma to transverse cervical artery in a fall from height incidence; however, the victim had survived after surgical intervention. Kaplan 1 reported a case of delayed fatal
Downloaded from msl.sagepub.com at UNIV OF GEORGIA LIBRARIES on June 25, 2015
176
Medicine, Science and the Law 54(3)
hemothorax due to traumatic carotid dissection due to occult neck trauma in a case of accidental sledding. Silvernail et al.10 reported three patients presenting with carotid artery injury produced by blunt nonpenetrating trauma to neck; however, the cases were non-fatal and the complications in the victims were not due to hemorrhage in the thorax. Seamon et al.6 reported a case where stab injury to the neck resulted in massive hemothorax due to transection of thyrocervical trunk; however, the patient survived. In our case, the victim was in sitting position, while he was struck multiple times with the iron rod on to his head, neck and face. One such blow had landed on the front aspect of lower one-third of neck, leading to laceration of left common carotid artery. The extravasated blood had seeped underneath the damaged pre-tracheal fascia of the visceral space in the neck, into the chest cavity, causing massive hemothorax and death. At autopsy, external examination of neck revealed contusion, but on dissection there was hematoma surrounding the damaged artery. The hematoma was tracked along the damaged left common carotid artery, crossing the bifurcation of trachea into the chest cavity causing hemothorax. Histopathology of large vessels of neck revealed no pre-existing pathology. Although, in our case, the victim was brought dead to hospital due to considerable time-lag, it is important to mention that if immediate medical attention would have been made available, there was a possibility of survival. The authors could thus establish the pattern of injury, the cause of death in this case and highlight the fact that blunt trauma to the neck could result in carotid injuries with subsequent fatal hemothorax.
Declaration of conflicting interests The authors declare that there is no conflict of interest.
References 1. Kaplan JA. Delayed fatal hemothorax due to traumatic carotid dissection: a case report of a previously unreported cause of death. J Forensic Sci 1994; 39: 552–556. 2. Ballard JL, Bunt TJ, Fitzpatrick B, et al. Bilateral traumatic internal carotid artery dissections: case report. J Vasc Surg 1992; 15: 431–435. 3. Mann CI, Dietrich RB, Schrader MT, et al. Post traumatic carotid artery dissection in children: evaluation with MR angiography. AJR 1993; 160: 134–136. 4. Pozzati E, Giuliani G, Poppi M, et al. Blunt traumatic carotid dissection with delayed symptoms. Stroke 1989; 20: 412–416. 5. Zelenock GB, Kazmers A, Whitehouse MA, et al. Extracranial internal carotid dissections. Arch Surg 1982; 117: 425–432. 6. Seamon MJ, Choudry R, Santora T, et al. Thyrocervical trunk transection: a rare cause of massive hemothorax. J Trauma 2007; 62: 1534. 7. Mokri D. Traumatic and spontaneous extracranial internal carotid artery dissection. J Neurol 1990; 237: 356–361. 8. Levy DB and Gruber BS. Neck trauma. Emedicine, http://emedicine.medscape.com/article/827223-overview (last accessed 30 October 2012). 9. Tanizaki S and Hayashi H. Massive hemothorax after blunt transverse cervical artery injury. J Emerg Med 2012; 43: e397–399. 10. Silvernail WI , Croutcher DL, Byrd BR, et al. Carotid artery injury produced by blunt neck trauma. South Med J 1975; 68: 310–313.
Downloaded from msl.sagepub.com at UNIV OF GEORGIA LIBRARIES on June 25, 2015
