Forensic Pathology for Police - Brainshare Public Online Library

324 12 Blunt Force Injury Deaths
although some have argued that this definition is too limiting, and cases with cardiac
injury that do not lead to exsanguination or cardiac tamponade should be included
in the definition of commotio cordis.
Traumatic disruption of a pre-existing natural disease process (or even a preexisting
injury that was previously not severe enough to be lethal) with subsequent
hemorrhage and death is also known to occur. An example is a person who has a
cerebral artery berry aneurysm that ruptures when someone punches the person in
the face. In such a case, the blunt force trauma and underlying natural disease process
should be included in the cause of death statement. The manner of death should
be determined based on the circumstances of the blunt trauma. In the example case
provided, homicide is an appropriate ruling.
Delayed Deaths Related to Blunt Force Injury
Death does not have to occur immediately when blunt trauma is the underlying
cause of death. Such delayed deaths may occur several hours, days, weeks, months,
or even years after the initial traumatic event. As long as an uninterrupted chain of
events can link the underlying trauma to the eventual death, it is appropriate to rule
the underlying trauma as the underlying cause of death.
A frequent example of a delayed death following blunt trauma is a situation
where the victim initially survives the trauma as a result of valiant efforts by emergency
medical services and hospital personnel. Despite these efforts, the massive
stress associated with severe traumatic injuries can be too much for the victim to
overcome. Various complications related to shock, trauma, inflammation, and stress
can ultimately lead to death despite all efforts to avoid such complications.
A variety of other situations can cause death in persons who have survived the initial
effects of blunt trauma, the most frequent being pulmonary embolism. Persons
who are bedridden for whatever reason have an increased risk of developing thrombi
(blood clots) within the deep veins of their legs and the risk is increased even more
if there are also injuries of the legs. Many trauma victims are in such a situation.
If the clots within the leg veins break free and travel upward into the inferior vena
cava and ultimately through the right side of heart into the pulmonary arteries, they
can cause a massive “pulmonary embolism” (Fig. 12.26) which results in an abrupt
stopping of all blood flow to the lungs and sudden death. This is discussed further
in Chapter 21.
Another complication that can occur following any type of injury is infection.
As with any infection, a localized infection can spread to involve the entire body
(referred to as “sepsis”) which is a life-threatening event and can rapidly lead to
death.
The fat embolism syndrome is a relatively rare complication, and usually occurs
several days after severe trauma, typically including skeletal trauma. Clinically, it is
characterized by the sudden onset of respiratory distress, with or without neurological
symptoms. At autopsy, gross examination of the brain can reveal numerous small