jiafm, 2010-32(2) april-june. - forensic medicine

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ISSN 0971-0973 J Indian Acad Forensic Med, 32(2)combination with others. SDH was associatedwith cerebral injury in 65.6% of the cases.9. Subarachnoid haemorrhage (SAH):Its distribution, location according toage, association with fractures and cerebralinjury:This lesion was noted in 88.355 of the totalcases. It was present alone in only 28.75% of thecases; in most, it was present in combinationwith others (71.25%). Isolated SAH was bilateralin all instances. Whether alone, or incombination, it was associated with fractures in86.20%, and with cerebral injury in 69.46% ofthe cases.10. Management of hospitalized cases andoverall period of survival:Of the total cases, 67.27% wereadmitted in the hospital after sustaining injuryand were managed either surgically (49.22%) orconservatively (50.78%). On analysis of periodof survival, it is evident that 16.90% of thevictims died on the spot. Of the remainder,23.76% died within 24 hours of sustaininginjury, 6.34 within 1-3 days, and 47.70% within3-15 days. Only 5.3% survived for more than 15days. None of the victims who were operatedupon died within the first 24 hours aftersustaining injury, and that more of them survivedlonger (49.22%) than those who wereconservatively managed (32.81%).11. Cause of death:Head injury was the sole cause of deathin 51.35% of the cases. Pneumonia whichdeveloped subsequent to head injury was acontributory cause of death in 38.7%. Headinjury associated with shock and haemorrhage in4.20%. Pyogenic meningitis as a post traumaticcomplication was the cause of death in 3.7%while sepsis following head injury had causeddeath in only 2.1%.Discussion:The observations and results of the presentstudy were compared and contrasted with the work ofpreceding researchers.Among the cases studied; malesoutnumbered females (88.35% vs 11.15% a ratio of7.6 to 1). The age range of male victims were 8 –9months to 85 years, with a mean of 37.08 years,while in females, the range was 21/2 months to 80years, with a mean of 29.37 years. Malepreponderance was observed in all age groups; afinding that has been reported in previous workconducted by various researchers [3, 4, 5, 8, 14, 15],and is attributed to the fact that males are moreexposed to the outer world than females.In the present study the highest number ofvictims who suffered blunt head injury were in thethird and fourth decades of age. This observation wassimilar to the observation of researchers. [3, 7, 8] Thehigh mortality observed in this age group may bebecause of 1) this being the most active period of life,persons in this age group are the most frequent usersof roads, vehicles, the suburban railway and othermodes of transportation and 2) they are moreinvolved in outdoor activities. The low incidenceobserved at extremes of age can be attributed to thefact that both children and old people are confined totheir homes; and hence the risk of exposure to theouter hazardous environment is low.The highest number of blunt head injurieswas accidental in nature (91.5%). In 5.3 % thecircumstances was either not known or occurredunder other circumstances. Homicidal head injurydue to blunt trauma was next; suicidal head injurywas recorded in the least number of cases (2 cases).Of the accidents, railway accidents wereresponsible for the maximum number of fatal blunthead injuries (40.2%) (because the primary mode oftransportation in the city of Mumbai is the suburbanlocal train), followed by motor vehicle and roadtraffic accidents (27.5%) and falls (24.9%). Most ofthe fatalities among railway travelers (67.1%)occurred because they were knocked down byrunning trains while crossing the railway trackillegally.Pedestrian involvement (57.7%) wascharacteristic of motor vehicle and road trafficaccidents. In the city of Mumbai, this is because 1)pedestrians are the frequents road users, 2) footpathsmeant for their use are occupied b y hawkers to suchan extent that pedestrians are forced onto the roads,3) traffic rules re: zebra crossings and waiting forgreen lights are ignored, and 4) drivers of vehiclesflout signal and lane discipline, and exceedprescribed speed limits. Motorcyclists/riders ofscooters accounted for 26.9% of victims, passengersof motor vehicle for 7.7%, those who fell fromrunning buses for 5.8% and drivers of motor vehiclesfor 1.9%. These findings correlate with the works ofother researchers. [3, 4, 5, 8, 10, 11, 12]Falls causing fatal blunt head injury(whether accidental or suicidal) had occurred in24.9% of cases. Falls from heights were responsiblein 48.9%, slipping in bathrooms in 31.9% and fromstaircase or ladders in 19.2%. The reason for thismight be the proliferation of highrise buildings in thiscity to accommodate a burgeoning population. Theobservations tallied more or less with those of otherauthors. [3, 8, 11, 14]Regarding the time at which head injury wassustained, this study revealed that the highest numberof fatalities (29.6%) occurred during the peak hours146
J Indian Acad Forensic Med, 32(2) ISSN 0971-0973of the day (0600 hrs to 1200 hrs) when most of thevictims were on their way to work or involved insome outdoor activities, followed by a minimallylesser peak 28.6% between 1800 hrs to 2400 hrs, atime when people are returning home. Ourobservations closely match those of anotherresearcher. [6]Skull fractures were noted in 87.3% ofcases. Fractures involving both the base and the vaultwere seen in 58.2%, while isolated fractures of thebase and the vault were observed in 25.4% & 16.4%respectively. These observations were concordantwith those of other researchers. [4, 8, 9, 10] Thefissured fracture was the most common type offracture observed (59.2%), followed by combinationsof fractures (31.2%), depressed fractures (7.2%) andsutural fractures (2.4%). The above observationswere consistent with the work of other authors. [7,13, 15] Among the specialized fracture of the base ofthe skull, the type 1 hinge fracture was the mostcommon (78.8%) followed by type 2 (15.20%) andtype (36.0%). Unfortunately, no specific work on thisaspect of cranial injuries was available forcomparison, except that of Dimaio. [6]Of the primary intracranial lesions, isolatedintracranial haemorrhages were seen in 30.68%. Ofthese, SAH was the commonest (25.4%), SDH(4.23%) & EDH (1.05%). Combinations ofintracranial haemorrhages were observed in 83.6%,the commonest being SAH & SDH (59.6%). Cerebralcontusion was noted in 62.96% and laceration in26.45%. Deep brain haemorrhages in the basalganglia, pons and midbrain accounted for 40.25. Theabove observations were in accordance with thestudies of other researchers. [6, 7, 8]EDH was seen in 16.4%. Isolated EDHswere noted in 6.45% all were unilateral and incombination with other intracranial haemorrhageswas observed in 93.55%. Fractures of the skull werenoted in all cases, an observation also made by otherauthorsSDH was found in 66.13% of the totalnumber of cases. It had occurred alone in 6.4%; allwere unilaterally located. In combination with otherICHs, it was observed in 93.6%. SAH was thecommonest intracranial haemorrhages observed88.35%, seen alone in 28.75% and all bilaterallysituated. SAH in combination with other ICHs wasfound in 71.25%. These findings compared well withthose of others. [7, 8]SAH was the commonest intracranialhaemorrhage observed 88.35%, seen alone in 28.75%and all bilaterally situated. SAH in combination withother ICHs was found in 71.25%.Secondary intracranial lesions were found in44.44% of the total cases. Cerebral infarctionaccounted for the highest percentage of these41.70%.The overall period of survival ranges from 0(16.90%) to 35 days. In the first extreme, deaths hadoccurred on the spot, or on the way to the hospital, orin peripheral health care facilities and some of thevictims were brought dead. Of the remaining 83.1%had survived for 0-6 hrs, 8.64% for 6+ - 24 hrs,6.34% for 1+ - 3 days, 24.90% for 3+ - 7 days and22.80% for 7+ 15 days. Only 5.3% of the cases livedfor longer than 15 days after sustaining injury.Of the total, 67.27% of cases werehospitalized and managed either surgically (withdecompression procedures, trephination orcraniotomies) (49.22%) or conservatively (50.78%).The observations that 17.98% of conservativelymanaged victims died within 24 hours, while none ofthe patients managed surgically died within 24 hoursof operation, and that the survival period of the lattergroup were longer in all instances, bear out theconclusions of Tyagi et al. [8]With regard to the cause of death, blunttraumatic craniocerebral injury was the primary causeof death in slightly more than the half of the victims(51.30%). If deaths due to the complication of headinjury are included, the percentage increases to57.14%. Both figures differ significantly from theresults of Tyagi et al [8]; it was not possible toidentify the reason for this.Summary and Conclusion:The current study was conducted and thedata generated were compared with the work done byprevious researchers. The observations of the presenttallied in almost all respects with the studiesconducted by previous researchers, which recognizedmotor vehicle and road traffic accidents as thepredominant cause of fatal head injury due to blunttrauma. But since this study was conducted in the cityof Mumbai (where suburban local trains are theprimary means of transportation), it was observedthat railway accidents were responsible for themaximum number of fatalities. Blunt craniocerebraltrauma was the predominant cause of death identifiedin this study. This study also revealed pneumonia asthe commonest cause of death contributing to headinjury, which has not been reported in any of theprevious studies. The possible explanation for thehigh occurrence of this complication may be thecontinuous recumbent posture in these (unconscious,comatose & bedridden) victims, which helps in thedevelopment of this hypostatic condition. Another,but less likely, explanation of this condition might bethe use of ventilators as supportive respiratorymeasures. From the present study we feel that aseparate study should conducted in near future inorder to identify the cause and relationship ( if any)147
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