Accidental asphyxia in bed in severely disabled children

Age-Related Vulnerability to Lethal Craniocerebral Crush Injuries from Electrical Beds/Tables

Vulnerability to accidents characterizes the extremes of life for reasons that may be similar in each age group. Two cases are reported to demonstrate increased risks of entrapment and crushing injury involving the use of electrically controlled beds/tables. Case 1: A frail 98-year-old woman with a history of dementia suffered a lethal crush injury to her head when she fell out of bed and accidentally activated its lowering mechanism. Case 2: An 18-month-old girl suffered a lethal crush injury to her head when she became trapped under a lowered electric massage table. Common devices may be dangerous if individuals do not have the mental or physical capabilities to deal with them. The forensic assessment of such deaths involves an evaluation of the neurocognitive level and physical strength of the decedent as documented in previous clinical assessments, in addition to a careful examination of the structure and function of the bed/table.

Investigation of Deaths of Chronically Disabled Persons and Institutionalized Persons

The investigation of deaths involving chronically disabled and/or institutionalized persons represents an important challenge to the medicolegal death investigation community. For the purposes of this review, the chronically disabled and/or institutionalized are considered to include three non-mutually exclusive subcategories: the disabled elderly, the severely disabled, and psychiatric patients. Because deaths within certain of these populations tend to be common and expected, a very important goal when such deaths occur is the appropriate referral of cases to the medical examiner/coroner. Although each subcategory has distinct issues of importance regarding death investigation, there is also a reasonable amount of overlap between the three groups. This review provides an overview of the three subcategories, the reasons such persons may be at risk for premature, unexpected, or unnatural death, the many important issues of concern when investigating deaths within these vulnerable populations, and important preventative strategies within each group.

Forensic issues in Down syndrome fatalities

Down syndrome, or trisomy 21, is the most common chromosomal abnormality associated with intellectual impairment. Premature death is a feature of the syndrome due to a wide variety of conditions including congenital heart disease, impaired immune responses resulting in respiratory infections, acute leukaemia, upper airway narrowing, pulmonary hypertension, Alzheimer disease and atlantoaxial instability. Cases of Down syndrome not uncommonly present for medicolegal autopsy, as the non-specificity of symptoms and signs often precludes accurate antemortem establishment of a cause of death. Manifestations of Down syndrome are reviewed with an analysis of possible mechanisms of death and findings at autopsy.

Mechanisms of unexpected and/or sudden death in Lafora disease

A 23-year-old male was found dead wedged between two chairs at his home address. His past history included a diagnosis of Lafora disease (a type of heritable progressive myoclonic epilepsy) at the age of 16 years. This had been characterised by the development of epilepsy and progressive motor impairment and mental deterioration. Diagnosis had been confirmed by demonstration of mutation in the EPM2A gene on chromosome 6q24. At autopsy, petechial haemorrhages were noted of the face and conjunctivae bilaterally. There were no other significant findings apart from gastric contents within the airways. Death was attributed to positional asphyxia complicated by aspiration of gastric contents. Although death in Lafora disease is usually predictable and often protracted, sudden and/or unexpected death may occur and involve status epilepticus, sudden unexpected epileptic death, choking, aspiration of gastric contents, and cardiac arrhythmias. In addition, the possibility exists of unnatural causes of death, such as accidents, provoked by epilepsy or physical inability of the victims to extricate themselves from dangerous situations, or homicides, provoked by difficulties in caring for individuals with significant and progressive disabilities.

A Clinical Report of Adverse Health Effects Due to Bed Sharing in Two Children with Spinal Cord Injury and Traumatic Brain Injury

This paper explores the possibility that bed sharing may carry particular risks for children with special healthcare needs (CSHCN). Two cases of CSHCN who may have sustained adverse health effects from bed sharing are described. These two case reports indicate that CSHCN may be particularly susceptible to risks associated with bed sharing. Healthcare providers for CSHCN may need to inquire about patients' sleeping arrangements and, when bed sharing is acknowledged, provide counseling regarding the potential risks and benefits. They may need to monitor more closely for adverse events when bed sharing is a factor and should consider reporting health problems that may have occurred in concurrence with bed sharing.

Prevention of unintentional injury to people with intellectual disability: a review of the evidence

BACKGROUND

Recent research evidence shows that people with intellectual disability (ID) have double the unintentional injury risk of the general population and the risk is further increased in the presence of psychopathology and epilepsy. The pattern of injury and the circumstances surrounding an injury event in those with ID have some similarity with that of young children in the general population. Interventions to prevent injuries are an important health priority in this vulnerable population. This paper reviews evidence from injury prevention studies for people with ID and also considers the relevance of general population injury interventions for this population.

METHOD

Information regarding injury prevention in both ID and general populations was identified using online systems and consultation with research and public health organizations.

RESULTS

Few published studies were identified addressing the issue of injury prevention for those with ID. Possible injury prevention strategies appropriate for the major causes of injury in the ID population were identified from the general population literature. While many environmental injury prevention strategies for young children in the general population are applicable to the population with ID, some may require design modification to ensure effectiveness. Other promising approaches include improved information for parents/carers, primary care physician counselling, and home visits by well-informed and motivated professionals. There may be injury prevention benefit from improved management of psychopathology and epilepsy.

CONCLUSIONS

The issue of injury prevention for those with ID has not been addressed to the extent that the magnitude of the problem requires. Injury prevention programmes trialling a variety of evidence-based approaches and strategies are needed to protect the quality of life for the ID population and their families.

Fatal unintentional traumatic asphyxia in childhood

OBJECTIVE

The present study was undertaken to examine specific features of unintentional traumatic asphyxial deaths in childhood.

METHODS

Coronial files and records at the Forensic Science Centre in Adelaide, South Australia, were examined over a 35-year period from 1966 to 2000 for all cases of traumatic asphyxial death occurring in children under the age of 17 years.

RESULTS

Six cases of unintentional fatal traumatic asphyxia were identified. All of the victims were boys with an age range of 2-15 years (mean 6.8 years) and all were found dead at the scene. Fatal traumatic asphyxia resulted from entrapment beneath a chest of drawers, beneath a table tennis table, between a pile of wooden pallets and a metal fence, between a conveyor belt and its frame, and under a motor vehicle (in two cases).

CONCLUSIONS

Fatal traumatic asphyxia in childhood is a rare event, with younger children commonly being trapped by furniture or by industrial equipment while playing, and older children being trapped under motor vehicles in similar circumstances to adult traumatic asphyxial deaths. Unsupervised play of young children around heavy and potentially unstable pieces of furniture may be dangerous, particularly if more than one child is present. Unsupervised play of young children in industrial yards should be avoided.

Accidental hanging by a sweater: an unusual case

An accidental atypical hanging with the collar of a sweater is reported. A 67-year-old man was found dead in the sitting position with the collar of his sweater hanging off the brake handle of a motorcycle. Autopsy findings revealed a ligature mark on the surface of the neck; hemorrhages in the sternohyoid muscles; submucosal hemorrhages in the left greater horn of the hyoid bone; a large degree of submucosal petechial hemorrhages in the larynx, oral mucosa, and palpebral conjunctivae; and dark-red liquid blood with little clotting in the heart cavities. The alcohol levels in the blood and urine were 2.84 mg/ml and 3.52 mg/ml, respectively. It was concluded that the man had died from hanging by the sweater, and it was speculated that when he became inebriated, he might have lost consciousness and then fell with the collar of his sweater hanging from the brake handle of the motorcycle.

Specific dangers associated with infants sleeping on sofas

AIM

A study was undertaken to examine specific circumstances that may lead to accidental asphyxial deaths in infants on sofas.

METHODS

Coronial files in South Australia (Australia) from 1989 to 1998, and files at the Office of the Medical Examiner in San Diego County (USA) from 1991 to 1998 were searched for all cases of infant deaths occurring on sofas.

RESULTS

A total of 10 cases with complete death scene descriptions were found. Four deaths were attributed to sudden infant death syndrome and six deaths to accidental asphyxia, of which four involved shared sleeping with an adult. Lethal circumstances involved infants being overlayed by an adult (n = 2), wedged between an adult and the back of a sofa (n = 1), sleeping with an intoxicated/sedated adult (n = 2), wedged between pillows and the back of a sofa (n = 1), and wedged into the back of a sofa (n = 1).

CONCLUSIONS

Although shared sleeping of an adult with an infant on a sofa may result in accidental asphyxia, there is also the potential for wedging and accidental asphyxia of infants sleeping alone on a sofa. For this reason the use of sofas for both shared and solitary infant sleeping is discouraged.

Car window entrapment and accidental childhood asphyxia

A 3-year-old boy was found hanging from a partly opened car window. Attempted resuscitation was unsuccessful. Postmortem reconstruction of events leading up to death indicated that the boy had slipped while standing on his tricycle and entrapped his head as he was attempting either to look into the car, or to climb in through the window. While it is not always possible to completely secure childhood environments, open cars should not be regarded as safe places for young children to play in or around when an adult is not in attendance. To minimize the chance of injury or death to children from parked cars, young children should be removed from vehicles and all windows and doors securely closed and locked, if they are to be left in the vicinity of the car to play unsupervised.