Penetrating injury to the left ventricle caused by attempted suicide-a case report

Penetrating cardiac injuries are rare but are one of the most urgent emergencies because they require early intervention in order to prevent death. The mortality rate of such injuries, including pre-hospitalization deaths, goes up to 90%. The most commonly injured heart chamber is the right ventricle since it takes over half of the anterior thoracic wall. The left ventricle is injured less often, but these patients usually have worse prognoses and higher mortality rates because such injuries lead to hemodynamic instability faster. We present a unique case of a suicide attempt in which the patient stabbed himself with a knife, penetrated the left ventricle, and survived even though he transected the second diagonal branch of the left anterior descending coronary artery and pulled the knife out of his chest.

A cut throat: a case of C5-C8 brachial plexus root transection providing evidence of T1 innervation of thumb and finger extensors

The T1 nerve root is not routinely thought of as innervating the extensors of the thumb and fingers. Work by Bertelli and Ghizoni proposed that the pattern of brachial plexus paralysis with intact hand function and thumb and finger extensors traditionally attributed to C5/6/7 root injury is in fact a C5/6/7/8 injury, with only T1 remaining intact - a 'T1 hand'. This case presents a 19-year-old male who was stabbed in the neck; exploratory surgery determined complete transection of the brachial plexus, with only the T1 nerve root remaining intact. Clinical examination demonstrated grade M4 pronation (with pronator quadratus), wrist extension (with extensor carpi ulnaris), thumb and finger extension (with extensor policis longus and brevis, extensor digitorum communis and extensor index proprius), wrist flexion (with palmaris longus), finger flexion (with flexor digitorum superficialis and profundus), thumb flexion (with flexor policis longus), and thenar and hypothenar muscles. Extensor carpi radialis longus and brevis, flexor carpi radialis and flexor carpi ulnaris were paralyzed. Triceps scored M2. This case provides unequivocal evidence that the T1 root provides significant innervation to the extrinsic thumb and finger extensors.

Piercing the surface: A mechanical analysis of stabbing with household tools

Estimating the applied power during a stabbing incident, or estimating the minimal force necessary to penetrate the body with a certain weapon is a challenging task in forensic practice. A thorough forensic evaluation of stabbing forces needs objective numerical experimental data. Stabbing tests of 12 different weapons - including knives, a pair of scissors, a fork, screwdrivers, a rasp, a corkscrew, and a utility knife blade - were performed with a Mecmesin MultiTest-dV material tester on pork loin and ballistic gel to estimate the stabbing forces and dynamics. Penetration force (F_p ) and maximal force (F_max ) were recorded, and the registered force curves were analyzed. F_max was 159.8-212.07 Newton (N), 30.56-30.58 N, 168.9-185.48 N for various knives; 171.39-190.43 N for the pair of scissors, 233.6 N for the fork; 532.65-562.65 N, 370.31-367.19 N and 314.51-432.89 N for various screwdrivers, 44.14-56.62 N for utility knife during pork loin stabbing. The butter knife, corkscrew and rasp were not able to penetrate the pork loin, and the curved fork bent during stabbing. The results prove that weapon characteristics greatly influence the force necessary for penetration. Maximal stabbing force depends mostly on tip sharpness, and the force sharply decreases after penetration occurs, which indicates that edge sharpness is not as important as tip characteristics during stabbing perpendicular to skin surface. The penetration force during stabbing with a pair of scissors is comparable to the penetration force of knives. Stabbing with screwdrivers generally needs larger force than average knives but depends greatly on screwdriver size.

A cardiac injury and pericardial tamponade following a stab wound to the chest: a case report

A stab wound in the heart is associated with high mortality rates. Rapid patient transfer to the closest hospital, maximal speed in establishing a diagnosis, and highly trained prompt surgical intervention are all crucial to achieving a positive result in the treatment of these critical patients.

Case presentation

This report presents a 28-year-old man with a stab wound to the chest, causing pericardial tamponade and a myocardial injury that presented with shock. The patient was diagnosed by chest ultrasonography and operated on successfully after 45 min of the stab without complications.

Clinical discussion and conclusion

Cardiac repair should be attempted as soon as possible if the patient with the stab wound to the heart is not dead upon arrival. The time from the stabbing to the start of the operation is vital, and any delay in the operation may lose the patient. Glasgow Coma Scale could be considered as predicting variable for complications or mortality in patients with stab heart wounds.

Left-sided chylothorax following ipsilateral hemithoracic stab wound in a 20-year-old man: the first case report

When the chyle, the liquid that is formed from the connection of the body's lymphatic flows, leaks to the pleural space, chylothorax expression comes into existence. Traumatic types are due to penetrating wounds or iatrogenic during heavy thoracic oncology surgeries. To the best of our knowledge, we have reported the first case of left-sided chylothorax following an isolated stab wound in the fifth intercostal space of the same side treated by tube drainage and 'nil per os' dietary condition.

Ureteral Injury by a Retained Knife After Abdominal Trauma: A Case Report

Isolated ureteral injuries are rare, occurring particularly in gunshot wounds to the abdomen. These are much rarer in the context of stab wounds. These lesions are usually silent. We report a 30-year-old man with a history of abdominal penetrating trauma with a knife, 11 years ago before the actual admission to the urology department. The patient's report describes a retained metallic foreign body in the right lumbar area. At admission, the patient presented with a four-months history of right lumbago. An abdominal computed tomography scan revealed the presence of a right para-renal small urinoma and identified the 52 x 20 mm metallic foreign body at the level of L3 and L4 vertebral bodies, with the presence of mild right ureterohydronephrosis. Ureteral injuries can lead to significant morbidity and mortality when unrecognized or mismanaged. The basis of therapy for patients with ureteral injuries is to maintain renal drainage with options depending on individual cases.

Late Presentation of Peritonitis Post Jejunal Perforation Due to Flank Stab Wound

Abdominal trauma injuries are caused by many mechanisms including blunt and penetrating trauma injuries. Penetrating injuries are far more common than blunt injuries. Subsequently, the most affected organ during such injuries is small intestine perforations. As far as we know, there were no cases reported before about jejunal injury due to penetrating trauma. We present a case of a 20-year-old male with a stab wound injury who was initially stable in the emergency department (ED). After a set of investigations were done, the patient was discharged home. Yet, the patient presented again with late signs of peritonitis. Imaging was done and showed pneumoperitoneum. Thereafter, the patient was rushed to the operation room (OR) where the jejunal repair was performed. ED physicians must be vigilant regarding any signs of deterioration in penetrating trauma patients and should provide clear instructions to patients regarding any symptoms of the acute abdomen before any discharge.

[Is thoracoscopic heart suturing possible for stab wounds?]

The authors report two clinical cases with similar stab wounds of the heart. The first patient underwent open wound closure, the second one - thoracoscopic suturing of the wound. The authors concluded that conversion may be unnecessary after diagnosis of heart injury if severe bleeding is absent.

[Morphological features of skin injuries caused by conducted energy weapons (CEWs)]

The objective of the study is to identify, compare and analyze morphological features of skin injuries resulting from the experimental firing of various models of conducted energy weapons (CEWs) In the experimental study, the design features of the provided CEWs models and characteristics of skin injuries were studied using a simulator, a pig carcass, shot without a barrier point-blank, and at the distance of 0.5 cm, 5 cm, 50 cm, and 4.5 m. The results of expert and experimental studies showed differences in morphological features of skin lesions from two different CEW models with different designs. To make an objective expert conclusion on the kind of CEW used to damage the skin, distance, and angle to the target, it is necessary to perform appropriate experiments with at least two different models of these devices.

Incidence, Demographics, and Outcomes of Penetrating Trauma in Sweden During the Past Decade

Trauma injury is the sixth leading cause of death worldwide, and interpersonal violence is one of the major contributors in particular regarding injuries to the head and neck. The incidence, demographics, and outcomes of penetrating trauma reaching hospitals in Sweden are not known. We report the largest, nationwide epidemiological study of penetrating injuries in Sweden, using the Swedish Trauma Registry (SweTrau). A multi-center retrospective descriptive study of 4,776 patients was conducted with penetrating injuries in Sweden, between 2012 and 2018. Due to the increase in coverage of the SweTrau registry during the same period, we chose to analyze the average number of cases for the time intervals 2013-2015 and 2016-2018 and compare those trends to the reports of the Swedish National Council for Crime Prevention (Brå) as well. A total of 663 patients had Injury Severity Score (ISS) ≥ 15 at admission and were included in the study. Three hundred and sixty-eight (55.5%) were stab wounds (SW), 245 (37.0%) gunshot wounds (GSW), and 50 (7.5%) other traumas. A majority of the cases involved injuries to the head, neck, and face. SW increased from 145 during 2013-2015 to 184 during the second period of 2016-2018. The increase was greater for GSW from 92 to 141 during the same respective periods. This trend of increase over time was also seen in head, neck, and face injuries. The 30-day mortality was unaffected (48-47%) in GSW and trended toward lower in SW (24-21%) when comparing 2013-2015 with 2016-2018. Patients with head trauma had 45% mortality compared to 18% for non-head trauma patients. Head trauma also resulted in worse outcomes, only 13% had Glasgow outcome score (GOS) 5 compared to 27% in non-head trauma. The increasing number of cases of both SW and GSW corresponded well with reports from Brå although further studies also are needed to address deaths outside of hospitals and not registered at the SweTrau. The majority of cases had injuries to the head, neck, and face and were associated with higher mortality and poor outcomes. Further studies are needed to understand the contributing factors to these worse outcomes in Sweden and whether more targeted trauma care of these patients can improve outcomes.

An unusual penetrating injury of the back: retroperitoneal hematoma from a glass stabbing injury: a case report

In stab injury of the back visceral or vascular injuries are more uncommon than anterior abdominal stab injuries. The authors report the case of a 52-year-old man who presented to the emergency center with glass fragments lodged in his back after falling on a glass door on his back. On a retroperitoneal computed tomography (CT) scan, two foreign bodies were detected in left paraspinal and psoas muscles. Furthermore, hematoma with active bleeding was seen in the retroperitoneal cavity. He was referred to a general surgeon for retroperitoneal active bleeding, but emergency laparotomy was not deemed necessary considering the patient's stable condition in terms of vital signs, the level of hemoglobin, and the amount of bleeding. Therefore, we performed conservative treatment, such as packed cell transfusion and back compression, after removing the glass fragment through the posterior approach. The paravertebral muscle was dissected through the open wound, the tip of the piece of glass was accessible. The piece of glass was carefully removed, and there was no active bleeding. The postoperative CT scan showed continued active bleeding and increased retroperitoneal hematoma, but the patient's vital signs were stable. Conservative treatment was administered continuously, a follow-up CT scan taken a month later showed hematoma resolution and no more dye leakage. If the patient's vital signs are stable and the patient is neurologically intact, conservative treatment may be prioritized without laparotomy.

Transient astrocyte-like NG2 glia subpopulation emerges solely following permanent brain ischemia

NG2 glia display wide proliferation and differentiation potential under physiological and pathological conditions. Here, we examined these two features following different types of brain disorders such as focal cerebral ischemia (FCI), cortical stab wound (SW), and demyelination (DEMY) in 3‐month‐old mice, in which NG2 glia are labeled by tdTomato under the Cspg4 promoter. To compare NG2 glia expression profiles following different CNS injuries, we employed single‐cell RT‐qPCR and self‐organizing Kohonen map analysis of tdTomato‐positive cells isolated from the uninjured cortex/corpus callosum and those after specific injury. Such approach enabled us to distinguish two main cell populations (NG2 glia, oligodendrocytes), each of them comprising four distinct subpopulations. The gene expression profiling revealed that a subpopulation of NG2 glia expressing GFAP, a marker of reactive astrocytes, is only present transiently after FCI. However, following less severe injuries, namely the SW and DEMY, subpopulations mirroring different stages of oligodendrocyte maturation markedly prevail. Such injury‐dependent incidence of distinct subpopulations was also confirmed by immunohistochemistry. To characterize this unique subpopulation of transient astrocyte‐like NG2 glia, we used single‐cell RNA‐sequencing analysis and to disclose their basic membrane properties, the patch‐clamp technique was employed. Overall, we have proved that astrocyte‐like NG2 glia are a specific subpopulation of NG2 glia emerging transiently only following FCI. These cells, located in the postischemic glial scar, are active in the cell cycle and display a current pattern similar to that identified in cortical astrocytes. Astrocyte‐like NG2 glia may represent important players in glial scar formation and repair processes, following ischemia.

Hybrid Management of a Pseudoaneurysm of the Inferior Gluteal Artery Following a Stab Wound

Aneurysms and pseudoaneurysms of the gluteal artery are rare. They represent less than 1% of the described arterial aneurysms. Those that touch the inferior gluteal artery are even rarer. Only a few cases have been described worldwide. Such cases often present with a variable time course, mode of injury, and associated symptoms, leading to their misdiagnosis and improper treatment. We present the case of a 30-year-old male, who presented to our emergency room one week after a stab wound in the left gluteal region causing a pseudoaneurysm of the left inferior gluteal artery with a sciatic compartment syndrome treated by a hybrid approach.

Penetrating injuries in Germany - epidemiology, management and outcome an analysis based on the TraumaRegister DGU®

Background

The management of penetrating wounds is a rare challenge for trauma surgeons in Germany and Central Europe as a result of the low incidence of this type of trauma. In Germany, penetrating injuries are reported to occur in 4–5 % of the severely injured patients who are enrolled in the TraumaRegister DGU® (trauma registry of the German Trauma Society). They include gunshot injuries, knife stab injuries, which are far more common, and penetrating injuries of other origin, for example trauma caused by accidents. The objective of this study was to assess the epidemiology and outcome of penetrating injuries in Germany, with a particular focus on the level of care provided by the treating trauma centre to gain more understanding of this trauma mechanism and to anticipate the necessary steps in the initial treatment.

Materials and methods

Since 2009, the TraumaRegister DGU® has been used to assess not only whether a trauma was penetrating but also whether it was caused by gunshot or stabbing. Data were taken from the standard documentation forms that participating German hospitals completed between 2009 and 2018. Excluded were patients with a maximum abbreviated injury scale (MAIS) score of 1 with a view to obtaining a realistic idea of this injury entity, which is rare in Germany.

Results

From 2009 to 2018, there were 1123 patients with gunshot wounds, corresponding to a prevalence rate of 0.5 %, and 4333 patients with stab wounds (1.8 %), which were frequently caused by violent crime. The high proportion of intentionally self-inflicted gunshot wounds to the head resulted in a cumulative mortality rate of 41 % for gunshot injuries. Stab wounds were associated with a lower mortality rate (6.8 %). Every fourth to fifth patient with a gunshot or stab wound presented with haemorrhagic shock, which is a problem that is seen during both the prehospital and the inhospital phase of patient management. Of the patients with penetrating injuries, 18.3 % required transfusions. This percentage was more than two times higher than that of the basic group of patients of the TraumaRegister DGU®, which consists of patients with a MAIS ≥ 3 and patients with a MAIS of 2 who died or were treated on the intensive care unit.

Conclusions

In Germany, gunshot and stab wounds have a low incidence and are mostly caused by violent crime or attempted suicides. Depending on the site of injury, they have a high mortality and are often associated with major haemorrhage. As a result of the low incidence of these types of trauma, further data and analyses are required in order to provide the basis for evaluating the long-term quality of the management of patients with stab or gunshot wounds.

Penetrating Thoracoabdominal Trauma With a Cryptic Diaphragmatic Injury in a 23-Year-Old Male

Traumatic diaphragmatic injuries are a rare entity and can occur in relation to penetrating thoracic and abdominal trauma. The most common clinical features of diaphragm rupture include chest or abdominal bruising, decreased breath sounds, and signs of bowel obstruction. However, the classic signs and symptoms of diaphragmatic injury are not always present and can be obscured even in the highest resolution imaging. This highlights the importance for maintaining a high index of suspicion to make the diagnosis and properly manage these patients. Here, we present a rare case of a 23-year-old male who experienced a laceration to his left thorax and was later discovered to have concurrent diaphragmatic injury despite an initially noncontributory physical exam and imaging findings. The patient subsequently underwent robotic repair of the injury and reduction of herniated contents.

Superimposed CT imaging using fusion function to visualize the relationship between the knife and the wound path in a stabbing victim

With the increasing use of postmortem computed tomography (PMCT) in medicolegal autopsies, three-dimensional (3D) models of injured areas can now be generated from multislice computed tomography images. However, since PMCT has low sensitivity for detecting injuries in solid organs in the absence of contrast administration, it has been difficult to demonstrate the tracks of stab wounds leading to solid organ injury using 3D reconstruction. Here, we report one homicide case with two stab wounds. On the skin surface, the stab wounds were located on the neck and anterior chest wall. A medicolegal autopsy revealed that one stab wound in the neck had penetrated the wall of the right pleural cavity and the upper portion of the right lung whereas the other stab wound in the anterior chest wall had penetrated the right diaphragm and the heart. To illustrate the tracks of the stab wounds, superimposed CT images of the body, the excised organ, and a knife model were constructed to obtain a 3D model. This allowed clear and concise visualization of the complex relationship of the knife to the heart incision and the stab wound on the chest surface.

Successful Laparoscopic Repair of Posttraumatic Diaphragmatic Injury

Diaphragmatic injuries can be a direct result of penetrating thoracoabdominal trauma such as gunshot or stab wounds. Diaphragmatic rupture can lead to herniation of intra-abdominal organs into the thoracic cavity. Diagnosis can be difficult as the results of a physical exam can be unremarkable. A CT scan of the chest is diagnostic for diaphragmatic injuries. In most emergency cases, diaphragmatic injuries are managed with laparotomy where CT was diagnostic. We report a rare case of a 25-year-old man with right diaphragmatic injury sustained after a stab wound to the right liver managed successfully with laparoscopy.

High-quality Digital 3D Reconstruction of Microscopic Findings in Forensic Pathology: The Terminal Pathway of a Heart Stab Wound

High-quality digital three-dimensional (3D) reconstructions of microscopic findings have been used in anatomical and histopathologic research, but their use in forensic pathology may also be of interest. This paper presents an application of these methods to better characterize the pathway of a stab wound of the anterior surface of the heart in a case of suicide. A portion of the heart wall including the stab wound was serially sectioned for microscopic analysis along the full extent of the wound. Histologic sections were digitally acquired, and a 3D reconstruction was created with ImageJ software for 3D computer graphics. This showed a full-thickness wound path extending to the endocardial surface of the left ventricle, curvilinear in appearance. After correction for shrinkage, 3D reconstruction allowed estimation of the dimensions of the myocardial injury and comparison of the appearance of the wound with the suspected knife used. The curvilinear appearance was considered to reflect injury during myocardial contraction. Complete microscopic sectioning and 3D reconstruction may allow virtual sectioning through various orientations and also provide useful forensic information for selected injuries.

A self-resolving, post-traumatic aortopulmonary shunt

A 34-year-old Hispanic man sustained a stab wound to his chest complicated with hemopericardium and pericardial tamponade. He underwent emergent clamshell thoracotomy as well as repair to the pulmonary artery. A transthoracic echocardiogram showed no evidence of intracardiac shunt. Two months later, a new murmur was noted, with a transthoracic echocardiogram revealing high-velocity flow between the left coronary sinus and the main pulmonary artery, with which a coronary computed tomography angiogram concurred. A transesophageal echocardiogram was performed which revealed an aortopulmonic fistula from the left coronary sinus of Valsalva, approximately 1cm anterior to the ostium of the left main coronary artery, to the main pulmonary artery just distal to the pulmonic valve. Pulmonary insufficiency was minimal. The main pulmonary artery was dilated, measuring 3.2 cm by coronary computed tomography angiogram. Right ventricular systolic function was normal. Right and left heart catheterizations were performed to further assess hemodynamics and coronary anatomy; pulmonary artery pressures were 16/8 mm Hg. Aortopulmonary fistula was seen on aortogram. Surgery was deferred in view of lack of symptoms and uncertainty in its natural history in the setting of traumatic etiology. A repeat transthoracic echocardiogram at six-month follow-up showed spontaneous closure of the fistula.

Inferior vena cava injury: survival of a rare case

The inferior vena cava is the most commonly injured abdominal vessel and accounts for about 25% of abdominal vascular injuries. Despite improved preoperative care and operative techniques, the mortality rates for the inferior vena cava injuries are still high due to delayed presentation, inadequate or delayed fluid resuscitation, difficulty of diagnosis and technical problems in repair. A case of the inferior vena cava injury encountered after abdominal stab injury with about 4cm vertical tear of infrarenal vena cava, survived due to immediate transportation, appropriate and successful perioperative fluid and blood resuscitation, prompt surgical management with a team approach and critical post-operative surgical management.

Imaging of penetrating thoracic trauma in a large Nordic trauma center

Background

Penetrating trauma is rarely encountered in Nordic trauma centers, yet the incidence is increasing. Typical imaging findings in penetrating trauma should thus be familiar to all radiologists.

Purpose

To evaluate incidence and imaging findings of penetrating chest trauma, gunshot wound (GSW) and stab wound (SW) injury spectrum, imaging protocols, and outcome in a large trauma center.

Material and Methods

Trauma registry data from 2013–2016 was retrieved, and imaging accessed through hospital PACS. Retrieved variables included age, gender, injury severity scores, mechanism of injury, time to CT, and 30-day mortality. Depth of thoracic, pulmonary, abdominal and skeletal injury, active bleeding, and use of chest tubes were evaluated.

Results

Of 636 patients with penetrating injuries, 443 (69.7%) underwent imaging. Of these, 161 (36.3%) had penetrating thoracic injuries. Of 161 patients with penetrating chest trauma in imaging, 151 (93.8%) were men (mean age = 34.9 years) and 10 (6.2%) were women (mean age = 40.7 years). The majority of patients had SWs (138 SW vs. 15 GSW). Patients with GSWs were more severely injured (mean ISS 17.00 vs. 8.84 [P=0.0014] and ISS≥16 in 53.3% vs. 16.7%) than SW patients. In CT, intrathoracic injuries were found in 49.4% (77/156) and active bleeding in 26.3% (41/156). Emergency surgery was performed in 6.2% (10/161) with postoperative CT imaging. Thirty-day mortality rate was 1.2% (2/161).

Conclusion

Penetrating thoracic trauma often violates intrathoracic structures and nearby compartments. Arterial phase whole-body CT is recommended as multiple injuries and active bleeding are common. CT after emergency surgery is warranted, especially to assess injuries outside the surgical field.

Anesthetic management of stab wound in right ventricle of heart

Stab wound in right ventricle of heart requires a prompt and focused surgical intervention. Cardiac tamponade is a common finding when dealing with stabbed hearts, which must be diagnosed and treated in a timely fashion. We report a case of 28-year-old man who presented in emergency department following accidental stab trauma during a religious ceremony. The challenges faced in the perioperative period were the management of impending cardiac tamponade and hemodynamic stability.

Mandatory Laparotomy in Penetrating Abdominal Injuries with Omental Evisceration: Experience in a Major Trauma Center in the Philippines

BACKGROUND

Omental evisceration due to abdominal stab injuries connotes peritoneal penetration and translates to around 70% risk of intra-abdominal injury. Such cases are being managed with mandatory laparotomy at the Philippine General Hospital. This study aims to review the patient profile and laparotomy outcomes in such cases.

METHODS

This is a retrospective review of 98 consecutive laparotomies performed for patients with omental evisceration secondary to abdominal stab wounds between January 2004 to April 2018.

RESULTS

Almost all patients were male (99%) with a mean age of 32.1 years (range 14-70). The majority (81%) had a therapeutic laparotomy, and only 19 patients (19%) had a non-therapeutic laparotomy. The most commonly injured organs include the small bowel, stomach, colon, diaphragm, and liver. There was no significant difference in age, sex, duration of injury, systolic blood pressure and heart rate at presentation between the two groups. There were significantly more patients who presented with peritonism in the therapeutic laparotomy group compared to the non-therapeutic laparotomy group (82% vs 53%, p=0.005). Patients who presented with peritonism were six times more likely to have a therapeutic laparotomy. There was no significant difference between morbidity and mortality rates in the two groups. The length of hospital stay for the non-therapeutic laparotomy group was significantly shorter compared to the therapeutic laparotomy group (3.6 vs 5.7 days, p=0.006).

CONCLUSION

The rate of therapeutic laparotomy remains to be significantly higher among patients with omental evisceration. Hence, omental evisceration, particularly those associated with peritonism, should continue to prompt operative management.

Thoracic Visceral Compression-A Useful Technique for Demonstrating Small Bleeding Points in the Dissected Neck at Autopsy

A 29-year-old man died at the scene of an altercation from a stab wound to the left side of the neck. At autopsy, careful in situ examination of the common carotid artery did not reveal any evidence of hemorrhage or apparent vascular injury. However, applying pressure to the chest wall and underlying thoracic viscera (lungs and heart) resulted in filling of the collapsed vessel with blood causing hemorrhage from a small incision on the medial aspect of the common carotid artery. Release of pressure and drying of the dissection field enabled the artery to be opened and the small defect to be identified. This technique may be used to temporarily restore blood to a vessel to help identify a small bleeding point that may otherwise be difficult to detect.

Assessment of cases with sharp and penetrating object injuries

Background

Sharp and penetrating object injuries (SPOIs) are seen frequently in forensic medicine practice. In this study, we aimed to retrospectively investigate cases with SPOIs.

Materials and Methods

This study investigated the charts of patients treated at Adiyaman University Education and Research Hospital between January 1, 2013, and December 31, 2017. A total of 934 inpatients with sharp object injuries were included in the study. Data were assessed using a suitable computer-aided package program. Cases were examined in terms of age, gender, injury body site, suicide or homicide, radiologic findings, presence of vital danger, and severity of injury.

Results

In this study, we examined the charts for 934 inpatients with stab wounds. It was stated that 124 (13.27%) of those injured were female and 810 (86.63%) male; the average age of the injured persons was 29.8 ± 18.2 years. It was found that 214 (22.91%) people were exposed to vital danger and that 720 (77.09%) suffered from soft tissue injuries (penetrating skin and muscle injuries). Also, 69.27% of the cases (n = 647) involved people less than 35 years of age.

Conclusion

Considering that stab injuries are more frequent in the lower age groups, we believe that such injuries could be reduced by increasing training programs for young people.

Abdominal Stab Wounds with Tension Pneumopericardium Confirmed by Autopsy and Postmortem Computed Tomography

We present the first report of pneumopericardium observed by autopsy and on postmortem computed tomography (PMCT) images. The subject was a woman who died of self-inflicted stab wounds to the abdomen. The PMCT scan revealed air in the pericardial sac, a "flattened heart" sign, and retroperitoneal hemorrhage. Medicolegal autopsy revealed two abdominal stab wounds near the xiphoid process that had cut the apical pericardium and adjacent diaphragm and liver. Examination of the open thorax confirmed that the pericardial sac was distended with air. The wound extended to the abdominal aorta, causing retroperitoneal hemorrhage. PMCT images showed that the pneumopericardial volume was 133 mL. We believe that cardiac tamponade occurred resulting from the tension pneumopericardium; however, the effects were mitigated by hypovolemia secondary to the retroperitoneal hemorrhage as well as obstructive shock. Therefore, the cause of death appears to have been low-pressure cardiac tamponade.

Accidental cut-throat injuries from the broken windshield of an auto rickshaw: Two unusual cases

Accidental cut-throat injuries are extremely rare and usually involve a sharp-edged weapon. In this paper, two cases of a cut-throat wound to two auto-rickshaw drivers are presented where the broken windshield of the auto-rickshaws was responsible for the wounds. In both the cases, fatal incised wounds were present over the neck, cutting the soft tissue along with the major vessels. The death occurred due to exsanguination caused by neck-vessel injury in one case and trachea along with neck-vessel injury in the second case. Although the wounds on the neck initially suggested homicide, they were found to have occurred accidentally as a result of a road traffic accident involving a head-on collision of auto rickshaws. The injuries were inflicted by the shattered glass of the windshield.

The Cane Sword

This report provides an overview of the injuries caused by a unique blade-type weapon known as a cane sword. The cane sword usually consists of a blade that is stored in a cylindrical "cane" that can be released at the handle to reveal the hidden blade within. The victim of the case was found to have a stab wound in the left mid-back that caused perforation of both the lower and upper lobes of the left lung, resulting in a left hemothorax. Upon autopsy, it was concluded that the patient died from injuries caused by the stab wound to the back. Given the shape of the wound and the fact that the weapon itself was found at the site of the homicide, the weapon that caused the injury was believed to be a cane sword. This case will inform forensic pathologists, law-enforcement officers, emergency medical personnel, and physicians about rare weapon, the cane sword.

Atypical stab injury suggesting ritual suicide

Sharp weapons have been one of the most common deadly tools in cases of homicide and suicide for a long time. Tentative incisions accompany the majority of suicides by sharp force and the absence of hesitation marks provokes questions about the manner of death. We present the bizarre fatality of a 41-year-old male with an isolated circumscribed incision on the right neck, where the body was found lying in a pool of blood in the shower of his apartment. The internal examination revealed a 4-cm-long channel-like defect running inwardly and downwardly along the right sternocleidomastoid region. The cause of death was external bleeding from an injured right carotid artery and internal jugular vein. The wound had clean non-contused margins without any conspicuous hesitation injuries. A fragment of a razor blade, found in blood splatters, was identified as the only potential injuring tool. The case was classified as a suicide.

A review of stab wound injuries at a tertiary trauma centre in Singapore: are self-inflicted ones less severe?

INTRODUCTION

In Singapore, as strict laws are a strong deterrent against armed violence, little is known about the epidemiology of penetrating stab wound injuries. Our study aimed to investigate the epidemiology of stab wound injuries at a major trauma centre in Singapore and determine if there was a difference in severity between self-inflicted stab wound (SI) injuries and those inflicted by others (IO).

METHODS

We retrospectively reviewed all penetrating injuries at Tan Tock Seng Hospital, and identified and categorised all stab wound injuries as SI or IO. Basic demographic information, injury severity characteristics and outcome data were compared between these two groups. A review of all mortalities was performed, including recording the causes of death.

RESULTS

Between 2005 and 2010, there were a total of 149 stab wound injuries, of which 24 (16.1%) were SI and 125 (83.9%) were IO injuries. Patients tended to be young (mean age 34.1 ± 14.2 years). The mean Injury Severity Score was significantly different between the SI and IO groups (8.8 ± 6.5 vs. 12.3 ± 8.1; p = 0.03). In both groups, the majority underwent an operative procedure (83.3% vs. 85.6%) and had an average hospital stay of four days.

CONCLUSION

The study confirms our hypothesis that SI injuries tend to be less severe than IO injuries and are more likely to occur at home rather than at a public area. This finding may be useful in the triage of patients with stab wound injuries.

Abdominal self-stabbing: A case report

While abdominal stabbings are frequently associated with homicides, abdominal self-stabbing is uncommon and poses a challenge for the investigators. In cases of sharp force trauma, the presence of hesitation cuts over the neck and extremities help to distinguish self-inflicted injuries from homicides. Hesitation cuts are not associated with self-inflicted sharp force injuries to the abdomen, and thus are of limited use in distinguishing suicidal from homicidal abdominal stab wounds. In this study, we present a case of self-inflicted abdominal stabbing along with a detailed review of literature to help elucidate such cases.

Neurological findings in pediatric penetrating head injury at a university teaching hospital in Durban, South Africa: a 23-year retrospective study

OBJECTIVES Penetrating traumatic brain injuries (TBIs) can be divided into gunshot wounds or stab wounds based on the mechanisms of injury. Pediatric penetrating TBIs are of major concern as many parental and social factors may be involved in the causation. The authors describe the penetrating cranial injuries in pediatric patient subgroups at risk and presenting to the Department of Neurosurgery at the University of KwaZulu-Natal, by assessment of the Glasgow Coma Scale (GCS) score and review of the common neurological manifestations including cranial nerve abnormalities. METHODS The authors performed a retrospective chart review of children who presented with penetrating TBIs between 1985 and 2007 at a university teaching hospital. Descriptive statistical analysis with univariate and multivariate logistic regression was used to assess the variables. RESULTS Out of 223 children aged 16 years and younger with penetrating TBIs seen during the study period, stab wounds were causal in 127 (57%) of the patients, while gunshot injuries were causal in 96 (43%). Eighty-four percent of the patients were male. Apart from abnormal GCS scores, other neurological abnormalities were noted in 109 (48.9%) of the patients, the most common being cranial nerve deficits (22.4%) and hemiparesis. There was a strong correlation between left-sided stab wounds and development of seizures. The mean age of patients with neurological abnormalities was 11.72 years whereas that of patients with no neurological abnormalities was 8.96 years. CONCLUSIONS Penetrating head injuries in children are not as uncommon as previously thought. There was no correlation between the age group of the patients and the mechanism of injury, which implies that stab or gunshot injuries could occur in any of our pediatric population with the same frequency. While gunshot injuries accounted for 56% of the patient population, stab injuries still accounted for 44%. Following penetrating head injuries, neurological abnormalities tend to occur in the older subgroup of the pediatric patients. The most common neurological abnormalities were hemiparesis followed by cranial nerve deficits. Facial nerve deficits were the most commonly seen cranial nerve abnormality. Immediate convulsions were a significant feature in patients with stab injuries to the head compared to those with gunshot injuries.

Lethal penetrating stab injury to the vertebral artery: A case report with review of literature

The vertebral arteries are rarely injured in penetrating neck trauma due to their deep location in the foramen transversarium. These injuries in isolation are not associated with neurological deficits or ischemic changes on radiology as the collaterals are usually sufficient. We report a case of fatal unilateral vertebral artery stab injury leading to bilateral cerebellar and brainstem infarction. The carotid Doppler ruled out the presence of any carotid artery injury. Life-threatening injuries are possible in the presence of hypoplastic contralateral vertebral artery or inadequate flow from the anterior circulation not making up for the deficit. This emphasizes that thorough evaluation and timely management of suspected injuries to even a single vertebral artery should be undertaken.

Positive video-assisted thoracoscopic pericardial window management of a right ventricle stab wound with minimally invasive technique

This is a case report of a successful right ventricle stab wound suture through a video-assisted pericardial thoracoscopic window, avoiding the need of a thoracotomy diminishing its associated risks, morbidity and costs. A 22-year-old patient was admitted to the emergency room with a stab wound on the left side of his chest, the patient showed symptoms of dyspnea and signs of pulmonary hypoventilation on his left lung, a chest tube were placed on the affected side with an improvement on his symptoms. A video-assisted thoracoscopic pericardial window (VATPW) was performed within the next 24 hours to rule out underlying heart wound. A VATPW shows a 1 cm right ventricle wound which was treated through the same portals avoiding a thoracotomy. The left chest tube was removed 48 hours after de procedure and the patient underwent a control echocardiogram, with no abnormalities reported and no symptoms of dyspnea, respiratory distress or palpitation the patient was subsequently discharged. The VATPW is a feasible and safe procedure to rule out underlying heart injury in individualized cases and it provides a minimally invasive treatment option in selected patients avoiding major surgery like thoracotomy or sternotomy and the added morbidity that carry with them.

Self-inflicted injuries are an important cause of penetrating traumatic injuries in Japan

Aim

Japan has a low crime rate, but a high suicide rate. The aim of this study is to review the causes of penetrating traumatic injuries in a tertiary care emergency center in Japan.

Methods

We retrospectively reviewed all admissions for traumatic injuries over a 3-year period, and calculated the proportion of patients with penetrating traumatic injuries. Weapon used, age, gender, Injury Severity Score, cause of injury, and site of injury in all patients with penetrating injuries were reviewed. The proportion of patients with penetrating injuries among patients with all types of traumatic injuries requiring surgical intervention was calculated.

Results

Of 1,321 patients admitted over 3 years, 65 patients (5%) suffered from penetrating injuries. Most were stab wounds, with only one gunshot (2%). The most common site of injury was an extremity (48%). The most common cause of penetrating injury was self-inflicted (38%). The abdomen is the most common site injured among self-inflicted injuries. Of patients with all types of traumatic injuries requiring surgical intervention, penetrating injuries accounted for 23%.

Conclusion

Penetrating injuries represent 23% of all patients with traumatic injuries who required surgical intervention. Self-inflicted penetrating injuries were most common, supporting the need for preventive services. Acute care surgeons must be familiar with the surgical management of penetrating traumatic injuries, even in a country with a low crime rate.

Delayed myelopathy secondary to stab wound with a retained blade tip within the laminae: case report

Delayed neurologic deficit after a stab wound with a retained foreign body near the spinal canal is unusual, adequate radiological examination is fundamental in detecting retained foreign bodies, especially the CT scan, surgical extraction of the foreign body is the primary task and the surgical outcome is satisfactory. Here, we report a rare case of delayed myelopathy caused by spinal stenosis secondary to broken blade tip within thoracic laminae in an old man, who was injured in a knife attack 39 years ago. The incidence, clinical presentation, diagnosis and prognosis are discussed.

Strategy for endovascular coil embolization of a penetrating vertebral artery injury

Background:

Penetrating vertebral artery injuries (VAIs) are even rarer than carotid artery injuries. For anatomical reasons, the surgical management of VAI is difficult, and endovascular management often yields a good outcome. We report our strategy for the endovascular treatment of a patient with a penetrating VAI at the V2 segment of the left vertebral artery.

Case Description:

In a fall on a large rake, a 76-year-old man was stabbed in the left neck by three tines. Although he manifested no neurological deficits, computed tomography (CT) suggested penetrating VAI. Digital subtraction angiography confirmed VAI and extravasation, and he underwent endovascular coil embolization. Two microcatheters, inserted proximal and distal to the injury sites, were used for successful endovascular coil embolization. Postoperative magnetic resonance imaging - and single photon emission CT studies denied cerebral infarction and a decrease in cerebral perfusion. The patient exhibited no neurological deficits and was able to leave the hospital on foot.

Conclusion:

This is the rare documentation of a patient whose penetrating VAI was treated by simultaneous coil embolization and foreign body removal. Imaging studies confirmed the patency and perfusion of the intracranial artery. Our treatment strategy produced a good outcome in this unusual patient.

An analysis of predictors of morbidity after stab wounds of the pancreas in 78 consecutive injuries

INTRODUCTION

Penetrating injuries of the pancreas may result in serious complications. This study assessed the factors influencing morbidity after stab wounds of the pancreas.

METHODS

A retrospective univariate cohort analysis was carried out of 78 patients (74 men) with a median age of 26 years (range: 16-62 years) with stab wounds of the pancreas between 1982 and 2011.

RESULTS

The median revised trauma score (RTS) was 7.8 (range: 2.0-7.8). Injuries involved the body (n=36), tail (n=24), head/uncinate process (n=16) and neck (n=2) of the pancreas. All 78 patients underwent a laparotomy. Sixty-five patients had AAST (American Association for the Surgery of Trauma) grade I or II pancreatic injuries and thirteen had grade III, IV or V injuries. Eight patients (10.3%) had an initial damage control operation. Sixty-nine patients (84.6%) had drainage of the pancreas only, six had a distal pancreatectomy and one had a pancreaticoduodenectomy. Most pancreas related complications occurred in patients with AAST grade III injuries; eight patients (10.2%) developed a pancreatic fistula. Four patients (5.1%) died. Grade of pancreatic injury (AAST grade I-II vs grade III-V injuries, p<0.001), RTS (odds ratio [OR]: 5.01, 95% confidence interval [CI]: 1.46-17.19, p<0.007), presence of shock on admission (OR: 3.31, 95% CI: 1.16-9.42, p=0.022), need for a blood transfusion (OR: 6.46, 95% CI: 2.40-17.40, p<0.001) and repeat laparotomy (p<0.001) had a significant influence on the development of general complications.

CONCLUSIONS

Although mortality was low after a pancreatic stab wound, morbidity was high. Increasing AAST grade of injury, high RTS, shock on admission to hospital, need for blood transfusion and repeat laparotomy were significant factors related to morbidity.

Microscopic analysis of sharp force trauma in bone and cartilage: a validation study

Sharp force trauma research lacks agreement on reported error rates for correctly identifying toolmark characteristics on bone and cartilage. This study provides error rates for determining blade class (serrated, partially serrated, nonserrated) and type of edge bevel (left, right, even). Three analysts examined cuts to a wax medium, cartilage, and bone using two types of microscopes. Additionally, the observers examined impressions taken from the wax medium and the cartilage. Overall, a total of 504 observations were performed. Serrated blades were distinguishable from nonserrated blades due to their patterned striations. Some difficulties were encountered in distinguishing serrated and partially serrated blades; however, when these groups were considered together as one classification type (serrated), classification accuracy improved from 79% to 96%. Classification accuracy for edge bevel was 65%. Error rates were similar when comparing direct observation of the cut marks versus indirect observation (impressions). Additionally, the type of microscope used did not affect error rates.

Calcium-dependent N-cadherin up-regulation mediates reactive astrogliosis and neuroprotection after brain injury

Brain injury induces phenotypic changes in astrocytes, known as reactive astrogliosis, which may influence neuronal survival. Here we show that brain injury induces inositol 1,4,5-trisphosphate (IP3)-dependent Ca(2+) signaling in astrocytes, and that the Ca(2+) signaling is required for astrogliosis. We found that type 2 IP3 receptor knockout (IP3R2KO) mice deficient in astrocytic Ca(2+) signaling have impaired reactive astrogliosis and increased injury-associated neuronal death. We identified N-cadherin and pumilio 2 (Pum2) as downstream signaling molecules, and found that brain injury induces up-regulation of N-cadherin around the injured site. This effect is mediated by Ca(2+)-dependent down-regulation of Pum2, which in turn attenuates Pum2-dependent translational repression of N-cadherin. Furthermore, we show that astrocyte-specific knockout of N-cadherin results in impairment of astrogliosis and neuroprotection. Thus, astrocytic Ca(2+) signaling and the downstream function of N-cadherin play indispensable roles in the cellular responses to brain injury. These findings define a previously unreported signaling axis required for reactive astrogliosis and neuroprotection following brain injury.

Computed tomography angiography reveals the crime instrument - case report

BACKGROUND

The development of multislice CT technology enabled imaging of post-traumatic brain lesions with isotropic resolution, which led to unexpected results in the presented case

CASE REPORT

An unconscious, 49-year-old male with a suspected trauma underwent a routine CT examination of the head, which revealed an unusual intracerebral bleeding and therefore was followed by CT angiography (CTA). The thorough analysis of CTA source scans led to the detection of the bleeding cause.

CONCLUSIONS

The presented case showed that a careful analysis of a CT scan allows not only to define the extent of pathological lesions in the intracranial space but it also helps to detect the crime instrument, which is of medico-legal significance.