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Case Report
 
Cut throat injury by vehicular accident
Shrabana Kumar Naik, Devinder Kumar Atal, Atul Murari, Yashoda Rani

Corresponding Author
: Dr. Shrabana K Naik
Associate Professor,
Department of Forensic Medicine,
Lady Hardinge Medical College,
New Delhi-
110001. India.
Tel: 91-11-23408158(O)
Email: naikshrabana@yahoo.co.in


History : Received - 08-07-2011 Accepted - 06-09-2011 Published Online -  23-Sep-2011
DOI : http://dx.doi.org/10.7713/ijms.2012.0021


Abstract

Cut throat injury can be homicidal or suicidal, but rarely accidental. Presence of tentative cuts at the beginning of the wound may serve as a guide to differentiate suicidal and homicidal cut throat injuries. Accidental cut throat injuries are usually associated with other bodily injuries. Accidental cut throat injury, though possible in road traffic collision, are rarely reported in forensic literatures. A case is being described where forward ejection of front seat occupant of a car into the laminated front windscreen, had caused deep cut on the front of neck. Death occurred as result of exsanguination caused by the injuries to major blood vessels of the neck. Presence of glass fragments nearby the wound, associated bodily injuries and inspection of vehicles associated with the road traffic collision was very useful to determine the exact manner of such injury.

Keywords : Wounds and injuries; pharynx; larynx; traffic accidents; seat belts.

Cut throat injuries are mostly caused by either suicide or homicide using sharp cutting weapon like razor blade, knife or sword. Light weight sharp cutting weapon are commonly used in suicidal cut throat injury whereas moderate or heavy sharp cutting weapon are mostly used for homicidal cut throat injury. Cut throat injury from broken glass fragment is very rare unless there is assaul  following altercation in a bar. Although cut throat injury can be caused by glass fragment following road traffic collision, such cases have been rarely reported in the forensic literatures. Perception and opinion about the injuries caused by broken glass piece vary among different authors. Some forensic experts describe these injuries under lacerated wound whereas others prefer to describe them under incised wound. Sharpness of the weapon depends upon the hardness, thinness and regularity of its margin. Therefore, injury caused by glass may show mixed features of both incised and lacerated wounds. Few Indian experts term such injury as cut laceration. In the present case, the injury caused by glass fragment has been described as cut laceration.

Report of case

A male dead body was brought to the Department of Forensic Medicine, Lady Hardinge Medical College and Associated Hospitals for medico-legal autopsy. There was alleged history that while the deceased was travelling as a front seat occupant in a car at about 3.15 AM, met side collision with another car during passing a signalled crossing. Due to forward and right lateral ejection, front windscreen was broken entrapping his head and neck parts. He was then rescued by the police personnel and transported to a nearby hospital, but was declared brought dead. All other passengers including the drivers of both vehicles escaped the accident with some minor injuries.

External examination showed few small broken glass fragments near the neck regions of body and wearing apparel of the deceased (Figure 1). External injuries observed were- (i) lacerated wound of size 3cm x 0.8cm, subcutaneous deep, situated on the upper eyelid and lateral angle of left eye (ii) L-shaped lacerated wound of size 10cm x 3cm, muscle deep, situated on the cheek, extended downwards and to the left from right angle of mouth across the chin (iii) multiple cut lacerated wounds of sizes varying from 2cm to 7cm x 0.1 to 0.4 cm, subcutaneous deep, associated with abrasions in the surrounding areas were found on both sides of face (iv) cut lacerated wound of size 21cm x 6cm x 7cm (muscle deep) was situated horizontally on the anterior half of neck above the level of laryngeal prominence and 3cm below chin (Figure 2). Right end of the wound was 3cm below right angle of mandible on the right antero-lateral aspect of neck, whereas its left end lay 4cm below left angle of mandible on the left antero-lateral aspect of neck. All the strap muscles of neck including both sides sternocliedomastoid muscles, nerves, all major blood vessels including carotid arteries and jugular veins, pharynx at the level of epiglottis were found completely transected at the wound level. Few broken glass fragments were found in and near the neck injury. (v) Abrasion, red in colour of size 3cm x 2cm was situated on the posterior aspect of left elbow (vi) Right thigh was found swollen and deformed.


Figure 1- showing broken glass fragments near the neck wound


Figure 2- showing the cut throat injury

Internal examination revealed that internal organs of head, chest and abdominal cavities were intact and pale. Both side chambers of heart were empty. Trachea was intact and free from any blood collection. Stomach contained 100 ml of semidigested food materials emitting strong alcoholic odour. Dissection of right thigh revealed extravasation of about 800ml of blood into the muscle planes with fracture of right femur near the level of upper 1/3 and lower 2/3 junction.

Examination of the accidental vehicles and their inspection reports revealed that right half of front part of the car inside which the deceased was sitting was badly damaged (Figure 3a). Laminated front windscreen was broken showing multiple cracks and a defect towards the right side that could accommodate one adult head (Figure 3b). Huge amount of blood collection was seen below the defect on front window screen. Posterior margin of the deformed and raised metallic bonnet lying towards the front windscreen showed no blood stain, thus excluded possibility of the cut throat injury by it. Seat belt of left side front seat was found intact. Left front aspect of the other car was showing some minor damage.


Figure 3a- showing the accidental vehicle, b- showing the gap in broken front wind screen

Based on paleness of the internal organs in a healthy adult body and extravasation of blood in the accidental vehicle, cause of death was opined as haemorrhagic shock as a result of injury to major blood vessels of the neck.

Discussion

Incised wounds of the neck can be accidental, homicidal, or suicidal whereas lacerated wounds can either be accidental or homicidal, but rarely suicidal in nature [1]. Suicidal and homicidal injuries to the neck are mostly caused by sharp force. Accidental neck traumas are usually caused by foreign object such as those made of metal or glass, when the foreign object acts as a projectile or the human body falls over it. Such injuries usually do not result in extensive collateral tissue damage, but foreign bodies may remain in the neck [2]. A review of twenty-two cases of accidental sharp force injury to the neck found that about half of the cases involved some type of motorised machinery [3]. Injuries resulting from the use of angle grinders are numerous. The most common sites injured are the head and face [4]. A case of accidental death has occurred when a spinning circular saw of a cutting machine in a workshop came off its place and cut the throat of a 30 year male operating the machine. The incised wound was of size 15 cm x 5 cm, cutting trachea, left trapezius muscle, carotid artery and jugular vein in a horizontal plane. Accidental deaths from wood cutting machine have been reported wherein carotid arteries were transected on one side after sustaining injuries [5,6].

Road traffic collisions can produce wide range of injuries, from minor abrasion and contusion, to fracture and crush injury. Burn injury from hot part of the vehicle and cut wounds from broken glass fragments are not commonly encountered in vehicular accidents. Accidental injury to the neck can be resulted from blunt force, sharp force or firearm projectile. In the present case, the neck trauma was caused by broken glass of front windscreen following ejection of the deceased.

Two cases of neck injuries have been reported following vehicular accidents. The first patient was a 48 year truck driver who suffered severe dyspnoea after jamming his neck in a truck door. The second patient was a 36 year male who suffered severe dyspnoea after having his neck caught in a chain while driving a motorcycle [7].

Cut throat injury due to vehicular accident is rarely reported in forensic literatures. Two cut throat injuries following vehicular accident have been reported recently [8]. In the present case, the fatal neck injury was a large deep cut laceration, lying horizontally on the upper part of the front of neck that could raise suspicion of foul play. However, presence of glass fragments in and near by the neck wound, other associated bodily injuries and inspection of alleged accidental vehicles supported the alleged history of road traffic collision.

In cut throat injury, the carotid arteries and jugular veins are the most vulnerable vessels, often causing neurological deficits and shock [9]. In the present case, both side carotid arteries and jugular veins were found severed leading to haemorrhagic shock and death.

Injury to the epiglottis and pharynx is very rare in neck trauma overall. One case of 43year woman had lacerations to the epiglottis and pharynx [10]. A complete disruption of the cervical trachea due to blunt trauma is relatively rare. Because of dislocation of the disrupted trachea and/or bleeding into airway, this is a mostly fatal accident. A case of 60 year male, who had complete disruption of the cervical trachea following a cervical blunt trauma by traffic accident has also been reported [11]. In the present case, there was complete transection of pharynx at the level of epiglottis.There was neither injury to the trachea, nor any blood collection inside. There was also no sign of cyanosis on the body of the deceased.

The likelihood and the severity of a crash depends on the vehicular speed. A 5% increase in average
speed leads to an approximately 10% increase in crashes that cause injuries, and a 20% increase in fatal crashes [12]. In the present case, damage to the accidental vehicles and confession of driver/occupants revealed that vehicles were at high speed, which is not unusual on Indian roads during late hours of night.

Drinking alcohol and driving increases both the risk of a crash and the likelihood that death or a serious injury will result. The risk of involvement in a crash increases significantly above a blood alcohol concentration (BAC) of 0.04 gm/dL [13]. In the present case, blood alcohol concentrations of the drivers of accidental vehicles are not available, however strong alcohol odour was emitting out of stomach contents of the deceased. Due to alcohol intoxication, his reaction time to untoward incident could have increased.

Wearing a seat belt reduces the risk of a fatality among front seat passengers by 40-50% and among rear seat car occupants by 25-75% [14]. In the present case, seat belt was not used by the deceased as reported by the fellow passengers.

The early windshield used in cars protected the driver as long as the glass remained intact. The moment the glass broke, the windshield often became more deadly than the auto accident, with possibility of large shards of glass acting as flying object due to high speed of the vehicle. Decapitation and maiming occurred far more often in the early days of automobile accidents because the windshields were fabricated from ordinary glass. The laminated glass of today is made by sandwiching a layer of polyvinyl butyral between two or more layers of traditional glass. The modern windshield no longer shatters into dangerous shards, but instead breaks into thousands of tiny pieces of almost non-lethal glass. Every piece of broken glass then sticks to the polyvinyl just as the glass stuck to the flask of Edouard Benedictus, the inventor of laminated glass, thus preventing broken glass of a windshield from spraying everywhere during a car accident. By keeping the shattered windshield intact, the middle layer of lamination provides a barrier between the car occupants and exterior accident debris as well as prevents ejection injuries. In the present case, though laminated front windshield was able to prevent ejection injury to some extent, it acted as a killer in disguise [15].

References

  1. Demirci S, Dogan KH, Gunaydin G. Throatcutting of accidental origin. J Forensic Sci 2008;53:965-7.[PUBMED]
  2. Lydiatt WM, Snyder MC, Lydiatt DD. Penetrating Injuries of the Neck. http://emedicine.medscape.com/article/ 869579-overview; Accessed on 22th January, 2010.
  3. Prahlow JA, Ross KF, Lene WJ WBS, Kirby DBBS. Accidental Sharp Force Injury Fatalities. American J Forensic Med Pathol 2001;22:358-66.[PUBMED]
  4. Carter LM , Wales CJ, Varley I, Telfer MR. Penetrating facial injury from angle grinder use: management and prevention. Head Face Med 2008, 4:1.[PUBMED]
  5. Karger B, Niemeyer J, Brinkmann B. Physical activity following fatal injury from sharppointed weapons. Int J Legal Med 1999;112:188–91.[PUBMED]
  6. Atal DK, Naik SK, Murari A. Accidental neck injury by wood cutting machine: A Case report. J Clin Pathol Forensic Med 2010;1:5- 7.
  7. Asai Y, Kaneko M, Imaizumi H, Kobayashi K, Hamamoto M, Takada R, et al. Traumatic cervical tracheal disruption: report of two cases. Surg Today 1996;26:353-6.[PUBMED]
  8. Pranav P, Shaikh MI. Suspected accident?: a case report. Medico-Legal Update 2010;10: 40-2.
  9. Arai H, Kiyoshi F, Onuma T. Penetrating injury of the common carotid artery: report of a case. No Shinkei Geka 1992;20:991-5.[PUBMED]
  10. Warabi R, Tanno K, Hirayama S, Warabi T, Sakakibara N, Kimura Y. Occult lacerations to the epiglottis and pharynx by glass fragments. Am J Emerg Med 2008;26:518.e1-3.[PUBMED]
  11. Yamanda T, Aoki T, Kaneko K, Miyazawa M, Yoshida K, Haniuda M. Complete disruption of the trachea due to blunt neck trauma- a case report. Nippon Kyobu Geka Gakkai Zasshi 1995;43:543-6.[PUBMED]
  12. Transport Research Centre. Speed management report. OECD publishing, Paris 2006.
  13. http://goarticles. com/article/The- Advantages-Of-Laminated-Glass/2910681/; Accessed on 24th Feb’2011

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