Injury patterns in motor vehicle collision-youth pedestrian deaths.

OBJECTIVE: The objective of this study was to describe fatal pedestrian injury patterns in youth aged 15 to 24 years old and correlate them with motor vehicle collision (MVC) dynamics and pedestrian kinematics using data from medicolegal death investigations of MVCs occurring in the current Canadian motor vehicle (MV) fleet. METHODS: Based on a systematic literature review, MVC-pedestrian injuries were collated in an injury data collection form (IDCF). The IDCF was coded using the Abbreviated Injury Scale (AIS) 2015 revision. The AIS of the most frequent severe injury was noted for individual body regions. The Maximum AIS (MAIS) was used to define the most severe injury to the body overall and by body regions (MAISBR). This study focused on serious to maximal injuries (AIS 3-6) that had an increasing likelihood of causing death. The IDCF was used to extract collision and injury data from the Office of the Chief Coroner for Ontario (OCCO) database of postmortem examinations done at the Provincial Forensic Pathology Unit (PFPU) in Toronto, Canada, and other provincial facilities between 2013 and 2019. Injury data were correlated with data about the MVs and MV dynamics and pedestrian kinematics.The study was approved by the Western University Health Science Research Ethics Board (Project ID: 113440; Lawson Health Research Institute Approval No. R-19-066). RESULTS: There were 88 youth, including 54 (61.4%) males and 34 (38.6%) females. Youth pedestrians comprised 13.1% (88/670) of all autopsied pedestrians. Cars (n = 25/88, 28.4%) were the most frequent type of vehicle in single-vehicle impacts, but collectively vehicles with high hood edges (i.e., greater distance between the ground and hood edge) were in the majority. Forward projection (n = 34/88, 38.6%) was the most frequent type of pedestrian kinematics. Regardless of the type of vehicle, there was a tendency in most cases for the median MAISBR ≥ 3 to involve the head and thorax. A similar trend was seen in most of the pedestrian kinematics involving the various frontal impacts. Of the 88 cases, at least 63 (71.6%) were known to be engaged in risk-taking behaviors (e.g., activity on roadway). At least 12 deaths were nonaccidental (8 suicides and 4 homicides). Some activities may have been impairment related, because 26/63 (41.3%) pedestrians undertaking risk-taking behavior on the roadway were impaired. Toxicological analyses revealed that over half of the cases (47/88, 53.4%) tested positive for a drug that could have affected behavior. Ethanol was the most common. Thirty-one had positive blood results. CONCLUSION: A fatal dyad of head and thorax trauma was observed for pedestrians struck by cars. For those pedestrians hit by vehicles with high hood edges, which were involved in the majority of cases, a fatal triad of injuries to the head, thorax, and abdomen/retroperitoneum was observed. Most deaths occurred from frontal collisions and at speeds more than 35 km/h.

Implementation of a road traffic crash injury surveillance tool in a trauma referral hospital in Kisumu City, Western Kenya: Lessons learned from the pilot study.

OBJECTIVE: Road traffic injury (RTI) is a major public health concern in Kenya with more than 13,000 deaths estimated annually. The primary objective of this study was to design and implement an injury surveillance tool for the collection of injury data, and assess the tool's feasibility for the development of a hospital-based trauma registry in a leading Kenyan referral hospital. Secondarily, an epidemiologic profile was created to characterize RTI in the region. METHODS: An injury surveillance tool was developed and implemented, on a pilot basis, in a level 5 trauma hospital, Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH), in Kisumu City, Western Kenya, for a 4-week period from 2019-07-15 to 2019-08-11. A descriptive statistical analysis summarized injury frequency counts and percentages. RESULTS: Over the pilot phase, 371 patients had forms completed, but 488 official injury-related hospital registrations, indicating that 117 injury patients (24%) were missed. A process evaluation of the tool implementation revealed issues in the collection protocol that required revisions, resulting in improved data form completeness rates. For the 368 cases with cause documented, the most common mechanisms of injury were RTI (46.5%; n = 171), assaults (23.9%; n = 88), and falls (14.9%; n = 55). For RTI patients, the median age was 28 years (IQR = 16) and 77% (n = 132) were males, with motorbike collision injuries (n = 91; 53.2%) the leading RTI mechanism. There were 348 injuries for 171 patients. The most common anatomical regions for RTI were the lower limb 32.8% (n = 114), upper limb (15.2%; n = 53), followed by head lacerations 8.6% (n = 30) and concussions 7.2% (n = 25). Two-thirds of patients (n = 113; 66.1%) were discharged from ED, just over a quarter (n = 46; 26.9%) were admitted to hospital and 9 patients succumbed to RTI (5.3%). CONCLUSIONS: This injury surveillance pilot study produced the first injury dataset in Kisumu City, demonstrating the significant magnitude of RTI in Western Kenya, the leading cause of injury for the region. This dataset can be replicated in other hospitals to create an injury surveillance system for the collection of trauma data, needed for the development of countermeasures for the reduction of trauma, as well as for quality initiatives to improve patient outcomes.

Injury patterns in motor vehicle collision-pediatric pedestrian deaths.

OBJECTIVE: To describe fatal pediatric pedestrian injury patterns and correlate them with motor vehicle collision (MVC) characteristics and pedestrian kinematics using data from medicolegal death investigations of MVCs occurring in the current Canadian MV fleet and determine the applicability of the classical "Waddell's triad" comprising knee, hip (femur) or pelvis and craniocerebral injuries to present data injury patterns. METHODS: An Injury Data Collection Form was used to extract MV, MVC, pedestrian demographic and injury information from the Office of the Chief Coroner for Ontario database using autopsy data from 2013 to 2018. Injuries were coded using the Abbreviated Injury Scale (AIS) 2015 revision. The study focused on AIS ≥3 injuries utilizing the Maximum Abbreviated Injury Scale (MAIS), MAIS by Body Region (MAISBR) and Injury Severity Score (ISS). RESULTS: Between 2013 and 2018, there were 25 pediatric deaths. The pedestrians were either struck and run over (n = 17, 68%; 56% low speed) or struck and projected (n = 8, 32%). Twenty-two deaths were from frontal impacts; three were from reversing vehicles. Fourteen of the 17 (82.4%) run over cases occurred at low speed (<30 km/h). In 9 (36%) cases, the vehicle was turning at impact (right n = 3, left n = 6). A majority of the vehicles had a high hood edge. The head was the most severely injured (median MAISBR = 5 overall and ≤10 years; median MAISBR = 6 for 11-14 years old) followed by the neck (MAISBR = 3 overall; 6-14 years old), and the thorax (median MAISBR = 3 overall; all age groups). For the early adolescents (11-14 years old), the serious injury pattern included the abdomen (median MAISBR = 3.5). Nearly half (n = 11, 44%) sustained brainstem injuries. Over fifty percent of the 16 cases with neck injuries (n = 9, 56.3%) had atlanto-occipital or axial dislocation. CONCLUSION: More than half of the deaths occurred during low speed run overs. MAIS ≥3 injuries trended to a dyad of head and thorax in ≤5 years old, a triad of head, neck, and thorax injuries in children 6-10 years old and a tetrad with the addition of abdominal injuries in pedestrians ≥11 years old. Waddell's triad was not applicable to the fatal cases in the present study.

A Neuropathological Study of Diffuse Vascular Injury in Fatal Motor Vehicle Collisions.

In Canada, 42 929 people were involved in fatal motor vehicle collisions (MVCs) between 1999 and 2018. Traumatic brain injuries (TBIs), including diffuse vascular injury (DVI), were the most frequent cause of death. The neuroanatomical injury pattern and severity of DVI in relation to data on MVC dynamics and other MVC factors were the focus of the current study. Five cases of fatal MVCs investigated by Western University's Motor Vehicle Safety (MOVES) Research Team with the neuropathological diagnosis of DVI were reviewed. DVI was seen in single and multiple vehicle collisions, with/without rollover and with/without partial occupant ejection. DVI occurred regardless of seatbelt use and airbag deployment and in vehicles equipped with/without antilock brakes. All DVI cases sustained head impacts and had focal TBIs, including basal skull fractures and subarachnoid hemorrhages. DVI was seen in MVCs that ranged in severity based on the change in velocity (delta-V) during the crash (minimum 31 km/hour) and occupant compartment intrusion (minimum 25 cm). In all cases, DVI in frontal white matter, corpus callosum and pontine tegmentum were common. In cases with more extensive DVI, pronounced vehicle rotation occurred before the final impact. Extensive DVI was seen in drivers who experienced sudden acceleration during vehicle rotation and deceleration.

Fatal anaphylaxis due to peanut exposure from oral intercourse.

BACKGROUND: Intimacy-related allergic reactions, including anaphylaxis, are under-reported due to social stigma, lack of awareness, and misdiagnosis. The differential diagnosis for intimacy-related anaphylaxis is extensive and includes systemic human seminal plasma allergy, exercise-induced anaphylaxis, asthma exacerbation, latex allergy, and transference of food or drug allergens through saliva or seminal fluid. CASE PRESENTATION: Two adolescents met on a popular dating phone application. One individual had a long-standing history of asthma and peanut allergy. Although they never kissed, the male with peanut allergy received fellatio, while the other male had eaten peanut butter before they met. During fellatio, the peanut allergic male developed respiratory symptoms, used his bronchodilator, and collapsed. He remained unconscious despite aggressive interventions by emergency personnel called to the site. The clinical history and autopsy results suggested anaphylaxis to peanut allergen exposure from the intimate exposure as the cause of death. DISCUSSION AND CONCLUSIONS: To date, nearly all reported cases of intimacy-related anaphylaxis involve symptomatic women. This is the first report of intimacy-related anaphylaxis involving men who have sex with men and the first report of potential allergen transfer from oral mucosa to a patient receiving fellatio. Based on the paucity of published cases, death from intimacy-related anaphylaxis is exceedingly rare. Post-mortem analysis is inherently difficult, as an elevated tryptase level has myriad potential causes; nevertheless, the authors suggest that intimacy-related anaphylaxis due to peanut allergy is the most likely diagnosis. With increasing popularity of relationship applications, especially amongst stigmatized populations, this case highlights the importance of allergy awareness and patient education to decrease risk, particularly in the adolescent population, who are already at increased risk of severe anaphylaxis. Especially amongst those participating in intimate activities, disclosure of one's allergies warrants discussion, as the outcome can be fatal. Our case demonstrates the crucial need for increased advocacy in food allergy, education around intimacy-related anaphylaxis, and the importance of allergy awareness and prevention across all populations.

A novel homozygous variant in REN in a family presenting with classic features of disorders involving the renin-angiotensin pathway, without renal tubular dysgenesis.

Autosomal recessively inherited pathogenic variants in genes associated with the renin-angiotensin-aldosterone system (RAAS) result in early onset oligohydramnios and clinical features of the Potter sequence, typically in association with proximal renal tubules dysgenesis. We describe two siblings and a first cousin who had severe oligohydramnios in the second trimester, and presented at birth with loose skin, wide fontanelles and sutures, and pulmonary insufficiency. Two had refractory hypotension during their brief lives and one received palliative care after birth. All were found to have a homozygous nonsense variant, REN: c.891delG; p.Tyr287*, on exome sequencing. Autopsy limited to the genitourinary system in two of the children revealed normal renal tubular histology in both. Immunoblotting confirmed diminished expression of renin within cultured skin fibroblasts. To our knowledge, this is the first identification of an association between biallelic variants in REN and oligohydramnios in the absence of renal tubular dysgenesis. Due to its role in the RAAS, it has previously been proposed that the decreased expression of REN results in hypotension, ischemia, and decreased urine production. We suggest sequencing of genes in the RAAS, including REN, should be considered in cases of severe early onset oligohydramnios, even when renal morphology and histology are normal.

The Significance of a Knee Injury in the Investigation of an Unsuspected Motor Vehicle-Pedestrian Collision.

Characteristic injury patterns have been described in pedestrians struck by motor vehicles. The common injury pattern seen in upright pedestrians consists of a triad of head, pelvis, and lower extremity trauma. There are several factors such as vehicular type, design, mass and speed, and impact surfaces that influence the type and distribution of these injuries. We report a case that illustrates the importance of examination of the knee at autopsy when the typical lower extremity diaphyseal fractures that are usually seen in a motor vehicle-pedestrian collision are absent.

Fatal Motor Vehicle-Pedestrian Collision Injury Patterns-A Systematic Literature Review.

INTRODUCTION: Injury patterns in pedestrians struck by motor vehicles were described in medical literature first published almost a half century ago. "Classical" triads of injury distribution were described for adults (skull-pelvis-extremity) and subsequently applied to children (head-hip or pelvis-distal femur/knee joint). Notably, these classical triads were derived from two publications reporting clinical observations of only 11 patients, all of whom were adults. METHODS: A systematic literature review was conducted using Medline, CINAHL, EMBASE, and Cochrane to determine the evidence-base for motor vehicle collision (MVC)-pedestrian injury "triads" and other trauma patterns described for pedestrians in the adult and pediatric age groups. RESULTS: Of the 1540 full-text articles identified in the review, 56 articles published in English met the inclusion criteria, that is, motor vehicle-pedestrian collision resulting in specific, fatal injuries determined by postmortem examinations. There were variations in injury patterns that differed from the "classical" triads. These differences likely stem from advances in vehicle design and safety features which have affected the nature and distribution of injuries. DISCUSSION: Further research on the correlation of specific injuries sustained by pedestrians of different ages with various types of vehicles and impacts are needed to assess the validity of previously observed injury patterns in relation to the current motor vehicle fleet. Delineation of injury patterns can assist health care teams in trauma management. Vehicle manufacturers and government regulators can better assess whether the introduction of advanced driver assistance features designed to protect pedestrians when struck will be effective in reducing severe injuries. In forensic pathology practice, knowledge of pedestrian injury patterns based on data representative of impacts involving modern vehicles can provide MVC death investigators the means to determine MVC dynamics and pedestrian kinematics.

A Self-Inflicted Gunshot Wound With an Unusual Hand Injury.

Self-inflicted gunshot wounds are a common cause of firearm-related deaths. The appearance and location of the entry wound, other concomitant findings at autopsy, and correlation with the scene and circumstances are critical in determining the manner of death. A case of a 72-year-old man with a self-inflicted gunshot wound with an unusual injury pattern is described. There was a contact range gunshot entry in the right temple, and an exit wound was seen in the left parietal region. There was a re-entry with an associated exit wound on the left hand.

A New Reference Source for Postmortem Body Measurements and Organ Weights in Neonates and Infants: A Statistical Analysis Based on Sudden Death Classification (Part 2).

Reference charts for body and organ measurements of neonates and infants were derived from data on 900 investigations done by the Office of the Chief Coroner for Ontario. The statistical analyses in this new reference source addressed deficiencies in sources currently available to pathologists.The present study also considered whether organ weights differed based on the classification of infant deaths using the original definition of either sudden infant death syndrome (SIDS) or sudden unexplained death (SUDS) which considers cases occurring in an unsafe sleeping environment or under adverse socioeconomic conditions. Cases of SUDS for both sexes peaked in 5 to 16 weeks of age. The thymus in the SUDS/SIDS age groups less than 25 weeks weighed more than the control group. Adrenal weights in SUDS cases between 9 and 16 weeks weighed less than SIDS cases. This could mean that deaths in unsafe sleep environments are truly sudden in infants who may have a limited adrenal response to acute hypoxia but have been unaffected by preceding chronic stressors.

A Case Report of Sudden Death From Intracardiac Leiomyomatosis.

Sudden death resulting from intracardiac leiomyomatosis is rare. In this case, a 50-year-old woman was found to have intracardiac leiomyomatosis, which originated in veins in the broad ligament. Tumor filled the entire inferior vena cava and extended into the right heart where it had embolized and occluded the right main pulmonary artery. The mechanism of death was sudden right heart failure.

Injury Patterns Sustained in Fatal Motor Vehicle Collisions with Driver's Third-Generation Airbag Deployment.

The Office of the Chief Coroner for Ontario database for 2011-2012 was used to compare fatal injury patterns in drivers whose third-generation airbags deployed compared to first- and second-generation airbag deployments and airbag nondeployments with and without seatbelt use. There were 110 frontal and offset frontal crashes analyzed. The small sample size meant that the odds of craniocerebral, cervical spinal, thoracic, and abdominal injuries were not statistically different for airbag generation, deployment status, and seatbelt use; however, the risk of fatal thoracic injuries in third- and second-generation cases was increased. Seatbelt usage in third- and second-generation deployment cases reduced the risk of all injuries except abdominal trauma. High severity impacts and occupant compartment intrusion were frequently observed. The analyses in this retrospective study were challenged by data that were not collated in a standardized way and were limited in details about scene, vehicle, and driver variables.

Retrospective Analysis of Hanging Deaths in Ontario.

Hanging deaths from investigation standpoint are rarely problematic. Unusual circumstances can on occasion raise suspicion of foul play. Associated neck injuries are reported in the literature with variable frequency (from 0% to 76.8%). This study retrospectively analyzed 755 hanging deaths in Ontario (Canada) to evaluate the demographic features and circumstances of hanging fatalities, and the frequency of hanging-related neck injuries. A number of cases showed unusual/special circumstances (e.g., complex, double suicides, restraints). Among 632 cases with complete autopsies, hyoid and larynx fractures were present in 46 cases (7.3%) with the most common being isolated hyoid fractures. The incidence of cricoid fractures was 0.5% and cervical spine injuries, 1.1%. A higher incidence of neck injuries occurred among males, long drop hangings, and in cases with complete suspension. There was a tendency for the number of fractures to increase with increasing age and weight of the deceased.

Postmortem Body and Organ Measurements in Neonates and Infants: A Review of Reference Resources Used by Ontario Pathologists (Part 1).

It is common practice in pediatric autopsies to compare the body and organ measurements of the deceased child against the existing reference data. Although a number of resources are available, many are outdated and have significant limitations. The goal of this study was to assess the reference sources currently used by the Ontario pathologists in pediatric autopsies. A survey of 14 Ontario pathologists, who do coroners' pediatric autopsies, identified 20 publications commonly referenced for body and organ measurements. Of all the cited sources, only a few had all the features regarded by the pathologists as ideal for a reference source. These features included accessibility to the source, large sample size, defined control populations, statistical analyses, and sex distinctions. The results of this study will be used to guide the development of a new reference, based on Ontario data, that will enhance measurement standards in pediatric autopsy practice.

An Autopsy Checklist: A Monitor of Safety and Risk Management.

Any autopsy has safety and risk management issues, which can arise in the preautopsy, autopsy, and postautopsy phases. The London Health Sciences Department of Pathology and Laboratory Medicine Autopsy Checklist was developed to address these issues. The current study assessed 1 measure of autopsy safety: the effectiveness of the checklist in documenting pathologists' communication of the actual or potential risk of blood-borne infections to support staff. Autopsy checklists for cases done in 2012 and 2013 were reviewed. The frequency of communication, as recorded in checklists, by pathologists to staff of previously diagnosed blood-borne infections (hepatitis B/C and human immunodeficiency virus) or the risk of infection based on lifestyle (eg, intravenous drug abuse) was tabulated. These data were compared with medical histories of the deceased and circumstances of their deaths described in the final autopsy reports. Information about blood-borne infections was recorded less frequently in the checklists compared with the final reports. Of 4 known human immunodeficiency virus cases, there was no checklist documentation in 3. All 11 hand injuries were documented. None of these cases had known infectious risks. The Autopsy Checklist is a standardized means of documenting safety and risk issues arising during the autopsy process, but its effectiveness relies on accurate completion.

Febrile Illness in an Infant With an Intracardiac Inflammatory Myofibroblastic Tumor.

We report a case of a child with a right ventricular inflammatory myofibroblastic tumor (IMT) who presented with fever, viral symptoms, and abdominal discomfort. Including this case, 49 intracardiac tumors have been previously reported in all age groups. The majority of intracardiac IMTs occur in pediatric patients, with approximately half presenting in children aged <12 months. Intracardiac IMTs are generally described as benign tumors; however, depending on their location, the initial presentation may involve heart failure or sudden death.(1) In addition to cardiac signs and symptoms, the clinical presentation of IMTs may also include constitutional signs such as fever, anemia, and elevated inflammatory markers. This case report reviews the diagnosis and management of IMTs, as well as the histopathologic features of this rare tumor type. Clinicians should be aware of their clinical presentation because early diagnosis and treatment can significantly reduce morbidity and mortality.

Delayed Fatal Hemorrhage Due to Small Bowel Mesenteric Laceration.

Injuries of small bowel and its mesentery due to blunt trauma are uncommon. Of deaths due to delayed intra-abdominal hemorrhage, mesenteric laceration is a rare cause of hemoperitoneum.A case of a 33-year-old man, who was hospitalized with chest and retroperitoneal trauma after a forklift rollover, is presented. He died 10 days after the incident. At autopsy, he had a massive hemoperitoneum due to a small bowel mesenteric laceration, which was not diagnosed during his clinical course. Microscopic examination of the hematoma around the laceration revealed healing and ruptured pseudoaneurysms in the distal branches of the superior mesenteric artery.

An experimental model of tool mark striations by a serrated blade in human soft tissues.

Tool mark analysis is a method of matching a weapon with the injury it caused. In a homicidal stabbing using a serrated knife, a stab wound that involves a cartilage may leave striations from the serration points on the blade edge. Assessing tissue striations is a means of identifying the weapon as having a serrated blade. This prospective study examines the possibility that similar striations may be produced in human soft tissues. Using tissues taken at the time of hospital-consented autopsies, stab wound tracks were assessed in a variety of human tissues (aorta, skin, liver, kidney, and cardiac and skeletal muscle). Stab wounds were produced postmortem with similar serrated and smooth-edged blades. The walls of the stab wounds were exposed, documented by photography and cast with dental impression material. Striations were identified by naked-eye examination in the skin and aorta. Photodocumentation of fresh tissue was best achieved in the aorta. Striations were not identified in wound tracks produced by the smooth-edged blade. Three blinded forensic pathologists were assessed for their ability to detect striations in photographs of wound tracks and had substantial interobserver agreement (κ = 0.76) identifying striations. This study demonstrates that tool mark striations can be present in some noncartilaginous human tissues.

Spontaneous retroperitoneal hemorrhage in a patient with prolymphocytic transformation of chronic lymphocytic leukemia.

Prolymphocytic transformation of chronic lymphocytic leukemia is a rare but recognized entity. We present the case of a 76-year-old gentleman with a previous diagnosis of chronic lymphocytic leukemia who presented with fatigue, fever, and a white blood cell count of 500 000 with prolymphocytes on peripheral blood examination. Chlorambucil and dexamethasone were initiated. He developed progressive anemia during his admission with no clear cause on initial CT examination. Bilateral hip pain began several days later and he was unfortunately diagnosed with a large spontaneous retroperitoneal hemorrhage postmortem. This condition is rare and generally occurs in those receiving therapeutic anticoagulation or dialysis, with known bleeding disorders or vascular malformation, none of which were present in our patient. Pathology revealed marked leukemoid engorgement of the vessels of many organs with prolymphocytes. We discuss the potential etiologies and relationships between these critical diagnoses.