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Evaluation of suicidal self-inflicted stab wounds to the abdomen: Differences with the forensic experience
Letters to the Editor concerned however at the apparent backwards step taken by these ‘‘consensus guidelines’’ in suggesting that the most obvious or dramatic-appearing injury should be treated ahead of a potentially life-threatening one. I think guidelines should be simple and consistent if they are to be of value, and these ‘‘consensus guidelines’’ appear to be contradictory to the majority of emergency care pathways, which appropriately place the ‘‘ABC’s’’ over and above anything other than a SAFE approach. I believe these ‘‘consensus guidelines’’ are inappropriate in the priorities they set, and undermine the well-proven principles of emergency medical care. Allison and Porter hoped that their guidelines could be ‘‘updated as new evidence or arrangements for burns patients are made’’. I wonder if they could be ‘‘updated’’ with old evidence of good and effective practice?
669 injuries, although critical and definitive airway management may require an experienced anaesthetist and/or someone capable to undertaking a surgical airway. Table 3 was not written to capture all scenarios for all practitioners. However, we would agree in line with CSCATT and ABC assessment for the qualified practitioner the assessment of AcBC should be undertaken after the SAFE approach and stopping the burning process. K.M. Porter* K. Allison Pinderfields General Hospital, Department of Orthopaedics, Wakefield, W. Yorks WF1 4DG, UK *Corresponding author doi:10.1016/j.injury.2006.01.041
Reference 1. Allison K, Porter K. Consensus on the pre-hospital approach to burns patient management. Injury 2004;35:734—8.
Toby Branfoot* St. James’s University Hospital, Beckett Street, Leeds LS9 TF, United Kingdom *Present address: 5 Psalter Croft, Sheffield S11 8PU, United Kingdom Tel.: +44 113 206 4798; fax: +44 113 206 5156 E-mail address: [email protected] doi:10.1016/j.injury.2006.01.040
AUTHOR’S REPLY Consensus on the pre-hospital approach to burns patient management We thank Toby Branfoot for his comments. The guidelines were designed to capture all burn injuries, the majority of which, based on total figures are relatively minor household burns and scalds. The concept of a SAFE approach, stopping the burning process and cooling the burn is something that most lay personnel could undertake when directed to do so by telephone via the ambulance dispatch system. A more advanced practitioner should be trained to manage the immediate life threatening problems that may be part of the burn injury or associated DOI of original article: 10.1016/j.injury.2006.01.040.
LETTER TO THE EDITOR Evaluation of suicidal self-inflicted stab wounds to the abdomen: Differences with the forensic experience To the Editor, With great interest we read the paper regarding a retrospective study on abdominal self-inflicted stab wounds (ASWs) cases reported by Abdullah et al.1 Recently we have experienced a very unusual case of fatal self inflicted abdominal knife wounds as cause of death in a 64-year-old woman with a recent history of depression. The crime scene was as follows: a family member found the old woman dead in her bedroom at home with a kitchen knife in the right hand: a forensic autopsy was performed. On external examination, three horizontally aligned stab wounds where located on the left upper quadrant of the abdomen and two other superficial stab wounds parallel to each other on the left anterior region of the neck were documented. Two out of the three stab wounds in the abdomen were superficial tentative marks–—hesitation injuries; the third one was penetrating the abdomen. At autopsy the stab wound penetrating the abdomen (Fig. 1) observed on external examination was directed upward through the thoracic cavity, reached the heart and passed through the right ventricle to the posterior wall (Fig. 2). About 700 cm3 of blood were notice in each pleural cavity as well as 500 cm3 of similar fluid with clots in the DOI of original article: 10.1016/j.injury.2006.02.011.
670
Letters to the Editor
Figure 1
Stab wound penetrating in abdomen.
pericardium associated with bleeding around the soft tissue. No other vital structures were affected. The remaining two stab wounds of the neck were superficial. According to the autopsy findings, the cause of death was due to cardiac failure following acute haemorrhage by fatal self-inflicted stab wound of the right anterior and posterior ventricular cavity of the heart. Suicide by stabbing is a rare event, representing only 1.6—3% of all suicides.2,3 Although self-inflicted incised wounds are a well-recognised method of suicide, cases are uncommon and there is always a potential risk for confusion with homicide. The present case is interesting especially because of the lethal aspect of the wounds observed at the autopsy. Differing from Abdullah’s opinion, our case demonstrates that stabs wounds to the abdomen may involve the heart and can be lethal. In fact according to previous investigations,4,5 in the vast majority of suicides perpetrated through self-inflicted stab lesions to the abdomen, the wounds enter the upper
abdomen, below the costal arch, usually with upwards tracks reaching the organs of thoracic cavity. This occurrence may depend due to the perpetrator’s intent to avoid anatomic obstacles like ribs and thus to seek access to the heart via the abdominal cavity. Our interpretations regarding self-inflicted ASWs differ from Abdullah’s conclusions probably also because of the different nature of the observer: forensic perspective is one of the possible explanations. Although significant criteria to determine the manner of death have been established on the base of the site, axis and pattern of the wounds, hesitation marks, defence wounds, capacity of physical activity and potential lethal effects of the single injuries, multiple aspects are still debated in either clinical and forensic evaluation of self-inflicted ASWs.
References 1. Abdullah F, Nuernberg A, Rabinovici R. Self inflicted abdominal stab wounds. Injury 2003;34:35—9. 2. Byard RW, Klitte A, Gilbert JD, James RA. Clinicopathologic features of fatal self inflicted incised and stab wounds: a 20 years study. Am J Forensic Med Pathol 2002;23:15—8. 3. Karger B, Wennemann B. Suicide by more than 90 stab wounds including perforation of the skull. Int J Legal Med 2001;115: 167—9. 4. Karlsson T, Ormstad K, Rajs J. Patterns in sharp force fatalities– —a comprehensive forensic medical study. Part 2. Suicidal sharp force injury in the Stockholm area 1972—1984. J Forensic Sci 1988 Mar;33(2):448—61. 5. Karger B, Niemeyer J, Brinkmann B. Suicides by sharp force: typical and atypical features. Int J Legal Med 2000;113:259—62.
Francesca Cittadini Vincenzo L. Pascali Antonio Oliva* Institute of Forensic Medicine, Catholic University, Rome, Italy *Corresponding author E-mail address: [email protected] (A. Oliva) doi:10.1016/j.injury.2006.02.014
REPLY TO LETTER TO THE EDITOR Evaluation of suicidal self-inflicted stab wounds to the abdomen: Differences with the forensic experience We thank Dr. Cittadini and his colleagues for their remarks and interest in our recent article.1 We Figure 2 Stab wound of the right anterior and posterior ventricular cavity of the heart.
DOI of original article: 10.1016/j.injury.2006.02.014.
669 injuries, although critical and definitive airway management may require an experienced anaesthetist and/or someone capable to undertaking a surgical airway. Table 3 was not written to capture all scenarios for all practitioners. However, we would agree in line with CSCATT and ABC assessment for the qualified practitioner the assessment of AcBC should be undertaken after the SAFE approach and stopping the burning process. K.M. Porter* K. Allison Pinderfields General Hospital, Department of Orthopaedics, Wakefield, W. Yorks WF1 4DG, UK *Corresponding author doi:10.1016/j.injury.2006.01.041
Reference 1. Allison K, Porter K. Consensus on the pre-hospital approach to burns patient management. Injury 2004;35:734—8.
Toby Branfoot* St. James’s University Hospital, Beckett Street, Leeds LS9 TF, United Kingdom *Present address: 5 Psalter Croft, Sheffield S11 8PU, United Kingdom Tel.: +44 113 206 4798; fax: +44 113 206 5156 E-mail address: [email protected] doi:10.1016/j.injury.2006.01.040
AUTHOR’S REPLY Consensus on the pre-hospital approach to burns patient management We thank Toby Branfoot for his comments. The guidelines were designed to capture all burn injuries, the majority of which, based on total figures are relatively minor household burns and scalds. The concept of a SAFE approach, stopping the burning process and cooling the burn is something that most lay personnel could undertake when directed to do so by telephone via the ambulance dispatch system. A more advanced practitioner should be trained to manage the immediate life threatening problems that may be part of the burn injury or associated DOI of original article: 10.1016/j.injury.2006.01.040.
LETTER TO THE EDITOR Evaluation of suicidal self-inflicted stab wounds to the abdomen: Differences with the forensic experience To the Editor, With great interest we read the paper regarding a retrospective study on abdominal self-inflicted stab wounds (ASWs) cases reported by Abdullah et al.1 Recently we have experienced a very unusual case of fatal self inflicted abdominal knife wounds as cause of death in a 64-year-old woman with a recent history of depression. The crime scene was as follows: a family member found the old woman dead in her bedroom at home with a kitchen knife in the right hand: a forensic autopsy was performed. On external examination, three horizontally aligned stab wounds where located on the left upper quadrant of the abdomen and two other superficial stab wounds parallel to each other on the left anterior region of the neck were documented. Two out of the three stab wounds in the abdomen were superficial tentative marks–—hesitation injuries; the third one was penetrating the abdomen. At autopsy the stab wound penetrating the abdomen (Fig. 1) observed on external examination was directed upward through the thoracic cavity, reached the heart and passed through the right ventricle to the posterior wall (Fig. 2). About 700 cm3 of blood were notice in each pleural cavity as well as 500 cm3 of similar fluid with clots in the DOI of original article: 10.1016/j.injury.2006.02.011.
670
Letters to the Editor
Figure 1
Stab wound penetrating in abdomen.
pericardium associated with bleeding around the soft tissue. No other vital structures were affected. The remaining two stab wounds of the neck were superficial. According to the autopsy findings, the cause of death was due to cardiac failure following acute haemorrhage by fatal self-inflicted stab wound of the right anterior and posterior ventricular cavity of the heart. Suicide by stabbing is a rare event, representing only 1.6—3% of all suicides.2,3 Although self-inflicted incised wounds are a well-recognised method of suicide, cases are uncommon and there is always a potential risk for confusion with homicide. The present case is interesting especially because of the lethal aspect of the wounds observed at the autopsy. Differing from Abdullah’s opinion, our case demonstrates that stabs wounds to the abdomen may involve the heart and can be lethal. In fact according to previous investigations,4,5 in the vast majority of suicides perpetrated through self-inflicted stab lesions to the abdomen, the wounds enter the upper
abdomen, below the costal arch, usually with upwards tracks reaching the organs of thoracic cavity. This occurrence may depend due to the perpetrator’s intent to avoid anatomic obstacles like ribs and thus to seek access to the heart via the abdominal cavity. Our interpretations regarding self-inflicted ASWs differ from Abdullah’s conclusions probably also because of the different nature of the observer: forensic perspective is one of the possible explanations. Although significant criteria to determine the manner of death have been established on the base of the site, axis and pattern of the wounds, hesitation marks, defence wounds, capacity of physical activity and potential lethal effects of the single injuries, multiple aspects are still debated in either clinical and forensic evaluation of self-inflicted ASWs.
References 1. Abdullah F, Nuernberg A, Rabinovici R. Self inflicted abdominal stab wounds. Injury 2003;34:35—9. 2. Byard RW, Klitte A, Gilbert JD, James RA. Clinicopathologic features of fatal self inflicted incised and stab wounds: a 20 years study. Am J Forensic Med Pathol 2002;23:15—8. 3. Karger B, Wennemann B. Suicide by more than 90 stab wounds including perforation of the skull. Int J Legal Med 2001;115: 167—9. 4. Karlsson T, Ormstad K, Rajs J. Patterns in sharp force fatalities– —a comprehensive forensic medical study. Part 2. Suicidal sharp force injury in the Stockholm area 1972—1984. J Forensic Sci 1988 Mar;33(2):448—61. 5. Karger B, Niemeyer J, Brinkmann B. Suicides by sharp force: typical and atypical features. Int J Legal Med 2000;113:259—62.
Francesca Cittadini Vincenzo L. Pascali Antonio Oliva* Institute of Forensic Medicine, Catholic University, Rome, Italy *Corresponding author E-mail address: [email protected] (A. Oliva) doi:10.1016/j.injury.2006.02.014
REPLY TO LETTER TO THE EDITOR Evaluation of suicidal self-inflicted stab wounds to the abdomen: Differences with the forensic experience We thank Dr. Cittadini and his colleagues for their remarks and interest in our recent article.1 We Figure 2 Stab wound of the right anterior and posterior ventricular cavity of the heart.
DOI of original article: 10.1016/j.injury.2006.02.014.