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The hazard of sharp force injuries: Factors influencing outcome
Journal of Forensic and Legal Medicine 37 (2016) 71e77
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Original communication
The hazard of sharp force injuries: Factors influencing outcome Normann c, Inge Morild a, b, Peer Kåre Lilleng a, b, f, Stine Kristoffersen a, b, *, Stig-Andre d, e, f Jon-Kenneth Heltne a
Department of Pathology, The Gade Institute, Haukeland University Hospital, 5021 Bergen, Norway Department of Clinical Medicine, Gade Laboratory of Pathology, University of Bergen and Haukeland University Hospital, 5021 Bergen, Norway c Cand.Med.-Degree Programme, Faculty of Medicine and Dentistry, University of Bergen, Norway d Department of Anaesthesia and Intensive Care, Haukeland University Hospital, 5021 Bergen, Norway e Department of Clinical Medicine, University of Bergen, Bergen, Norway b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 25 May 2015 Received in revised form 4 September 2015 Accepted 24 October 2015 Available online 5 November 2015
The risk of dying from sharp force injury is difficult to ascertain. To the best of our knowledge, no study has been performed in Norway regarding mortality due to sharp force injury or factors that impact survival. Thus, the objective of the present study was to investigate and assess mortality in subjects with sharp force injury. This retrospective study comprises data on 136 subjects (34 female, 102 male) with suspected severe sharp force injury (self-inflicted or inflicted by others) admitted to Haukeland University Hospital between 2001 and 2010. The majority of subjects were intoxicated, and the injury was most often inflicted by a knife. The incidence of sharp force injury in Western Norway is similar to the incidence in other European countries. Almost half of the subjects with self-inflicted injury died. In cases with injury inflicted by another individual, one in five died. Mortality rates were higher in those with penetrating chest injuries than those with penetrating abdominal injuries and higher in cases with cardiac injury compared to pleural or lung injury. Sharp force injury can be fatal, but the overall mortality rate in this study was 29%. Factors influencing mortality rate were the number of injuries, the topographic regions of the body injured, the anatomical organs/structures inflicted, and emergency measures performed. © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Sharp force injury Knife Attack Self-infliction Mortality rate Injury Severity Score
1. Introduction In court, forensic pathologists are often asked, “How dangerous is a knife injury?” The underlying question is, “What is the risk of dying from sharp force injury?” Therefore, the primary purpose of the present study was to assess mortality in victims of sharp force injuries. We investigated this issue in surviving and deceased victims of sharp force injury admitted to Haukeland University Hospital. We studied subjects with sharp force injury inflicted by others or by the subjects themselves according to The World Health Organisation's definition of violence1: “The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.”
* Corresponding author. Department of Pathology, Haukeland University Hospital, 5021 Bergen, Norway. Tel.: þ47 55972567; fax: þ47 55973158. E-mail address: [email protected] (S. Kristoffersen). f Joint last authorship.
The incidence of sharp force injury in Western Norway is difficult to ascertain, as such patients are treated in different health facilities (e.g., general practitioners, local accident and emergency departments, and hospitals) and there is no coordinated recording of all sharp force injuries. In addition, an unknown proportion of subjects with sharp force injury never seek any treatment. Also, criminal statistics do not provide the full picture, as many victims do not press legal charges, supposedly because of low confidence in the police and justice system.2 Between 2001 and 2007, all types of violence were between 2.5 and 3.3% of all crimes reported to the police in Western Norway.3 At the accident and emergency department of Bergen, 10% of assaulted patients are treated for minor sharp force injury.2 The real incidence of self-inflicted sharp force injury is also difficult to estimate, as it frequently occurs in secret and the injuries are often superficial, not requiring medical attention.4,5 The Child and Adolescent Self-harm in Europe (CASE) study has estimated a lifetime prevalence of all acts of self-harm in Norway to be 16% for women and 5% for men.6 According to the homicide statistics of the National Criminal Investigation Service (NCIS), 50% of all homicides in Norway in 2011 were caused by sharp force injury.7 According to Statistics Norway, sharp force
http://dx.doi.org/10.1016/j.jflm.2015.10.005 1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
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injury caused between 2.1 and 3.6% of all suicides in Norway between 2001 and 2010.8 Inclusion criteria and registration procedures vary in different studies of victims of sharp force injury, making a comparison of the success ratios difficult. This study includes subjects with severe injuries or injuries suspected of being severe enough to be admitted to hospital, as well as those who died at the scene. Only one study from Oslo has assessed survival time after sharp force injury in Norway, but all of the cases had fatal outcomes.9 To the best of our knowledge, no study has been performed in Norway regarding the mortality rate of sharp force injury and factors that impact survival. 2. Material and methods Haukeland University Hospital serves as the local hospital of Bergen, the central hospital of Hordaland County, and the regional hospital of Hordaland, Rogaland, and Sogn and Fjordane Counties,10 covering a population of 996,712 inhabitants in 2009.11e13 Data included deceased and surviving subjects with sharp force injury considered severe or potentially severe who were brought to the hospital between 1 January 2001 and 31 December 2010. We included subjects with self-inflicted injury and those with injury inflicted by others. Subjects with sharp force injuries due to accidents were excluded. The study subjects resided mainly in Bergen, the second largest city of Norway, and its surrounding municipalities. Data were obtained from the database of the emergency department, the database of the Norwegian Air Ambulance Service, and from the archive of forensic reports in The Gade Laboratory of Pathology. The Trauma Coordinator of Haukeland University Hospital provided additional data for the years 2009 and 2010 from a new database established in 2009 with new registration procedures. Medical records from surviving patients comprised as little as one short page with limited information to several pages. Post-mortem examinations included an assessment of injuries, and in most cases a toxicology report based on analyses of fluid or tissue samples (e.g., blood, urine, psoas major muscle, or vitreous humour). In deceased subjects, the levels of ethanol and drugs were determined, but in surviving subjects the levels of substances were not often given in the medical records. Therefore, substances were simply recorded as being present or absent in the blood, urine, psoas major muscle, or vitreous fluid. In deceased subjects, postmortal fermentation of ethanol was verified by the presence of metabolic products of ethanol, ethyl glucuronide and ethyl sulphate. Significance was determined by chi-square tests using SPSS PAWS Statistics, versions 20 and 21. Diagrams were created in Excel (version 2007 and Mac 2011). The following parameters were recorded: age, perpetratorevictim relationship, scene of event, nationality, weapon/tool used, date of event, number of injuries, anatomical regions injured, organ injury, toxicology results, and treatment. The subjects were grouped according to whether the injuries were self-inflicted or inflicted by others, and by outcome (non-fatal or fatal) and gender. Subjects were scored according to the Injury Severity Score (ISS) in order to compare our results to those of other studies (Appendix 1). A high ISS is associated with poor performance status/potentially fatal injury. When an ISS was not in the medical records, we calculated it based on the information available. 3. Results 3.1. Characteristics of the study population The study population included 34 women and 102 men divided into four groups (Table 1). Surviving victims with sharp force
injury inflicted by others were assigned to group 1 (n ¼ 72). Victims of homicide by sharp force injury were group 2 (n ¼ 17). Surviving victims with self-inflicted sharp force injury were group 3 (n ¼ 25). Victims of suicide by sharp force injury were group 4 (n ¼ 22). Grouping subject ages in intervals of 10 years revealed that the age distribution was different in the groups (l2 ¼ 63.7, df ¼ 18, p ¼ 0.001), with the lowest median age in group 1 and highest in group 4. Subjects who survived an attack (group 1) were younger than subjects who were killed in an attack (group 2), and subjects who survived self-inflicted injury (group 3) were younger than those who committed suicide (group 4). Comparing the first and last 5 years of the study period, we found a 47% increase in sharp force injury due to an increase in males in groups 1 and 4. However, the increase was not significant. Gender proportions were different in the four subject groups (l2 ¼ 17.6, df ¼ 3, p ¼ 0.001). Among attacked individuals (groups 1 and 2), there were gender differences in perpetrator/victim relationships. A considerable proportion of female victims (39%) had sharp force injury inflicted by a past or present intimate male partner (spouse, co-habitant, or boyfriend), and 56% of these subjects died. In contrast, 9% of male victims were attacked by female intimate partners, and all survived. The scene was unknown in 40% of the cases in group 1, most related to male victims, reflecting that these subjects claimed to have been attacked by a stranger. In all other groups, a private home was the predominant scene of events (68e82%) (l2 ¼ 44, df ¼ 21, p < 0.002). In our study population, 81% of the subjects were of Norwegian nationality. The distribution of subjects of non-Norwegian nationality was unevenly distributed between the groups. The proportion of subjects of non-Norwegian nationality was highest in group 1 (28%) (l2 ¼ 8.6, df ¼ 3, p ¼ 0.034). 3.2. Weapon In 83% of the incidents, a knife was the weapon used to inflict the injury. In 8% of the cases, broken glass was utilised (predominantly in group 1), and in the remaining cases various tools and sharp objects (e.g., scissors, screwdriver, and bayonet). We found no significant differences in regards to the weapon used in relation to subject group, gender, or mortality outcome. 3.3. Time of incident In groups 1 and 2, a higher occurrence of events occurred on the weekend than in the earlier days of the week. In groups 3 and 4, events were evenly distributed throughout the week. This difference was not significant. In the total study population, most sharp force incidents occurred in the summer. 3.4. Ethanol and drugs Levels of ethanol and drugs were determined in deceased subjects (groups 2 and 4) and in surviving subjects (groups 1 and 3) if given in the medical records. In surviving subjects, the levels of substances most often were not given in the medical records, just the presence. This made it impossible to compare surviving and deceased subjects in regard to levels of substances. Ethanol, drugs, or both were detected in 79% of the subjects. The highest proportion of subjects under the influence of ethanol only or both ethanol and drugs was in group 1. The highest proportion of subjects under the influence of drugs only was in group 3 (l2 ¼ 71.5, df ¼ 12, p < 0.001; Fig. 1). Ethanol, drugs, or both were detected in a higher proportion of males than females (83% and 65%,
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Table 1 Gender, median age, and nationality.
Number of subjects Males/females Median age (years) Total Males Females Norwegian nationality Non-Norwegian nationality
Group 1: Surviving subjects, attacked by others
Group 2: Killed subjects
Group 3: Surviving subjects, self-mutilated
Group 4: Subjects committing suicide
72 60/12
17 6/11
25 18/7
22 18/4
27.5 27 28 52 20
36 34 37 14 3
38 44 26 24 1
54 49 72 20 2
Fig. 1. Ethanol and/or drugs in subjects with sharp force injury (l2 ¼ 71.5, df ¼ 12, p < 0.001).
respectively; l2 ¼ 18.8, df ¼ 4, p < 0.001) and in a higher proportion of survivors (groups 1 and 3) than deceased subjects (groups 2 and 4) (85% and 64%, respectively; l2 ¼ 26.0, df ¼ 4, p < 0.001). 3.5. Number of injuries The median number of sharp force injuries was 2, and the mean was 4.4 (range 1e147, SD 13.2). Nearly half of the subjects had only one sharp force injury. Twenty-six percent had two to three sharp force injuries and 27% had four or more. Most survivors had only one injury (62%) and most deceased subjects (87%) had more than one injury (l2 ¼ 30.7, df ¼ 2, p < 0.001; Fig. 2). We found no significant difference between the genders in regards to the number of injuries. 3.6. Injuries in regards to topographic regions The injuries were classified according to anatomical region (head, neck, chest, abdomen, upper limbs, lower limbs, or multiple regions). We found no significant difference between the genders in regards to injury distribution (l2 ¼ 1.9, df ¼ 6, p ¼ 0.92) or between attacked subjects (groups 1 and 2) and subjects with self-inflicted injury (groups 3 and 4) (l2 ¼ 7.1, df ¼ 6, p ¼ 0.31). No subjects with self-inflicted injury had injuries to the head. Over half (56%) of the deceased subjects (groups 2 and 4) had injuries to multiple regions, whereas multiple region injuries were found in a minority (27%) of surviving subjects (groups 1 and 3). The most striking difference was a lower proportion of injuries to the abdomen (both penetrating and non-penetrating injury) in
deceased subjects (2.5%) compared to surviving subjects (26%) (l2 ¼ 16, df ¼ 6, p ¼ 0.01; Fig. 3). 3.7. Mortality rate related to penetrating injuries and topographic region Forty-three percent of all subjects had penetrating injuries through the thoracic or abdominal wall. Injuries to both the thorax and abdomen were classified according to the most severe injury, the injury that contributed most to death. Notably, even when a weapon penetrates the abdominal wall, the most severe injury is sometimes localised in the thoracic cavity and vice versa, particularly when the sharp force injury is inflicted at an angle with the weapon pointing either upwards or downwards. Penetrating sharp force injury to the chest resulted in a fatal outcome in 47% of the subjects, whereas 15% of subjects with penetrating injury through the abdominal wall died (l2 ¼ 5.9, df ¼ 1, p ¼ 0.015; Fig. 4). Penetrating injury through the abdominal wall can lead to death from bleeding in cases of organ or vessel injury, as well as peritonitis, though with a more prolonged course. Penetrating sharp force injury through the thoracic wall often leads to pneumothorax, and many subjects suffer from injury to the heart, lung(s), and various vessels. Pneumothorax and/or lung injury had lethal outcomes in 26% of cases. Isolated heart injury had lethal outcomes in 80% of cases. Combined injuries (pneumothorax/lung and heart injury) led to death in 82% of the cases (l2 ¼ 11.5, df ¼ 2, p ¼ 0.003). Of the three subjects with penetrating abdominal injury who died, one had injuries to both the intestines and the aorta. The
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Fig. 2. Number of sharp force injuries, related to outcome (l2 ¼ 30.7, df ¼ 2, p < 0.001).
Fig. 3. Distribution of sharp force injury in surviving and deceased subjects, related to anatomical regions (both penetrating and non-penetrating injuries) (l2 ¼ 16.0, df ¼ 6, p ¼ 0.01).
Fig. 4. Number of surviving and deceased subjects with penetrating sharp force injury (l2 ¼ 5.9, df ¼ 1, p ¼ 0.015).
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other two subjects had injuries to multiple small mesenterial vessels, as well as numerous injuries to multiple anatomical regions, and died from the overall exsanguination. Seventeen subjects with penetrating abdominal injuries of various types and severities survived. The difference in abdominal structures injured in deceased subjects and survivors was not significant. In all subjects with penetrating abdominal injury, various types of knives caused the injury, and our number of subjects is too small to assess the outcome of penetrating abdominal injuries related to weapon. 3.8. Treatment The median length of hospital stay was 1 day, the mean 2.7 days. Thirty-nine percent of all subjects in our study had injuries considered to be of low severity (ISS 1e14), 31% had injuries of moderate severity (ISS 15e74), and 30% had injuries of high severity (ISS 75). All subjects with an ISS of 75 had fatal outcomes, except one. This subject had injuries to multiple regions, transportation time of more than 10 min, and injuries that required laparotomy, but survived. Most subjects who died were declared dead at the scene (91%). Four subjects were alive long enough to be admitted to the hospital before they died; three had been attacked and one had self-inflicted injuries. Two of these subjects had injuries to the thoracic region and two to multiple regions. Two of the four subjects had a transportation time of more than 10 min in an ambulance, and two had a transportation time of less than 10 min (Table 2). Most invasive emergency procedures were performed after the subjects were admitted to the hospital. Fifty percent of subjects undergoing thoracotomy survived, whereas two-thirds of the subjects who were intubated survived. All subjects who underwent laparotomy or received a thoracic drainage tube survived. 4. Discussion In this material from Western Norway, 50% of male and 91% of female homicide victims were killed in a private home. These results correspond well with a study from Oslo/Copenhagen in which the proportions were 49% and 78%, respectively.14 We think this reflects that men are involved in street fights, gang criminality, or arguing with strangers in public places, often under the influence of drugs and/or ethanol, more often than women, whereas women are more often killed by their intimate partners in private homes. A knife was used in 83% and broken glass in 9% of the sharp force incidents. Broken glass was most often recorded as having been used in cases of attacked, surviving subjects, reflecting the use of broken bottles in fights in public places. A Swedish study reported that various types of knives are most often the weapons of choice in homicides, whereas kitchen knives and razor blades are most often used in suicides.15 Multiple injuries or injuries involving the abdomen, chest, and upper limbs were most common in our study. Sharp force injury to
Table 2 Number of subjects related to transportation time, ISS, and outcome. Transportation time
ISS 1e14
ISS 15e74
ISS 75
Total
<10 min
19 0 dead 29 0 dead 5 0 dead
18 0 dead 23 0 dead 1 0 dead
17 17 dead 23 22 dead 1 0 dead
54 17 dead 75 22 dead 7 0 dead
>10 min Unknown
75
multiple regions was associated with the highest mortality, followed by the chest and upper limbs alone. We did not find any gender differences in regards to the topographic regions affected. In a study from Oslo/Copenhagen, the majority of female homicide victims had injuries to three or four anatomical regions, compared to one region in most males.14 Nearly half of the subjects with penetrating chest injury in our study died. Quick physical collapse is correlated with sharp force cardiac injury >1.5 cm in length or multiple cardiac stab injuries. A special case of interest in our study was a female attack victim who survived as many as 29 injuries, probably because the weapon was a screwdriver, which is narrower than most knife blades. A case has been reported of nearly 2 days survival before a 1.5cm penetrating cardiac sharp force injury to the right ventricle was successfully sutured.16 In another exceptional case, a schizophrenic man who had inflicted a sharp force injury to his chest refused a medical examination and treatment from the ambulance personnel called by his neighbours. He then succeeded in committing suicide by jumping from a high building 13 days later, with the forensic post-mortem examination revealing a penetrating cardiac sharp force injury.17 A prolonged course is sometimes conditioned by heart muscle tissue contracting near the injured area18 or the formation of blood clots.19 Potential contraction and blood clot formation are associated with a ventricular rather than an atrial heart injury due to the thickness and configuration of the walls.20,21 Although cardiac tamponade has been claimed to increase the risk of a deadly outcome,18 some authors have claimed the opposite because the pressure effect of pericardial blood slows exsanguination to some extent.20,22 Pneumothorax or lung injury is not necessarily lethal, but if the injury is lethal it is tolerated longer before the subject dies compared to cardiac or major thoracic vessel injury.23 Most subjects with penetrating injuries through the abdominal wall survive. Therefore, it is tempting to suggest that injuries to this region are most often not fatal if treated within a short time. However, it is important to emphasise that injury to blood-filled organs, such as the liver and spleen, in addition to major blood vessels, or multiple injuries to small mesenterial vessels, may be fatal. There is also a risk of developing peritonitis over a longer time span. Nevertheless, the outcome of abdominal penetrating injury relative to specific abdominal injuries is often random and unpredictable. Sharp force injury to the upper limbs occurred in 15% of the attacked subjects, most often as defence injuries, and 19% of the self-harmed subjects. In suicidal individuals, deaths caused by multiple and deep lesions to the upper limbs suggest a strong death wish. Typically, several injuries are found in close proximity on the flexor side of the wrist, often including more superficial tentative wounds and hesitation marks.24,25 High survival rate in some countries can be explained by the fact that all subjects with sharp force injury (from mild to severe) are admitted to the same health facility. In addition, the prevalence of sharp force events is high in some countries, allowing emergency staff to gain expertise. Studies from England have reported that 99.5% of subjects admitted to a hospital with sharp force injuries survive. These studies are not comparable to our study because the subjects who died before being admitted to a hospital were not included.26,27 A study from Scotland between 1992 and 1996 that covered all penetrating and possible penetrating knife injuries in victims of attack reported a mortality rate of 17%. This study excluded subjects with self-inflicted injuries and is not entirely comparable to our study.28 In a study from Honduras, 19% of subjects with severe stab injuries died. This study included sharp force injury as a result of attack, self-
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infliction, and accident, and excluded subjects under the age of 15 years.29 Therefore, the population in this study is somewhat different from ours. In Norway, patients with less severe sharp force injuries are offered health care services at local health centres. Surviving subjects in our study only includes subjects admitted to the hospital; thus, our subject group has more severe injuries or injuries appearing to be more severe than a population comprising all victims of sharp force injuries. In the study from Scotland, the majority of survivors had an ISS <15, and 95% of fatal cases had scores >15. Of the subjects who died after being stabbed, 60% had no signs of life when reached by medical staff, 15% died at the scene of the crime or in transit to the hospital, and 25% lived long enough to be admitted to the hospital.28 In contrast, 35 of the deceased subjects (90%) in our study were declared dead at the scene. Four subjects (10%) who later died lived long enough to be admitted to the hospital. One subject survived with an ISS of 75 and injuries that required laparotomy. However, the number of subjects is too small to make any general assumptions. Quite similar to this study, a study of sharp force injury in a California prison identified 11 prisoners with thoracic injuries, five of which were taken to the hospital with varying vital signs. Four of these five subjects had repairable injuries, but two died from complications. The two survivors had minor injuries to the right heart ventricle and tamponade and were transported quickly.30 Few subjects in our study developed signs of respiratory or circulatory failure while being transported to the hospital if they had not shown any signs before transportation. Yet, fast transportation is crucial, as shown in a study from France in which survival time 2 h was strongly associated with a high ISS.31 A review based on 46 articles concluded that load-and-go contributes to a higher survival rate.32 Due to short transportation distances, most invasive emergency procedures were done after the subjects in this study were admitted to the hospital. An exception to this was thoracotomy, a procedure performed to evacuate bleeding causing cardiac tamponade, control intrathoracic bleeding, facilitate open cardiac massage, or temporarily occlude the descending part of the aorta. The highest survival rate is seen in cases of cardiac tamponade when thoracotomy is performed at the scene.33 The indications for laparotomy are haemodynamic instability and peritonitis. Laparotomy is normally performed in patients with a lower ISS than indicated for thoracotomy.34,35 In our study, none of the patients treated with laparotomy died.
committing suicide, the death wish is probably stronger, as reflected in their more severe injuries. 6. Conclusion The risk of dying from sharp force injury is hard to ascertain. The overall mortality rate in this study was 29% and knives were the weapon of choice. Factors that influenced mortality were the number of injuries, the topographic regions of the body injured, the anatomical organs/structures of infliction, and the emergency measures performed. However, the outcome of sharp force injury is often random and unpredictable. Conflict of interest The authors declare that they have no conflicts of interest. Funding None declared. Ethical approval This study complies with the current laws of Norway and was given approval from the Director of Public Prosecutions (Riksadvokaten) and Regional Committee for Medical and Health Research er for medisinsk og helsefaglig Ethics (Regionale komite forskningsetikk). Acknowledgements We thank the Trauma Coordinator of Haukeland University Hospital, Kurt Børslid Andersen, for identifying additional patients with sharp force injuries who were admitted between 2009 and 2010 from the Trauma Database. Appendix 1. Injury Severity Score regions.
Each injury is assigned an Abbreviated Injury Scale (AIS) score corresponding to one of the six body regions in the table. Regions Head, neck, and cervical spine Face, including nose, mouth, eyes, and ears Thorax, thoracic spine, and diaphragm Abdomen and lumbar spine Extremities, including pelvis External soft tissue
5. Limitations of the study The number of subjects in our study was small, reflecting that subjects with sharp force injury are most often treated by general practitioners and in local accident and emergency departments. Also, some subjects never seek medical treatment and are never recorded in any medical database. The subjects included in our study often had severe injuries or injuries appearing to be severe, resulting in immediate transportation to the hospital or referral from primary treatment facilities to the hospital. This implies that our study population is skewed. In addition, comparing subjects with sharp force injury inflicted by others and subjects with selfinflicted injury is problematic due to different underlying injury mechanisms and levels of intent to cause injury. Similarly, surviving subjects with self-inflicted injury are not necessarily comparable to subjects who committed suicide. This is reflected by less severe injuries in group 3 in our study, indicating that the purpose is often to inflict pain rather than to induce a fatal outcome. In the group
Appendix 2. Abbreviated Injury Scale (AIS) score meanings. Only the highest AIS in each body region is used. Adding the square AIS of the three most severely injured body regions results in the ISS (0e75). If any region is assigned an AIS of 6 (unsurvivable injury), the ISS is automatically assigned to 75.36,37 AIS score
Meaning
1 2 3 4 5 6
Minor Moderate Serious Severe Critical Maximal
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References 1. WHO Global Consultation on Violence and Health. Violence: a public health priority. Geneva: World Health Organization; 1996 [doc. WHO/EHA/SPI.POA.2], http://www.who.int/violence_injury_prevention/violence/world_report/en/ introduction.pdf [05/08/2014]. 2. Steen K, Hunskaar S. Violence in an urban community from the perspective of an accident and emergency department: a two-year prospective study. Med Sci Monit 2004;10(2):CR75e9. 3. Statistics Norway. Tabell: 04623: Utsatthet og uro for lovbrudd, etter type -lovbrudd og landsdel (prosent) [Table: 04623: Exposure and anxiety for crime e by type of offences and regions (per cent)]. https://www.ssb.no/statistikkbanken/ selectvarval/saveselections.asp [05/08/2014]. 4. Mental Health Foundation. Truth hurts e report of the national inquiry into self-harm among young people, ISBN 978-1-903645-81-9. http://www. mentalhealth.org.uk/publications/truth-hurts-report1/ [04/08/2014]. 5. Bowen ACL, John AMH. Gender differences in presentation and conceptualization of adolescent self-injurious behaviour: implications for therapeutic practice. Couns Psychol Q 2001;14(4):357e79. 6. Madge N, Hewitt A, Hawton K, de Wilde EJ, Corcoran P, Fekete S, et al. Deliberate self-harm within an international community sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study. J Child Psychol 2008;49:667e77. 7. Statistics Norway. Table: 08877: Suicides, by sex, age and method. https://www. ssb.no/statistikkbanken/SelectVarVal/saveselections.asp [31/12/2014]. 8. Kripos (National Criminal Investigation Service). Drapsoversikt [Overview of homicides]. 2011. https://www.politi.no/vedlegg/lokale_vedlegg/kripos/ Vedlegg_1578.pdf [31/12/2014]. 9. Thoresen SØ, Rognum T. Survival time and acting capability after fatal injury by sharp weapons. Forensic Sci Int 1986;31:181e7. 10. Web page: Haukeland University Hospital. http://www.helse-bergen.no/english/ Sider/side.aspx [31/12/2014]. 11. Statistics Norway. Tabell 11 Rogaland. Folkemengde 1. januar og endringer i året. 1951 [Table 11 Rogaland. Population January 1. and changes throughout the year. 1951]. http://www.ssb.no/emner/02/02/folkendrhist/tabeller/tab/11.html [31/ 12/2014]. 12. Statistics Norway. Tabell 12 Hordaland. Folkemengde 1. januar og endringer i året. 1951 [Table 12 Hordaland. Population January 1. and changes throughout the year. 1951]. http://www.ssb.no/emner/02/02/folkendrhist/tabeller/tab/12.html [31/12/2014]. 13. Norway. Tabell 14 Sogn og Fjordane. Folkemengde 1. januar og endringer i året. 1951 [Table 14 Sogn and Fjordane. Population January 1. and changes throughout the year. 1951]. http://www.ssb.no/emner/02/02/folkendrhist/tabeller/tab/ arkiv/2010/14.html [31/12/2014]. 14. Rogde S, Hougen HP, Poulsen K. Homicide by sharp force in two Scandinavian capitals. Forensic Sci Int 2000;109:135e45. 15. Karlsson T. Homicidal and suicidal sharp force fatalities in Stockholm, Sweden. Orientation of entrance wounds in stabs gives information in the classification. Forensic Sci Int 1998;93(1):21e32. 16. Rehn AL. Uber penetrierende herzwunden und herznaht. Arch Klin Chir 1897;55:315e7. 17. Fieseler S, Zinka B, Kunz SN. Survived stab to the heart in a schizophrenic man. Arch Kriminol 2011;228(3e4):126e31.
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18. Karger B, Niemeyer J, Brinkmann B. Physical activity following fatal injury from sharp pointed weapons. Int J Legal Med 1999;112:188e91. 19. Perdekamp MG, Riede UN, Pollak S. Penetrating stab injury to the heart with unusually long survival. Arch Kriminol 2000;206(3e4):102e9. 20. Campbell NC, Thomson SR, Muckart DJJ, Meunann CM, van Middelkoop I, Botha JBC. Review of 1198 cases of penetrating cardiac trauma. Br J Surg 1997;84:1737e40. 21. Taylor AS. Wounds of the heart. Principles of medical jurisprudence. 12th ed., vol. 1. London: J&A Churchill; 1965. p. 248. 22. Moreno C, Moore EE, Majure JA, Hopeman AR. Pericardial tamponade: a critical determinant for survival following penetrating cardiac wounds. J Trauma 1986;26(9):821e5. 23. Weissberg D, Refaely Y. Pneumothorax. Experience with 1,199 patients. Chest 2000;117(5):1279e85. 24. Assuncao LA, Santos A, Magelhaes T. Suicide by sharp force injuries e a study in Oporto. Leg Med 2009;11:S216e9. 25. Fukube S, Hayashi T, Ishida Y, Kamon H, Kawaguchi M, Kimura A, et al. Retrospective study on suicidal cases by sharp force injuries. J Forensic Leg Med 2008;15(3):163e7. 26. Maxwell R, Trotter C, Verne J, Brown P, Gunnell D. Trends in admissions to hospital involving an assault using a knife or other sharp instrument, England, 1997e2005. J Public Health (Oxf) 2007;29(2):186e90. 27. Pallett J, Sutherland E, Gluckman E, Tunnicliff M, Keep J. A cross-sectional study of knife injuries at a London major trauma center. Ann R Coll Surg Engl 2014;96(1):23e6. 28. Webb E, Wyatt JP, Henry J, Busuttil A. A comparison of fatal with non-fatal knife injuries in Edinburgh. Forensic Sci Int 1999;99(3):179e87. 29. Yacoub S, Arellano S, Padgett-Moncada D. Violence related injuries, deaths and disabilities in the capital of Honduras. Injury 2006;37(5):428e34. 30. Walton CB, Blaisdell FW, Jordan RG, Bodai BI. The injury potential and lethality of stab wounds: a Folsom Prison Study. J Trauma 1989;29(1):99e101. 31. Cros J, Alvarez JC, Sbidian E, Charlier P, de la Grandmaison GL. Survival time estimation using Injury Severity Score (ISS) in homicide cases. Forensic Sci Int 2013;233:99e103. 32. Ryyn€ anen OP, Iirola T, Reitala J, P€ alve H, Malmivaara A. Is advanced life support better than basic life support in prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med 2010;18:62 [31/12/2014]. 33. Powell DW, Moore EE, Cothren CC, Ciesla DJ, Burch JM, Moore JB, et al. Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary rescuscitaion. J Am Coll Surg 2004;199(2):211e5. 34. Nair MS, Uzzaman MM, Al-Zuhir N, Jadeja A, Navaratnam R. Changing trends in the pattern and outcome of stab injuries at a North London hospital. J Emerg Trauma Shock 2011;4(4):455e60. 35. Jansen JO, Inaba K, Rizoli SB, Boffard KD, Demetriades D. Selective nonoperative management of penetrating abdominal injury in Great Britain and Ireland: survey of practice. Injury 2012;43(11):1799e804. 36. Baker SP, O'Neill B. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14: 187e96. 37. AAAM (Association for the Advancement of Automotive Medicine). The Abbreviated Injury Scale (AIS). 2008. http://www.aaam1.org/ais/ AISClarified2012.pdf [02/01/2015].
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Original communication
The hazard of sharp force injuries: Factors influencing outcome Normann c, Inge Morild a, b, Peer Kåre Lilleng a, b, f, Stine Kristoffersen a, b, *, Stig-Andre d, e, f Jon-Kenneth Heltne a
Department of Pathology, The Gade Institute, Haukeland University Hospital, 5021 Bergen, Norway Department of Clinical Medicine, Gade Laboratory of Pathology, University of Bergen and Haukeland University Hospital, 5021 Bergen, Norway c Cand.Med.-Degree Programme, Faculty of Medicine and Dentistry, University of Bergen, Norway d Department of Anaesthesia and Intensive Care, Haukeland University Hospital, 5021 Bergen, Norway e Department of Clinical Medicine, University of Bergen, Bergen, Norway b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 25 May 2015 Received in revised form 4 September 2015 Accepted 24 October 2015 Available online 5 November 2015
The risk of dying from sharp force injury is difficult to ascertain. To the best of our knowledge, no study has been performed in Norway regarding mortality due to sharp force injury or factors that impact survival. Thus, the objective of the present study was to investigate and assess mortality in subjects with sharp force injury. This retrospective study comprises data on 136 subjects (34 female, 102 male) with suspected severe sharp force injury (self-inflicted or inflicted by others) admitted to Haukeland University Hospital between 2001 and 2010. The majority of subjects were intoxicated, and the injury was most often inflicted by a knife. The incidence of sharp force injury in Western Norway is similar to the incidence in other European countries. Almost half of the subjects with self-inflicted injury died. In cases with injury inflicted by another individual, one in five died. Mortality rates were higher in those with penetrating chest injuries than those with penetrating abdominal injuries and higher in cases with cardiac injury compared to pleural or lung injury. Sharp force injury can be fatal, but the overall mortality rate in this study was 29%. Factors influencing mortality rate were the number of injuries, the topographic regions of the body injured, the anatomical organs/structures inflicted, and emergency measures performed. © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Sharp force injury Knife Attack Self-infliction Mortality rate Injury Severity Score
1. Introduction In court, forensic pathologists are often asked, “How dangerous is a knife injury?” The underlying question is, “What is the risk of dying from sharp force injury?” Therefore, the primary purpose of the present study was to assess mortality in victims of sharp force injuries. We investigated this issue in surviving and deceased victims of sharp force injury admitted to Haukeland University Hospital. We studied subjects with sharp force injury inflicted by others or by the subjects themselves according to The World Health Organisation's definition of violence1: “The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.”
* Corresponding author. Department of Pathology, Haukeland University Hospital, 5021 Bergen, Norway. Tel.: þ47 55972567; fax: þ47 55973158. E-mail address: [email protected] (S. Kristoffersen). f Joint last authorship.
The incidence of sharp force injury in Western Norway is difficult to ascertain, as such patients are treated in different health facilities (e.g., general practitioners, local accident and emergency departments, and hospitals) and there is no coordinated recording of all sharp force injuries. In addition, an unknown proportion of subjects with sharp force injury never seek any treatment. Also, criminal statistics do not provide the full picture, as many victims do not press legal charges, supposedly because of low confidence in the police and justice system.2 Between 2001 and 2007, all types of violence were between 2.5 and 3.3% of all crimes reported to the police in Western Norway.3 At the accident and emergency department of Bergen, 10% of assaulted patients are treated for minor sharp force injury.2 The real incidence of self-inflicted sharp force injury is also difficult to estimate, as it frequently occurs in secret and the injuries are often superficial, not requiring medical attention.4,5 The Child and Adolescent Self-harm in Europe (CASE) study has estimated a lifetime prevalence of all acts of self-harm in Norway to be 16% for women and 5% for men.6 According to the homicide statistics of the National Criminal Investigation Service (NCIS), 50% of all homicides in Norway in 2011 were caused by sharp force injury.7 According to Statistics Norway, sharp force
http://dx.doi.org/10.1016/j.jflm.2015.10.005 1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
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injury caused between 2.1 and 3.6% of all suicides in Norway between 2001 and 2010.8 Inclusion criteria and registration procedures vary in different studies of victims of sharp force injury, making a comparison of the success ratios difficult. This study includes subjects with severe injuries or injuries suspected of being severe enough to be admitted to hospital, as well as those who died at the scene. Only one study from Oslo has assessed survival time after sharp force injury in Norway, but all of the cases had fatal outcomes.9 To the best of our knowledge, no study has been performed in Norway regarding the mortality rate of sharp force injury and factors that impact survival. 2. Material and methods Haukeland University Hospital serves as the local hospital of Bergen, the central hospital of Hordaland County, and the regional hospital of Hordaland, Rogaland, and Sogn and Fjordane Counties,10 covering a population of 996,712 inhabitants in 2009.11e13 Data included deceased and surviving subjects with sharp force injury considered severe or potentially severe who were brought to the hospital between 1 January 2001 and 31 December 2010. We included subjects with self-inflicted injury and those with injury inflicted by others. Subjects with sharp force injuries due to accidents were excluded. The study subjects resided mainly in Bergen, the second largest city of Norway, and its surrounding municipalities. Data were obtained from the database of the emergency department, the database of the Norwegian Air Ambulance Service, and from the archive of forensic reports in The Gade Laboratory of Pathology. The Trauma Coordinator of Haukeland University Hospital provided additional data for the years 2009 and 2010 from a new database established in 2009 with new registration procedures. Medical records from surviving patients comprised as little as one short page with limited information to several pages. Post-mortem examinations included an assessment of injuries, and in most cases a toxicology report based on analyses of fluid or tissue samples (e.g., blood, urine, psoas major muscle, or vitreous humour). In deceased subjects, the levels of ethanol and drugs were determined, but in surviving subjects the levels of substances were not often given in the medical records. Therefore, substances were simply recorded as being present or absent in the blood, urine, psoas major muscle, or vitreous fluid. In deceased subjects, postmortal fermentation of ethanol was verified by the presence of metabolic products of ethanol, ethyl glucuronide and ethyl sulphate. Significance was determined by chi-square tests using SPSS PAWS Statistics, versions 20 and 21. Diagrams were created in Excel (version 2007 and Mac 2011). The following parameters were recorded: age, perpetratorevictim relationship, scene of event, nationality, weapon/tool used, date of event, number of injuries, anatomical regions injured, organ injury, toxicology results, and treatment. The subjects were grouped according to whether the injuries were self-inflicted or inflicted by others, and by outcome (non-fatal or fatal) and gender. Subjects were scored according to the Injury Severity Score (ISS) in order to compare our results to those of other studies (Appendix 1). A high ISS is associated with poor performance status/potentially fatal injury. When an ISS was not in the medical records, we calculated it based on the information available. 3. Results 3.1. Characteristics of the study population The study population included 34 women and 102 men divided into four groups (Table 1). Surviving victims with sharp force
injury inflicted by others were assigned to group 1 (n ¼ 72). Victims of homicide by sharp force injury were group 2 (n ¼ 17). Surviving victims with self-inflicted sharp force injury were group 3 (n ¼ 25). Victims of suicide by sharp force injury were group 4 (n ¼ 22). Grouping subject ages in intervals of 10 years revealed that the age distribution was different in the groups (l2 ¼ 63.7, df ¼ 18, p ¼ 0.001), with the lowest median age in group 1 and highest in group 4. Subjects who survived an attack (group 1) were younger than subjects who were killed in an attack (group 2), and subjects who survived self-inflicted injury (group 3) were younger than those who committed suicide (group 4). Comparing the first and last 5 years of the study period, we found a 47% increase in sharp force injury due to an increase in males in groups 1 and 4. However, the increase was not significant. Gender proportions were different in the four subject groups (l2 ¼ 17.6, df ¼ 3, p ¼ 0.001). Among attacked individuals (groups 1 and 2), there were gender differences in perpetrator/victim relationships. A considerable proportion of female victims (39%) had sharp force injury inflicted by a past or present intimate male partner (spouse, co-habitant, or boyfriend), and 56% of these subjects died. In contrast, 9% of male victims were attacked by female intimate partners, and all survived. The scene was unknown in 40% of the cases in group 1, most related to male victims, reflecting that these subjects claimed to have been attacked by a stranger. In all other groups, a private home was the predominant scene of events (68e82%) (l2 ¼ 44, df ¼ 21, p < 0.002). In our study population, 81% of the subjects were of Norwegian nationality. The distribution of subjects of non-Norwegian nationality was unevenly distributed between the groups. The proportion of subjects of non-Norwegian nationality was highest in group 1 (28%) (l2 ¼ 8.6, df ¼ 3, p ¼ 0.034). 3.2. Weapon In 83% of the incidents, a knife was the weapon used to inflict the injury. In 8% of the cases, broken glass was utilised (predominantly in group 1), and in the remaining cases various tools and sharp objects (e.g., scissors, screwdriver, and bayonet). We found no significant differences in regards to the weapon used in relation to subject group, gender, or mortality outcome. 3.3. Time of incident In groups 1 and 2, a higher occurrence of events occurred on the weekend than in the earlier days of the week. In groups 3 and 4, events were evenly distributed throughout the week. This difference was not significant. In the total study population, most sharp force incidents occurred in the summer. 3.4. Ethanol and drugs Levels of ethanol and drugs were determined in deceased subjects (groups 2 and 4) and in surviving subjects (groups 1 and 3) if given in the medical records. In surviving subjects, the levels of substances most often were not given in the medical records, just the presence. This made it impossible to compare surviving and deceased subjects in regard to levels of substances. Ethanol, drugs, or both were detected in 79% of the subjects. The highest proportion of subjects under the influence of ethanol only or both ethanol and drugs was in group 1. The highest proportion of subjects under the influence of drugs only was in group 3 (l2 ¼ 71.5, df ¼ 12, p < 0.001; Fig. 1). Ethanol, drugs, or both were detected in a higher proportion of males than females (83% and 65%,
S. Kristoffersen et al. / Journal of Forensic and Legal Medicine 37 (2016) 71e77
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Table 1 Gender, median age, and nationality.
Number of subjects Males/females Median age (years) Total Males Females Norwegian nationality Non-Norwegian nationality
Group 1: Surviving subjects, attacked by others
Group 2: Killed subjects
Group 3: Surviving subjects, self-mutilated
Group 4: Subjects committing suicide
72 60/12
17 6/11
25 18/7
22 18/4
27.5 27 28 52 20
36 34 37 14 3
38 44 26 24 1
54 49 72 20 2
Fig. 1. Ethanol and/or drugs in subjects with sharp force injury (l2 ¼ 71.5, df ¼ 12, p < 0.001).
respectively; l2 ¼ 18.8, df ¼ 4, p < 0.001) and in a higher proportion of survivors (groups 1 and 3) than deceased subjects (groups 2 and 4) (85% and 64%, respectively; l2 ¼ 26.0, df ¼ 4, p < 0.001). 3.5. Number of injuries The median number of sharp force injuries was 2, and the mean was 4.4 (range 1e147, SD 13.2). Nearly half of the subjects had only one sharp force injury. Twenty-six percent had two to three sharp force injuries and 27% had four or more. Most survivors had only one injury (62%) and most deceased subjects (87%) had more than one injury (l2 ¼ 30.7, df ¼ 2, p < 0.001; Fig. 2). We found no significant difference between the genders in regards to the number of injuries. 3.6. Injuries in regards to topographic regions The injuries were classified according to anatomical region (head, neck, chest, abdomen, upper limbs, lower limbs, or multiple regions). We found no significant difference between the genders in regards to injury distribution (l2 ¼ 1.9, df ¼ 6, p ¼ 0.92) or between attacked subjects (groups 1 and 2) and subjects with self-inflicted injury (groups 3 and 4) (l2 ¼ 7.1, df ¼ 6, p ¼ 0.31). No subjects with self-inflicted injury had injuries to the head. Over half (56%) of the deceased subjects (groups 2 and 4) had injuries to multiple regions, whereas multiple region injuries were found in a minority (27%) of surviving subjects (groups 1 and 3). The most striking difference was a lower proportion of injuries to the abdomen (both penetrating and non-penetrating injury) in
deceased subjects (2.5%) compared to surviving subjects (26%) (l2 ¼ 16, df ¼ 6, p ¼ 0.01; Fig. 3). 3.7. Mortality rate related to penetrating injuries and topographic region Forty-three percent of all subjects had penetrating injuries through the thoracic or abdominal wall. Injuries to both the thorax and abdomen were classified according to the most severe injury, the injury that contributed most to death. Notably, even when a weapon penetrates the abdominal wall, the most severe injury is sometimes localised in the thoracic cavity and vice versa, particularly when the sharp force injury is inflicted at an angle with the weapon pointing either upwards or downwards. Penetrating sharp force injury to the chest resulted in a fatal outcome in 47% of the subjects, whereas 15% of subjects with penetrating injury through the abdominal wall died (l2 ¼ 5.9, df ¼ 1, p ¼ 0.015; Fig. 4). Penetrating injury through the abdominal wall can lead to death from bleeding in cases of organ or vessel injury, as well as peritonitis, though with a more prolonged course. Penetrating sharp force injury through the thoracic wall often leads to pneumothorax, and many subjects suffer from injury to the heart, lung(s), and various vessels. Pneumothorax and/or lung injury had lethal outcomes in 26% of cases. Isolated heart injury had lethal outcomes in 80% of cases. Combined injuries (pneumothorax/lung and heart injury) led to death in 82% of the cases (l2 ¼ 11.5, df ¼ 2, p ¼ 0.003). Of the three subjects with penetrating abdominal injury who died, one had injuries to both the intestines and the aorta. The
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Fig. 2. Number of sharp force injuries, related to outcome (l2 ¼ 30.7, df ¼ 2, p < 0.001).
Fig. 3. Distribution of sharp force injury in surviving and deceased subjects, related to anatomical regions (both penetrating and non-penetrating injuries) (l2 ¼ 16.0, df ¼ 6, p ¼ 0.01).
Fig. 4. Number of surviving and deceased subjects with penetrating sharp force injury (l2 ¼ 5.9, df ¼ 1, p ¼ 0.015).
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other two subjects had injuries to multiple small mesenterial vessels, as well as numerous injuries to multiple anatomical regions, and died from the overall exsanguination. Seventeen subjects with penetrating abdominal injuries of various types and severities survived. The difference in abdominal structures injured in deceased subjects and survivors was not significant. In all subjects with penetrating abdominal injury, various types of knives caused the injury, and our number of subjects is too small to assess the outcome of penetrating abdominal injuries related to weapon. 3.8. Treatment The median length of hospital stay was 1 day, the mean 2.7 days. Thirty-nine percent of all subjects in our study had injuries considered to be of low severity (ISS 1e14), 31% had injuries of moderate severity (ISS 15e74), and 30% had injuries of high severity (ISS 75). All subjects with an ISS of 75 had fatal outcomes, except one. This subject had injuries to multiple regions, transportation time of more than 10 min, and injuries that required laparotomy, but survived. Most subjects who died were declared dead at the scene (91%). Four subjects were alive long enough to be admitted to the hospital before they died; three had been attacked and one had self-inflicted injuries. Two of these subjects had injuries to the thoracic region and two to multiple regions. Two of the four subjects had a transportation time of more than 10 min in an ambulance, and two had a transportation time of less than 10 min (Table 2). Most invasive emergency procedures were performed after the subjects were admitted to the hospital. Fifty percent of subjects undergoing thoracotomy survived, whereas two-thirds of the subjects who were intubated survived. All subjects who underwent laparotomy or received a thoracic drainage tube survived. 4. Discussion In this material from Western Norway, 50% of male and 91% of female homicide victims were killed in a private home. These results correspond well with a study from Oslo/Copenhagen in which the proportions were 49% and 78%, respectively.14 We think this reflects that men are involved in street fights, gang criminality, or arguing with strangers in public places, often under the influence of drugs and/or ethanol, more often than women, whereas women are more often killed by their intimate partners in private homes. A knife was used in 83% and broken glass in 9% of the sharp force incidents. Broken glass was most often recorded as having been used in cases of attacked, surviving subjects, reflecting the use of broken bottles in fights in public places. A Swedish study reported that various types of knives are most often the weapons of choice in homicides, whereas kitchen knives and razor blades are most often used in suicides.15 Multiple injuries or injuries involving the abdomen, chest, and upper limbs were most common in our study. Sharp force injury to
Table 2 Number of subjects related to transportation time, ISS, and outcome. Transportation time
ISS 1e14
ISS 15e74
ISS 75
Total
<10 min
19 0 dead 29 0 dead 5 0 dead
18 0 dead 23 0 dead 1 0 dead
17 17 dead 23 22 dead 1 0 dead
54 17 dead 75 22 dead 7 0 dead
>10 min Unknown
75
multiple regions was associated with the highest mortality, followed by the chest and upper limbs alone. We did not find any gender differences in regards to the topographic regions affected. In a study from Oslo/Copenhagen, the majority of female homicide victims had injuries to three or four anatomical regions, compared to one region in most males.14 Nearly half of the subjects with penetrating chest injury in our study died. Quick physical collapse is correlated with sharp force cardiac injury >1.5 cm in length or multiple cardiac stab injuries. A special case of interest in our study was a female attack victim who survived as many as 29 injuries, probably because the weapon was a screwdriver, which is narrower than most knife blades. A case has been reported of nearly 2 days survival before a 1.5cm penetrating cardiac sharp force injury to the right ventricle was successfully sutured.16 In another exceptional case, a schizophrenic man who had inflicted a sharp force injury to his chest refused a medical examination and treatment from the ambulance personnel called by his neighbours. He then succeeded in committing suicide by jumping from a high building 13 days later, with the forensic post-mortem examination revealing a penetrating cardiac sharp force injury.17 A prolonged course is sometimes conditioned by heart muscle tissue contracting near the injured area18 or the formation of blood clots.19 Potential contraction and blood clot formation are associated with a ventricular rather than an atrial heart injury due to the thickness and configuration of the walls.20,21 Although cardiac tamponade has been claimed to increase the risk of a deadly outcome,18 some authors have claimed the opposite because the pressure effect of pericardial blood slows exsanguination to some extent.20,22 Pneumothorax or lung injury is not necessarily lethal, but if the injury is lethal it is tolerated longer before the subject dies compared to cardiac or major thoracic vessel injury.23 Most subjects with penetrating injuries through the abdominal wall survive. Therefore, it is tempting to suggest that injuries to this region are most often not fatal if treated within a short time. However, it is important to emphasise that injury to blood-filled organs, such as the liver and spleen, in addition to major blood vessels, or multiple injuries to small mesenterial vessels, may be fatal. There is also a risk of developing peritonitis over a longer time span. Nevertheless, the outcome of abdominal penetrating injury relative to specific abdominal injuries is often random and unpredictable. Sharp force injury to the upper limbs occurred in 15% of the attacked subjects, most often as defence injuries, and 19% of the self-harmed subjects. In suicidal individuals, deaths caused by multiple and deep lesions to the upper limbs suggest a strong death wish. Typically, several injuries are found in close proximity on the flexor side of the wrist, often including more superficial tentative wounds and hesitation marks.24,25 High survival rate in some countries can be explained by the fact that all subjects with sharp force injury (from mild to severe) are admitted to the same health facility. In addition, the prevalence of sharp force events is high in some countries, allowing emergency staff to gain expertise. Studies from England have reported that 99.5% of subjects admitted to a hospital with sharp force injuries survive. These studies are not comparable to our study because the subjects who died before being admitted to a hospital were not included.26,27 A study from Scotland between 1992 and 1996 that covered all penetrating and possible penetrating knife injuries in victims of attack reported a mortality rate of 17%. This study excluded subjects with self-inflicted injuries and is not entirely comparable to our study.28 In a study from Honduras, 19% of subjects with severe stab injuries died. This study included sharp force injury as a result of attack, self-
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infliction, and accident, and excluded subjects under the age of 15 years.29 Therefore, the population in this study is somewhat different from ours. In Norway, patients with less severe sharp force injuries are offered health care services at local health centres. Surviving subjects in our study only includes subjects admitted to the hospital; thus, our subject group has more severe injuries or injuries appearing to be more severe than a population comprising all victims of sharp force injuries. In the study from Scotland, the majority of survivors had an ISS <15, and 95% of fatal cases had scores >15. Of the subjects who died after being stabbed, 60% had no signs of life when reached by medical staff, 15% died at the scene of the crime or in transit to the hospital, and 25% lived long enough to be admitted to the hospital.28 In contrast, 35 of the deceased subjects (90%) in our study were declared dead at the scene. Four subjects (10%) who later died lived long enough to be admitted to the hospital. One subject survived with an ISS of 75 and injuries that required laparotomy. However, the number of subjects is too small to make any general assumptions. Quite similar to this study, a study of sharp force injury in a California prison identified 11 prisoners with thoracic injuries, five of which were taken to the hospital with varying vital signs. Four of these five subjects had repairable injuries, but two died from complications. The two survivors had minor injuries to the right heart ventricle and tamponade and were transported quickly.30 Few subjects in our study developed signs of respiratory or circulatory failure while being transported to the hospital if they had not shown any signs before transportation. Yet, fast transportation is crucial, as shown in a study from France in which survival time 2 h was strongly associated with a high ISS.31 A review based on 46 articles concluded that load-and-go contributes to a higher survival rate.32 Due to short transportation distances, most invasive emergency procedures were done after the subjects in this study were admitted to the hospital. An exception to this was thoracotomy, a procedure performed to evacuate bleeding causing cardiac tamponade, control intrathoracic bleeding, facilitate open cardiac massage, or temporarily occlude the descending part of the aorta. The highest survival rate is seen in cases of cardiac tamponade when thoracotomy is performed at the scene.33 The indications for laparotomy are haemodynamic instability and peritonitis. Laparotomy is normally performed in patients with a lower ISS than indicated for thoracotomy.34,35 In our study, none of the patients treated with laparotomy died.
committing suicide, the death wish is probably stronger, as reflected in their more severe injuries. 6. Conclusion The risk of dying from sharp force injury is hard to ascertain. The overall mortality rate in this study was 29% and knives were the weapon of choice. Factors that influenced mortality were the number of injuries, the topographic regions of the body injured, the anatomical organs/structures of infliction, and the emergency measures performed. However, the outcome of sharp force injury is often random and unpredictable. Conflict of interest The authors declare that they have no conflicts of interest. Funding None declared. Ethical approval This study complies with the current laws of Norway and was given approval from the Director of Public Prosecutions (Riksadvokaten) and Regional Committee for Medical and Health Research er for medisinsk og helsefaglig Ethics (Regionale komite forskningsetikk). Acknowledgements We thank the Trauma Coordinator of Haukeland University Hospital, Kurt Børslid Andersen, for identifying additional patients with sharp force injuries who were admitted between 2009 and 2010 from the Trauma Database. Appendix 1. Injury Severity Score regions.
Each injury is assigned an Abbreviated Injury Scale (AIS) score corresponding to one of the six body regions in the table. Regions Head, neck, and cervical spine Face, including nose, mouth, eyes, and ears Thorax, thoracic spine, and diaphragm Abdomen and lumbar spine Extremities, including pelvis External soft tissue
5. Limitations of the study The number of subjects in our study was small, reflecting that subjects with sharp force injury are most often treated by general practitioners and in local accident and emergency departments. Also, some subjects never seek medical treatment and are never recorded in any medical database. The subjects included in our study often had severe injuries or injuries appearing to be severe, resulting in immediate transportation to the hospital or referral from primary treatment facilities to the hospital. This implies that our study population is skewed. In addition, comparing subjects with sharp force injury inflicted by others and subjects with selfinflicted injury is problematic due to different underlying injury mechanisms and levels of intent to cause injury. Similarly, surviving subjects with self-inflicted injury are not necessarily comparable to subjects who committed suicide. This is reflected by less severe injuries in group 3 in our study, indicating that the purpose is often to inflict pain rather than to induce a fatal outcome. In the group
Appendix 2. Abbreviated Injury Scale (AIS) score meanings. Only the highest AIS in each body region is used. Adding the square AIS of the three most severely injured body regions results in the ISS (0e75). If any region is assigned an AIS of 6 (unsurvivable injury), the ISS is automatically assigned to 75.36,37 AIS score
Meaning
1 2 3 4 5 6
Minor Moderate Serious Severe Critical Maximal
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References 1. WHO Global Consultation on Violence and Health. Violence: a public health priority. Geneva: World Health Organization; 1996 [doc. WHO/EHA/SPI.POA.2], http://www.who.int/violence_injury_prevention/violence/world_report/en/ introduction.pdf [05/08/2014]. 2. Steen K, Hunskaar S. Violence in an urban community from the perspective of an accident and emergency department: a two-year prospective study. Med Sci Monit 2004;10(2):CR75e9. 3. Statistics Norway. Tabell: 04623: Utsatthet og uro for lovbrudd, etter type -lovbrudd og landsdel (prosent) [Table: 04623: Exposure and anxiety for crime e by type of offences and regions (per cent)]. https://www.ssb.no/statistikkbanken/ selectvarval/saveselections.asp [05/08/2014]. 4. Mental Health Foundation. Truth hurts e report of the national inquiry into self-harm among young people, ISBN 978-1-903645-81-9. http://www. mentalhealth.org.uk/publications/truth-hurts-report1/ [04/08/2014]. 5. Bowen ACL, John AMH. Gender differences in presentation and conceptualization of adolescent self-injurious behaviour: implications for therapeutic practice. Couns Psychol Q 2001;14(4):357e79. 6. Madge N, Hewitt A, Hawton K, de Wilde EJ, Corcoran P, Fekete S, et al. Deliberate self-harm within an international community sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study. J Child Psychol 2008;49:667e77. 7. Statistics Norway. Table: 08877: Suicides, by sex, age and method. https://www. ssb.no/statistikkbanken/SelectVarVal/saveselections.asp [31/12/2014]. 8. Kripos (National Criminal Investigation Service). Drapsoversikt [Overview of homicides]. 2011. https://www.politi.no/vedlegg/lokale_vedlegg/kripos/ Vedlegg_1578.pdf [31/12/2014]. 9. Thoresen SØ, Rognum T. Survival time and acting capability after fatal injury by sharp weapons. Forensic Sci Int 1986;31:181e7. 10. Web page: Haukeland University Hospital. http://www.helse-bergen.no/english/ Sider/side.aspx [31/12/2014]. 11. Statistics Norway. Tabell 11 Rogaland. Folkemengde 1. januar og endringer i året. 1951 [Table 11 Rogaland. Population January 1. and changes throughout the year. 1951]. http://www.ssb.no/emner/02/02/folkendrhist/tabeller/tab/11.html [31/ 12/2014]. 12. Statistics Norway. Tabell 12 Hordaland. Folkemengde 1. januar og endringer i året. 1951 [Table 12 Hordaland. Population January 1. and changes throughout the year. 1951]. http://www.ssb.no/emner/02/02/folkendrhist/tabeller/tab/12.html [31/12/2014]. 13. Norway. Tabell 14 Sogn og Fjordane. Folkemengde 1. januar og endringer i året. 1951 [Table 14 Sogn and Fjordane. Population January 1. and changes throughout the year. 1951]. http://www.ssb.no/emner/02/02/folkendrhist/tabeller/tab/ arkiv/2010/14.html [31/12/2014]. 14. Rogde S, Hougen HP, Poulsen K. Homicide by sharp force in two Scandinavian capitals. Forensic Sci Int 2000;109:135e45. 15. Karlsson T. Homicidal and suicidal sharp force fatalities in Stockholm, Sweden. Orientation of entrance wounds in stabs gives information in the classification. Forensic Sci Int 1998;93(1):21e32. 16. Rehn AL. Uber penetrierende herzwunden und herznaht. Arch Klin Chir 1897;55:315e7. 17. Fieseler S, Zinka B, Kunz SN. Survived stab to the heart in a schizophrenic man. Arch Kriminol 2011;228(3e4):126e31.
77
18. Karger B, Niemeyer J, Brinkmann B. Physical activity following fatal injury from sharp pointed weapons. Int J Legal Med 1999;112:188e91. 19. Perdekamp MG, Riede UN, Pollak S. Penetrating stab injury to the heart with unusually long survival. Arch Kriminol 2000;206(3e4):102e9. 20. Campbell NC, Thomson SR, Muckart DJJ, Meunann CM, van Middelkoop I, Botha JBC. Review of 1198 cases of penetrating cardiac trauma. Br J Surg 1997;84:1737e40. 21. Taylor AS. Wounds of the heart. Principles of medical jurisprudence. 12th ed., vol. 1. London: J&A Churchill; 1965. p. 248. 22. Moreno C, Moore EE, Majure JA, Hopeman AR. Pericardial tamponade: a critical determinant for survival following penetrating cardiac wounds. J Trauma 1986;26(9):821e5. 23. Weissberg D, Refaely Y. Pneumothorax. Experience with 1,199 patients. Chest 2000;117(5):1279e85. 24. Assuncao LA, Santos A, Magelhaes T. Suicide by sharp force injuries e a study in Oporto. Leg Med 2009;11:S216e9. 25. Fukube S, Hayashi T, Ishida Y, Kamon H, Kawaguchi M, Kimura A, et al. Retrospective study on suicidal cases by sharp force injuries. J Forensic Leg Med 2008;15(3):163e7. 26. Maxwell R, Trotter C, Verne J, Brown P, Gunnell D. Trends in admissions to hospital involving an assault using a knife or other sharp instrument, England, 1997e2005. J Public Health (Oxf) 2007;29(2):186e90. 27. Pallett J, Sutherland E, Gluckman E, Tunnicliff M, Keep J. A cross-sectional study of knife injuries at a London major trauma center. Ann R Coll Surg Engl 2014;96(1):23e6. 28. Webb E, Wyatt JP, Henry J, Busuttil A. A comparison of fatal with non-fatal knife injuries in Edinburgh. Forensic Sci Int 1999;99(3):179e87. 29. Yacoub S, Arellano S, Padgett-Moncada D. Violence related injuries, deaths and disabilities in the capital of Honduras. Injury 2006;37(5):428e34. 30. Walton CB, Blaisdell FW, Jordan RG, Bodai BI. The injury potential and lethality of stab wounds: a Folsom Prison Study. J Trauma 1989;29(1):99e101. 31. Cros J, Alvarez JC, Sbidian E, Charlier P, de la Grandmaison GL. Survival time estimation using Injury Severity Score (ISS) in homicide cases. Forensic Sci Int 2013;233:99e103. 32. Ryyn€ anen OP, Iirola T, Reitala J, P€ alve H, Malmivaara A. Is advanced life support better than basic life support in prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med 2010;18:62 [31/12/2014]. 33. Powell DW, Moore EE, Cothren CC, Ciesla DJ, Burch JM, Moore JB, et al. Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary rescuscitaion. J Am Coll Surg 2004;199(2):211e5. 34. Nair MS, Uzzaman MM, Al-Zuhir N, Jadeja A, Navaratnam R. Changing trends in the pattern and outcome of stab injuries at a North London hospital. J Emerg Trauma Shock 2011;4(4):455e60. 35. Jansen JO, Inaba K, Rizoli SB, Boffard KD, Demetriades D. Selective nonoperative management of penetrating abdominal injury in Great Britain and Ireland: survey of practice. Injury 2012;43(11):1799e804. 36. Baker SP, O'Neill B. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14: 187e96. 37. AAAM (Association for the Advancement of Automotive Medicine). The Abbreviated Injury Scale (AIS). 2008. http://www.aaam1.org/ais/ AISClarified2012.pdf [02/01/2015].