Accidental death in a jack-knife position

Accidental

death

in

a

jack-knife

position

Francesco

Simonit

*

,

Leonardo

Ciccone

,

Lorenzo

Desinan

a_{IstitutodiMedicinaLegale,UniversitàdegliStudidiTrieste,OspedalediCattinara,StradadiFiume447,34146Trieste,Italy} b_{DipartimentodiAreaMedica,MedicinaLegale,UniversitàdegliStudidiUdine,p.leS.MariadellaMisericordia15,33100Udine,Italy}

ABSTRACT

Postural(or“positional”)asphyxiaoccursduetoapersonbeinginaprolongedabnormalbodypositionthatprevents adequatebreathing.Itsdiagnosisisbasedonseveralcriteria,inparticulartheexclusionofinvolvementofother people and other causes of death. This case report is about a 73-year-old woman whose body was found in a jack-knifedpositionbyherson.Shewasonthefloor,wedgedintothespacebetweenthelegsandseatofachair.Theman attemptedunsuccessfullytoextricateherfromthatpositionandcalledformedicalassistance.Therescuerstook pictures of the scene before freeing the victim from the chair and providing unsuccessful resuscitation. External examinationdisclosedabrasionsonthethighsandthebackofthevictim,whichcorrespondedtopartsofthechair, ecchymosesontheupperlimbs(ascribedtothegrippingattempts),conjunctivalpetechiae,facialcongestionand swelling. Autopsy disclosed brain and lung congestion and edema and atherosclerotic coronary disease without acutecardiaclesions.Alltheseconsiderationscontributedtothecauseofdeathbeingdeterminedasbeingdueto posturalasphyxia. ARTICLE INFO Keywords: Posturalasphyxia Positionalasphyxia Jack-knifeposition Deathsceneinvestigation

1. Introduction

Theterm“positional”(or“postural”)asphyxiareferstoasituationin whichanenforcedandabnormaladoptionofthepostureofthebodyfor anextendedtimeinterferesmechanicallywiththepulmonary ventila-tion,causingastateofimpairedoxygenation[1–6].Fatalitiesfromthis typeofasphyxiaarerare,butacarefuldiagnosticapproachtothesecases isneeded.Severalposturesarereportedintheliterature,suchas hyper-flexedhead,head-downposition[2,3,7,8],hogtiepositionduetorestrain [4,9]jack-knifeposition[10]andreversejack-knifeposition[11].Acase ofposturalasphyxiationduetojack-knifepositionisherepresented.

2. Casereport

A73-year-oldCaucasianfemale withnohistoryofsevereorganic illnesswasfoundonthefloor,wedgedintothespacebetweenthelegsand seatofachair(Fig.1AandB)byherson.Thetorsowashyperflexedina jack-knifeposition.Themantriedunsuccessfullytofreehismotherand thenhealertedmedicalassistance.Rescuerstookpicturesofthescene (Fig.1AandB)beforebreakingthechairtoextricatethewomanand providingunsuccessfulresuscitation.

Atpostmortemexamination,theface,theanterioraspectoftheneckand oftheupperthoraxwerebluishandswollen.Conjunctivalpetechiaewere present.Fixedhypostasisinvolvedthelowerbackandforearms.Several abrasionsandecchymoseswereobserved:atransverselinearabrasiononthe

centralmiddleback;atransversebruisemarkontheposteriorsurfaceofthe upperrightthigh;atransverseabrasionmarkontheposteriorsurfaceofboth thighsatthesamelevelanddistaltothepreviouslydescribedlesion(Fig.2); variousovalecchymosesonbothupperlimbs(Fig.3A,BandC).

Autopsyruledoutcardiovascularcausesofdeath:acalcifiedcoronary atherosclerosiswasdetected,withoutevidenceofacutecardiacinjuries. Brainedemaandcongestion,pleural,trachealandpericardialpetechiae andribfractures wereobserved.Thelungswereincreasedin weight (right =930g, left =790g; normal=360–570grams (right) and 325–480(left)[12]),werecongestedandedematousandairwayswere freefromobstructions.

The cause of death was determined as postural asphyxia due to enforcedandprolongedjack-knifeposition.

3. Discussion

Reports in theliterature indicate that most of the deaths due to positionalasphyxiaareaccidental.Althoughinonecaseinvolvingan elderlywoman,thepossibilityof suicidecouldnotbe ruledout[1]. Reportsofteninvolvemiddle-agedvictimsinadruggedstate,[2,10,13], or patientswith neurologicaldisease[1,14]. Cases involvingelderly victimsarealsoreported[1,7].Diagnosticcriteriaforposturalasphyxia weredevelopedbyBellandPadosch[2,13],affirmingthat:

1) thepersonmustbediscoveredinapositionthatdoesnotallow adequatebreathing;

* Correspondingauthor.

E-mail addresses:simonit.francesco@hotmail.it(F. Simonit),leonardo.ciccone.med.legale@gmail.com(L. Ciccone),lorenzo.desinan@uniud.it(L. Desinan).

http://doi.org/10.1016/j.fsir.2019.100048

Received30July2019;Receivedinrevisedform11October2019;Accepted16October2019 Available online 18 October 2019

2665-9107/©2019PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

ForensicScienceInternational:Reports1(2019)100048

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Forensic

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2) sceneandhistoricalevidencemustshowthatthedecedentplaced him/herselfinthatpositionwithouttheactionofotherpeople; 3) thevictimcouldnotescapethatposition;

4) thereisnoevidenceofinternalairwayobstruction; 5) gasintoxicationhastoberuledout;

6) theremustbenoevidenceofsignificantcardiacdisease.

Point 6) wasmodified by Byard, statingthat “in certaincases an underlyingorganicillness(cardiacorrespiratory)maybeeitherunrelatedto theterminalepisodeormaypredisposetoposturalasphyxia”[1].

Inthiscasethevictimwasfoundonthefloor,wedgedintothespace betweenthelegsandseatofthechair.Bruisesontheupperlimbswere compatiblewithgrippinglesions,confirmingthehypothesisthatherson attemptedtoextricate thewomanfrom that abnormal position.The morphologiesofthelinearbruiseswerecompatiblewiththebodybeingin contactwiththerungs(posterioraspectofthethighs)andtheflatsurfaces (back)ofthechair.Itwasverydifficulttoextricatethevictimfromthat position,sincerescuershadtobreaktheseatofthechairtoliberateher. Thehyperflexedpositionofthetrunkandtheneckwasabletoprevent adequatechestwallandabdomenmovements.Autopsyhighlightedthat airwayswerefree,nootheracutecausesofdeathwerediscovered,and no evidence of gas intoxication was found. The combination of circumstantialevidence,morphologicalfindings,andlackofevidence ofinvolvementofanotherpersonsuggestedthatanaccidentalseriesof

eventsledtothewomanbeingfoundinthisposition.Becauseofthe coronaryatherosclerosislesionsfoundatautopsy,itispossiblethatan underlying history of coronary disease was the risk factor that predisposedthispatienttoanunexpectedcardiaceventatthistime.A suddencardiacdeatheventcouldhaveledtoafallfromthechairontothe floor.Ifthewomansomehowbecameentrappedunderthechairinthe sittingpositionwhileunconscious,thisjack-knifepositionwouldhave preventedbreathingmovements.

Deathbypositionalasphyxiaisrelatedtodifferentmechanisms. Jack-knifepositionpreventsadequatebreathing,impedingchestwall,abdominal anddiaphragmmovements[5]andcausingapartialorcompleteairway obstruction[10].Furthermore,positionalasphyxiaisalsocharacterizedby anobstructedvenousreturntotherightheart,whichcancauseanincreased hydrostatic pressure in the upper parts of the body and an increased transmuralvenouspressureinthebrain[7,13];anincreasedstaticpressure inthecarotidsinusmayalsooccur,resultinginadecreasedarterialpressure [3,10,15].Incasesofaconsciousvictim,acatecholaminehyperstimulation may be present, leading to increased metabolic rate oxygen demand, tachycardia,andpotentialarrhythmias,andpromotingbrainhypoxia.

Externalandinternalsignsdependonthepathophysiologyofpostural asphyxia,butinseveralcasesnospecificfindingsmaybehighlightedby bodyexamination[1].Petechiaemaybepresentonconjunctivaeandon theserousmembranes[1,4]:theirformationisdirectlyproportionalto the degree of vein occlusion and is in inverse relation to arterial compressionabove theheart[16]. Howeveronly punctiform hemor-rhagesnotlocatedonlividityareasmaybeclassifiedasvitalpetechiae [4]. Conjunctival petechiae and remarkable facial congestion and swellingmaybepresentincaseswheretheheadhasbeendependent, buttheystillturnouttobeunspecificanddifficulttointerpret[1,3,10]. Postural asphyxia may lead to brain edema and leptomeninges congestion[3].Similarlytoanothercase-studyconcerningafatalitydue tojack-knifeposition,wereportedincreasedlungweight,lungcongestion andedema[10].

Diagnosisofposturalasphyxiamustbebasedonasolidfoundation.It isessentialtohaveapropersceneinvestigationtodemonstratethatthe victim was found in an abnormal position preventing adequate respirationandthatitwasnotpossibletochangethatposture.Other causesofdeath,bothnaturalorviolentmustbeexcluded.

Inthiscasetheroleoftherescuerswasfundamental,sincetheytook picturesastheyenteredthescene,witnessingtheabnormalpostureofthe victim.The only findings compatiblewith an aggressionweresome ecchymosesontheforearms,buttheycorrespondedtotheattemptsto extricatethewomanfromthechairbyherson.Autopsyexcludedother

Fig.1.AandB.Thescenebeforetherescuersremovedthevictim:thebodyofthewomanisonthefloor,wedgedintothespacebetweenthelegsandseatofachair.

Fig.2.Lesionsduetothecontactwiththepartsofthechair;detailsofthe transverse abrasiononthebackandofthelinear transversebruises onthe posterior aspects of the thighs.

F.Simonitetal. FSIR1(2019)100048

organiccausesofdeath.Itwasthusassumedthatthewomenattemptedto sitonthechair,butsheslipped,andherbodywasdraggeddownintoa jack-knifepositionwedgedintothespacebetweenthelegsandtheseatof achair.

Althoughsomepeoplemaydisagreewiththefinalpoliceconclusionin this instance, this report aims to document the findings from this particularcase,addtothegrowingliteratureinthisarea,andstimulate constructiveforensicconclusions.

Funding

Thisresearchdidnotreceiveanyspecificgrantfromfundingagencies inthepublic,commercial,ornot-for-profitsectors

DeclarationofCompetingInterest

Theauthorsdeclarenoconflictofinterest.

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Fig.3.A,BandC.Ecchymosesontheupperlimbs.

F.Simonitetal. FSIR1(2019)100048