Original Article
Fatal head injury: a sequelae to electric shock – a case report
Medico-Legal Journal 2015, Vol. 83(1) 47–50 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025817214528235 mlj.sagepub.com
SH Jayanth, Basappa S Hugar, YP Girish Chandra and A Gokula Krishnan
Abstract Deaths due to electric shock are increasing despite stringent laws and preventive measures. These shocks are a leading cause of death amongst construction workers. In about 20% of the cases, no visible injury due to electricity can be seen. In some cases, non-electrical injuries are present and at times there are no eyewitnesses to provide a detailed account of events. In such circumstances, examination of scene of death, autopsy and accident reconstruction with the help of an electrical expert are all necessary to determine the cause of death. Here, we report one such case where a mason working on the second floor of a building under construction sustained an electrical injury, following which he was thrown to the ground sustaining a fatal traumatic injury. After careful consideration, his death was attributed to the head injury.
Keywords Forensic pathology, electrical injury, fall from height, head injury
Introduction Electricity usually causes death when it enters and exits the body. The causes of death due to electricity are cardiac arrhythmias, respiratory arrest and rarely mechanical injury sustained as a consequence of electro trauma. Sometimes high-voltage electricity may cause death by flash burns involving a large surface area of skin without causing entry and exit injuries.1 A rare scenario is when the electric current causes flash burns over skin, enters and exits the body and later a non-electrical fatal injury is sustained due to fall from a height. The severe internal injuries at autopsy may be associated either with the blast of the electrical discharge or with the secondary fall.2 In such circumstances, attributing the immediate cause of death to either electrical injury or to the consequent fatal injury is a challenging task for the forensic pathologists.
Case report A 32-year-old man was subjected to a medico legal autopsy at MS Ramaiah Medical College and Hospital; an eye witness had seen him sustain injuries after a fall from a height. En route to the hospital his condition deteriorated, resuscitative attempts at the emergency
room failed. The individual had survived for about 4 h. Further investigation by the police revealed that he was a mason working on the second floor of a building that was close to a high-tension electrical transformer. At autopsy, the T-shirt on the body was burnt in places (Figure 1) and the sole of the left boot was blackened with a hole in its centre (Figure 2). A hospital bandage was around the forehead and intravenous injection marks were seen over the dorsum of both hands. The middle of the forehead showed a laceration with underlying fractured frontal bone. Multiple abrasions and contusions were present on the face, chest and the limbs. The left arm showed burns in places (with singed hair around them) consistent with electric flash burns (Figure 3). Skin splits with raised edges were present in the sole of the left foot consistent with an electrical exit injury (Figure 4). Department of Forensic Medicine, MS Ramaiah Medical College, Bangalore, India Corresponding author: SH Jayanth, Department of Forensic Medicine, MS Ramaiah Medical College, MSRIT Post, MSR Nagar, Bangalore 560054, India. Email: [email protected]
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Figure 1. T-shirt burnt at front.
Figure 4. Electrical exit injury over left sole.
Figure 5. Comminuted fracture of frontal bone.
Figure 2. Sole of left boot showing blackening and a hole.
On internal examination, diffuse extravasation of blood was seen over the scalp and the frontal bone showed a comminuted fracture extending to the base of the skull (Figure 5). Diffuse subdural and subarachnoid haemorrhages were seen over both cerebral hemispheres. The second and third ribs were fractured on the right side, and the third and fourth ribs were fractured on the left side along the mid-axillary line. Other internal organs were intact but congested. The non-electrical injuries were consistent with a fall from a height. After considering the crime scene investigation report and autopsy findings, the immediate cause of death was attributed to the head injury sustained as a result of the fall from a height as a sequel to the electrical shock.
Discussion
Figure 3. Electric flash burns over left upper limb.
Despite the advent of specialised power distribution systems and electrical safety equipment, the risk of electrical shock and injury still exists. Fatal occupational
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Jayanth et al.
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accidents are the most important health problems of construction workers. A review of deaths in the construction sector revealed that 14.4% of the cases had died because of electrocution.3 Documentation of injuries is important not only for the immediate care and resuscitation of the victim but also from the medico legal view point. Nearly all cases of electrical injuries eventually involve litigation for negligence, product liability or worker compensation.4 In this case, negligence can be attributed to the power distributor or to the person in charge of construction where the deceased was working. Sometimes the deceased himself can be careless in following safety precautions. Most deaths from electricity are from cardiac arrhythmias, usually ventricular fibrillation. The second most common cause of death is from respiratory arrest from paralysis of the intercostal muscles and diaphragm. Some cases sustain injury from falls and other associated trauma. Victims of electric shock may be thrown from a height that may lead to fractures and serious injuries.5 Electrical flash burns are usually superficial partialthickness burns, similar to other flash burns. Isolated thermal burns may also be seen when clothing ignites. The total body surface area affected by burns in electrical injury averages 10% to 25%.6 In the present case, the clothing was burnt and superficial burns were sustained over 10% of body surface area. In the case of low-voltage electric burns, characteristic electrical burn marks may appear. Their usual macroscopic appearance is of a round or oval shape, and sometimes they are an imprint of the form of the electro-conductive object involved. In the case of contact with high-voltage electricity, wide burn areas on the skin and deeper tissues can be caused and observed and can lead to carbonisation. The presence of electrical burn marks does not necessarily mean that the cause of death is due to electrical injury. Electrical burn marks can often be observed for a period of months in people who have survived electrical injury. Electrical burn marks can appear after the moment of death.4 In contrast to low-voltage burns, high-voltage burns tend to be relatively obvious and may be extremely severe, with charring of the body. If the burns occur from contact or proximity to a high-voltage line, numerous individual and confluent areas of thirddegree burns will be present.7 In the present case, though the deceased was exposed to high-voltage electricity, only first and second degree burns were observed and the electric current had also exited from the body as characterised by the exit wound on left foot. Death due to electrocution does not necessarily occur immediately. There appears to be a delay between
the shock and the death.8 In the interval, the victim may be conscious and even apparently recovering. In this interval, severe non-electrical injuries can be sustained which cause immediate death. At autopsy, such severe internal injuries should be carefully interpreted as they may be associated with the blast of the electrical discharge or due to a fall.2 The deceased upon nearing the transformer had sustained electrical flash burns which had thrown him from a height causing fatal injuries. The head injury sustained could prove fatal even in the absence of electrical injuries. In the present case, entry and exit electrical injuries were present. Injuries characteristic of electrical blast effect were absent. Thus, the severe internal injuries were non-electrical in nature, and were consistent with a fall from height sustained after electro trauma. Both electrical and non-electrical injuries were considered as cause of death. As the person had survived for about 4 h, it was more likely that he would have died from a non-electrical fatal head injury rather than the effect of electrical injury.
Conclusion Deaths due to electricity need not always be from the direct effects of electric current on the body; injuries as a consequence of a fall may sometimes be the immediate cause of death. In this case, there was a fatal nonelectrical head injury as well as first and second degree flash burns and exit wounds. In these circumstances, the severity of the non-electrical injuries, the survival period and the sequence of events which has caused death are helpful in ascertaining the immediate cause of death. References 1. Cooper PN. Injuries and death caused by heat and electricity. In: Jason P-J, Anthony B and William S (eds) Forensic medicine clinical and pathological aspects. London (England): Greenwich Medical Media Ltd, 2003, pp.191–197. 2. Moar JJ and Hunt JB. Death from electrical arc flash burns. A case report of two cases. S Afr Med J 1987; 71: 181–182. 3. Colaki B, Etiler N and Bicer U. Fatal occupational injuries in the construction sector in Kocaeli, Turkey, 1990–2001. Ind Health 2004; 42: 424–430. 4. Dokov W and Dokava K. Epidemiology and diagnostic problems of electrical injury in forensic medicine. In: Duarte Nuno Vieira (ed.) Forensic medicine – from old problems to new challenges. Rijeka, Croatia: InTech, 2011, pp.121–136. 5. Saukko P and Knight B. Knight’s forensic pathology, 3rd ed. London: Arnold Publication, 2004, pp.326–338. 6. Price TG and Cooper MA. Electrical and lightning injuries. In: Marx JA, Hockberger RS, Walls RM, et al. (eds)
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Rosen’s emergency medicine: concepts and clinical practice, 7th ed. Philadelphia, PA: Mosby Elsevier, 2009, pp.2267–2278. 7. DiMaio VJ and DiMaio D. Forensic pathology, 2nd ed. New York, NY: CRC Press, 2001, pp.409–415.
8. Somogyi E and Tedeschi CG. Injury by electrical force. In: Tedeschi CG, Eckert WG and Tedeschi LG (eds) Forensic medicine Vol. I. Philadelphia: WB: Saunders, 1977, pp.645–676.
Downloaded from mlj.sagepub.com by guest on November 18, 2015
Fatal head injury: a sequelae to electric shock – a case report
Medico-Legal Journal 2015, Vol. 83(1) 47–50 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025817214528235 mlj.sagepub.com
SH Jayanth, Basappa S Hugar, YP Girish Chandra and A Gokula Krishnan
Abstract Deaths due to electric shock are increasing despite stringent laws and preventive measures. These shocks are a leading cause of death amongst construction workers. In about 20% of the cases, no visible injury due to electricity can be seen. In some cases, non-electrical injuries are present and at times there are no eyewitnesses to provide a detailed account of events. In such circumstances, examination of scene of death, autopsy and accident reconstruction with the help of an electrical expert are all necessary to determine the cause of death. Here, we report one such case where a mason working on the second floor of a building under construction sustained an electrical injury, following which he was thrown to the ground sustaining a fatal traumatic injury. After careful consideration, his death was attributed to the head injury.
Keywords Forensic pathology, electrical injury, fall from height, head injury
Introduction Electricity usually causes death when it enters and exits the body. The causes of death due to electricity are cardiac arrhythmias, respiratory arrest and rarely mechanical injury sustained as a consequence of electro trauma. Sometimes high-voltage electricity may cause death by flash burns involving a large surface area of skin without causing entry and exit injuries.1 A rare scenario is when the electric current causes flash burns over skin, enters and exits the body and later a non-electrical fatal injury is sustained due to fall from a height. The severe internal injuries at autopsy may be associated either with the blast of the electrical discharge or with the secondary fall.2 In such circumstances, attributing the immediate cause of death to either electrical injury or to the consequent fatal injury is a challenging task for the forensic pathologists.
Case report A 32-year-old man was subjected to a medico legal autopsy at MS Ramaiah Medical College and Hospital; an eye witness had seen him sustain injuries after a fall from a height. En route to the hospital his condition deteriorated, resuscitative attempts at the emergency
room failed. The individual had survived for about 4 h. Further investigation by the police revealed that he was a mason working on the second floor of a building that was close to a high-tension electrical transformer. At autopsy, the T-shirt on the body was burnt in places (Figure 1) and the sole of the left boot was blackened with a hole in its centre (Figure 2). A hospital bandage was around the forehead and intravenous injection marks were seen over the dorsum of both hands. The middle of the forehead showed a laceration with underlying fractured frontal bone. Multiple abrasions and contusions were present on the face, chest and the limbs. The left arm showed burns in places (with singed hair around them) consistent with electric flash burns (Figure 3). Skin splits with raised edges were present in the sole of the left foot consistent with an electrical exit injury (Figure 4). Department of Forensic Medicine, MS Ramaiah Medical College, Bangalore, India Corresponding author: SH Jayanth, Department of Forensic Medicine, MS Ramaiah Medical College, MSRIT Post, MSR Nagar, Bangalore 560054, India. Email: [email protected]
Downloaded from mlj.sagepub.com by guest on November 18, 2015
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Figure 1. T-shirt burnt at front.
Figure 4. Electrical exit injury over left sole.
Figure 5. Comminuted fracture of frontal bone.
Figure 2. Sole of left boot showing blackening and a hole.
On internal examination, diffuse extravasation of blood was seen over the scalp and the frontal bone showed a comminuted fracture extending to the base of the skull (Figure 5). Diffuse subdural and subarachnoid haemorrhages were seen over both cerebral hemispheres. The second and third ribs were fractured on the right side, and the third and fourth ribs were fractured on the left side along the mid-axillary line. Other internal organs were intact but congested. The non-electrical injuries were consistent with a fall from a height. After considering the crime scene investigation report and autopsy findings, the immediate cause of death was attributed to the head injury sustained as a result of the fall from a height as a sequel to the electrical shock.
Discussion
Figure 3. Electric flash burns over left upper limb.
Despite the advent of specialised power distribution systems and electrical safety equipment, the risk of electrical shock and injury still exists. Fatal occupational
Downloaded from mlj.sagepub.com by guest on November 18, 2015
Jayanth et al.
49
accidents are the most important health problems of construction workers. A review of deaths in the construction sector revealed that 14.4% of the cases had died because of electrocution.3 Documentation of injuries is important not only for the immediate care and resuscitation of the victim but also from the medico legal view point. Nearly all cases of electrical injuries eventually involve litigation for negligence, product liability or worker compensation.4 In this case, negligence can be attributed to the power distributor or to the person in charge of construction where the deceased was working. Sometimes the deceased himself can be careless in following safety precautions. Most deaths from electricity are from cardiac arrhythmias, usually ventricular fibrillation. The second most common cause of death is from respiratory arrest from paralysis of the intercostal muscles and diaphragm. Some cases sustain injury from falls and other associated trauma. Victims of electric shock may be thrown from a height that may lead to fractures and serious injuries.5 Electrical flash burns are usually superficial partialthickness burns, similar to other flash burns. Isolated thermal burns may also be seen when clothing ignites. The total body surface area affected by burns in electrical injury averages 10% to 25%.6 In the present case, the clothing was burnt and superficial burns were sustained over 10% of body surface area. In the case of low-voltage electric burns, characteristic electrical burn marks may appear. Their usual macroscopic appearance is of a round or oval shape, and sometimes they are an imprint of the form of the electro-conductive object involved. In the case of contact with high-voltage electricity, wide burn areas on the skin and deeper tissues can be caused and observed and can lead to carbonisation. The presence of electrical burn marks does not necessarily mean that the cause of death is due to electrical injury. Electrical burn marks can often be observed for a period of months in people who have survived electrical injury. Electrical burn marks can appear after the moment of death.4 In contrast to low-voltage burns, high-voltage burns tend to be relatively obvious and may be extremely severe, with charring of the body. If the burns occur from contact or proximity to a high-voltage line, numerous individual and confluent areas of thirddegree burns will be present.7 In the present case, though the deceased was exposed to high-voltage electricity, only first and second degree burns were observed and the electric current had also exited from the body as characterised by the exit wound on left foot. Death due to electrocution does not necessarily occur immediately. There appears to be a delay between
the shock and the death.8 In the interval, the victim may be conscious and even apparently recovering. In this interval, severe non-electrical injuries can be sustained which cause immediate death. At autopsy, such severe internal injuries should be carefully interpreted as they may be associated with the blast of the electrical discharge or due to a fall.2 The deceased upon nearing the transformer had sustained electrical flash burns which had thrown him from a height causing fatal injuries. The head injury sustained could prove fatal even in the absence of electrical injuries. In the present case, entry and exit electrical injuries were present. Injuries characteristic of electrical blast effect were absent. Thus, the severe internal injuries were non-electrical in nature, and were consistent with a fall from height sustained after electro trauma. Both electrical and non-electrical injuries were considered as cause of death. As the person had survived for about 4 h, it was more likely that he would have died from a non-electrical fatal head injury rather than the effect of electrical injury.
Conclusion Deaths due to electricity need not always be from the direct effects of electric current on the body; injuries as a consequence of a fall may sometimes be the immediate cause of death. In this case, there was a fatal nonelectrical head injury as well as first and second degree flash burns and exit wounds. In these circumstances, the severity of the non-electrical injuries, the survival period and the sequence of events which has caused death are helpful in ascertaining the immediate cause of death. References 1. Cooper PN. Injuries and death caused by heat and electricity. In: Jason P-J, Anthony B and William S (eds) Forensic medicine clinical and pathological aspects. London (England): Greenwich Medical Media Ltd, 2003, pp.191–197. 2. Moar JJ and Hunt JB. Death from electrical arc flash burns. A case report of two cases. S Afr Med J 1987; 71: 181–182. 3. Colaki B, Etiler N and Bicer U. Fatal occupational injuries in the construction sector in Kocaeli, Turkey, 1990–2001. Ind Health 2004; 42: 424–430. 4. Dokov W and Dokava K. Epidemiology and diagnostic problems of electrical injury in forensic medicine. In: Duarte Nuno Vieira (ed.) Forensic medicine – from old problems to new challenges. Rijeka, Croatia: InTech, 2011, pp.121–136. 5. Saukko P and Knight B. Knight’s forensic pathology, 3rd ed. London: Arnold Publication, 2004, pp.326–338. 6. Price TG and Cooper MA. Electrical and lightning injuries. In: Marx JA, Hockberger RS, Walls RM, et al. (eds)
Downloaded from mlj.sagepub.com by guest on November 18, 2015
50
Medico-Legal Journal 83(1)
Rosen’s emergency medicine: concepts and clinical practice, 7th ed. Philadelphia, PA: Mosby Elsevier, 2009, pp.2267–2278. 7. DiMaio VJ and DiMaio D. Forensic pathology, 2nd ed. New York, NY: CRC Press, 2001, pp.409–415.
8. Somogyi E and Tedeschi CG. Injury by electrical force. In: Tedeschi CG, Eckert WG and Tedeschi LG (eds) Forensic medicine Vol. I. Philadelphia: WB: Saunders, 1977, pp.645–676.
Downloaded from mlj.sagepub.com by guest on November 18, 2015
