Journal of Forensic and Legal Medicine 32 (2015) 30e33
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
Case report
Occupational death due to bilateral carotid artery occlusion e A medico-legal case report Siddhartha Das*, Ambika Prasad Patra, Kusa Kumar Shaha, Sanjay Sukumar, Vinod Ashok Chaudhari, Nisreen Abdul Rahman Department of Forensic Medicine & Toxicology, JIPMER, Puducherry, India
a r t i c l e i n f o
a b s t r a c t
Article history: Received 9 January 2015 Accepted 15 February 2015 Available online 21 February 2015
Occupational deaths are work-related deaths and usually occur in the work place of an individual. A case of occupational death in a female factory worker has been described, where the saree she was wearing accidentally got entangled in the moving belt and caused ligature strangulation. She was unconscious throughout indicating bilateral occlusion of the carotids and died a day after the incident. The authors have described the correlation between the distribution of the injuries on the body and the manner a saree is worn. Investigation of the workplace revealed that the place where she was standing was located between two machines, and the space was inadequate for normal movement. Some suggestions have been offered which may decrease the incidences of occupational ligature strangulation due to entanglement of dress materials in the moving machineries. © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Occupational death Ligature strangulation Carotid occlusion Cerebral anoxia
1. Introduction An occupational death, commonly called as ‘occupational fatality’ (OF) or ‘work-related deaths/fatalities’ is a death that occurs while a person is at work or performing work related tasks. According to International Labour Organisation (ILO) data, an estimated 337 million workplace accidents and 2.3 million deaths occur every year, with some 6300 deaths per day.1,2 350,000 of these deaths are due to accidents, and the rest are due to occupational illnesses and diseases. China and India together are estimated to account for over 100,000 accident-related deaths.2 Common causes of OFs include falls, machine-related incidents, motor vehicle accidents, electrocution, falling objects etc.3 A 5-year study on OF in New Mexico reported 17% of the deaths to have been caused due to contact with objects and equipments.4 Entanglement of clothing's or some body part in the machine was responsible for 9.8% of occupational deaths in the old farmers.5 Incidents of accidental strangulation by uncovered wheels of vehicles or machineries is a common occurrence, especially among Indian women whose traditional dress is a saree or a chunni. A number of cases of such accidental ligature strangulation have been reported.6e11 A saree is worn in a manner wherein one of its free
* Corresponding author. Tel.: þ91 9677523598. E-mail addresses: [email protected], [email protected] (S. Das).
ends dangles from the back of the left shoulder (Fig. 1A and B), making it vulnerable for entanglement in machines or wheels of vehicles. Here we report the case of a female worker of a cement manufacturing factory who succumbed to her injuries following accidental ligature strangulation in a running machine.
2. Case report A female worker at a cement processing factory was received in our hospital with a history of accidental ligature strangulation while at work. At the time of admission, she was unconscious with a Glasgow Coma Scale score of 5/15 (E1V1M3). There was no history of vomiting or seizures. Her pulse, blood pressure and respiratory rates were within normal limits. There was extensor plantar response on both sides. X-ray of the cervical spine showed no injuries to the cervical vertebra or the spinal cord. CT scan of the brain revealed a left sided middle cerebral artery territory infarct with right sided fronto-parietal infarct. She was referred to neurology who advised her intravenous mannitol along with ranitidine, aspirin and atorvastatin. She succumbed to her injuries a day after the incident. At autopsy, the following injuries were noted on her body. 1. A grazed abrasion of size 41 4 cm extending from the posterior axillary line of the left side, going obliquely upwards and
http://dx.doi.org/10.1016/j.jflm.2015.02.009 1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
S. Das et al. / Journal of Forensic and Legal Medicine 32 (2015) 30e33
2.
3.
4. 5.
6.
31
medially above the left shoulder to the front of chest to end 4 cm below the supra sternal notch (Fig. 2A and B). A ligature impression in the form of an abrasion of size 13 0.8 cm extending from 1 cm below the supra sternal notch, going obliquely upwards along the right side of neck to end behind the right shoulder (Fig. 2B and C). A grazed abrasion of size 20 4 cm present on the back, extending from a point 26 cm below the external occipital protuberance and 5 cm to the right of midline, going obliquely upwards along the right infra-scapular margin (Fig. 2D). An abrasion of size 10 1.5 cm present obliquely below the above-mentioned injury no. 4 (Fig. 2D). A grazed abrasion of size 12 2 cm present obliquely over the left side of back, 36 cm below the external occipital protuberance and 5 cm to the left of the midline (Fig. 2D). A grazed abrasion of size 11 7 cm was present adjoining and just above the above-mentioned injury no. 6 (Fig. 2D).
On internal examination, contusion of muscles of the neck was noticed underneath the injuries. The carotid arteries, laryngeal cartilages and hyoid bone were found to be intact. Brain and both lungs were congested and oedematous to a variable degree. Rest of the examination was unremarkable. Toxicological analysis of the viscera did not show the presence of any sedative or intoxicating substance. Death was due to cerebral anoxia arising as a consequence of ligature strangulation. 3. Discussion Fig. 1. The way a saree is worn. (A) Front view. (B) Rear view. Note the free end dangling from the back of left shoulder.
In ligature strangulation, a constricting force other than the weight of the body is applied directly to the ligature. They are usually considered homicidal and should be presumed to be
Fig. 2. Numerals denote the injury numbers mentioned in the text.
32
S. Das et al. / Journal of Forensic and Legal Medicine 32 (2015) 30e33
Fig. 3. The star denotes the place where the deceased was standing, close to the machine belt. Note the window in the opposite wall.
homicidal unless the contrary is proved.6,12 Accidental ligature strangulation though rare may occur in children, intoxicated adults and when clothing's get entangled in moving machineries.6,13 The condition proves more fatal in roller type electric operated machines, as the continued motion of the machine with the entangled cloth causes increasingly more constriction of the neck. In one case, accidental ligature strangulation involved a blouse that got entangled in a roller type massage device.14 Compression of the carotid arteries is one of the mechanisms of death in ligature strangulation. As they are situated deep to the sternocleidomastoid muscle, they are less commonly occluded as compared to the venous occlusion. In bilateral occlusion of the carotids, almost immediate unconsciousness ensues, as the supply of arterial blood to the brain by the vertebral circulation is inadequate to maintain cortical function, which depends mainly upon the anterior and middle cerebral arteries that arise from the carotid supply. Constant pressure over the carotid arteries for 10e15 s causes unconsciousness, and irreversible cerebral damage may occur if the carotid circulation is totally occluded for four or more minutes.15,16 In the present case, the deceased was unconscious
throughout indicating bilateral occlusion of the carotids, which was confirmed by CT scan of the brain. History revealed that the victim was bending over and mixing the ingredients with her hand that were falling from the upper slide into the lower slide (Fig. 3). Her back was turned towards the machine, and the free end of her saree that was dangling from her left shoulder was very close to the moving belt. What we assume is that a whiff of air entering the room from the window situated on the opposite wall (Fig. 3) would have entangled the saree in the moving belt. Once the saree got entangled in the moving belt, it must have pulled her backwards. As a reflex action, her left hand would have grabbed the saree and pulled it forwards to release it from the belt. This motion along with the motion of the moving belt would have caused the saree to press firmly against the left scapular region (Fig. 4A) and the front of left side of the neck (Fig. 4B) producing injury nos. 1 and 2 and the occlusion of the left carotid supply. The pulling force of the moving belt caused not only the thali (necklace worn by married females) impression on the neck (injury no.3) but was also responsible for occluding the right carotid supply. Injury nos. 4e7 were present obliquely over the bare area of the back (area between lower end of blouse and the hip area of the saree) and correlates with the oblique manner a saree is draped on the back (Fig. 4C). Because of the pull on the saree by the motion of the moving belt, the victim would have rotated in an anti-clockwise direction and thus had been partially disrobed. The intensity of the force gradually decreased from injury no.1 to 7. Injury nos. 1, 4 and 6 were more severe as compared to the other injuries. This can be explained by the fact that maximum force was exerted over injury no. 1, and injury nos. 4 and 6 were situated over a bare area. Secondly the saree would have got crumpled up over this area, thus leaving a deeper imprint. Injury nos. 2, 5 and 7 had a faint impression because of non-crumpling of the saree. Injury nos. 3e7, the front portion of the injury no. 1 and upper portion of the injury no. 2 were present over the bare area of skin. The distribution of the injuries on the front and back correlates with the manner in which a saree is worn and also the way in which the saree moved over the body during the disrobing process. The space where she was standing, and working was very narrow and always ran the risk of a possible accidental contact between dress materials and the moving belt. Ideally, there should have been enough space between the machines for her normal
Fig. 4. The arrows denote the direction of pull on the saree by the moving belt. The injuries shown in Fig. 2 correspond to the way a saree is worn and also the way in which the saree moved over the body during the disrobing process.
S. Das et al. / Journal of Forensic and Legal Medicine 32 (2015) 30e33
movement. It would have been better if she had stood on the other side of the slide besides the pillar. In the case of space constraint, a long handled spatula type device could have been used so that the worker did not have to stand too close to the machines. In order to prevent such incidences wearing of buttoned coats over the dresses should be made mandatory. As an additional measure some covering should be present around the moving belt, and provisions made so that the electrical connection to the machine gets switched off automatically in the eventual incident of such accidental entanglement of dress materials. A regulatory authority should be there to enforce strict workplace laws, and the stakeholders should be brought under its purview. Conflict of interest The authors declare that there is no conflict of interest. Funding None declared. Ethical approval None declared. References 1. World day for safety and health at work 2011. 26 April 2011. Press Release. Retrieved from, www.ilo.org.
33
2. Pearson Karen. The causes and incidence of occupational accidents and ill-health across the globe. British Safety Council; April 2009. 3. Hamalainen P, Takala J, Saarela KL. Global estimates of occupational accidents. Saf Sci 2006;44:137e56. 4. Mulloy KB, Moraga-McHaley S, Crandall C, Kesler DO. Occupational injury mortality: New Mexico 1998e2002. Am J Ind Med 2007;50:910e20. 5. Voaklander DC, Hartling L, Pickett W, Dimich-Ward H, Brison RJ. Work-related mortality among older farmers in Canada. Can Fam Physician 1999;45: 2903e10. 6. Aggarwal NK, Aggarwal BBL. Accidental strangulation in a cycle rickshaw. Med Sci Law 1998;38:263e5. 7. Ambade VN, Godbole HV, Dixit PG, Kukde HG. Accidental ligature strangulation due to crop thrasher. J Forensic Leg Med 2008;15:263e5. 8. Shetty M, Shetty BS. Accidental ligature strangulation due to electric grinder. J Clin Forensic Med 2006;13:148e50. 9. Gupta BD, Jani CB, Datta RG. Accidental strangulation: a case report. Med Sci Law 2004;44:359e62. 10. Chattopadhyay S, Pal I. Survival following accidental ligature strangulation: a case report. J Forensic Leg Med 2008;15:53e5. 11. Agrawal A, Ninave S, Srivastava T, Sunkara A, Agrawal S. Accidental unilateral and incomplete strangulation injury in a patient while travelling on a bicycle. J Forensic Leg Med 2009;16:350e1. 12. Demirci S, Dogan KH, Erkol Z, Gunaydin G. Ligature strangulation deaths in the province of Konya (Turkey). J Forensic Leg Med 2009;16:248e52. 13. Verma SK, Aggarwal NK, Kohli A. Accidental ligature strangulation deaths in East Delhi (India). Med Sci Law 2005;45:47e51. 14. Russel D, Deidiker MD. Accidental ligature strangulation due to a roller type massage device. Am J Forensic Med Pathol 1999;20:354e5. 15. Saukko P, Knight B. Fatal pressure on the neck. In: Saukko P, Knight B, editors. Knight's forensic pathology. London: Arnold; 2004. p. 368e94. 16. DiMaio VJ, DiMaio D. Asphyxia. In: Maio VJ, Maio D, editors. Forensic pathology. Boca Raton: CRC Press; 2001. p. 229e77.
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
Case report
Occupational death due to bilateral carotid artery occlusion e A medico-legal case report Siddhartha Das*, Ambika Prasad Patra, Kusa Kumar Shaha, Sanjay Sukumar, Vinod Ashok Chaudhari, Nisreen Abdul Rahman Department of Forensic Medicine & Toxicology, JIPMER, Puducherry, India
a r t i c l e i n f o
a b s t r a c t
Article history: Received 9 January 2015 Accepted 15 February 2015 Available online 21 February 2015
Occupational deaths are work-related deaths and usually occur in the work place of an individual. A case of occupational death in a female factory worker has been described, where the saree she was wearing accidentally got entangled in the moving belt and caused ligature strangulation. She was unconscious throughout indicating bilateral occlusion of the carotids and died a day after the incident. The authors have described the correlation between the distribution of the injuries on the body and the manner a saree is worn. Investigation of the workplace revealed that the place where she was standing was located between two machines, and the space was inadequate for normal movement. Some suggestions have been offered which may decrease the incidences of occupational ligature strangulation due to entanglement of dress materials in the moving machineries. © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Occupational death Ligature strangulation Carotid occlusion Cerebral anoxia
1. Introduction An occupational death, commonly called as ‘occupational fatality’ (OF) or ‘work-related deaths/fatalities’ is a death that occurs while a person is at work or performing work related tasks. According to International Labour Organisation (ILO) data, an estimated 337 million workplace accidents and 2.3 million deaths occur every year, with some 6300 deaths per day.1,2 350,000 of these deaths are due to accidents, and the rest are due to occupational illnesses and diseases. China and India together are estimated to account for over 100,000 accident-related deaths.2 Common causes of OFs include falls, machine-related incidents, motor vehicle accidents, electrocution, falling objects etc.3 A 5-year study on OF in New Mexico reported 17% of the deaths to have been caused due to contact with objects and equipments.4 Entanglement of clothing's or some body part in the machine was responsible for 9.8% of occupational deaths in the old farmers.5 Incidents of accidental strangulation by uncovered wheels of vehicles or machineries is a common occurrence, especially among Indian women whose traditional dress is a saree or a chunni. A number of cases of such accidental ligature strangulation have been reported.6e11 A saree is worn in a manner wherein one of its free
* Corresponding author. Tel.: þ91 9677523598. E-mail addresses: [email protected], [email protected] (S. Das).
ends dangles from the back of the left shoulder (Fig. 1A and B), making it vulnerable for entanglement in machines or wheels of vehicles. Here we report the case of a female worker of a cement manufacturing factory who succumbed to her injuries following accidental ligature strangulation in a running machine.
2. Case report A female worker at a cement processing factory was received in our hospital with a history of accidental ligature strangulation while at work. At the time of admission, she was unconscious with a Glasgow Coma Scale score of 5/15 (E1V1M3). There was no history of vomiting or seizures. Her pulse, blood pressure and respiratory rates were within normal limits. There was extensor plantar response on both sides. X-ray of the cervical spine showed no injuries to the cervical vertebra or the spinal cord. CT scan of the brain revealed a left sided middle cerebral artery territory infarct with right sided fronto-parietal infarct. She was referred to neurology who advised her intravenous mannitol along with ranitidine, aspirin and atorvastatin. She succumbed to her injuries a day after the incident. At autopsy, the following injuries were noted on her body. 1. A grazed abrasion of size 41 4 cm extending from the posterior axillary line of the left side, going obliquely upwards and
http://dx.doi.org/10.1016/j.jflm.2015.02.009 1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
S. Das et al. / Journal of Forensic and Legal Medicine 32 (2015) 30e33
2.
3.
4. 5.
6.
31
medially above the left shoulder to the front of chest to end 4 cm below the supra sternal notch (Fig. 2A and B). A ligature impression in the form of an abrasion of size 13 0.8 cm extending from 1 cm below the supra sternal notch, going obliquely upwards along the right side of neck to end behind the right shoulder (Fig. 2B and C). A grazed abrasion of size 20 4 cm present on the back, extending from a point 26 cm below the external occipital protuberance and 5 cm to the right of midline, going obliquely upwards along the right infra-scapular margin (Fig. 2D). An abrasion of size 10 1.5 cm present obliquely below the above-mentioned injury no. 4 (Fig. 2D). A grazed abrasion of size 12 2 cm present obliquely over the left side of back, 36 cm below the external occipital protuberance and 5 cm to the left of the midline (Fig. 2D). A grazed abrasion of size 11 7 cm was present adjoining and just above the above-mentioned injury no. 6 (Fig. 2D).
On internal examination, contusion of muscles of the neck was noticed underneath the injuries. The carotid arteries, laryngeal cartilages and hyoid bone were found to be intact. Brain and both lungs were congested and oedematous to a variable degree. Rest of the examination was unremarkable. Toxicological analysis of the viscera did not show the presence of any sedative or intoxicating substance. Death was due to cerebral anoxia arising as a consequence of ligature strangulation. 3. Discussion Fig. 1. The way a saree is worn. (A) Front view. (B) Rear view. Note the free end dangling from the back of left shoulder.
In ligature strangulation, a constricting force other than the weight of the body is applied directly to the ligature. They are usually considered homicidal and should be presumed to be
Fig. 2. Numerals denote the injury numbers mentioned in the text.
32
S. Das et al. / Journal of Forensic and Legal Medicine 32 (2015) 30e33
Fig. 3. The star denotes the place where the deceased was standing, close to the machine belt. Note the window in the opposite wall.
homicidal unless the contrary is proved.6,12 Accidental ligature strangulation though rare may occur in children, intoxicated adults and when clothing's get entangled in moving machineries.6,13 The condition proves more fatal in roller type electric operated machines, as the continued motion of the machine with the entangled cloth causes increasingly more constriction of the neck. In one case, accidental ligature strangulation involved a blouse that got entangled in a roller type massage device.14 Compression of the carotid arteries is one of the mechanisms of death in ligature strangulation. As they are situated deep to the sternocleidomastoid muscle, they are less commonly occluded as compared to the venous occlusion. In bilateral occlusion of the carotids, almost immediate unconsciousness ensues, as the supply of arterial blood to the brain by the vertebral circulation is inadequate to maintain cortical function, which depends mainly upon the anterior and middle cerebral arteries that arise from the carotid supply. Constant pressure over the carotid arteries for 10e15 s causes unconsciousness, and irreversible cerebral damage may occur if the carotid circulation is totally occluded for four or more minutes.15,16 In the present case, the deceased was unconscious
throughout indicating bilateral occlusion of the carotids, which was confirmed by CT scan of the brain. History revealed that the victim was bending over and mixing the ingredients with her hand that were falling from the upper slide into the lower slide (Fig. 3). Her back was turned towards the machine, and the free end of her saree that was dangling from her left shoulder was very close to the moving belt. What we assume is that a whiff of air entering the room from the window situated on the opposite wall (Fig. 3) would have entangled the saree in the moving belt. Once the saree got entangled in the moving belt, it must have pulled her backwards. As a reflex action, her left hand would have grabbed the saree and pulled it forwards to release it from the belt. This motion along with the motion of the moving belt would have caused the saree to press firmly against the left scapular region (Fig. 4A) and the front of left side of the neck (Fig. 4B) producing injury nos. 1 and 2 and the occlusion of the left carotid supply. The pulling force of the moving belt caused not only the thali (necklace worn by married females) impression on the neck (injury no.3) but was also responsible for occluding the right carotid supply. Injury nos. 4e7 were present obliquely over the bare area of the back (area between lower end of blouse and the hip area of the saree) and correlates with the oblique manner a saree is draped on the back (Fig. 4C). Because of the pull on the saree by the motion of the moving belt, the victim would have rotated in an anti-clockwise direction and thus had been partially disrobed. The intensity of the force gradually decreased from injury no.1 to 7. Injury nos. 1, 4 and 6 were more severe as compared to the other injuries. This can be explained by the fact that maximum force was exerted over injury no. 1, and injury nos. 4 and 6 were situated over a bare area. Secondly the saree would have got crumpled up over this area, thus leaving a deeper imprint. Injury nos. 2, 5 and 7 had a faint impression because of non-crumpling of the saree. Injury nos. 3e7, the front portion of the injury no. 1 and upper portion of the injury no. 2 were present over the bare area of skin. The distribution of the injuries on the front and back correlates with the manner in which a saree is worn and also the way in which the saree moved over the body during the disrobing process. The space where she was standing, and working was very narrow and always ran the risk of a possible accidental contact between dress materials and the moving belt. Ideally, there should have been enough space between the machines for her normal
Fig. 4. The arrows denote the direction of pull on the saree by the moving belt. The injuries shown in Fig. 2 correspond to the way a saree is worn and also the way in which the saree moved over the body during the disrobing process.
S. Das et al. / Journal of Forensic and Legal Medicine 32 (2015) 30e33
movement. It would have been better if she had stood on the other side of the slide besides the pillar. In the case of space constraint, a long handled spatula type device could have been used so that the worker did not have to stand too close to the machines. In order to prevent such incidences wearing of buttoned coats over the dresses should be made mandatory. As an additional measure some covering should be present around the moving belt, and provisions made so that the electrical connection to the machine gets switched off automatically in the eventual incident of such accidental entanglement of dress materials. A regulatory authority should be there to enforce strict workplace laws, and the stakeholders should be brought under its purview. Conflict of interest The authors declare that there is no conflict of interest. Funding None declared. Ethical approval None declared. References 1. World day for safety and health at work 2011. 26 April 2011. Press Release. Retrieved from, www.ilo.org.
33
2. Pearson Karen. The causes and incidence of occupational accidents and ill-health across the globe. British Safety Council; April 2009. 3. Hamalainen P, Takala J, Saarela KL. Global estimates of occupational accidents. Saf Sci 2006;44:137e56. 4. Mulloy KB, Moraga-McHaley S, Crandall C, Kesler DO. Occupational injury mortality: New Mexico 1998e2002. Am J Ind Med 2007;50:910e20. 5. Voaklander DC, Hartling L, Pickett W, Dimich-Ward H, Brison RJ. Work-related mortality among older farmers in Canada. Can Fam Physician 1999;45: 2903e10. 6. Aggarwal NK, Aggarwal BBL. Accidental strangulation in a cycle rickshaw. Med Sci Law 1998;38:263e5. 7. Ambade VN, Godbole HV, Dixit PG, Kukde HG. Accidental ligature strangulation due to crop thrasher. J Forensic Leg Med 2008;15:263e5. 8. Shetty M, Shetty BS. Accidental ligature strangulation due to electric grinder. J Clin Forensic Med 2006;13:148e50. 9. Gupta BD, Jani CB, Datta RG. Accidental strangulation: a case report. Med Sci Law 2004;44:359e62. 10. Chattopadhyay S, Pal I. Survival following accidental ligature strangulation: a case report. J Forensic Leg Med 2008;15:53e5. 11. Agrawal A, Ninave S, Srivastava T, Sunkara A, Agrawal S. Accidental unilateral and incomplete strangulation injury in a patient while travelling on a bicycle. J Forensic Leg Med 2009;16:350e1. 12. Demirci S, Dogan KH, Erkol Z, Gunaydin G. Ligature strangulation deaths in the province of Konya (Turkey). J Forensic Leg Med 2009;16:248e52. 13. Verma SK, Aggarwal NK, Kohli A. Accidental ligature strangulation deaths in East Delhi (India). Med Sci Law 2005;45:47e51. 14. Russel D, Deidiker MD. Accidental ligature strangulation due to a roller type massage device. Am J Forensic Med Pathol 1999;20:354e5. 15. Saukko P, Knight B. Fatal pressure on the neck. In: Saukko P, Knight B, editors. Knight's forensic pathology. London: Arnold; 2004. p. 368e94. 16. DiMaio VJ, DiMaio D. Asphyxia. In: Maio VJ, Maio D, editors. Forensic pathology. Boca Raton: CRC Press; 2001. p. 229e77.
