Int J Legal Med DOI 10.1007/s00414-015-1169-3
CASE REPORT
Traumatic asphyxia—fatal accident in an automatic revolving door J. Cortis & J. Falk & M. A. Rothschild
Received: 18 November 2014 / Accepted: 27 February 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Due to continuing modernisation, the number of automatic doors in routine use, including powered revolving doors, has increased in recent years. Automatic revolving doors are found mostly in department stores, airports, railway stations and hospitals. Although safety arrangements and guidelines concerning the installation of automatic doors are in existence, their disregard in conjunction with obsolete or incorrect installation can lead to fatal accidents. In this report, a 19-month-old boy is described whose right arm was caught between the elements of an automatic revolving door. As a direct result of rescue attempts, the child’s body was drawn further into the narrow gap between elements of the door. To get the boy’s body out of the 4-cm-wide gap between the fixed outer wall of the revolving door and the revolving inner, backup batteries had to be disconnected so as to stop the electrical motor powering the door. Cardiopulmonary resuscitation was begun immediately after the rescue but was unsuccessful; the child was declared dead at the hospital he was taken to. The cause of death was a combination of compression-related skull and brain injury together with thoracic compression. This case shows an outstanding example of the preventive aspect as a special task of forensic medicine. Additionally, it serves as a warning for the correct installation and use of automatic revolving doors. Even so, small children should not use these doors on their own, but only with an alert companion, so as to prevent further fatal accidents of this sort.
Introduction and background In Germany, approximately 600,000 automatic doors, including revolving doors, were in operation in 2004 [1]. The German manufacturers’ organisation estimated an annual increase of 50,000 automatic doors, of which revolving doors comprise only about 1 %. Statistics for the worldwide distribution of automatic doors are not known. Powered revolving doors having double, triple or quadruple wing doors are common in buildings with a great deal of movement of persons in and out. Hazards related to automatic revolving doors typically cause bruises on the hands, arms, legs, feet or even the whole body of small children. These injuries involve the fixed outer wall of the revolving door and the revolving inner one. To prevent these injuries, safety arrangements and guidelines with a voluntary character (which is criticised by the FTA [2]) exist [3], for example, mechanical and infrared sensors on the edges of the exterior posts and the inner edges of the revolving element which are designed to stop the motor on contact with a body and initiate a short reverse movement. An appropriate width between the walls can also be chosen. The worst accident, as in the present case, is a whole body bruise of a small child with lethal outcome.
Case report Anamnesis
Keywords Traumatic asphyxia . Automatic revolving door . Thoracic compression . Perthes syndrome
J. Cortis (*) : J. Falk : M. A. Rothschild Institut für Rechtsmedizin, Medizinische Fakultät, Universität zu Köln, Melatengürtel 60/62, 50823 Köln, Germany e-mail: [email protected]
The accident took place at the terminal building of a large international airport in Germany. One morning, a 19-monthold boy broke away from his mother in the terminal building and exited the building through one of the double-winged revolving doors. At the moment he tried to return through the same door, the segment of the revolving door was nearly closed (Fig. 1). His right arm became trapped in the gap; first
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Fig. 1 A 19-month-old boy returns through an automatic revolving door which is nearly closed (designed by MedizinFotoKöln, K. Schmidt)
his hand and then his whole arm (Fig. 2) were caught in the gap between the fixed outer wall of the revolving door and the revolving inner element. The mother, who was inside the building, saw her screaming child’s right arm jammed in the revolving door and physically tried to stop the door from rotating further. An airport security guard hurried to the scene and engaged the emergency switch for the revolving door. The purpose of this emergency switch was to open the door and create an exit in case of an emergency, even against resistance (such as luggage). It therefore operated only as an emergency-open switch, not as an emergency-off switch. This operation activated an opening procedure of the automatic revolving door which turned the revolving door with greater force. The child, who was already trapped with his right arm in the gap, was drawn fully into the narrow 40-mm gap between the revolving door and the stationary outer element (Fig. 3). In a combined effort, several persons were able to stop the door, but the
Fig. 2 The boy’s right arm was trapped in the gap; first his hand and then his whole arm were caught in the gap between the fixed outer wall of the revolving door and the revolving inner element (designed by MedizinFotoKöln, K. Schmidt)
Fig. 3 The child is drawn fully into the narrow 40-mm gap between the revolving door and the stationary outer element after the automatic opening procedure was activated by an emergency-open switch (designed by MedizinFotoKöln, K. Schmidt)
transmission of power from the motor to the rotating element continued until the fuses and the batteries had been accessed; the duration was not witnessed. It proved impossible to rotate the revolving door backward and to recover the child from the gap. Passers-by attempted to break the glass walls of the outer element, but failed as the glass was break-proof. Using special equipment, firemen broke the glass several minutes later. The emergency physician gained access to the child 10 min after the incident had taken place. Cardiopulmonary resuscitation was begun immediately but was unsuccessful; the child was taken to a hospital and declared dead there. Autopsy results External examination External examination confirmed the body of a 19-month-old boy of normal development with a weight of 12 kg and a height of 86 cm. There was only limited livor mortis. Closely spaced petechiae were observed on all of the facial skin including the conjunctiva and gingival mucosa, as well as the neck (Fig. 4). More petechiae were visible on the skin of the back, the thorax and the left arm. On the back, a sharp borderline was visible between the area with petechiae and the unwounded skin. On the head, several small abrasions were observed near to the right temple (Fig. 4). Parietally, on the right, there were small superficial cuts and further abrasions; some of these included small pieces of broken glass in the wound ground mainly in the occipital area. Both external ears, as well as the skin above and behind the ears, displayed a diffuse haematoma. On the right side of the neck in projection of the back side of the sternocleidomastoid muscle, a haematoma with formed intradermal bleeding was found. These appeared to be an impression of the textile fabric of the boy’s clothes.
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Fig. 4 View of the upper body of the 19-month-old boy at external examination. Closely spaced petechiae in the entire facial and thoracical skin and small haematomas/abrasions are clearly visible
Beyond the closely spaced petechiae, there were diffusely spread abrasions in the right thoracic region. On the hip, the gluteal region and both legs, there were consistently isolated small spotty, sometimes also fine-streaky excoriations and haematomas. The right upper arm displayed abrasions of up to 20-cm length parallel to the longitudinal axis of the arm. On the forearm, there were finely striped haematomas of diameter not more than 5 cm (Fig. 5). Internal examination Internal examination disclosed a widespread, thick and fresh haemorrhage in the scalp, and less in the temporal muscles. There was an extensive skull fracture involving the skull base as well as the neurocranium, consistent with a compression fracture by lateral pressure towards the temporal and parietal bones; the skull had burst at the crown suture along a length of approximately 10 cm (Fig. 6), to which a fracture line deviated in the direction of the occipital bone. An oblique fracture line ran through both middle cranial fossae, running vertically to
Fig. 5 Finely striped haematomas on the right forearm
Fig. 6 Skull fracture involving the skullbase and neurocranium with a burst at the crown suture over a length of approximately 10 cm
the body’s longitudinal axis and crossing the hypophysial fossa. Furthermore, impression fractures were detected in the basal part of the right temporal bone and in the left part of the occipital bone. These fractures led to a bleeding in the ventilated bone structures of the skull base and the posterior nasopharyngeal space. The brain showed a massive oedema in addition to two fresh haemorrhages, each of diameter 0.5 cm, in the area of the basal ganglia adjacent to the brain stem. Compression haemorrhages in the lung were observed, as well as haemorrhaging in the right renal bed. Further haemorrhages, matching the external injuries, were found in the onset of the right sternocleidomastoid muscle, in the right thyroid capsule, the musculature on the left side of the neck, and in the subcutaneous fatty tissue. There were no other injuries. Competitive causes of death were absent.
Histopathological examination Histological analyses revealed diffuse bleeding in the intraalveolar and interstitial space of all lobes of the lung. As a result of the attempted reanimation, the lung tissue was dystelectatic, with poorly ventilated areas, as well as having fine bubble emphysema regions. Consistent with the macroscopic findings, the right renal bed and the area of the basal ganglia adjacent to the brain stem showed a small haemorrhage. There was also a small amount of bleeding associated with the fatty tissue in the immediate vicinity of both adrenal glands (right>left). Other organs (heart, liver, spleen, kidneys, pancreas, thymus, brain) were normal for the boy’s age. Based on the external and internal examination, the cause of death was found to be a combination of compressionrelated skull and brain injury in connection with thoracic compression. The injuries indicated that the right hand, followed by the right arm and then the entire body had been drawn into the gap between the rotating and fixed elements of the door.
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Technical investigation The revolving door was a motorised, double-winged carousel revolving door with a diameter of approximately 3.6 m. The revolving element consisted of two selections separated by glass walls and circular outer segment (Fig. 1). To prevent the door from jamming, there are mechanical sensors on the edges of the exterior posts and the inner edges of the revolving element. These stop the motor on contact with a body and initiate a short reverse movement. When the sensor is free, the rotation continues. Norms and regulations prescribe safety arrangements to limit the application of forces to persons so as to prevent severe injuries. These forces may not exceed 400 N (40 kg) at 200-mm distance up to 1400 N (140 kg) at 500-mm distance between the closing leafs. Tests of the relevant revolving door showed forces of 817–2027 N. In each closing area, two optical infrared sensors also scan the critical zone immediately in front of the closing edges. If a person or object disrupts the beam, the motor is stopped. These sensors detect an object at a distance of 430 mm (sensor 1) and 460 mm (sensor 2) from the floor. As the carousel revolving door also acts as an emergency exit, there is an emergencyopen switch inside the building which causes the door to open from any position, even against resistance (such as luggage blocking it). This emergency function remains operative even in cases of an electrical power failure. In the technical analysis of the incident, it was assumed that the infrared sensors did not register the boy, as their function relies on the degree of reflection of light; measurements showed that there was a scatter band of 120–570 mm. The low-lying position of the sun was suggested as the reason for the malfunction of the light sensors. The technical expert suggested that the sensor at the foremost rim of the door might have touched the boy and stopped the door accordingly. Then, in view of the force applied, the boy’s body yielded and released the door switch, so the door moved again and drew the boy further into the gap. The second sensor on the external post had probably been bent away, so it did not cause the motor to stop. After the emergency-open switch was operated, the revolving door moved into the emergency exit position against the resistance offered by the child’s body, drawing the child fully into the gap. The door mechanism could then be turned off only by removing the fuses. A cause for the accident was suggested by the fact that the motor generated far more than the 400-N force stated in EU guidelines. The size of the gap (35–40 mm) offered protection against bruising fingers. Unfortunately, the drawing-in of larger body parts (hands, arms, head/neck) was facilitated. If the motor would have been permanently stopped by the sensors at the edges, the boy’s body could not have been further drawn into the gap. A smaller gap between the inner element of the revolving door and the fixed outer wall would also have
prevented the accident. In particular, the absence of an emergency-off switch (as according to the DIN EN 418 guideline published in the year 2000) was a further reason why this incident had a fatal outcome. It is not known why an emergency-off switch was not installed. In summary, the technical equipment and the functioning of the double-winged carousel revolving door did not correspond to the state of the art in safety technology in the year of the last safety testing.
Discussion Traumatic asphyxia is mainly found in children when they are run over by vehicles [4, 5], although incidents involving crushing by heavy objects have also been reported [6]. The incidence of traumatic asphyxia in adults is reported to be one case in every 18,500 accidents [4, 5]. The incidence in children is not known but these can be assumed to be rare events because of the greater elasticity of children’s rib cages. Byard’s work in 2003 analysed all fatal accidents in children under the age of 17 years who had been examined in the Forensic Science Centre in Adelaide, South Australia, during a period of 34 years. Byard and co-workers encountered six cases involving boys aged between 2 and 15 years (mean 6.8 years) who died as a result of fatal traumatic asphyxia due to accidents beneath/with a chest of drawers, a table tennis table, a metal fence, a conveyer belt and motor vehicles [6]. The observed incidence is low, as confirmed in other case studies [4, 5, 7]. Suffocation due to torso compression occurs most frequently in occupational accidents [8], in connection with burying incidents [9] and traffic accidents [10–12] or during incidents of mass panic. Gill et al. reported nine fatal accidents at a community basketball game in New York City in 1991. Newer case reports in 2003 referred to 21 fatalities in a nightclub in Chicago when hundreds of people ran towards the exit after a chemical spray had been used during an altercation [13]. Traumatic asphyxia has also been described in persons struggling violently to resist arrest by police [14]. Severe accidents with automatic revolving doors appear to be rare; in the literature, there is only a single publication concerning crush accidents in mechanical revolving doors [15]. In the burying or crushing of a body, primary injuries can be induced of sufficient severity to be an immediate cause of death. In massive torso compressions, the pressure and tractive forces may injure not only the skin and bones but also rupture the internal organs [16]. Fatal compression may occur without fractures in children due to the higher elasticity of their bones. Campbell-Hewson et al. asserted that heavy weights can be tolerated for a short time, although application of lighter weights for prolonged periods may lead to death [17]. Nishiyama’s work confirms this assertion. The authors
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refer to the survival of a 3-year-old boy who was compressed under a sports utility vehicle for 3 min [5]. Also a common cause of death is fixation of the upper abdomen and/or thorax, resulting in reduced exhalation and subsequent suffocation [18]. Traumatic asphyxia together with congestion of the upper body was defined as a distinct symptomatic complex by Perthes at the beginning of the twentieth century, with a displacement of venous blood into the upper thoracic area, the neck and the head as a result of thoracic compression [19, 20]. Pulmonary contusion, haemo-/pneumothorax and neurological symptoms are the most common additional injuries associated with Perthes’ syndrome [4, 7, 21] because of the nature of the accidents involved. Williams et al. found that thoracic compression alone is usually insufficient to cause petechiae [22]. It also appears to be necessary that the victim perceives the danger and experiences the fear associated with it [23]. The resulting increased intrathoracic pressure displaces blood into the craniocervical veins which are not protected by venous valves. This high pressure causes petechial haemorrhaging in the upper venous system. Typically, there is a triple manifestation of haemorrhages involving the conjunctivae, petechiae and cyanosis of the neck and head area [24]. Cervicofacial cyanosis is found in 95 %, cervicofacial petechiae in 84 % and subconjunctival haemorrhage in 91 % of cases described [24, 25]. When death occurs, it is usually due to a combination of asphyxia, resulting from compression of the torso and thorax, and pulmonary congestion. A further factor is a pulmonary microembolism syndrome resulting from the influx of fat and/or fatty tissues [16], although this was not detected in the present case. Here, the cause of death was a combination of compression-related skull and brain injury in relation to thoracic compression (Perthes) and a resulting brain oedema. Absence of an emergency-off switch, which would have disconnected all electrical power, contributed significantly to the accident. In this case, the existing emergency switch was clearly marked and was operated by one person. Its purpose was to open the door (and thus create an emergency exit) in the event of an emergency, even opening it against resistance. It therefore functioned only as an emergency-open switch, and not as an emergency-off switch which would have made it possible to open the door by hand. As a result of this fatal accident, all automatic revolving doors were removed from operation—not only at the airport involved but also in numerous hotels, town halls and department stores. An article in the local newspaper stated that 14 revolving doors were investigated immediately after the accident has happened, but all failed to achieve security standards. It was therefore recommended that they be shut down [26]. After this fatal accident, a discussion commenced concerning binding norms and security standards of powered
revolving doors with revised standards. The German professional association of BTürautomation^ (FTA) and the BAuA (Federal Office for Occupational Safety) BTüren und Tore^ overworked their guidelines for the service of automatic revolving doors [3, 27, 28]. The revised guideline no. 5 of the FTA (dated 31st of October 2014) offers a compendium of risk assessment; the safety-technical requirements of automatic doors are defined in DIN 18650 and EN 16005 [3]. DIN 18650 [27] specifies the request of the EU machinery directive in terms of automatic door systems. The standard would cover all safety aspects of automatic sliding, swing and revolving doors. It would also include the identification of any danger spots and their resulting safety requirements separately for each type of door. In addition, the new standard would include special requirements on automatic doors in escape and rescue routes. Doors with fire and smoke properties succumb to the requirements of the building. Differences are seen in the guidelines of the FTA and BAuA concerning the establishment of an emergency-off switch. Guideline BASR A 1.7^ of the BAuA BTüren und Tore^ (dated November 2009, last amended 2014) recommends to install the above-mentioned emergency-off switch at the entry of automatic revolving doors Bnotwithstanding sentence 1^ [28]. In contrast, guideline no. 2 of the FTA (date 1st of July 2014) summarises that it is possible to renounce the installation of an emergency-off switch if all safety installations on automatic door systems are selfmonitoring and fail-safe incorporated [3]. Moreover, especially in revolving doors for smoke and fire protection closure, the installation of an emergency-off switch would conflict with its self-closing function. As the presented case shows, absence of an emergency-off switch contributed significantly to the accident even if mechanical sensors as safety arrangements were installed. Their response should also be guaranteed in low height to recognise small children and pets. As automatic revolving doors are installed in daily routine worldwide, the fatality under discussion serves as a warning and also an appeal to critically evaluate the present safety arrangements and guidelines concerning the installation and use of automatic doors. Failure to do this, and obsolete or incorrect installation, could give rise to further fatal accidents. If powered revolving doors are necessary, the functional standard should be rigorously adhered to. Moreover, not only an emergency-open switch but also an emergency-off switch should be in place with clear labels if possible. In addition, small children and older or disabled persons should not use these doors on their own but in conjunction with an alert companion so as to prevent accidents of this sort. In summary, this case shows an outstanding example of the preventive aspect as a special task of forensic medicine and
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additionally serves as a warning for the correct installation and use of automatic revolving doors. Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Human and animal rights and informed consent This article does not contain any studies with human participants or animals performed by any of the authors.
References 1. Kölner Stadt-Anzeiger (rjo) (2004) 600 000 automatische Türen in Betrieb. Kölner Stadt-Anzeiger. http://www.ksta.de/panorama/600000-automatische-tueren-in-betrieb,15189504,13960874.html. Accessed: 05 Feb 2015 2. DPA (2004) Tödlicher Unfall am Flughafen: Drehtür nicht richtig kontrolliert. Die Welt. http://www.welt.de/print-welt/article300095/ Toedlicher-Unfall-am-Flughafen-Drehtuer-nicht-richtig-kontrolliert. html. Accessed: 05 Feb 2015 3. Fachverband Türautomation. FTA-Richtlinien. http://fta-online.de/ no_cache/richtlinien/fta-richtlinien.html. Accessed: 05 Feb 2015 4. Montes-Tapia F, Barreto-Arroyo I, Cura-Esquivel I, RodríguezTaméz A, de la O-Cavazos M (2014) Traumatic asphyxia. Pediatr Emerg Care 30(2):114–6. doi:10.1097/PEC.0000000000000067 5. Nishiyama T, Hanaoka K (2000) A traumatic asphyxia in a child. Can J Anaesth 47(11):1099–102 6. Byard RW, Hanson KA, James RA (2003) Fatal unintentional traumatic asphyxia in childhood. J Paediatr Child Health 39(1):31–2 7. Kamali S, Kesici S, Gunduz I, Kesici U (2013) A case of traumatic asphyxia due to motorcycle accident. Case Rep Emerg Med 2013: 857131. doi:10.1155/2013/857131 8. Lee MC, Wong SS, Chu JJ, Chang JP, Lin PJ, Shieh MJ, Chang CH (1991) Traumatic asphyxia. Ann Thorac Surg 51(1):86–8 9. Zarroug AE, Stavlo PL, Kays GA, Rodeberg DA, Moir CR (2004) Accidental burials in sand: a potentially fatal summertime hazard. Mayo Clin Proc 79(6):774–6 10. Adamec J, Graw M (2013) Rekonstruktion von verkehrsunfällen. Rechtsmedizin 23:423–438. doi:10.1007/s00194-013-0891-8 11. Lardi C, Mangin P, Fracasso T (2014) Überrollung eines radfahrers. Rechtsmedizin 24:118–122. doi:10.1007/s00194-013-0937-y
12. Hambeck W, Pueschel K (1981) Death by railway accident: incidence of traumatic asphyxia. J Trauma 21(1):28–31 13. Gill JR, Landi K (2004) Traumatic asphyxial deaths due to an uncontrolled crowd. Am J Forensic Med Pathol 25(4):358–61 14. Miyaishi S, Yoshitome K, Yamamoto Y, Naka T, Ishizu H (2004) Negligent homicide by traumatic asphyxia. Int J Legal Med 118(2): 106–10 15. Mikkelsen M, Thomsen S (1989) Crush accidents in mechanical revolving doors. Ugeskr Laeger 151(1):33, Article in Danish 16. Oehmichen M, Banaschak S, Madea B (2003) Sekundärfolgen mechanischer gewalteinwirkungen, todesursachen. In: Madea E (ed) Praxis rechtsmedizin, 2nd edn. Springer, Berlin Heidelberg 17. Campbell-Hewson G, Egleston CV, Cope AR (1997) Traumatic asphyxia in children. J Accid Emerg Med 14(1):47–9 18. Brinkmann B (1978) Zur pathophysiologie und pathomorphologie bei Tod durch druckstauung. Z Rechtsmed 82:79–96 19. Perthes G (1899) Ueber ausgedehnte blutextravasate am kopf infolge von kompression des thorax. Langenbeck’s Arch Surg 50(5):436– 443. doi:10.1007/BF02793038 20. Perthes G (1900) Ueber Bdruckstauung^. Langenbeck’s Arch Surg 55(3):384–392. doi:10.1007/BF02816133 21. Karamustafaoglu YA, Yavasman I, Tiryaki S, Yoruk Y (2010) Traumatic asphyxia. Int J Emerg Med 3(4):379–80. doi:10.1007/ s12245-010-0204-x 22. Williams JS, Minken SL, Adams JT (1968) Traumatic asphyxia– reappraised. Ann Surg 167(3):384–92 23. Lowe L, Rapini RP, Johnson TM (1990) Traumatic asphyxia. J Am Acad Dermatol 23(5 Pt 2):972–4 24. Gösling T, Schmidt U, Herzog T, Tscherne H (2001) Das perthessyndrom - Die klassische symptomtrias als rarität in der unfallchirurgischen praxis. Unfallchirurg 104(2):191–4 25. Jobé J, Ghuysen A, Hartstein G, D’orio V (2013) A fatal case of perthes syndrome. J Emerg Trauma Shock 6(4):296–7. doi:10. 4103/0974-2700.120385 26. Moeck T, Spilcker A (2004) 28.3.2004: Drehtür hatte keinen Notknopf. Kölner Stadt-Anzeiger. http://www.ksta.de/koeln/28-32004–drehtuer-hatte-keinen-notknopf,15187530,13960878.html. Accessed: 05 Feb 2015 27. Fachverband Türautomation (2006). 08.09.2006 - Neue DIN 18650: Klare Regelungen für automatische Türsysteme in Deutschland. http://fta-online.de/no_cache/richtlinien/meldungen/news-detail/ article/neue-din-18650-klare-regelungen-fuer-automatischetuersysteme-in-deutschland.html. Accessed: 05 Feb 2015 28. Bundesanstalt für Arbeitsschutz und Arbeitsmedizin (2009) Technische Regel für Arbeitsstätten ASR A1.7. http://www.baua. de/de/Themen-von-A-Z/Arbeitsstaetten/ASR/ASR-A1-7.html. Accessed: 05 Feb 2015
CASE REPORT
Traumatic asphyxia—fatal accident in an automatic revolving door J. Cortis & J. Falk & M. A. Rothschild
Received: 18 November 2014 / Accepted: 27 February 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Due to continuing modernisation, the number of automatic doors in routine use, including powered revolving doors, has increased in recent years. Automatic revolving doors are found mostly in department stores, airports, railway stations and hospitals. Although safety arrangements and guidelines concerning the installation of automatic doors are in existence, their disregard in conjunction with obsolete or incorrect installation can lead to fatal accidents. In this report, a 19-month-old boy is described whose right arm was caught between the elements of an automatic revolving door. As a direct result of rescue attempts, the child’s body was drawn further into the narrow gap between elements of the door. To get the boy’s body out of the 4-cm-wide gap between the fixed outer wall of the revolving door and the revolving inner, backup batteries had to be disconnected so as to stop the electrical motor powering the door. Cardiopulmonary resuscitation was begun immediately after the rescue but was unsuccessful; the child was declared dead at the hospital he was taken to. The cause of death was a combination of compression-related skull and brain injury together with thoracic compression. This case shows an outstanding example of the preventive aspect as a special task of forensic medicine. Additionally, it serves as a warning for the correct installation and use of automatic revolving doors. Even so, small children should not use these doors on their own, but only with an alert companion, so as to prevent further fatal accidents of this sort.
Introduction and background In Germany, approximately 600,000 automatic doors, including revolving doors, were in operation in 2004 [1]. The German manufacturers’ organisation estimated an annual increase of 50,000 automatic doors, of which revolving doors comprise only about 1 %. Statistics for the worldwide distribution of automatic doors are not known. Powered revolving doors having double, triple or quadruple wing doors are common in buildings with a great deal of movement of persons in and out. Hazards related to automatic revolving doors typically cause bruises on the hands, arms, legs, feet or even the whole body of small children. These injuries involve the fixed outer wall of the revolving door and the revolving inner one. To prevent these injuries, safety arrangements and guidelines with a voluntary character (which is criticised by the FTA [2]) exist [3], for example, mechanical and infrared sensors on the edges of the exterior posts and the inner edges of the revolving element which are designed to stop the motor on contact with a body and initiate a short reverse movement. An appropriate width between the walls can also be chosen. The worst accident, as in the present case, is a whole body bruise of a small child with lethal outcome.
Case report Anamnesis
Keywords Traumatic asphyxia . Automatic revolving door . Thoracic compression . Perthes syndrome
J. Cortis (*) : J. Falk : M. A. Rothschild Institut für Rechtsmedizin, Medizinische Fakultät, Universität zu Köln, Melatengürtel 60/62, 50823 Köln, Germany e-mail: [email protected]
The accident took place at the terminal building of a large international airport in Germany. One morning, a 19-monthold boy broke away from his mother in the terminal building and exited the building through one of the double-winged revolving doors. At the moment he tried to return through the same door, the segment of the revolving door was nearly closed (Fig. 1). His right arm became trapped in the gap; first
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Fig. 1 A 19-month-old boy returns through an automatic revolving door which is nearly closed (designed by MedizinFotoKöln, K. Schmidt)
his hand and then his whole arm (Fig. 2) were caught in the gap between the fixed outer wall of the revolving door and the revolving inner element. The mother, who was inside the building, saw her screaming child’s right arm jammed in the revolving door and physically tried to stop the door from rotating further. An airport security guard hurried to the scene and engaged the emergency switch for the revolving door. The purpose of this emergency switch was to open the door and create an exit in case of an emergency, even against resistance (such as luggage). It therefore operated only as an emergency-open switch, not as an emergency-off switch. This operation activated an opening procedure of the automatic revolving door which turned the revolving door with greater force. The child, who was already trapped with his right arm in the gap, was drawn fully into the narrow 40-mm gap between the revolving door and the stationary outer element (Fig. 3). In a combined effort, several persons were able to stop the door, but the
Fig. 2 The boy’s right arm was trapped in the gap; first his hand and then his whole arm were caught in the gap between the fixed outer wall of the revolving door and the revolving inner element (designed by MedizinFotoKöln, K. Schmidt)
Fig. 3 The child is drawn fully into the narrow 40-mm gap between the revolving door and the stationary outer element after the automatic opening procedure was activated by an emergency-open switch (designed by MedizinFotoKöln, K. Schmidt)
transmission of power from the motor to the rotating element continued until the fuses and the batteries had been accessed; the duration was not witnessed. It proved impossible to rotate the revolving door backward and to recover the child from the gap. Passers-by attempted to break the glass walls of the outer element, but failed as the glass was break-proof. Using special equipment, firemen broke the glass several minutes later. The emergency physician gained access to the child 10 min after the incident had taken place. Cardiopulmonary resuscitation was begun immediately but was unsuccessful; the child was taken to a hospital and declared dead there. Autopsy results External examination External examination confirmed the body of a 19-month-old boy of normal development with a weight of 12 kg and a height of 86 cm. There was only limited livor mortis. Closely spaced petechiae were observed on all of the facial skin including the conjunctiva and gingival mucosa, as well as the neck (Fig. 4). More petechiae were visible on the skin of the back, the thorax and the left arm. On the back, a sharp borderline was visible between the area with petechiae and the unwounded skin. On the head, several small abrasions were observed near to the right temple (Fig. 4). Parietally, on the right, there were small superficial cuts and further abrasions; some of these included small pieces of broken glass in the wound ground mainly in the occipital area. Both external ears, as well as the skin above and behind the ears, displayed a diffuse haematoma. On the right side of the neck in projection of the back side of the sternocleidomastoid muscle, a haematoma with formed intradermal bleeding was found. These appeared to be an impression of the textile fabric of the boy’s clothes.
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Fig. 4 View of the upper body of the 19-month-old boy at external examination. Closely spaced petechiae in the entire facial and thoracical skin and small haematomas/abrasions are clearly visible
Beyond the closely spaced petechiae, there were diffusely spread abrasions in the right thoracic region. On the hip, the gluteal region and both legs, there were consistently isolated small spotty, sometimes also fine-streaky excoriations and haematomas. The right upper arm displayed abrasions of up to 20-cm length parallel to the longitudinal axis of the arm. On the forearm, there were finely striped haematomas of diameter not more than 5 cm (Fig. 5). Internal examination Internal examination disclosed a widespread, thick and fresh haemorrhage in the scalp, and less in the temporal muscles. There was an extensive skull fracture involving the skull base as well as the neurocranium, consistent with a compression fracture by lateral pressure towards the temporal and parietal bones; the skull had burst at the crown suture along a length of approximately 10 cm (Fig. 6), to which a fracture line deviated in the direction of the occipital bone. An oblique fracture line ran through both middle cranial fossae, running vertically to
Fig. 5 Finely striped haematomas on the right forearm
Fig. 6 Skull fracture involving the skullbase and neurocranium with a burst at the crown suture over a length of approximately 10 cm
the body’s longitudinal axis and crossing the hypophysial fossa. Furthermore, impression fractures were detected in the basal part of the right temporal bone and in the left part of the occipital bone. These fractures led to a bleeding in the ventilated bone structures of the skull base and the posterior nasopharyngeal space. The brain showed a massive oedema in addition to two fresh haemorrhages, each of diameter 0.5 cm, in the area of the basal ganglia adjacent to the brain stem. Compression haemorrhages in the lung were observed, as well as haemorrhaging in the right renal bed. Further haemorrhages, matching the external injuries, were found in the onset of the right sternocleidomastoid muscle, in the right thyroid capsule, the musculature on the left side of the neck, and in the subcutaneous fatty tissue. There were no other injuries. Competitive causes of death were absent.
Histopathological examination Histological analyses revealed diffuse bleeding in the intraalveolar and interstitial space of all lobes of the lung. As a result of the attempted reanimation, the lung tissue was dystelectatic, with poorly ventilated areas, as well as having fine bubble emphysema regions. Consistent with the macroscopic findings, the right renal bed and the area of the basal ganglia adjacent to the brain stem showed a small haemorrhage. There was also a small amount of bleeding associated with the fatty tissue in the immediate vicinity of both adrenal glands (right>left). Other organs (heart, liver, spleen, kidneys, pancreas, thymus, brain) were normal for the boy’s age. Based on the external and internal examination, the cause of death was found to be a combination of compressionrelated skull and brain injury in connection with thoracic compression. The injuries indicated that the right hand, followed by the right arm and then the entire body had been drawn into the gap between the rotating and fixed elements of the door.
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Technical investigation The revolving door was a motorised, double-winged carousel revolving door with a diameter of approximately 3.6 m. The revolving element consisted of two selections separated by glass walls and circular outer segment (Fig. 1). To prevent the door from jamming, there are mechanical sensors on the edges of the exterior posts and the inner edges of the revolving element. These stop the motor on contact with a body and initiate a short reverse movement. When the sensor is free, the rotation continues. Norms and regulations prescribe safety arrangements to limit the application of forces to persons so as to prevent severe injuries. These forces may not exceed 400 N (40 kg) at 200-mm distance up to 1400 N (140 kg) at 500-mm distance between the closing leafs. Tests of the relevant revolving door showed forces of 817–2027 N. In each closing area, two optical infrared sensors also scan the critical zone immediately in front of the closing edges. If a person or object disrupts the beam, the motor is stopped. These sensors detect an object at a distance of 430 mm (sensor 1) and 460 mm (sensor 2) from the floor. As the carousel revolving door also acts as an emergency exit, there is an emergencyopen switch inside the building which causes the door to open from any position, even against resistance (such as luggage blocking it). This emergency function remains operative even in cases of an electrical power failure. In the technical analysis of the incident, it was assumed that the infrared sensors did not register the boy, as their function relies on the degree of reflection of light; measurements showed that there was a scatter band of 120–570 mm. The low-lying position of the sun was suggested as the reason for the malfunction of the light sensors. The technical expert suggested that the sensor at the foremost rim of the door might have touched the boy and stopped the door accordingly. Then, in view of the force applied, the boy’s body yielded and released the door switch, so the door moved again and drew the boy further into the gap. The second sensor on the external post had probably been bent away, so it did not cause the motor to stop. After the emergency-open switch was operated, the revolving door moved into the emergency exit position against the resistance offered by the child’s body, drawing the child fully into the gap. The door mechanism could then be turned off only by removing the fuses. A cause for the accident was suggested by the fact that the motor generated far more than the 400-N force stated in EU guidelines. The size of the gap (35–40 mm) offered protection against bruising fingers. Unfortunately, the drawing-in of larger body parts (hands, arms, head/neck) was facilitated. If the motor would have been permanently stopped by the sensors at the edges, the boy’s body could not have been further drawn into the gap. A smaller gap between the inner element of the revolving door and the fixed outer wall would also have
prevented the accident. In particular, the absence of an emergency-off switch (as according to the DIN EN 418 guideline published in the year 2000) was a further reason why this incident had a fatal outcome. It is not known why an emergency-off switch was not installed. In summary, the technical equipment and the functioning of the double-winged carousel revolving door did not correspond to the state of the art in safety technology in the year of the last safety testing.
Discussion Traumatic asphyxia is mainly found in children when they are run over by vehicles [4, 5], although incidents involving crushing by heavy objects have also been reported [6]. The incidence of traumatic asphyxia in adults is reported to be one case in every 18,500 accidents [4, 5]. The incidence in children is not known but these can be assumed to be rare events because of the greater elasticity of children’s rib cages. Byard’s work in 2003 analysed all fatal accidents in children under the age of 17 years who had been examined in the Forensic Science Centre in Adelaide, South Australia, during a period of 34 years. Byard and co-workers encountered six cases involving boys aged between 2 and 15 years (mean 6.8 years) who died as a result of fatal traumatic asphyxia due to accidents beneath/with a chest of drawers, a table tennis table, a metal fence, a conveyer belt and motor vehicles [6]. The observed incidence is low, as confirmed in other case studies [4, 5, 7]. Suffocation due to torso compression occurs most frequently in occupational accidents [8], in connection with burying incidents [9] and traffic accidents [10–12] or during incidents of mass panic. Gill et al. reported nine fatal accidents at a community basketball game in New York City in 1991. Newer case reports in 2003 referred to 21 fatalities in a nightclub in Chicago when hundreds of people ran towards the exit after a chemical spray had been used during an altercation [13]. Traumatic asphyxia has also been described in persons struggling violently to resist arrest by police [14]. Severe accidents with automatic revolving doors appear to be rare; in the literature, there is only a single publication concerning crush accidents in mechanical revolving doors [15]. In the burying or crushing of a body, primary injuries can be induced of sufficient severity to be an immediate cause of death. In massive torso compressions, the pressure and tractive forces may injure not only the skin and bones but also rupture the internal organs [16]. Fatal compression may occur without fractures in children due to the higher elasticity of their bones. Campbell-Hewson et al. asserted that heavy weights can be tolerated for a short time, although application of lighter weights for prolonged periods may lead to death [17]. Nishiyama’s work confirms this assertion. The authors
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refer to the survival of a 3-year-old boy who was compressed under a sports utility vehicle for 3 min [5]. Also a common cause of death is fixation of the upper abdomen and/or thorax, resulting in reduced exhalation and subsequent suffocation [18]. Traumatic asphyxia together with congestion of the upper body was defined as a distinct symptomatic complex by Perthes at the beginning of the twentieth century, with a displacement of venous blood into the upper thoracic area, the neck and the head as a result of thoracic compression [19, 20]. Pulmonary contusion, haemo-/pneumothorax and neurological symptoms are the most common additional injuries associated with Perthes’ syndrome [4, 7, 21] because of the nature of the accidents involved. Williams et al. found that thoracic compression alone is usually insufficient to cause petechiae [22]. It also appears to be necessary that the victim perceives the danger and experiences the fear associated with it [23]. The resulting increased intrathoracic pressure displaces blood into the craniocervical veins which are not protected by venous valves. This high pressure causes petechial haemorrhaging in the upper venous system. Typically, there is a triple manifestation of haemorrhages involving the conjunctivae, petechiae and cyanosis of the neck and head area [24]. Cervicofacial cyanosis is found in 95 %, cervicofacial petechiae in 84 % and subconjunctival haemorrhage in 91 % of cases described [24, 25]. When death occurs, it is usually due to a combination of asphyxia, resulting from compression of the torso and thorax, and pulmonary congestion. A further factor is a pulmonary microembolism syndrome resulting from the influx of fat and/or fatty tissues [16], although this was not detected in the present case. Here, the cause of death was a combination of compression-related skull and brain injury in relation to thoracic compression (Perthes) and a resulting brain oedema. Absence of an emergency-off switch, which would have disconnected all electrical power, contributed significantly to the accident. In this case, the existing emergency switch was clearly marked and was operated by one person. Its purpose was to open the door (and thus create an emergency exit) in the event of an emergency, even opening it against resistance. It therefore functioned only as an emergency-open switch, and not as an emergency-off switch which would have made it possible to open the door by hand. As a result of this fatal accident, all automatic revolving doors were removed from operation—not only at the airport involved but also in numerous hotels, town halls and department stores. An article in the local newspaper stated that 14 revolving doors were investigated immediately after the accident has happened, but all failed to achieve security standards. It was therefore recommended that they be shut down [26]. After this fatal accident, a discussion commenced concerning binding norms and security standards of powered
revolving doors with revised standards. The German professional association of BTürautomation^ (FTA) and the BAuA (Federal Office for Occupational Safety) BTüren und Tore^ overworked their guidelines for the service of automatic revolving doors [3, 27, 28]. The revised guideline no. 5 of the FTA (dated 31st of October 2014) offers a compendium of risk assessment; the safety-technical requirements of automatic doors are defined in DIN 18650 and EN 16005 [3]. DIN 18650 [27] specifies the request of the EU machinery directive in terms of automatic door systems. The standard would cover all safety aspects of automatic sliding, swing and revolving doors. It would also include the identification of any danger spots and their resulting safety requirements separately for each type of door. In addition, the new standard would include special requirements on automatic doors in escape and rescue routes. Doors with fire and smoke properties succumb to the requirements of the building. Differences are seen in the guidelines of the FTA and BAuA concerning the establishment of an emergency-off switch. Guideline BASR A 1.7^ of the BAuA BTüren und Tore^ (dated November 2009, last amended 2014) recommends to install the above-mentioned emergency-off switch at the entry of automatic revolving doors Bnotwithstanding sentence 1^ [28]. In contrast, guideline no. 2 of the FTA (date 1st of July 2014) summarises that it is possible to renounce the installation of an emergency-off switch if all safety installations on automatic door systems are selfmonitoring and fail-safe incorporated [3]. Moreover, especially in revolving doors for smoke and fire protection closure, the installation of an emergency-off switch would conflict with its self-closing function. As the presented case shows, absence of an emergency-off switch contributed significantly to the accident even if mechanical sensors as safety arrangements were installed. Their response should also be guaranteed in low height to recognise small children and pets. As automatic revolving doors are installed in daily routine worldwide, the fatality under discussion serves as a warning and also an appeal to critically evaluate the present safety arrangements and guidelines concerning the installation and use of automatic doors. Failure to do this, and obsolete or incorrect installation, could give rise to further fatal accidents. If powered revolving doors are necessary, the functional standard should be rigorously adhered to. Moreover, not only an emergency-open switch but also an emergency-off switch should be in place with clear labels if possible. In addition, small children and older or disabled persons should not use these doors on their own but in conjunction with an alert companion so as to prevent accidents of this sort. In summary, this case shows an outstanding example of the preventive aspect as a special task of forensic medicine and
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additionally serves as a warning for the correct installation and use of automatic revolving doors. Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Human and animal rights and informed consent This article does not contain any studies with human participants or animals performed by any of the authors.
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