Vladimir Živković

The effects of a new traffic safety law in the Republic of Serbia on driving under the influence of alcohol

The aim of the study presented here has been to see what the effects of the new traffic safety law are, 2 years into its initial implementation, on driving under the influence of alcohol. Until the end of 2009, the legal limit for blood concentration for drivers in Serbia was 0.5g/l; however, the new traffic safety law stipulates the new limit to be 0.3g/l. A retrospective autopsy study was performed over a 6-year period (from 2006 to 2011) whose sample covered cases of fatally injured drivers who had died at the scene of the incident, before being admitted to hospital. A total of 161 fatally injured drivers were examined for their blood alcohol concentration. The average age for these drivers was 40.2±15.4 years, with a significant male predominance of 152 men to 9 women (χ(2)=152.000, p<0.001). This study has shown no decrease in the ratio of drivers under the influence of alcohol vs. all drivers (Pearson χ(2)=4.415, df=5, p=0.491), nor in the number of drivers under the influence of alcohol (Pearson χ(2)=6.629, df=5, p=0.250), nor a decrease in the mean blood alcohol concentration in drivers (1.72±0.87 vs. 1.68±0.95g/l, t=0.177, df=80, p=0.860). The conclusion of this study is that the new law has had a limited effect on driving under the influence of alcohol, which still remains one of the major human factors, responsible for road-traffic crashes in Serbia.

Hyoid-laryngeal fractures in hanging: where was the knot in the noose?

The aims of this study were to determine the frequency of hyoid-laryngeal fractures in hanging in relation to the position of the ligature knot, to reconstruct the location of the ligature knot in cases of hanging when the furrow is not detectable on the skin, and to identify the possible mechanism of neck structure injuries. We report a retrospective autopsy study which included 557 cases of suicidal hanging: 413 men and 144 women, with an average age of 52.4 ± 17.8 years. In 57.3% of them, hyoid-laryngeal fractures were found (average age was 54.3 ± 16.5 years): 15.1% had only hyoid bone fracture, 26% had only thyroid cartilage fracture and 16.2% had both types of injury at the same time. Hyoid-laryngeal fractures were found more often in persons aged over 30 years. Hyoid bone fracture was a weak predictor of ligature knot position in our sample. Fracture frequencies of the thyroid cartilage show a statistically significant difference in relation to the ligature knot position among persons older than 30 years, which indicated the ipsilateral and posterior position of the knot. Absence or presence of any form of hyoid-laryngeal fracture indicated that knot position was anterior or posterior, respectively. The derived data would be useful for cases where the ligature has been removed from the body of the deceased shortly after hanging, where the noose is unavailable, and in cases where the ligature mark has faded such as with soft ligatures removed promptly or in decomposed bodies.

Planned Complex Occupation‐related Suicide by Captive‐bolt Gunshot and Hanging*

Abstract:  Planned complex suicides are committed by using two or more previously planned methods simultaneously to make sure that death will occur even if one method fails. Herein, we presented a case of occupation‐related planned complex suicide, committed by captive‐bolt gunshot and hanging. A 29‐year‐old man, who worked as a butcher, was found dead in the stable, hanging by the neck with a captive‐bolt gun embedded in the forehead region of his head. The hanging was complete. Along the bolt canal were bone fragments, and at the end of the path was the punched‐out fragment of the skin and soft tissue. There were no fractures of the hyoid bone and laryngeal cartilages, and a superficial hemorrhage was present in the right sternocleidomastoid muscle. Our case underlines the utility of forensic autopsy and death scene investigation in reconstructing the mechanism of death, as well as the dynamics of the event.

Systemic fat embolism and the patent foramen ovale—A prospective autopsy study

A fat embolism is a known and common complication of blunt force injuries, especially pelvic and long bones fractures. The aim of this study was to determine the importance of a patent foramen ovale (PFO) in developing systemic fat embolism (SFE) and eventually fat embolism syndrome (FES) in patients suffering from orthopaedic blunt injuries and consequent lung fat embolism. The sample was divided: 32 subjects with a sealed foramen ovale (SFO), and 20 subjects with a PFO. In our sample, there was no difference in either the incidence of renal fat embolism in subjects with PFO compared to those with SFO (Fishers exact test 0.228, p=0.154) or in the grade of renal fat embolism (Pearson Chi-square 2.728, p=0.435). However, there was a statistically significant correlation between the grade of lung fat embolism and the number of fractured bones for the whole sample (Spearmans rho 0.271, p=0.052), but no correlation between the grade of lung fat embolism and the ISS or NISS (Pearson correlation 0.048, p=0.736, and 0.108, p=0.445, respectively). In our study, the presence of fat emboli in the kidney, i.e. SFE, could effectively be predicted by the grade of lung fat embolism (the moderate and slight grades of lung fat embolism were better predictors than the massive one: logistic regression - Wald. Coeff.=11.446, p=0.003, Wald. Coeff.=10.553, p=0.001, and Wald. Coeff.=4.128, p=0.042), and less effectively by presence of PFO (Wald. Coeff.=2.850, p=0.091). This study pointed out that lung and SFE are not pure biomechanical events, so the role of a PFO is not crucial in developing a lung fat embolism into a systemic embolism: the fat embolism is more of a biochemical and pathophsyiological event, than a biomechanical one. The appearance of a patent foramen ovale associated with a systemic fat embolism should be less emphasised: maybe arteriovenous shunts and anastomosis between the functional and nutritive, i.e. systemic circulation of lungs play a more important role in developing a SFE than a PFO.

The significance of pontomedullar laceration in car occupants following frontal collisions: A retrospective autopsy study

The aim of this study was to determine the frequency of brainstem pontomedullar lacerations among fatally injured car occupants in head-on collisions, as well as the concomitant cranial injuries, and to establish a possible underlying mechanism for brainstem laceration. Brainstem pontomedullar lacerations (PML) are often associated with fractures of the skull base (hinge, ring or pyramidal fractures) or with cervical spine fractures. Out of 705 cases of deceased car occupants involved in head-on car collisions, some form of head injury was present in 447 cases (63.4%). These cases included 353 men and 94 women with an average age of 38.2±15.8 years (range 16-89 years). The collected cases included 229 drivers, 164 front-seat and 54 rear-seat passengers. PML were present in 67 of these cases (15%), 50 men and 17 women with an average age of 42.9±15.6 years (range 15-77 years), including 32 drivers, 26 front-seat and 9 rear-seat passengers. In all of these cases the brainstem laceration was partial and the depth varied approximately from 4mm to 8mm. To understand the mechanisms by which PML occurs, we classified the head impact areas into frontal, lateral, posterior and chin area, depending on the injuries to the soft tissue of the head and scalp, as well as facial and cranial fractures. Injury impact area of the head was a good predictor of PML occurrence (χ(2)=131.112, df=3, p=0.000). Chin impact was most often associated with PML-38 cases (Wald. coeff.=5.805, df=1, p=0.016). Presence or absence of mandibular fracture was significant for PML occurrence (χ(2)=11.413, df=1, p=0.001): persons without mandibular fracture have 2.3 times greater risk for PML than those with fracture (odd ratio=7.196). Among the observed skull base fractures, the best predictor of PML was ring fracture (Wald. coeff.=30.729, df=2, p=0.000). Our study showed that PML was present in a significant number of car occupants sustaining head injuries in head-on collisions (15%). Impact to the chin with or without a ring fracture to the skull base most often led to this fatal injury, probably after collision with the dashboard.

Cervical Soft Tissue Emphysema in Hanging-A Prospective Autopsy Study

Abstract:  The underlying mechanism of cervical soft tissue emphysema (CSTE) in hanging remains unclear. The aim of this study was to determine the frequency of CSTE in cases of hanging. The sample included 83 deceased persons, average age 55.3 ± 17.9 years. CSTE was established in 44 cases. CSTE is presented as frothy air, soap bubble‐like formations in superficial and/or deep connective tissue between the neck muscles up to the ligature mark, visible during gross neck examination, using special neck autopsy technique—preparation of the neck organs in layers. The interpretation of positive CSTE must be taken with caution: it could be an antemortem phenomenon possibly because of either Macklin Effect or direct or indirect trauma to the cervical airways, as well as an ante‐ or postmortem artifact.

Pontomedullary Lacerations in Falls from a Height—A Retrospective Autopsy Study

Abstract:  Brainstem pontomedullary laceration (PML) in falls from a height appears as isolated cases and usually in feet‐first impacts with a ring fracture. The aim of this study was to determine the frequency of PML in falls from a height, as well as the frequency of concomitant head and neck injuries. Out of 261 cases, PML was present in 40. An impact to the chin, as well as a feet‐ or buttocks‐first impact, most often led to PML owing to transmission of the impact force. Also, a lateral, frontal, or posterior head impact, with subsequent hinge fracture, as well as the frontoposterior hyperextension of the head associated with an upper spine fracture, could be possible mechanisms of PML in falls from a height. The jawbone and other facial bones act as shock absorbers, and their fracture diminishes energy transfer toward the skull and protects the brain and brainstem from injury.

Laryngeal Choking on Food and Acute Ethanol Intoxication in Adults—An Autopsy Study*

Abstract:  The retrospective autopsy study included 98 adults who died because of laryngeal choking on a bolus of food: 67 men and 31 women (χ2 = 6.843, p < 0.01), average age 58.61 ± 15.87 years (range 26–92 years). Most of the subjects had poor dentition (χ2 = 34.327, p < 0.01). Twenty individuals died in medical institutions, and 78 were nonhospitalized individuals. More than a third of the nonhospitalized individuals were under the influence of ethanol at the moment of death: average blood concentration 8.3 g/dL (SD = 11.0), ranged from 5.0 to 36.0. Nonhospitalized persons were at the moment of event more often under influence of ethanol than the subjects in control group (χ2 = 38.874, p < 0.01), and at the same time significantly more intoxicated (z = −7.126, p < 0.01). Our study pointed out that poor dentition and impairment of the swallowing reflex, as a consequence of ethanol intoxication in individuals without mental disorders, were the most important risk factors for bolus death.

Anomalous Anterior Papillary Muscle as an Autopsy Finding in Two Cases

Anomaly in the anterior papillary muscle (APM) is known to cause left ventricle outflow tract (LVOT) obstruction, and this rare congenital condition could be a cause of sudden cardiac death. This anomaly and its hemodynamic effects is similar to valvular heart disease. In our two described cases, in which cause of death was, respectively, hypertrophic cardiomyopathy and suicide by hanging, the cephalad portion of the left APM was inserted directly into the ventricular surface of the anterior mitral leaflet and chordae tendineae were absent in the area of the direct anomalous muscle insertion; the aberrant papillary muscle was very large and showed an exaggerated anterior displacement within the left ventricular cavity. The described anomaly is a cause of LVOT obstruction. This condition is considered to be rare, although incidence estimates do not exist. In the absence of other possible causes, this finding may indicate arrhythmia as being the immediate cause of death.

Protrusion of the tongue in bodies burned after death: Two cases of arson to cover homicide:

In the forensic assessment of burned bodies, the question of whether the victim was exposed to fire before or after death is of crucial importance. Many authors consider tongue protrusion in cases of burned bodies to be a post-mortem phenomenon. Deep-heating effects of fire are sufficient to cook muscle. The muscle becomes shortened by dehydration and protein denaturation. Exposure to heat causes flexion of the extremities on the contraction of muscles and tendons – heat rigour. The flexors, being bulkier than the extensors, contract more and force the limbs into the position of general flexion. The genioglossus is the major muscle of the tongue and is responsible for protruding or sticking out the tongue: by means of its inferior fibres, it draws the root of the tongue forward and protrudes the apex from the mouth. Similar to the action of limb flexors exposed to heat and the appearance of post-mortem general flexion of a burned body due to heat rigour, perhaps the geniglossus could be shortened by heat, causing post-mortem tongue protrusion to appear as heat rigour of the tongue. In this paper, we present two such cases of protrusion of the tongue in bodies burned after death – cases of arson to cover homicide.