The authors have seen a number of deaths following blunt trauma to the head in which no, or at least insignificant, anatomical injury to the brain could be documented. They fall into two categories. The first is illustrated by the case of an 8-year-old boy riding in the back seat of a motor vehicle that was involved in a head-on collision with another vehicle. The boy was propelled over the back seat, striking the top of his head against the windshield. He was dead at the scene within minutes of the accident. At autopsy, there was no evidence of any injury to the scalp, skull, brain, or neck (anterior and posterior dissection). A complete autopsy and toxicological screen were negative.
A second, similar case involved a 20-year-old man who fell 20 ft to the ground from a ladder. Death was immediate. At autopsy, there was a small laceration of the scalp in the temporal region without fracture of the skull or gross evidence of injury to the brain. A number of small perivascular hemorrhages were identified in the brain stem. There was no other evidence of injury. The neck was examined anteriorly and posteriorly. Death in this and the previous case was presumably due to diffuse axonal injury.
The second category of deaths involves individuals who, while acutely intoxicated with alcohol, are severely beaten about the head, usually with fists and feet (Figure 6.13). The individuals collapse and are subsequently found to be dead. At autopsy, the face shows extensive soft tissue injury. There is no intracranial hemorrhage (subdural, subarachnoid or intracranial). There are no skull fractures, though fractures of the nose may be present. Anterior and posterior dissection of the neck is unremarkable. The airway is patent. The blood alcohol is high, but not in the lethal level, i.e., above 0.15 %, but less than 0.400%. Analysis of vitreous humor indicates that, even if there had been prolonged survival, the blood alcohol level was never in the lethal range.
Milovanovic and Di Maio reported five such deaths.35 In all cases, there was extensive soft tissue injury to the face and head; no intracranial bleeding; no injury to the neck; no airway obstruction and no skull fractures. Three of the five individuals did, however, have nasal fractures. All five were intoxicated, with blood alcohol levels from 0.22 to 0.33 g/dl. Three of the five died within minutes of the assault; two were found dead.
Figure 6.13 A 35-year-old male severely beaten about face with fists. Blood alcohol 280 g/dL. No visible injury to brain.
The cause of death in this category of cases is posttraumatic apnea due to a combination of concussion and acute alcohol intoxication.35-36 Concussion, alone or in combination with alcohol, can produce posttraumatic apnea. With concussion alone, however, posttraumatic apnea is rare, brief, relatively mild and not life-threatening. Concussion in combination with alcohol produces apnea that can cause death. This was demonstrated by Zinc and Feustel in animal experiments.36 They concluded that alcohol augments the effects of concussive brain injury with resultant posttrau-matic apnea.
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