Most fatal stab wounds are located in the left chest region. Among a number of explanations is that most people are right handed and, when facing a victim, will tend to stab the left chest. In addition, if the intention is to kill someone, one would stab in the left chest where the heart is thought to be.
Most fatal stab wounds of the chest involve injury to the heart or aorta. Deaths due solely to a stab wound of the lung are less common. Fatal stab wounds of the right chest usually involve injury to the right ventricle, aorta, or right atrium. Stab wounds of the left chest usually injure the right ventricle when parasternal, and the left ventricle as the stab wounds become more lateral and inferior.4 While hemopericardium is common, death caused solely by cardiac tamponade is not. In cardiac tamponade, once a victim acutely accumulates more than 150 mL of blood in the pericardial sac, death can occur at any time. Rather than this scenario, however, most deaths are due to a combination of hemothorax, external blood loss, and hemopericardium.
Stab wounds of the heart with severing of the left anterior descending coronary artery are rapidly fatal. In stab wounds, damage to the atria or great vessels leading to and from the heart are more serious than those of the ventricles because the ventricular muscle can contract, thus slowing or terminating bleeding. Stab wounds of the heart are typically inflicted over the front of the chest, occasionally the sides, and least commonly the back. The majority of the stab wounds of the left chest also perforate the lungs. Some individuals survive stab wounds of the heart.
Stab wounds of the lungs, like those of the heart, typically occur from wounds over the front of the chest, less commonly the sides, and only occasionally the back. Most such wounds are associated with wounds of the heart.
Stab wounds of the lower chest can produce injuries to not only the heart and lungs, but also to the abdominal viscera. Fatal stab wounds of the abdomen usually involve injury to the liver or a major blood vessel, e.g., the aorta, vena cava, iliac, or mesenteric vessels. Occasionally, in wounds of the abdomen, death is not immediate. Rather, the victim develops peritonitis because of a wound of the bowel. The forensic pathologist, by virtue of his work, sees a biased sampling of cases — only those individuals who die of their injuries. Thus, in regard to all stab wounds of the abdomen, only two thirds enter the abdominal cavity and less than half of these inflict significant injury to the viscera.5
Less common are stab wounds of the head and neck. Stab wounds of the neck can produce rapid death by exsanguination; air embolism or asphyxia due to massive soft tissue hemorrhage with compression of the trachea and vessels in the neck. Delayed deaths might be due to cellulitis, or arterial thrombosis with cerebral emboli and infarction. In cases in which there are stab wounds of the head and neck, X-rays of the chest are suggested to rule out air embolus. Occasionally, in a stab wound of the neck, the knife will sever not only a major blood vessel, but also the trachea, with resultant massive hemorrhaging into the pulmonary tree.
Stab wounds of the brain are uncommon. Most occur through the eye or the temporal region because of the thinness of the bone in these areas. Often, single stab wounds of the brain are not immediately fatal, and the victim may walk or run away from the assailant. In some instances, victims may not realize that they have been stabbed.6,7 Rarely, stab wounds of the brain are not discovered until years after the assault. Sometimes, the knife blade might still be present. Victims of stab wounds of the brain have, on occasion, been hospitalized and the knife's entry into the brain not discovered because the wound was concealed by hair; in the fold of the eye or under the eyelid.6 Death in such cases was due to either continuing intracranial bleeding or infection. At autopsy, the skull defect produced by the weapon will match the width and thickness of the knife blade or screwdriver or the diameter of an ice pick. Bleeding from a stab wound of the brain may be subdural, subarachnoid, intracerebral, or a combination of all three.
Stab wounds of the spine are uncommon. Like stab wounds of the head, the knife blade may break off and be found in the spine. Injury to the cord will produce either complete or partial paralysis below the level of injury. Delayed presentation is rare, but occurred as long as 30 years after the stabbing in one case.8
While most lethal stab wounds involve the trunk, head, or neck, occasionally one will have a lethal stab wound of an extremity. Most commonly,
the vessel involved is the femoral artery. In virtually all these cases, the individuals stabbed are intoxicated and do not realize the lethality of their injury. Instead, they keep walking around bleeding copiously before they collapse and die.
Most stab wounds of the upper extremities are sustained by victims as they try to defend or protect themselves from assailants. Defense wounds of the lower extremities occur but are uncommon.
In rare instances, the weapon used to inflict a stab wound, e.g. an ice pick, may produce an inconspicuous external wound, with minimal or no external bleeding (Figure 7.18). This stab wound can be overlooked in examination of the body at the scene, where conditions for ideal examination are lacking.
Probing of stab wounds is usually of very little benefit, in that the probe, with very little force, will produce multiple erroneous wound tracks. Thus, probing is not recommended.
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