Stab injury--the experience of an East London Hospital 1978-1983

Criminal death by stabbing in the region of Kairouan, Tunisia: A retrospective study, 2008-2018

INTRODUCTION

Homicides by stabbing are the most common forensic form of criminal death in Tunisia. These homicides represent a type of violent death that requires investigation in a forensic setting.

AIM

To describe the epidemiological and forensic profile of stab wounds in the region of Kairouan, Tunisia Methods: We conducted a retrospective study of stab-wounds autopsy cases collected at the Forensic Department at the Ibn El Jazzar University Hospital in Kairouan over eleven years (01/01/2008 to 31/12/2018).

RESULTS

Forty-seven cases of homicide were retained. A male predominance was observed with a sex ratio of 22 (45H/2F, 96%). The mean age of the victims was 33.3±10.84 with ages ranging from 12 to 63 years. Most victims (79%) were of rural origin, singles (62%), and daily-laborers (89%). The months that recorded the highest numbers of homicides were November and August. The most common reason for the assault was a settling-score on the street. The perpetrator was known by the victim in 90% of cases, having used a knife as a weapon in 90% of cases. The thorax was the most frequently affected area, resulting in fatal heart wounds in 28 cases.

CONCLUSION

Autopsy remains an essential tool for drawing up a detailed injury assessment in homicides by stabbing and determining the injury mechanism of the wounds. The comparison of the autopsy findings with the data of the judicial investigation is of great help in the legal qualification of the facts and the determination of the responsibility of the aggressors.

A bizarre case of fatal main renal artery partial laceration without primary kidney injury due to a single stab wound in the chest

Reno-vascular injuries are a rare type of renal injury, and their second most frequent cause is penetrating wounds. The majority of the reports and of the studies are present in the urological and radiological literature and they focus on the clinical approach to such injuries. In the case here presented, an 18-year-old male died after being stabbed in the left hemithorax. During body examination, thoracic organs were found to be unremarkable (except for a small peripheral laceration of the left lung), but the diaphragm was transfixed and the upper wall of the left main renal artery was lacerated. The adjacent renal vein, the kidney, the aorta, the vena cava and the surrounding internal structures were not damaged (except for a small laceration of the pancreatic tail). A massive haemothorax and a large retroperitoneal haematoma in the left kidney area were observed. The cause of death was attributed to haemorrhagic shock following a partial laceration of the left main renal artery due to the stab wound to the chest. No other cases of similar fatal renovascular injuries due to stab wounds have been published in the current forensic literature.

Penetrating stab injuries in Iceland: a whole-nation study on incidence and outcome in patients hospitalized for penetrating stab injuries

Background

Studies on penetrating injuries in Europe are scarce and often represent data from single institutions. The aim of this study was to describe the incidence and demographic features of patients hospitalized for stab injury in a whole nation.

Materials and methods

This was a retrospective nationwide population-based study on all consecutive adult patients who were hospitalized in Iceland following knife and machete-related injuries, 2000–2015. Age-standardized incidence was calculated and Injury Severity Score (ISS) was used to assess severity of injury.

Results

Altogether, 73 patients (mean age 32.6 years, 90.4% males) were admitted during the 16-year study period, giving an age-standardized incidence of 1.54/100,000 inhabitants. The incidence did not vary significantly during the study period (P = 0.826). Most cases were assaults (95.9%) occurring at home or in public streets, and involved the chest (n = 32), abdomen (n = 26), upper limbs (n = 26), head/neck/face (n = 21), lower limbs (n = 10), and the back (n = 6). Median ISS was 9, with 14 patients (19.2%) having severe injuries (defined as ISS > 15). The median length of hospital stay was 2 days (range 0–53). Forty-seven patients (64.4%) underwent surgery and 26 of them (35.6%) required admission to an intensive care unit (ICU), all with ISS scores above 15. Three patients did not survive for 30 days (4.1%); all of them had severe injuries (ISS 17, 25, and 75).

Conclusion

Stab injuries that require hospital admission are rare in Iceland, and their incidence has remained relatively stable. One in every five patients sustained severe injuries, two-thirds of whom were treated with surgical interventions, and roughly one-third required ICU care. Although some patients were severely injured with high injury scores, their 30-day mortality was still low in comparison to other studies.

Temporal and geographic patterns of stab injuries in young people: a retrospective cohort study from a UK major trauma centre

OBJECTIVES

To describe the epidemiology of assaults resulting in stab injuries among young people. We hypothesised that there are specific patterns and risk factors for injury in different age groups.

DESIGN

Eleven-year retrospective cohort study.

SETTING

Urban major trauma centre in the UK.

PARTICIPANTS

1824 patients under the age of 25 years presenting to hospital after a stab injury resulting from assault.

OUTCOMES

Incident timings and locations were obtained from ambulance service records and triangulated with prospectively collected demographic and injury characteristics recorded in our hospital trauma registry. We used geospatial mapping of individual incidents to investigate the relationships between demographic characteristics and incident timing and location.

RESULTS

The majority of stabbings occurred in males from deprived communities, with a sharp increase in incidence between the ages of 14 and 18 years. With increasing age, injuries occurred progressively later in the day (r²=0.66, p<0.01) and were less frequent within 5 km of home (r²=0.59, p<0.01). Among children (age <16), a significant peak in injuries occurred between 16:00 and 18:00 hours, accounting for 22% (38/172) of injuries in this group compared with 11% (182/1652) of injuries in young adults. In children, stabbings occurred earlier on school days (hours from 08:00: 11.1 vs non-school day 13.7, p<0.01) and a greater proportion were within 5 km of home (90% vs non-school day 74%, p=0.02). Mapping individual incidents demonstrated that the spike in frequency in the late afternoon and early evening was attributable to incidents occurring on school days and close to home.

CONCLUSIONS

Age, gender and deprivation status are potent influences on the risk of violent injury in young people. Stab injuries occur in characteristic temporal and geographical patterns according to age group, with the immediate after-school period associated with a spike in incident frequency in children. This represents an opportunity for targeted prevention strategies in this population.

A cross-sectional study of knife injuries at a London major trauma centre

INTRODUCTION

No national recording systems for knife injuries exist in the UK. Understanding the true size and nature of the problem of knife injuries is the first stage in reducing the burden of this injury. The aim of this study was to survey every knife injury seen in a single inner city emergency department (ED) over a one-year period.

METHODS

A cross-sectional observational study was performed of all patients attending with a knife injury to the ED of a London major trauma centre in 2011. Demographic characteristics, patterns of injury, morbidity and mortality data were collected.

RESULTS

A total of 938 knife injuries were identified from 127,191 attendances (0.77% of all visits) with a case fatality rate of 0.53%. A quarter (24%) of the major trauma team’s caseload was for knife injuries. Overall, 44% of injuries were selfreported as assaults, 49% as accidents and 8% as deliberate self-harm. The highest age specific incident rate occurred in the 16–24 year age category (263/100,000). Multiple injuries were seen in 19% of cases, of which only 81% were recorded as assaults. The mean length of stay for those admitted to hospital was 3.04 days. Intrathoracic injury was seen in 26% of cases of chest trauma and 24% of abdominal injuries had a second additional chest injury.

CONCLUSIONS

Violent intentional injuries are a significant contributory factor to the workload of the major trauma team at this centre. This paper contributes to a more comprehensive understanding of the nature of these injuries seen in the ED.

[Evisceration of intestines following abdominal stab wounds: epidemiology and clinical aspects of emergency room management]

STUDY AIM

The aim of the study was an estimation of the incidence and clinical aspects of emergency room (ER) parameters of penetrating abdominal injury patients with bowel evisceration.

STUDY DESIGN AND METHODS

The study involved a retrospective cohort analysis of ER data from the Chris Hani Baragwanath Academic Hospitals, Soweto, Johannesburg, South Africa between September 2000 to May 2005.

RESULTS

Out of 9,010 ER patients, 4,390 suffered penetrating injuries with 8 out of 71 eviscerations due to a single gunshot wound, 60 out of 71 eviscerations due to single stab wounds and 3 further patients suffered multiple injuries. The ER mortality was 1 out of 71(1.6 %) with an average ER mortality of 4.2 %. The only death seen was a single abdominal gunshot wound with vascular injury. The causative mortality due to abdominal stab wounds with evisceration of the bowels was therefore zero. The heart rate in patients with abdominal stab wounds with and without bowel evisceration showed no significant difference, thus mesentery tearing or vagal overstimulation could not be seen, neither with bradycardia nor hypotension.

CONCLUSION

Evisceration itself is not a cause for increased mortality or cardiovascular instability seen in the ER. There is ample time for diagnostic procedures before laparotomy is performed.

Selective nonoperative management of anterior abdominal stab wounds: 1992-2008

BACKGROUND

The use of selective nonoperative management for anterior abdominal stab wounds has evolved into a readily accepted practice. Multiple reports have shown this strategy to be both safe and effective. However, there is a paucity of long-term studies.

METHODS

A retrospective review was performed of all trauma patients presenting for anterior abdominal stab wounds at a Level I trauma center during a 17-year time period. Primary outcomes were the percentage of patients undergoing an exploratory laparotomy and the negative laparotomy rate.

RESULTS

A total of 7,033 patients sustained a stab wound with 1,961 involving the anterior abdomen. The percentage of patients undergoing exploratory laparotomy decreased during the study period from 64.8% to 37.6% (overall 45.8%). The negative laparotomy rate decreased from 21.3% to 8.6% (overall 18.7%). The negative laparotomy rate of patients who underwent exploratory laparotomy immediately did not change over time (13.8%), whereas the negative laparotomy rate of those patients who underwent exploratory laparotomy in a delayed fashion decreased from 25.0% to 6.25%. The overall mortality was 1.9%, with 6.2% mortality for patients undergoing an immediate laparotomy, 0.7% for patients undergoing a delayed laparotomy, and 0.0% for patients managed nonoperatively (p<0.04). The mean length of hospital stay was 6.6 days±0.5 days, with a mean of 9.4 days±0.9 days in patients undergoing an immediate laparotomy, 8.1 days±0.5 days in patients undergo a delayed laparotomy, and 3.8 days±0.2 days in patients managed nonoperatively (p<0.001).

CONCLUSIONS

Selective nonoperative management for stab wounds to the anterior abdomen is associated with a decreased operative rate and decreased negative laparotomy rate over time. Selective nonoperative management is both safe and effective for anterior abdominal stab wounds.

Flupirtine in pain management: pharmacological properties and clinical use

Flupirtine is a centrally acting, non-opioid analgesic that is available in a number of European countries for the treatment of a variety of pain states. The therapeutic benefits seen with flupirtine relate to its unique pharmacological properties. Flupirtine displays indirect NDMA receptor antagonism via activation of potassium channels and is the first representative of a pharmacological class denoted the 'selective neuronal potassium channel openers'. The generation of the M-current is facilitated by flupirtine via the opening of neuronal Kv7 potassium channels. The opening of these channels inhibits exaggerated neuronal action potential generation and controls neuronal excitability. Neuronal hyperexcitability is a physiological component of many pain states such as chronic pain, migraine and neurogenic pain. Although large-scale clinical trials are lacking, the clinical trial database available to date from smaller-scale studies, together with extensive clinical experience, indicate that flupirtine effectively reduces chronic musculoskeletal pain, migraine and neuralgias, amongst other types of pain. In addition, flupirtine produces, at recommended clinical doses, muscle-relaxing effects in the presence of abnormally increased muscle tension. Its analgesic and muscle-relaxant properties were comparable to tramadol and chlormezanone, respectively, in two prospective trials in patients with lower back pain. Cytoprotective, anti-apoptotic and antioxidant properties have also been associated with flupirtine use in a small number of studies to date. When provided as combination therapy with morphine, flupirtine increases the antinociceptive activity of morphine 4-fold. Flupirtine displays superior tolerability when compared with tramadol and pentazocine. The most common adverse effects associated with flupirtine use are drowsiness, dizziness, heartburn, dry mouth, fatigue and nausea. With respect to its molecular structure, mechanism of action and adverse event profile, flupirtine is a unique drug. Flupirtine is an analgesic with many potential therapeutic benefits that may prove useful in the treatment of many disease states.

SEVERE TRAUMA CAUSED BY STABBING AND FIREARMS IN METROPOLITAN SYDNEY, NEW SOUTH WALES, AUSTRALIA

BACKGROUND

Stabbing and firearm trauma causing severe injuries (injury severity score (ISS) >15) and death is uncommon in Australia. The present study describes the experience with stabbings and firearm trauma causing severe injuries at a major Australian urban trauma centre.

METHODS

Data from a prospectively generated trauma registry regarding all patients presenting to Royal Prince Alfred Hospital (RPAH), Sydney, Australia with penetrating trauma causing severe injuries from July 1991 to June 2001 was retrospectively analysed.

RESULTS

Of all patients presenting to RPAH with stabbing and firearms wounds over the 11 year study period, 28% received an ISS >15. One hundred and forty patients were identified. 94% were male. The mean age was 34 years (15-82 years). The number of cases/year has not shown an increasing trend. Thirty per cent of patients sustained firearm related injuries, with the remainder mainly caused by knives or machetes. Fifteen per cent of injuries were self inflicted. The most common location of injury was on a public street. Fifty-two per cent of patients were injured in more than one anatomical region, with the abdomen being the most common site of injury (53%). On hundred and seventy-four operations were performed - laparotomies (43%), thoracotomies (26%), craniotomies (5%) and orthopaedic, vascular, wound explorations and other procedures (26%). Twenty-eight per cent of patients suffered at least one complication during their admission, with coagulopathy being the most common complication (20%). Mean length of stay was 10.4 days (1-107 days). The total mortality rate for the severely injured patients was 21%, with gun-related injuries having a higher mortality rate than stabbing injury (36%vs 15%). Sixty per cent of deaths were related to exsanguination.

CONCLUSIONS

Stabbings and firearm trauma are associated with significant morbidity, mortality and utilization of hospital resources in metropolitan Sydney. Overall mortality rates are similar to institutions with higher volumes of penetrating trauma.

Is penetrating injury on the increase in south-western Sydney?

BACKGROUND

Few Australian studies describe the epidemiology of penetrating trauma. This study describes the incidence and demographic features of penetrating injuries with emphasis on trends and severity analysis.

METHODS

Case analysis was performed utilizing data from the Liverpool Hospital Trauma Registry (1989-94), NSW Department of Health Hospital Separations (1991-93), and the NSW Bureau of Crime Statistics (1991-93) with reference to the Liverpool and Fairfield Local Government Areas (LGA).

RESULTS

The Trauma Registry revealed 251 of penetrating trauma. The median age was 26 years (interquartile range 21-33). Ninety-one per cent of the victims were male. Fourteen per cent of patients had an Injury Severity Score (ISS) > 15. Sixty-five per cent of cases were stab injuries and 20% gunshot injuries with the abdomen being the most commonly injured site. Twenty-one per cent of patients underwent laparotomy, 1.6% thoracotomy and 1.2% thoracotomy and laparatomy. There were 10 (4%) deaths. Trends in incidence of penetrating trauma and violent crime involving weapons were analysed. Static trends were observed for the annual incidence of penetrating trauma from the Liverpool Hospital Trauma Registry. Separations for penetrating trauma from Liverpool and Fairfield hospitals showed a slightly increasing trend. Violent crimes involving weapons in the Liverpool and Fairfield LGA showed a static trend. Nevertheless, separations for penetrating trauma and rates of violent crimes involving weapons were higher in south-western Sydney than metropolitan Sydney or NSW. Eight per cent of the LGA population are Vietnamese but this study identified 16% of victims as being Vietnamese.

CONCLUSIONS

This study found no significant increase in penetrating trauma or violent crime predisposing to penetrating injury in south-western Sydney.

Neurotoxicity in rat cortical cells caused by N-methyl-D-aspartate (NMDA) and gp120 of HIV-1: induction and pharmacological intervention

Incubation of highly enriched neurons from rat cerebral cortex with the human immunodeficiency virus type 1 (HIV-1) coat protein gp120 for 18 h results in fragmentation of DNA at internucleosomal linkers, a feature of apoptosis. We report that neurons respond to exposure to gp120 with an increased release of arachidonic acid via activation of phospholipase A2. This process is not inhibited by antagonists of the N-methyl-D-aspartate (NMDA) receptor channels. To investigate the influence of arachidonic acid on the sensitivity of NMDA receptor towards its against, low concentrations of NMDA were coadministered with arachidonic acid. Under these conditions the NMDA-mediated cytotoxicity was enhanced. We conclude that gp120 causes an activation of phospholipase A2, resulting in an increased release of arachidonic acid which in turn sensitizes the NMDA receptor. Two compounds were found to act cytoprotectively against the deleterious effect caused by gp120 on neurons: Memantine [1-amino-3,5-dimethyladamantane] and Flupirtine [2-amino-3-ethoxycarbonylamino-6-(4-fluoro-benzyl-amino)-pyridine maleate]. Both compounds have been found to display a potent cytoprotective effect on neurons treated with the excitatory amino acid NMDA or with the human immunodeficiency virus type 1 (HIV-1) coat protein gp120. The NMDA antagonist Memantine, a drug currently used in the therapy of spasticity and Parkinson's disease, prevented the effects of gp120 at micromolar concentrations. Flupirtine was previously found to be a centrally acting, nonopiate analgesic agent which additionally possesses anticonvulsant and muscle-relaxant activity at doses similar to those producing analgesia. The cytoprotective effect of Flupirtine in vitro was significant (above 10 microM). Considering the fact that both Memantine and Flupirtine display almost no clinical side effects, these drugs may prove useful both in preventing primary infection of brain cells with the HIV virus, as well as in treating the neurological disorders often associated with the immunodeficiency syndrome such as AIDS-related dementia.

An autopsy evaluation of defence wounds in 195 homicidal deaths due to stabbing

Defence wounds may be of value in differentiating between homicide, suicide and accidental death. A study of 3183 forensic autopsies in Istanbul between 1988 and 1989 showed that 195 deaths (6.1%) were due to stab wounds, and that defence wounds were found in 38.5% of the victims. Defence wounds were seen on 35.2% of males, and 54.5% of females; 39.7% of defence wounds were classified as 'active' and 60.3% as 'passive'; 40.5% were seen on the right hand and forearm, and 59.5% on the left side. There was no connection in this study between the occurrence of defence wounds and the consumption of alcohol by the victim before the stabbing.

The use of Histoacryl for episiotomy repair

Histoacryl-tissue adhesive (B. Braun Melsungen AG W. Germany) was used in place of skin sutures (2/0 chromic catgut, Ethicon Ltd, Edinburgh, Scotland) for episiotomy repair in a group of 20 women. This group was compared with two groups of women undergoing first and repeat episiotomy. Variables analysed included pain in the episiotomy site, pain while walking, sitting, sleeping, lying down, breast-feeding, micturating and defaecating. The Histoacryl group was superior with regard to all the variables. This simple, new method can reduce pain and inconvenience for patients, especially following the first delivery.

Analgesic activity of flupirtine maleate: a controlled double-blind study with diclofenac sodium in orthopaedics

A controlled, parallel group study of the analgesic efficacy of flupirtine maleate, was compared against diclofenac sodium in 40 orthopaedic patients with post-operative pain. Clinically, both drugs were of equal analgesic efficacy. A mathematical model has been developed, however, to evaluate the speed, intensity and duration of the analgesic effect and provides data which significantly favour flupirtine maleate in the treatment of these patients.