Forensics exam
Medico-Legal Investigation of Death
Major Duties of a Forensic Pathologist:
Determine cause and manner of death.
Identify the deceased if unknown.
Collect evidence from the body.
Document injuries or lack thereof.
Deduce how the injuries occurred.
Document any underlying natural disease.
Attend scene of crime.
Determine or exclude other causes of death.
Provide expert testimony.
Teaching Philosophy:
Rule 1: Don’t be Shy.
Rule 2: You Snooze – You Lose.
Rule 3: What determines the strength of a tree? Strong Roots.
Rule 4: All Types of Intelligence (Emotional, Philosophical, Spiritual).
Philosophy of Medico-Legal Investigation:
Even in primitive tribal society, there was interest in discovering causes of death, especially sudden, unexpected, or unwitnessed deaths, which signaled potential danger from within or outside the society.
Legal medicine is the application of medical knowledge to the administration of the law and the furthering of justice, including the legal relations of the medical practitioner.
Legal medicine adapts to scientific, technological, sociocultural, and legal contexts throughout history and is in constant evolution.
It is crucial for justice and the honour and freedom of people.
The philosophy remains the same across countries: the application of medical knowledge and methodology for the resolution of legal questions and problems for individuals and societies.
Without good legal medicine, there can never be good justice!
Forensic Disciplines:
FORENSIC MEDICINE - THE LIVING.
FORENSIC PATHOLOGY - THE DEAD.
History of Forensic Medicine:
Ancient:
3000 BC – China - Writings about medicines
1700 BC – Babylon – Code of Hammurabi
220 BC – China – Bamboo texts with Rules
10 BC – India, Egypt, Persia, Greece
572 BC – Lex Aquillia
460-355 BC – Hippocrates of Kos
449 BC – Rome – Lex duoecimo tabulorum
Modern:
The Bamberg Criminal Code (1507).
The famous criminal code of Emperor Charles V, Constitutio Criminalis Carolina (1532).
Ambroise Pare, Condronchius, Fortunatus Fidelis, Methodus testificanti, De relationibus medicorum (1575).
Paolo Zacchia, Questiones medicolegalis (1584-1659).
The Roman Empire:
Rome started in 753 BC and ended in 476 AD.
Rome was master of all the peoples around the Mediterranean Sea (including even England and some parts of Asia).
The Roman jurists came up with laws to manage their subjects.
Height of the Roman Empire:
Classical Roman Law.
At the end of the fourth century AD, the Roman Empire split.
Western Roman Empire (Rome).
Eastern Roman Empire (Byzantium).
West invaded by Goths, Franks, barbarians.
The Roman Catholic Church: Canon Law:
Re: The Western Roman Empire.
A Germanic Ruler came to the thrown.
Roman Law formed the foundation of church law.
Church law later became canon law.
Canon law influences modern law.
For example a mere agreement between two people can be enforced by law.
The Eastern Roman Empire:
The old classical Roman law survived in the Eastern Roman Empire (Byzantium / Constantinople / Istanbul).
The Emperor in the 6th century was called Justinian.
He ‘codified’ the law.
The law was collected and written down.
Justinian enactments:
The Corpus Iuris Civilis.
Between AD 529 and 564.
‘The highest point of achievement in forensic medicine in the ancient world’ – Sydney Smith
Roman-Law Spreads
12th century renewed interest in Roman Law.
Roman law spread to medieval universities.
15th, 16th and 17th centuries spread through Europe.
Roman-French law, Roman-German law.
It’s reception in Netherlands is where our story starts.
Arrival in the Cape
Old Dutch authorities: Hugo de Groot and Johannes Voet. Their writings still used today in our courts of law.
Jan van Riebeeck 1652, employee Dutch East India Company, arrives in Cape.
Artyckelbrief and Placaeten.
Roman-Dutch Law.
English Law
British occupation Cape: 1795 and then 1806.
British government got rid of old courts of landdrost and heemraden replaced them with magistrates.
English became official language.
Trial by jury was abolished in 1969.
African customary / indigenous law
Many different black tribes lived according to their own laws and cultures.
Second half nineteenth century - Recognized.
Largely unwritten law.
In terms of the Constitution, the courts must apply where applicable.
The Constitution
In 1996 The Constitution of the Republic of South Africa was adopted.
This is an important event in the development of the history of our law.
History of Law in RSA
Roman Law (753 BC – 476 AD)
Roman-Dutch Law
South African Law (1652-)
English Law
Indigenous Law
Authoritative Sources
Legislation / statutes / Acts of Parliament
Court Decisions
Common Law
Custom Law
African Indigenous Law
All subject to the Constitution
Classification of Law
Public Law:
International Law
Constitutional Law
Criminal Law
Law of procedure
Private Law:
Law of Persons
Law of Family Relations
Law of Personality
Law of Patrimony
Miscellaneous:
Mercantile Law
Labour Law
Conflict of Laws
The Cape
In 1652, Jan van Riebeeck.
For the next 150 years, established a Roman-Dutch legal system.
1660: A postmortem upon the body of a boatswain’s mate, signed by the Senior Ship’s Surgeon (P Chevalier):
“Having been requested by Mr van Riebeeck to report my examination on the body of the boatswain’s mate, made in the presence of the Fiscal and the surgeon Pieter van Clinckenbergh, I beg to state that the jugular vein and carotid artery (vena jugeloere en aortery carotides) were severed; death ensued from loss of blood.”
Other parts of Southern Africa
The legislative framework pertaining to the medicolegal investigation of death which had been established in South Africa early in the 20th century thereafter also prevailed in various other southern African states, including those of Namibia (then South West Africa, under the administrative control of South Africa), Swaziland, Botswana, Lesotho, and Southern and Northern Rhodesia.
District surgeons
1910, the Union of South Africa, divided into magisterial districts, presided over by magistrates.
Under British colonial rule across the empire, many medical practitioners had been drafted into service of the state as “civil surgeons” to perform inter alia medicolegal duties.
In South Africa, these medical practitioners were known as—referred to as—“district surgeons” in South Africa.
With approximately 315 magisterial districts across the entire country—and as more than 1 district surgeon was often appointed in each district—
Were thus officially engaged in rendering forensic medical services nationwide.
District surgeons and state pathologists were never in the employ of the police, it is clear that a close working relationship would likely develop over time between such state pathologists/medical practitioners and the mortuary police officers and management structures, working together on a daily basis—with the potential at least, for dual loyalties and lack of independence, to develop.
Whether indeed there were material instances of (forensic) medical practitioners colluding with police officers or contriving to falsify, misrepresent, or misinterpret autopsy findings is hard to say.
Sir Sydney Smith
During political unrest in Egypt, (1919-1922), the Procurator General of Egypt, suggested that forensic pathologist Sir Sydney Smith reconsider his medico-legal reports in favour of the Government:
“Excellency,” I said, “my report concerns what I actually found, and it is not subject to revision. What you do with it is no concern of mine, but I cannot alter it.”
IPID
The introduction of a civilian police watchdog agency, the Independent Complaints Directorate (created by statute in the SA Police Services Act, Act no. 68 of 1995), which was subsequently replaced by the Independent Police Investigative Directorate (IPID Act, Act 1 of 2011).
Modern Advancements
Extraordinary progress recent years has enabled the judicial system to become faster and more efficient.
Decisions are now more scientifically grounded.
Devastating new technology!
Drones.
New facial recognition software.
Laboratories on a chip.
Homicide by cell phone.
‘Upgrading the healthy’ vs ‘curing the sick’ .
‘The Universe of’ theory…
As a forensic pathologist, we need data to make decisions.
What is happening West Coast, to Phalaborwa, to Springbok, East Rand?
There are ‘Universes of’. The further away from universities you move, the more distant from the centre of the solar system you become.
Not as academic as universities, these medical professionals tend to live in their own ‘Universes’ .
Tend to develop their own ecosystems.
If you are the Magistrate of a very small town in South Africa, you are essentially a God – or a Goddess - No-one will dare question you.
So too, if you are a physiotherapist in some small town.
Or a paramedic on some lonesome stretch of highway.
Or a GP on the East Rand…
Therefore…
We all need to be on the same page!
We all need to talk the same language!
Definitions!
Basic concepts:
The primary medical cause of death – the disease or injury which initiated the train of morbid events leading directly to death.
Circumstances in which death occurred – use the terms “as gathered”, “as informed”
Mechanisms of death – physiological changes
Basic concepts (cont.)
Contributing cause of death – Contributes to an earlier death (atherosclerosis + CO)
Predisposing cause or condition – underlying conditions which may cause an accident (alcohol in MVA)
Precipitating cause – Excitement of fury may precipitate a cerebral haemorrhage.
More Concepts:
Terminal cause of death – Is usually a complication which occurs (head injury with pneumonia.)
The exclusive (sole) cause of death – No contributing factors play a role (stab wound to the heart.)
Primary Medical Cause of Death
The disease or injury which initiated the process or sequence of physiological events or complications which led to the death of the patient
Circumstances of Death
"As informed…'"
"As gathered…"
Contributing cause or condition
Contributes to an earlier death.
For example, atherosclerosis will contribute to an earlier or accelerated death if the person were strangled.
Predisposing cause or condition
Alcohol, barbiturate ingestion or epileptic fits are examples of predisposing or underlying conditions which may cause an accident.
Fury or excitement – Rupture of a berry aneurysm.
Precipitating cause or condition
“Precipitates” something to happen immediately, or causes the immediate development of a particular illness.
Excitement or fury may for example cause a cerebral haemorrhage or myocardial ischaemia resulting in death.
Terminal cause of death
Is usually the complication which occurs.
A person with a head injury (the primary medical cause) often develops bronchopneumonia (terminal cause).
The exclusive cause of death
The sole cause of death.
No contributing or other factors play a role.
For example, stab wound to the heart; Meconium aspiration; Head injury; Birth trauma.
Selected examples:
Coronary atherosclerosis with MI
Rupture of berry aneurysm with SA bleed.
Measles with terminal bronchopneumonia.
Penicillin with Anaphylactic reaction.
Meconium aspiration
Injury with tetanus.
Head injury with pulmonary embolism.
Mechanism of Death
The pathophysiological derangement which sets in (as a result of the primary medical condition) and which ultimately is responsible for the death of the patient
Manner of Death
(Determined by Magistrate!)
Homicide
Suicide
Accident
Natural
Undetermined
Different courts, different ‘tests’ .
Criminal law: ‘Beyond a reasonable doubt’.
Civil law: ‘On a balance of probabilities’.
HPCSA: ‘Negligence’.
The Death Certificate/Notification:
Identity
Confirm death
Natural or other than natural?
Cause of death
“Death Certificate” : Notification of death / stillbirth (Form DHA-1663)
The DHA-I663
Administrative function: To register the death of the person at the Department of Home Affairs and also this is a statutory requirement. This is necessary in order for the family to wrap up the estate of the deceased.
Statistical function: The second page of the DHA-1663 contains details of the deceased and the cause of death, which is used by Statistics SA to gather mortality statistics for the country.
Medical Practitioner must issue a death certificate immediately irrespective of whether the death was natural or unnatural.
Information must be true and correct.
Follow instructions carefully.
Print clearly.
Delete non-applicable paragraphs.
If particulars are not known – indicate so.
Primary medical cause of death must be stated.
If death was solely and exclusively due to natural causes – complete appropriate section.
If death was due to unnatural causes, complete appropriate section.
No fee may be charged for the completion of a death certificate.
Legislation:
What Acts to know for day-to-day functioning?
Important laws:
Births and Deaths Registration Act (Act 51 of 1992.)
Inquests Act 58/59.
The Health Professions Act (Section 56, Act 1974).
National Health Act (61 0f 2003)
Births and Deaths Registration Act (Act 51 of 1992)
Sections:
Section 14: Death due to natural causes (replaced by Act 43 of 1998) (Any person who attended death must notify GP)
14 (2): GP satisfied – issue DHA1663.
14 (3): Reasonable doubt – inform police officer.
14 (4): After prescribed burial order been issued, reasonable doubt, withdraw and cancel burial order.
Section 15: Certificate by medical practitioner.
15 (1) GP satisfied – natural – issue certificate.
15 (2) GP did not attend death, but after death examined the corpse. Satisfied – issue certificate.
15 (3) GP – doubt – inform policeman.
Section 17: Death due to other than natural causes.
Inquests Act (Act no 58 of 1959).
Section 18: Still-birth
18 (1): GP present – satisfied – issue DHA1663.
18 (2): GP not present – make declaration.
18 (3): Declaration deemed to be notice of still-birth.
18 (4): Reasonable doubt – shall not issue burial order – inform policeman.
Inquests Act (Act no 58 of 1959)
The Inquests (Death) Act of 1875
The old Fire Inquests Act, 1883 (Cape of Good Hope) and Fire Inquests Law, 1884 (Natal)
Inquest into unnatural deaths: Factual investigation only - NOT a court case against someone.
Makes provision for investigation of deaths which were apparently the result of unnatural causes.
Sections:
Duty to report deaths: Reason to believe, other than natural causes, report to policeman.
Investigation of circumstances of certain deaths: District surgeon, other medical practitioner, examination of internal organs
Section 2: Duty to report deaths. - (1) Any person who has reason to believe that any other person has died and that death was due to other than natural causes, shall as soon as possible report accordingly to a policeman, unless he has reason to believe that a report has been or will be made by any other person.
Section 3: Investigation of unnatural deaths Policeman: - must investigate circumstances - report to magistrate
Section 4: Report to public prosecutor (DIRECTOR OF PUBLIC PROSECUTIONS)
Section 5: Decision to hold inquest
Section 8: Witnesses and evidence
Section 9: Assessors at inquests
Other than natural causes – body shall be examined by medical doctor (to ascertain cause of death with greater certainty)
Any part or internal organ may be removed from body and taken to any place as may be necessary
A body that has been interred may be disinterred
No-one may be present at PM other than police, GP or those with a substantial and peculiar interest
Section 16: Presiding Officer’s Finding: - identity of deceased - cause of death - date of death - was death due to an act or omission which prima facie amounts to a criminal offence ?
Natural and Unnatural death (NB!):
A death caused by the application of a force or any other physical or chemical factors, direct or indirect, and with or without complications.
Any death, which in the medical practitioner’s opinion was caused by an act or an omission on the part of somebody.
A death in term of section 56 of the Health Professions Act, 1974. (Section 48 of the Health Professions Amendment Act (29 of 2007).
Any unattended, suspicious, (unexplained), or sudden unexpected death (at rest, or exertion).
Health Professions Act, 1974 (section 56)
"Procedure related deaths"
"Procedure related death" vs "Anaesthetic death"
“The death of a person undergoing, or as a result of,
a procedure of a therapeutic, diagnostic or palliative nature,
or of which any aspect of such a procedure has been a contributory cause, shall not be deemed to be a death from natural causes…..”
Section 48 of the Health Professions Amendment Act (Act 29 of 2007)
i) The death of a person during a local or general anaesthetic = unnatural death.
ii) If death takes place within 24 hours of such a procedure = phone Forensic Pathologist
iii) If in the considered opinion of attending medical practitioner, the administration of an anaesthetic has been a contributory cause = unnatural death
iv) A death which appears to be the result of negligence or medical misadventure on the part of the attending health care provider or institution = unnatural death
National Health Act (Act 61 0f 2003)
National Code of Guidelines for Forensic Pathology Practice in South Africa (To be read in conjunction with the regulations of the National Health Act 61 of 2003)
Framework of FPS:
National Code of Guidelines for Forensic Pathology Practice in South Africa..
To be read in conjunction with the Regulations of the National Health Act (61 of 2003)
Vision of FPS
The rendering of a medico-legal investigation of death service that serves the judicial process.
It is essential that standardized and uniform protocols and procedures are followed nationally, rendering objective, impartial and scientifically accurate results.
Memorandum of Understanding (MoU) exists between FPS and SAPS.
Replaces the Manual for the Performance of Post Mortems GW 7/71 and SAPS Special Forces Order 05C/1992.
Intended for those in the employ of Forensic Pathology Services.
Regarding the rendering of Forensic Pathology Services.
The medico-legal investigation of death.
Standardised and uniform protocols.
To provide a framework for a structured uniform health system within the Republic, taking into account the obligations imposed by the Constitution and other laws on the national, provincial and local governments with regard to health services; and to provide for matters connected therewith.
Regulations with regard to:
Post mortem examination of body suspected of having died of communicable disease.
Notification to local authority of death from notifiable medical condition.
Removal and burial of dead body. (communicable diseases, cremation)
Regulations pertaining to Forensic Pathology Services
Chapter 8: Control of use of Blood, Blood products, Tissue and Gametes in Humans Donation / human bodies / tissue / medical or dental training / research or therapy / advancement of medicine or dentistry in general/ post mortem examination of certain human bodies
Documentation of death:
“Death Notification Form”: DHA–1663
Burial order – SAPS or Home Affairs
Cremation forms - referee
GW 7/24 “Anesthetic/procedure” death
Transport outside district / country – removal order
EXAMPLES OF SPECIAL CASES (requiring specialized procedures and protocols):
High-Profile deaths.
Deaths in detention / custody / police action
Deaths related to medical procedures
Mass fatalities
Aircraft fatalities
Scuba fatalities.
Exhumations.
Child abuse cases.
Deaths outside SA
“Obscure autopsy" (little / no positive findings)
Burials / Cremation
Burial order necessary in town Local authority responsible for indigent
Burial at sea - special permit Not closer than 3 sea miles from coast
Cremation: Provincial rules & regulations may differ
Disposal & Handling of Bodies
Not to be kept in a room where someone lives, sleep, work or where food is prepared or kept.
Not to be kept for more than 24 hours outside of a mortuary.
Removal order necessary if buried somewhere other than area where death occurred.
Permit if outside RSA.
General Traumatology
Definitions
Traumatology = “ The study of wounds and injuries and their scientific description”
It includes studying the natural properties of the forces applied and the bodies involved (receiving) and the pathology that may result.
Injury - Lesion, internal or external, on the body resulting from the application of any force (physical, chemical) that is more than what the body threshold can tolerate
Wound - Morphologic disruption of the continuity of the skin
Causes of Injury
Physical
Mechanical
Sharp force
Blunt force
Firearm discharge
Non-mechanical
Thermal (Temperature)
Electricity
Pressure (Barotrauma)
Ionising radiation
Chemical
Irritants / Corrosives
Biological
Bites
Mechanism of injury
Interaction between the force (Kinetic / Thermal / Electrical energy) applied and the body
Wounds are caused when the tensile strength of the tissues is exceeded.
Nature and extent of injury depends on many factors: - Type of object, - Surface of the object - Consistency of object
Applied force evoking a counterforce.
Wounding capability – Force • Area of application • Duration of application • Behaviour of the object at the time of impact…(moving or not)
Biomechanical properties of the body tissues – Condition of the body ……May influence the severity of the results of trauma • Type of tissue force applied on • Healthy vs. Underlying pathology • Intervening material • Protective Clothing, thick Hair, intermediary (window), whether Fat or thin
Circumstances of wound infliction
Intentional (Sharp force /Firearm discharge) – Inflicted by others (homicide)
Stabbed chest
Firearm discharge
Self-inflicted – (suicide)
Stabbed chest (heart)
Firearm discharge
Therapeutic - intercostal drain insertion)
Non-intentional
Accidental -
Impaled by broken glass
Firearm discharge while cleaning the gun
Pattern of Injury
When examining injuries, note: – Site – Size – Orientation of the wound
Particular action results in a particular pattern of injuries – Self-inflicted injuries – Defence injuries • Natural reaction of victims to protect themselves.
Pattern of injuries may also assist with determining
The cause/ weapon
Circumstances
Suicide (multiple/parallel incised wounds over vital structures)
Child abuse (scalding on the buttocks)
Sexual assault (discoid bruises on the thighs)
Community assault (tramline injuries)
Complication of injuries
Haemorrhage • External or internal • Site NB
Infection -Introduction of m.o into the wound/body • Cellulitis /Meningitis • Pneumonia • Peritonitis / Necrotizing fasciaitis
Metabolic disturbances
Shock Stasis related
Decubitus ulcer/ pressure sores
Pneumonia.
Thrombus formation Embolism • Pulmonary thrombo-embolism • Fat embolism. • Foreign body • Amniotic fluid / Air embolism
Organ failure – • Diffuse alveolar damage – lungs • Tubular damage – kidney • Disseminated intravascular coagulopathy (DIC)
Advancement = PM radiology
Many death investigation systems in 1st world countries have post-mortem (PM) radiology in their routine.
PM radiological imaging assists in – Evaluating Injuries and their complications – Localize radio-opaque foreign objects in firearm-related deaths
May reduce the need for an autopsy
In RSA, most FPS facilities can access PM radiology • On-site (Full-body digital X-ray scanner ) – Smaller facilities access (x-ray) at nearby bigger FPS facility • Share with the living at local hospitals – CT Scan shared with the living • Postmortem Ct Angiography – not readily available
Traumatology (Regional Injuries)
Introduction
Different regions of the body can sustain injuries caused by various objects
These injuries may be limited to one body cavity or may affect two cavities due to their proximity or occur from same event – (Head and Cervical spine) or (Chest and Abdomen)
The location of an injury will determine whether injury is fatal or not – Stab wound on the leg vs to chest – Kick to the chest vs head
Injuries can be open (penetrating / with a overlying skin wound) or closed (non penetrating)
Circumstance of injury – Intentional (suicide, homicide ) – Non-intentional (accident)
Head Injuries
Most common injuries noted
Caused by
Blunt force (RTA, Assault, Birth trauma, Sports-related)
Sharp force (Stab and Chop)
Missiles Projectiles / Firearms (Gunshot and shotguns wounds, Shrapnel, Crossbow, and Stun-guns)
Iatrogenic (surgical procedure)
Injuries can be on the
Scalp
Skull
Brain
Meninges
Facial structures
Scalp
Can sustain the same injuries as skin anywhere in the body (BF, SF, GSW)
Affected by – Hair - serves as a cushion and minimizes injury or hides the injury.
Numerous blood vessels in the subcutaneous layer of the scalp – Bleed profusely even if small – Bruises may track to the loose skin on the eyelid ➔ periorbital bruise – May spread infection into the cranium through the emissary veins leading to meningitis or cerebral vein thrombosis
Laceration may be confused for incised wounds
Skull fractures
Vault fractures
Linear – Low-velocity impact over a large area flat surface or ground – Very common and often requires no treatment
Depressed – Large amount of force applied to a small area by a low-velocity object. – Both tables are fractured with the inner table more fragmented – Bone intrudes into the cavity, lacerating the underlying brain tissue. – Require treatment
Mosaic/ Spider’s web – Series of complete or incomplete linear fractures encircling a depressed point of impact – The fractures are small and free-floating at the epicentre
Diastasis fracture – Bursting of suture lines. Fractures travel through suture lines – an area of weakness
Base of skull
Hinge - extends across the base of the skull
Ring - floor of the middle cranial fossa and squama of temporal bone surrounding the foramen Magna
Punched out fracture – GSW fracture • Has bevelling ➔ direction of the bullet
Iatrogenic fractures- burr hole and ventricular puncture to be differentiated
No bevelling – Both fractures are associated with lacerated meninges
Medico-legal significance
Indicate the application of force to the head
More / severe fractures- imply increased force and likelihood of brain injury increased
Skull fractures do not kill, but brain injury and associated skull injury → blood aspiration may kill.
Intracranial Haemorrhage
Epidural
Haematoma seen between skull bone and dura matter – Arterial bleed – injured middle meningeal artery – Associated with fractured bone.
Subdural
Haematoma between dura and arachnoid matter – Venous bleed – torn bridging veins between cortical veins – Seen in the absence of skull fracture – inertia-related (acceleration / deceleration-related injury
In elderly patients with brain atrophy, the onset of symptoms may be delayed before a large haematoma accumulates
Subarachnoid Haematoma
Bleeding between the arachnoid and pia matter,
Due to tearing or rupture of
Cerebral blood vessels
Basilar- vertebral or internal carotid arteries
Rupture of intra-cerebral haematoma into the arachnoid space
Often patchy at times and in multiple areas
Blood can mix with CSF and follow the CSF pathway
Seen in association with other brain injuries
May be seen in the absence of a skull fracture
Seen in trauma and non-trauma (underlying vascular pathology) scenarios
Complicate ➔ Hydrocephalus following scarring of arachnoid villi
Blood can mix with CSF and follow the CSF pathway
Brain injuries
Brain injuries can be – Primary = occurring at the time of impact – Secondary = occurring as a complication
Mechanical causes can be – Contact = Impact-related – Non-contact = Inertia-related / Head motion
Seen on the cerebrum, brainstem or cerebellum
Types of injury – Cortical Contusion – Laceration – Haemorrhage – Diffuse Traumatic axonal injury
Cerebral /cortical contusion
Impact between brain and bone leading to haemorrhage into the cortex
May cause necrosis of the of the tissue
May be associated with subarachnoid haemorrhage
Present with neurological dysfunction that takes longer than 24 hour to clear up.
Cerebral /cortical lacerations
Sufficient force applied to the head causing rapid movement and shearing of the brain may cause laceration.
Coup injuries
Static head struck – Acceleration injury – On side of impact Coup injuries
Contra coup injuries
Moving head struck – Deceleration injury – Opposite to side of impact
Intra-cerebral haemorrhage
Primary bleeding in the brain parenchyma (white matter)
Vary in size from 1 mm (petechial) to large haematomas but well defined
Seen mostly temporal and frontal lobes
Associated with other injuries e.g. skull fracture
Can communicate with the ventricles or the subarachnoid space
*“burst lobe”Can also be seen in natural disease – hypertension (basal ganglia and brainstem) or tumour
Secondary bleeding may be a complication – fat embolism syndrome
Trauma vs natural Traumatic causes Natural causes Patient’s age Any age Elderly Site Near surface Deep seated- e.g. basal ganglia, brainstem Number of bleeding areas >1 site Usually 1