The relationship between the location, characteristics and severity of a wound and the body structure, organs and major vessels involved is critical in the assessment of internal and external bleeding of a victim. Amputation or destruction of the head, abdominal cavity or extremities will by their very nature produce massive blood loss while a lethal puncture or stab wound may produce minimal bleeding (Figure 5.10). The number of injuries and the increased number of anatomic areas involved increase the number of bleeding sites. Thus multiple gunshot wounds, lacerations, or stabbing and incised wounds to any area of the body often produce massive bleeding. The susceptibility of the organ or vessel in the body to injury is an important consideration. The brain is in a protected cavity surrounded by the skull and unless direct blunt force or penetrating trauma occurs, it is perhaps the best protected organ in the body. The head offers variable amounts of bleeding depending upon the area, extent and type of injury sustained by a victim. Scalp lacerations may produce severe bleeding espe- cially when the temporal arteries are involved. Intoxicated individuals frequently fall and suffer head injuries of this type that, when unattended
Figure 5.9 Self-inflicted gunshot wound with massive destruction of head and brain evisceration resulting from barrel of rifle in mouth at time of discharge as victim sat at computer.
may result in a fatal consequence. In a case in New Orleans, an intoxicated person was arrested and placed in a jail cell overnight. At some point during the night, the inmate fell and struck his head on the bed frame in his cell. He developed severe shock and died with his head hanging over the edge of the bed while bleeding. It was estimated that he lost approximately 1500 ml of blood which had accumulated on the floor of his cell. It is common to encounter skull fractures, evisceration of the brain and massive bleeding in numerous cases of fatal gunshot and blunt trauma. However, there are many documented cases of survival after sustaining severe head injuries. A victim survived an attack with a roofing ax where the skull was able to resist deep penetration. In another case, an individual sustained a severe shotgun wound of the face and survived the ordeal despite being without medical attention for 48 hours. The victim lost a large quantity of blood in his residence during this period of time. He was finally found by a friend who discovered him in a semi-comatose state on his bed. There was evidence that the victim had removed his bloody clothing, taken a shower, shaved and used the toilet during this period of time. The blast from the shotgun traveled upwards and severely damaged the right side of his face including the orbit of the eye (Figure 5.11). Some pellets remained in the brain but the victim has recovered and is living a normal life.
Figure 5.10 Massive destruction of the head and blood loss due to self-inflicted shotgun wound.
Penetrating gunshot wounds of the head may produce minimal bleeding from the entrance site. This may indicate a relatively rapid death or minimal intracranial pressure associated with the injury. Blunt force trauma that pro- duces basal skull fractures may only show evidence of bleeding from the nose or the ear in the absence of external lacerations.
The nose and mouth are prominent structures that are frequently injured due to their location and may produce considerable bleeding due to their vascularity. Significant bleeding is usually associated with fractures to the nose and sinuses, as well as certain medical conditions such as nasal polyps, blood disorders, or hypertension. Oral hemorrhages result from fractures of the jaw, lacerations of the mouth and tongue, as well as esoph- ageal varicies or hemoptysis. The mouth and nose are also associated with active bleeding to the respiratory tract including the lungs and trachea as the result of trauma, infections, tumors, or chemical inhalation. Death due to asphyxiation may also cause bleeding from the nose and mouth. A couple were found deceased and bound in a bomb shelter in the basement of their home (Figure 5.12). Death was attributed to ligature strangulation. The husband had bled considerably from the nose and mouth with no directly associated trauma to those areas. The bleeding was considered due to the effect of prescribed anticoagulants taken by the husband for a heart condition in conjunction with ruptured capillaries in the airway passages (Figure 5.13).
Figure 5.12 Victims found bound and strangled in basement bomb shelter of their home.
Figure 5.13 Dripping and transfer of blood on floor from nose and mouth of male victim.
Injuries to the neck produced by penetration of a projectile or by slashing or stabbing with a sharp instrument may produce severe bleeding due to the severance of the jugular vein or the carotid arteries. These major vessels of the neck are located near the surface and have a fixed structure beneath them and are perhaps the most vulnerable vessels in the body. The resulting hemorrhage is massive and disabling. Bleeding from the carotid arteries is rapid as it exits under pressure. The resulting bloodstain patterns are distinctive in their appearance. Death may ensue quickly due to acute blood loss and reduced oxygen supply to the brain. A young woman sur- vived a brutal attack in which she sustained in excess of 35 stab wounds. Many of these stab wounds were inflicted to the head but did not penetrate the skull. A large kitchen knife was left embedded into her neck which was later removed in the emergency room (Figure 5.14A and B). Despite exten- sive blood loss, the victim survived the attack and made a complete recovery. The organs of the chest including the heart, lungs, and aorta are located within the rib cage and are thus protected from all but severe injury to the chest. The amount of bleeding may be minimal to none when the injuries are not severe. Chest wounds of a blunt nature will cause hemothorax for- mation but often no external bleeding unless there is hemoptysis from an injured lung or crushed chest. Penetrating injuries to the chest related to gunshot or stab wounds often produce more internal bleeding than external bleeding unless there is a perforation of the heart or aorta or a large, gaping wound of the chest wall. In these situations there may be an unimpaired flow of blood from the external wound site. The blood volume that may accumu- late in the pericardial cavity after heart penetration may reach a volume of 100 to 200 ml. The effect of this blood accumulation in the pericardial sac acts as a hydraulic impediment to the movement of the heart. If there is injury to the coronary artery, there may be further reason for cardiac standstill and death. The amount of bleeding into the chest cavities after lung injury or aortic transection may be in a range of 1000 to 1500 ml. On one occasion where a robbery victim was stabbed in the anterior chest wall, he collapsed and regained consciousness only to be stabbed again in the back. At autopsy the knife outline produced by the stabbing in the back was clearly visible through the massive blood clot in the chest cavity produced by the initial injury.
In the abdominal cavity there is protection of the organs in the upper area where the lower rib cage is still a very significant protective factor. In the pelvic area the bones of the pelvis serve to protect the lower abdominal cavity organs including the bladder, rectosigmoid region, and large vessels below the abdominal aorta bifurcation. Injuries to the abdomen from blunt or penetrating trauma may show bleeding that may occur over a period of
time greater than that seen in chest injuries. A large entrance wound produced by shotgun discharge in the abdominal cavity will produce great damage to the abdominal wall as well as to the internal organs in that region. The liver is a frequent target for injury because of its size and location and may bleed over an extended period of time unless there are numerous sites of tear or
Figure 5.14 (A) Knife embedded in left side of neck of surviving victim; (B) view
rupture. The spleen is an extremely vascular organ and its rupture is associ- ated with rapid bleeding, shock, and ultimate death in the absence of medical intervention. Trauma to the kidneys may produce very serious bleeding depending upon the extent of the injury. Aortic injury or rupture produced severe bleeding in the chest and abdominal cavity that may rapidly produce shock and ultimate death unless rapid surgical intervention is available. Bleeding from mesenteric artery tears or injuries may be relatively slow depending upon the site of the injury. In a recent case involving a tear of the superior mesenteric artery of a child, a total of 750 ml of blood was observed in the abdominal cavity. The death occurred hours after injury, which was more of a squeezing injury than a blow. Damage to mesenteric vessels may impede circulation to portions of the intestine and result in delayed intestinal necrosis and perforation in surviving victims. The separation or fracture of the pelvis may produce a slowly forming retroperitoneal hematoma which may produce shock a day or more after injury. This is common in victims of vehicular accidents and falls.
Bleeding from urethral, anal, or vaginal orifices may be associated with natural disease including tumor formation, and polyps that may cause spon- taneous as well as voluntary expulsion of blood. Significant bleeding may also occur during the menstrual period. During the investigation of a suicidal hanging of a female who utilized a bed sheet, a large accumulation of blood was noted on the front of her blue jeans which had continued to drip onto the floor creating a large drip pattern and pool of blood. This was produced by a profuse menstrual blood flow from the victim.
There may also be an unnatural cause for bleeding from anal or vaginal orifices due to mechanical intrusion by foreign bodies or objects such as dildos, broom handles, etc. These intrusions may be associated with an assault upon the victim or may be acts of self abuse by the persons themselves. In the absence of an accurate history, these injuries may not be able to be identified as self-inflicted.
The femoral arteries and veins are also located in a vulnerable position, but they do not have a fixed body behind them so that their injury potential is much less than that of the neck vessels. However, the vessels of the elbows and wrists are located in vulnerable areas.
Large amounts of bleeding by a victim due to major injury can be des- ignated as quantities in excess of 200 ml or 6 ounces, and small amounts as less than that quantity. Large amounts of bleeding are associated with such events as decapitation, crushing of the head by blunt force, explosive destruc- tion of the body, amputation of an extremity, shotgun injuries to various areas of the body and slashing or stabbing with numerous varieties of sharp instruments. Denudement of large areas of skin and tissue such as may occur with motor vehicles and other types of machinery may produce massive
bleeding. Minimal bleeding may occur in a variety of situations. A short post-injury survival time may reduce bleeding of a victim. The bleeding from a lacerated face, nose, or mouth may be small in volume. In those areas of the body that lack large blood vessels, injury may not produce excessive bleeding. Bleeding from the nose or ear associated with skull fracture may be minimal. There may be some bleeding associated with multiple abrasions from blows or as a result of friction from contact with a surface onto which a victim has been thrown.
The amount of blood flow will vary in different anatomic regions of the body and is an important consideration not only for medicolegal purposes but also for the emergency medical team and emergency room physicians who may treat the victim in a trauma unit.