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Transportation injuries

Dr. Ravi Nanayakkara

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Transportation injuries.

• Road traffic injuries

• Railway injuries

• Aircraft Fatalities

• Navigational Injuries

Objectives

• Discuss the role of a judicial medical officer in a case of road traffic accidents

• Describe the injury pattern of each road user• Medico – legal investigation of a death due to

transportation injuries• Describe the injury pattern in victims of train

accidents

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Road Traffic Injuries

• 17th August 1896 in London,

Continued…..

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The World's First Death by Motor Vehicle• On 17th August 1896, Bridget Driscoll, a 44 year old mother of

two, became the first person ever killed by a motor vehicle. She and her teenage daughter were on their way to see a dance performance at Crystal palace in London. She was struck by a car as they crossed palace grounds. Witness said the car was going “at tremendous speed”. It may have been going at 8 miles/h (12.8 Km/h), though it was meant to be going no more than 4 miles/h (6.4 Km/h). A young man driving, giving free rides to demonstrate the new invention and , according to some, trying to impress a young female passenger. At the inquest, the coroner said, “This must never happen again”.

Source: World’s first road death. London, Roadpeace.(http://www.roadpeace.org/articles/worldfirstdeath.html)

-accessed on 11th December 2003.

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• Every day more than 3000 people die of RTA

• 1.2 million died from RTA, Over 70 % - age less than 45

• 2.1% of all global deaths - 11th leading cause of global deaths

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Road Traffic Deaths Worldwide by Sex and Age Group

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• Global burden of disease and injuries 1990 rank for RTA 9th

2020 rank for RTA 3rd

• 50 million people injured each year.

• 85% deaths due to RTA are in Low income & Middle income countries.

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Top 10 Leading Contributors to the Global Burden of Disease*

1990Disease or Injury

1. Lower res. tract infections2. Diarrhoeal disease3. Perinatal conditions4. Unipolar major depression5. Ischaemic heart disease6. Cerebrovascular disease7. Tuberculosis8. Measles

9. Road traffic injuries10. Congenital abnormalities

2020Disease or injury

1. Ischaemic heart disease2. Unipolar major depression

3. Road traffic injuries4. Cerebrovascular disease5. COPD6. Lower res. tract infections7. Tuberculosis8. War9. Diarrhoeal disease10. HIV

continued…..

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• Every hour 34 RTI deaths take place in South East Asia.

• By 2020 this will rise by 144 % compared to 2000.

• Every second six persons across the world either die or suffer severe injuries due to RTI

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• Sri Lanka 2009

• Every hour at least 6 road crashes

• 3 injured every hour - 1 killed every 4 1/2 hours

6 per day

• 33302 lives lost last 20 years - 1538 per year

• Each death costs US$ 1912 (60 times monthly per capita income of US$ 33)

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Sri Lanka

Road traffic deaths

2010- 2500 deaths2011- 2400 deaths2012- 2900 deaths

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Why should we know about transportation injuries?

1. To assess injuries for the purpose of treatment.

2. To evaluate the role of natural disease in the causation of accidents.

3. To reconstruct the accident.

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4. To collaborate, evidence of eyewitnesses.

5. To assist in identification of the vehicle.

6. To predict the state of the person involved in the accident. E.g. drunk or drugged.

7. Identification of the victim.

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8. Documentation of injuries for the purpose of compensation claims.

9. To determine the cause of death.

10. To evaluate the circumstances of death. Homicide? Suicide? Accidental?

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Factors affecting the outcome of a RTA

Road + Environment

Vehicle

Human Factors of the road user Driver Pedestrian

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• Road + Environment

Road Density ( Vehicle population on the road ) Condition Bends, narrow, Steep, Slippery, Pit holes Environment Night, rain, mist, fog, Snow, Sand stones, Smog, Poor lighting at night etc.)

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• Vehicle

Speed

Condition (whether road - worthy!) E.g. Absence of breaks Head lamps Horn Signal etc.

Continued……

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Safety devices They do not reduce the number of

accidents, though will reduce the fatality rate and morbidity. E.g. Seat Belt Head Rests Crash Helmets (in motor - cyclist) Collapsible steering wheels Safety Windscreen glass Breaking system (ABS) Air Bags Locking system etc.

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• Human factors (Commonest cause in Sri Lanka)

Driver a) General Health Old age Poor vision Poor hearing Prolong reaction time Co-morbid factors such as HTN, DM, IHD etc.

Continued………

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b. ) Alcohol Consumption/Intoxication

Alcohol is incriminated for > l/3 of all RTA Legal Limit < 80 mg / dl in Blood

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c) Fatigue

• DROWSINESS• TIREDNESS• LACK OF ALERTNESS• SLEEPINESS

• Taking more risks• Frequent yawning, nodding, blinking• Disinterest in carrying on a conversation

FATIGUE RELATED TRAFFIC ACCIDENTS

Common examples:PilgrimagesAirport dropsWeddingsHolidaymakersTaxi driversLong distance bus driversVan drivers

FATIGUE RELATED TRAFFIC ACCIDENTS

Alcohol Fatigue• Particular group Every driver• Measurable No tests• Preventable No warning• Curable Very few treatable

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• Pedestrians

Intoxicated (Alcohol, Drugs) Impaired Vision / Hearing Incapacitation due to,

• Extremes of age.• Illness• Injuries

Breech of road rules

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• Road traffic injuries

• Pedestrians• Car / Vehicle drivers and occupants• Motor cycle users• Pedal cycle users• Three wheeler drivers and occupants• Others - Heavy vehicles, Tractors• Bullock carts and hand carts users

32Pedestrians account for more than half of the road fatalities.

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• Pedestrian injuries.

• The commonest RTA fatalities

• How ? Towards vehicle Opposite Direction Crossing the road

Continued……

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• Nature and severity depend on,

1. Nature of the vehicle (car/ van/ bus etc. ) Height of the vehicle.• Below the centre of the gravity of the victim• Above the centre of the gravity of the victim

Type of the vehicle (Heavy lorry, van…) Speed of the vehicle. Nature of the striking surface of the vehicle.

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2. Victim Orientation of the victim. Height of the victim (Centre of gravity). Personal factors. Movements after impact (thrown on to

path of moving vehicle)

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3. Road surface Nature of the surface Objects – stationary / moving

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• Injuries.1. Impact injuries

Primary impact Secondary impact

2. Secondary injuries

3. Tertiary injuries Run over injuries Run under injuries Drag injuries

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• Primary impact injuries

As a result of first contact with the vehicle.

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• Types of injuries

Imprint abrasions

Lacerations

Fractures

Contusions

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• Area of the bodyKnee levelThighHipElbowShoulderChest or head

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• When the impact is below the center of gravity

E.g. Car• Primary impact at knee level

• Bumper fractures occur at 14 MPH in young adults.

• Victim is scooped up Secondary impact injuries. Speed > 25km/h

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• Secondary impact injuries (not a must) Small cut injuries due to shattered

windscreen glass Skull fracture Rib fracture Lacerations contusions

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• When the Impact is above the center of gravity

E.g. Van, Bus

Injuries to pelvis, abdomen, arms, head

Victim may be projected forward ( forward projection ) or run over.

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• Secondary injuries

As a result of victim falling on the ground after the Primary or Secondary impact.

Found in impact with any vehicle.

Are often more lethal, esp. to head, chest, pelvis

Distance thrown : Throw distanceContinued…..

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Depends on,• Force of the fall.• Nature of the object struck.

Injuries,• Grazed abrasions• Contusions• Lacerations • Fractures• Contre-coup injuries to the brain• Internal injuries

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• Run over injuries

A wheel passes over the body Chest and abdomen - tire marks imprinted Limbs ,

• Tears of skin & muscles • De-gloving injuries

Continued…….

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Features,• Clothes - Tire marks, grease, oil

• Skin - Tire marks - Flattening of affected area - Soft tissue ooze

• Crushing and degloving of limbs

• Multiple fractures.

• Internal injuries

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• Run under injuries

Vehicle goes over the body but no run over by tires

Body gets pinned between under surface of the vehicle & road

Any type of fracture, crush injuries

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• Drag injuries

Victim gets entangled and dragged along the road

Grazed abrasions with mud and dirt from road.

• Injuries to vehicle occupants 80% are frontal impacts – with another

vehicle or object

Severe deceleration Less commonly vehicle is hit from behind

Acceleration Side impacts Roll over

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Occupants of vehicles

• Driver • Front seat passenger• Rear seat passengers / other occupants

Tissue injury depend on G force applied per unit area - Larger the area lesser the injury G=C(V)2

C =0.0039 V – Velocity km/h

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Additional injuries depend on subsequent behavior of the victim and vehicle.

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• Injuries depend on, Change in rate of movement ( G forces )

Speed of the vehicle. Speed of the offending vehicle. Nature of the impact. Design or the interior of the vehicle / cabin. Availability / usage of safety devices. Trapped within / thrown out. Subsequent behavior of the vehicle Vehicle catching fire

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• Injuries to the driver,

Head and face hit the windscreen glass, frame or side pillars. -Blunt and sharp injuries.

Neck - Whip lash injuries , Fracture dislocation of cervical spine.

-Due to hyper flexion and hyper extension ( Hyperextension more serious )

Continued………

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• Bleeding into surrounding muscles• Rupture of anterior longitudinal ligament of

vertebra• Tear of intervertebral discs• Compression of nerve roots• Ischemic haemorrhages and pulping of spinal

cord

Commonest site upper two cervical vertebrae

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Chest injuriesFractures of ribs, contusions lacerations of lungs Heart compressed between sternum and vertebra

Abdominal injuriesRupture of rectus abdominis , liver, duodenum, bowels

Knee injuries due to hitting of dash board.

Driver hit brake or clutch pedals• Posterior dislocation of hip• Fractures of pelvis , lower limbs, ankle

Broken windscreen glass - superficial lacerations(sparrow foot marks)Continued………

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Tightly hold the steering wheel - upper limb fractures ( shoulder, forearm, humerus )

Thrown out injuries – Fatality X 5

Sudden deceleration cause a pendulous effect on heart resulting in step ladder tears of aorta

Side impacts

Injuries to front seat passenger

• Nothing between body and windscreen• Risk of thrown forward• Less anticipation than driver• Forward projection may hit front parts of

cabin.

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• Injuries to front seat passenger

Hyper flexion and hyper extension resulting whip lash injuries.

Injuries due to windscreen glass and windscreen pillar. (Sparrow foot cuts)

Knees hit the dashboard as in driver. Thrown out more common (unrestrained

without seat belt ). Side impacts.

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• Rear seat passenger

Injury to face and head due to impact on front seats.

Dislocation of hip if sitting legs crossed

Thrown between seats and ejected to the windscreen.

Thrown out.

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Passenger Vehicles

• Vans, Buses, etc.

• Passenger injuries depend on Nature of impact

Relative position of the victim to impactsubsequent behavior of the vehicle.

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• Function of seat belts

It restrains the body against severe deceleration.

It spreads the deceleration over a considerable area – G forces.

The strap stretches appreciably during severe deceleration.

The belt prevent ejection into the road.

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• Function of Air bags

These are designed to interpose itself between the occupant and frontal structures of the passenger cabin.

It helps to cushion the impact and prevent forceful contact and hyper flexion.

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• Injury to motor cycle users

Rider / Pillion rider Traveling openly Balancing on two wheels Risk of thrown forward Easily can speed, maneuver Risk of run over by other vehicles Mostly used by young people Pillion rider has a greater risk of being thrown

off on impact

Continued…….

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• Injuries

Fall on ground

Projection forwards

Side impacts

Run over injuries

Continued……

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Rider

Injuries to • Head ,chest and abdomen• Upper limb injuries• Fracture femur, tibia, fibula• Pelvis injuries• Ankle injuries

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• Head and neck injuries In spite of usual wearing of crash helmet. Worse when riders are not wearing crash

helmets.

Skull fractures and intracranial injuries Chin hitting the ground causing hinge

fractureContre-coup injuries

Cervical spine fracture dislocation

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Limb injuries

• Grazed abrasions

• Contusions

• Lacerations

• Fractures

• Silencer burns

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Pillion rider

• Nothing to hold on• Risk of thrown forward• Often escapes from primary impact from front• Similar injuries as rider

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• Pedal cycle users

Injuries are very common

Less severe due to low speed

Primary injuries occur from impacts by other vehicles – speed of other vehicle

Secondary injuries due to fall on ground

Run over injuries

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Impact injuries from the offending vehicle

Secondary injuries due to hitting on road surface, sliding across the road

Run over injuries by same vehicle or another

Head injuries with intracranial injuries Unlikely wear helmet Bicycle spoke injuries

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• Three wheeler users

More hazard to other road users

The offending vehicle of the most pedestrian injuries

Lively hood of many adult males – Attempt to get more hires as possible during rush hours

Continued…..

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Head on collision

Can topple

Passengers can thrown out

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Injuries are more prone

• Small and compact nature of the vehicle• Overloading • No safety devises• Drivers are young and takes more risks

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• Medico legal investigation of a case of Road Traffic Accident (Hit & run)

1. History

2. Scene visit

3. Identification

4. Preliminary procedures

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5. Examination of clothing

6. General external examination

7. Specific external examination

8. Complete internal examination

9. Specific investigations

10. Documentation

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Railway accidents

• Impact with the train

• Injuries to passengers

• Falling from train

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1. Impact with a train• Suicide

Jump to moving train• AccidentWalking or crossing the rail tractVehicles crossing unprotected rail tract• Homicide

Push to the moving train (rare)• Post mortem disposal

Murder and leave on the tract(PM injuries)

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2. Injuries to the passengers• Collide with another train• Derails

3. Persons falling from train• Accidental • Homicidal• Suicidal

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• Injuries following impact are usually fatal.

• Extensive musculoskeletal injuries.

• Decapitation

• Dismemberment / Amputation

• Bizarre injuries

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• Investigation of a body found in Rail tract ?

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• Unrelated to impact the trainElectrocution from overhead cablesNatural diseases (IHD, Epilepsy…)Snake biteLightening

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• Rail tract injuries

• Aviation injuries

• Navigational injuries

Read…..

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Mechanisms of injury in an adult pedestrian struck by a car at high

speed

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Summary

• Statistics• Pedestrian injuries• Vehicle occupants (car/passenger vehicle)• Motor cycle rider• Pedal cycle user• Three wheeler occupants• Train accidents• Medico legal investigation

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Case 1

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Case 2

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Thank you.