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  TRAUMATIC INJURIES AND THEIR TREATMENT

  How Would Death Occur from Blunt Head Trauma?

  Q: At the climax of my book there will be a death scene, and I want to make sure I portray it accurately. Essentially, my heroine's love interest sits on a motorcycle that is parked near a curb. The kickstand gives way, and he falls to the side while sitting on the bike. His head hits the curb, the impact killing him. What happens when a person dies from such a head injury? Does blood come out of the ears or nose, or is there no sign of outer trauma? Does the body shake in any way, or will he be found still? At first my heroine doesn't realize that he's hurt. From her view, she can't see the curb. How would he look to her only seconds after he falls? How will he look by the time the paramedics arrive a half hour later?

  A: We call this type of injury "blunt trauma," as opposed to "penetrating trauma" from a bullet or axe or other object. Blunt head trauma may result in anything from a simple bump on the head (contusion) to sudden death. The force of the blow alone may cause immediate loss of consciousness (concussion). To cause death, bleeding within or around the brain would most likely have to occur. This is called "intracranial bleeding." It may occur with

  rupture of an artery, a vein, or multiple small capillaries in and around the brain. Concussions and intracranial bleeds can occur with or without a fracture of the skull.

  A membrane called the dura mater covers the brain. The space between the dura and the skull is called the epidural space, while the area between the dura and the brain is termed the subdural space (Figure 1a).

  An intracranial bleed is one that occurs anywhere within the skull. They are of three basic types (Figure lb). Epidural and subdural bleeds occur in the space between the brain and the skull. Epidural bleeds are outside the dura mater and typically result from arterial bleeds from the epidural arteries, which are often torn by fractures of the skull. Subdural bleeds are usually venous in origin and occur in the subdural space. Intracerebral bleeds occur within the brain tissue itself. All are potentially lethal.

  Remember, the skull is a rigid capsule that protects the brain. However, if bleeding occurs within the skull or within the brain itself, the bony skull cannot expand. Thus, pressure inside the enclosure rises rapidly, effectively "squeezing" the brain (Figure 1c).

  At its posterior (toward the back) base (bottom), the brain narrows into a structure called the brain stem, which narrows further into the spinal cord, which in turn extends along the stack of bones called the spinal column down the back. The brain stem is a vital portion of the brain that, among other things, controls respiration.

  The only outlet from the skull cavity is the hole (called the foramen magnum) at the base of the skull where the brain stem and spinal cord exit. It lies near the back juncture of the head and neck. The mounting pressure within the skull shuts down all brain function and ultimately pushes brain material into the foramen magnum and down along the brain stem and spinal cord. Think toothpaste tube. We call this "herniation of the brain stem." Not only is consciousness lost, but the compression of the brain stem also shuts down respiration; death follows in short order.

  This process may occur over minutes, hours, or days. Remember how when you hit your head as a kid your mother would check you throughout the night to see if you were okay? That's because the bleeding may be slow, and headaches and coma and death may not occur for several hours. See, Mom was right.

  Occasionally, people who have suffered blunt trauma do not develop any neurologic symptoms until days or weeks later. When headaches, nausea, blurred vision, numbness, or weakness in their extremities (all symptoms associated with rising intracranial pressure) occur, they visit a doctor, and a slow intracranial bleed is discovered.

  The most likely injury in your situation would be a skull fracture with a rupture or tearing of an epidural artery (one of the many small arteries that course over the surface of the brain and are often torn with skull fractures), which would lead to bleeding. This would be classified as an epidural bleed. Arterial bleeding is usually brisk, and rising intracranial pressure, coma, apnea (loss of respiration), and death can occur very rapidly.

  Most likely your victim would merely lie there, neither moving nor breathing. Such trauma could trigger seizure activity, though usually not, and that wouldn't fit your scenario anyway. When the heroine sees him immediately after the event, he may appear as if he is merely asleep. With a skull fracture a trickle of blood may appear from the ear or nose or both. Also, he may have a blue-black swelling (contusion) at the point of impact. Or there may be no external signs of injury.

  A half hour later he would look . . . dead: blue-gray skin, flaccid (limp) limbs, dilated black pupils, no breathing, no pulse. The paramedics would most likely institute CPR and transport the victim to a hospital, where an M.D. would make the death pronouncement.

  Can My Heroine Survive an Auto Accident and Ruptured Spleen?

  Q: My sleuth is forced at gunpoint to drive to a remote area where she is certain she will be murdered. Her kidnapper, another woman, is riding in the passenger seat. They are traveling on a road temporarily closed for resurfacing. As they pass a few pieces of parked road equipment, my sleuth, desperate to save herself, spots a heavy-equipment trailer and veers into it at 30 miles per hour, hoping to selectively destroy the passenger side of the car. The steel trailer's rear bumper peels away the car's roof like the lid from a can, decapitating her tormentor. My heroine survives but is trapped with both shoulders broken and waits a half hour before being rescued. Later at the hospital we learn she has an injured spleen and is teetering between life and death. Needless to say, she is alive and beginning her long recovery by morning. Is my explanation way off the mark?

  A: A ruptured spleen fits this scenario perfectly. Blunt trauma in a car accident, which is likely from a steering wheel injury, often results in a splenic rupture. It is very common in motorcycle accidents, football and skateboarding injuries, and so forth.

  The spleen is a vascular organ (has a lot of blood in it); it sits in the left upper abdomen, tucked behind the lower margins of the ribs (Figure 2). It receives its blood from the splenic artery, a fairly large blood vessel. The spleen has a thin capsule that encases the soft and spongy splenic tissue (think blood-soaked sponge); thus it can rupture like a melon. In fact, its capsule is very easy to rupture or tear, and when breached, it will bleed profusely. During abdominal surgical procedures the spleen is handled with great care

  because even the delicate manipulations of the surgeon's fingers can injure it.

  Although they can, people don't usually die from splenic ruptures. The reason? After enough blood is lost, the blood pressure (BP) drops, and the flow of blood into the splenic artery and the spleen lessens, the bleeding slows, and the process stops. The blood pressure of the injured person may go down to 60 or 70, but he or she can survive for a while in this degree of shock. The classic example of a splenic rupture is the teenager who slams his motorbike into a tree or car and arrives at the ER awake but lethargic with a BP of 70. Interestingly, once the victim is given blood and fluids and the BP begins to rise, the bleeding worsens—higher BP,

  more blood into the spleen, more bleeding. Emergency surgery is the definitive treatment.

  Of course, with your character stuck in the sitting position, gravity will hasten and magnify the degree of BP drop and the resulting shock syndrome. Still, she should survive the incident unless medical care is delayed too long.

  Your character could exhibit several different symptoms as she waits for help and slips deeper into shock. Besides the pain in her damaged shoulders and abdomen, as the BP drops and shock sets in, your character will develop some or all of the following symptoms: dizziness, confusion, disorientation, hallucinations, nausea, vomiting, chills, shivering, thirst, cold sweats, blurred vision, sleepiness, weakness, a heavy feeling in her neck and extremities, and, finally, sleep or coma. Her reflection in the rearview mirror would be pale, even ghostly white, and maybe with a cyan
otic tint (blue-gray hue due to shock and low blood oxygen levels). She may be in and out of consciousness or perhaps have vivid remembrances of things past akin to waking dreams.

  Once rescued she will need immediate IV fluids, blood, and surgery to remove the spleen (splenectomy). Injured spleens are rarely repaired and almost always removed, since the spongy nature of the splenic tissue makes it very difficult to "fix." Besides, the spleen is not a vital organ, and people tend to get along quite well without one.

  She should recover completely from the splenic rupture and splenectomy, and were this her only injury, she would be out of bed in a couple of days, home in a week, and back to normal by six weeks. However, recovery from her shoulder injuries, which could require surgical repair, would take a few months. The shoulder surgery would likely be delayed for several days after the splenectomy so she could be stabilized and prepared for this procedure. Before and after the surgery, the shoulders would be immobilized by placing her arms in slings, and she would require sedation and analgesic medications for the pain.

  Where Can My Hero Be Shot and Survive?

  Q: In my story the protagonist is shot. Obviously, he survives, but he is partially incapacitated. He must overcome the antagonist in a hand-to-hand fight. Where could he be shot and still function?

  A: First, let's look at what happens when someone suffers a gunshot wound (GSW in medical shorthand). Ask any emergency department physician, and he will tell you that killing someone with a gun is not that easy. For a GSW to be immediately lethal, it must disrupt brain and/or heart function. Thus, a direct shot to the brain or heart is usually deadly in very short order. Also, a GSW to the lungs or a major blood vessel, such as the aorta, could be lethal in a manner of minutes or hours. Additionally, GSWs to the head, chest, or abdomen are severely incapacitating and would probably not fit your story.

  That said, I might point out the following:

  Many GSWs to the head do not penetrate the skull and thus do little brain damage. If the bullet approaches from a shallow angle, it may bounce off the skull and exit into the air or burrow beneath the scalp. In this situation a GSW that appears to be deadly at first would cause little harm, and your protagonist would fight on.

  A GSW to the chest likewise might not penetrate the chest cavity, but instead might glance off a rib or the sternum (breastbone). In this case no major organ damage would occur, and your hero could continue his pursuit. The bullet might fracture a rib, which would be very painful with any movement and with breathing, particularly if he has to chase the villain.

  A GSW to the abdomen might be well tolerated by your hero even if it doesn't simply embed in the flesh or muscles of the

  abdominal wall (which frequently happens) and actually penetrates the abdominal cavity. It would be very painful, more so than a GSW almost anywhere else, because the internal abdominal lining (peritoneum) is loaded with nerve fibers. But if no major blood vessel or organ (liver, kidney, or spleen) is damaged, your protagonist, if he is tough, could fight through the pain and overcome the enemy. Think James Bond.

  A GSW to an extremity seems best for your scenario. This would slow down your hero, but again, unless a major blood vessel was breached, it would not kill or greatly maim him. Besides, the injury could be tailored to hamper your hero's efforts to the greatest degree. If he must chase down the villain, then shoot him in the leg or hip or foot. If he must climb a rope or ladder or wrestle with the antagonist, shoot him in the arm. If he must swim, have the bullet enter his shoulder.

  I should also point out that people who suffer severe and potentially lethal GSWs often live long enough to kill their attacker or crawl to a phone or scrawl the killer's name in their own blood. If your protagonist is shot during the climax of your story, the wound could be more serious because he could survive long enough to do in the villain, call for medical help, and heal before the sequel.

  Can a Person with Broken Ribs Swim?

  Q: One of my characters is hit in the chest while standing on a sailboat and is knocked overboard. I later say that the blow broke a couple of ribs and one of the ribs punctured a lung, causing it to collapse. Using one arm he manages to keep himself afloat for the three or four minutes it takes for someone to haul him back aboard, using the boat's emergency sling.

  Would a person with a broken rib, let alone a col-

  lapsed lung, be able to use his arm well enough to keep himself afloat? And assuming that this character received competent medical treatment in a modern hospital within two hours of the accident, how long would it be before he could plausibly make his next appearance in the story?

  A: A rib fracture is extremely painful, especially since we can't "rest" it or immobilize it while it heals. A broken arm is splinted or placed in a cast; the chest cannot be restricted in this fashion, since breathing is not optional.

  Inhaling air into the lungs is an active process. The muscles between the ribs work to expand the chest, creating the negative pressure within the chest cavity required to pull air into the lungs. A fractured rib makes this an extremely painful process.

  The pain is typically localized to the area of the fracture and is very sharp—like a knife sticking into the chest. Each breath is excruciating. We call this type of pain "pleuritic." It results not only from the broken rib itself but also from the highly enervated (has a lot of nerves) lining of the chest cavity, called the "pleura."

  If the sharp end of the broken rib protrudes into the chest cavity, it may puncture the lung, causing it to collapse. We call this a "pneumothorax." The pneumo (for short) may be small or large, meaning the degree of lung collapse may be minor or significant. We grade these by percentage of collapse. A minor pneumothorax would be 10 to 20 percent, while a large pneumo would be 50 percent or more. A complete collapse would of course be a 100 percent pneumo.

  A minor collapse is painful but otherwise not severely debilitating. A complete collapse is painful and associated with marked shortness of breath. It would be lethal only if the victim has significant underlying heart or lung disease or if the pneumo is of the "tension" type. In a tension pneumothorax the hole in the lung acts as a ball valve, or one-way leak (Figure 3a). When the victim inhales, air passes from the lung, through the hole, and into the

  chest cavity (Figure 3a), yet when he attempts to exhale, the air cannot pass back through the hole, into the lung, and out through the mouth (Figure 3b). Each breath increases pressure within the chest, collapsing the lung further. As the pressure (tension) mounts, the heart and the "good" lung also become compressed, resulting in declining heart and lung function and ultimately death (Figure

  3c). This may occur rapidly, over minutes. Fortunately, most pneu-mos are not of the tension variety.

  Long-term treatment also depends on the degree of collapse. With minor pneumos, the victim is often observed in the hospital for a few days. The leak usually seals itself, the lung reinflates, and the person goes home and experiences a few weeks of chest pain as the fracture heals. When it is a major collapse, a thoracostomy tube (or chest tube) is inserted (Figure 3d). This plastic tube goes through the chest wall and into the chest cavity between the chest wall and the lung. Suction is applied for several days, allowing the lung to reinflate and the leak to heal. The tube is then removed. Subsequent recovery is the same as with a minor leak but may take a couple of weeks longer.

  In your scenario a fracture with a minor pneumo would work. Yes, he could swim. Yes, he could fight if necessary. Yes, it would be very painful, but heroes are forged from pain and perseverance. He could return to action in a few days if absolutely necessary or if he is stubborn and not one to follow doctor's orders.

  What Is the Mechanism of Death in a Suicide by Hanging?

  Q: A man in my novel commits suicide by tying a rope around his neck and kicking a step stool away. He's dis- covered about half an hour later. Is the cause of death, then, strangulation? Would he have urinated or defecated in the course of dying? Would there be a smell? Also, what would his
face look like? Would he have died differently if there was a drop of six feet? Can I assume a different cause of death? Broken neck? Would his face look different? Would his neck be distorted in any way?

  A: The result of a hanging depends on several factors—the weight of the victim, the size and muscularity of his neck, and the

  distance of the drop, to name a few. If the victim drops several feet, the noose would indeed fracture his neck, and death would be fairly instantaneous. He would simply fall and then hang limply. Yes, he would likely evacuate his bladder and bowels, and the smell would be as expected.

  On the other hand, if the fall is short, as in kicking a chair or stool out of the way or having a horse spooked from beneath him—a staple in old Westerns—his neck would not break, and death would be from strangulation. It would be slow and painful, with a great deal of kicking and struggling. When death finally occurs, the victim would likely soil himself as above.

  In the latter case, his face would be purplish and engorged with blood. His eyes would protrude; perhaps his tongue would be swollen and protruding; and his neck would be excoriated from the struggle against the rope. Also, the conjunctivae—the pink part of the inside of the eyelid—would show petechial hemorrhages. These look like small bright red spots, and they result from the increased pressure in the veins and capillaries in the tender tissues. Similar findings are common in manual or ligature strangulations.

  Most suicides by hanging are poorly executed and the victim does not fracture his neck and thus dies from asphyxiation or strangulation. When the chair is gone and the person finds that he isn't dead, religion and panic take over in short order, and a life-and-death struggle ensues, regardless of how committed the person was to the suicide in the first place. Suddenly, what looked good on paper isn't so attractive. And since in self-hangings the victim usually cannot tie his hands behind his back, he will use them in his struggles for survival. He will claw at his neck or try to climb the rope to ease the pressure of the noose. This results in scratches and tears of the flesh, ripping loose of fingernails, and rope burns on palms and fingers.