J O U R N A L O F

CLINICAL
FORENSIC
MEDICINE
Journal of Clinical Forensic Medicine 13 (2006) 344–348
www.elsevier.com/locate/jcfm

Case report

Delayed deaths after vascular traumatism: Two cases

Anny Sauvageau MD, MSc (Forensic Pathologist) *, Jean-Sébastien Trépanier BSc,
Stéphanie Racette BSc (Research Assistant)
Laboratoire de sciences judiciaires et de médecine légale, Édifice Wilfrid-Derome, 1701 Parthenais street, 12th floor, Montreal, Que., Canada H2K 3S7

Available online 5 October 2006

Abstract

During expert testimony in court, forensic pathologists are often asked to estimate the length of survival following fatal injuries.
Though it is impossible to be precise, fatal vascular trauma survival times are generally considered short. We here report two unusual
cases of delayed deaths, one following homicidal stabbing of the heart and the other by suicidal cutting of the neck. In those two cases,
investigation clearly provided evidence of prolonged survival: slightly more than 2 h for the first case and about 8 h for the second. Rel-
evant literature is revised and physiopathological hypotheses are discussed.
Ó 2006 Elsevier Ltd and AFP. All rights reserved.

Keywords: Survival time; Heart injuries; Neck injuries; Forensic pathology

1. Introduction
During medical testimony in the courtroom, forensic
pathologists are often asked about time delay between
occurrence of fatal injury and victim’s death as well as pos-
sible physical activity before collapse. Although this evalu-
ation of survival length is difficult, it is generally thought
that in critical cardiovascular trauma, death occurs within
minutes and that most people sustaining such injuries are
not even able to reach the hospital alive.1–4
We here report two cases of delayed death following
severe cardiovascular injuries.
2. Case reports
2.1. Case 1
A 71-year-old man was found lying down in the door-
way of his apartment by firemen during their fight against
flames. The victim’s hands were tied by a dressing gown
waist cloth and he was wearing underwear. Fire investiga-
*
Corresponding author. Tel.: +1 514 873 3300; fax: +1 514 873 4847.
E-mail address: a.sauvageau@msp.gouv.qc.ca (A. Sauvageau).
tion revealed two distinct ignition sites in the deceased bed-
room as well as an opened empty bottle of fondue gas. A
bloody kitchen knife was also present at the crime scene.
Autopsy revealed a white man of 70.4 kg and 1.53 m
with second and third degree burns covering about 34%
of the body surface: burns of the scalp (2%), torso (10%),
superior limbs (7%) and inferior limbs (15%). Blood had
a cherry red color and abundant soot was found at trachea
and bronchus opening.
Two stab wounds were also seen, one to the back and
the other to the chest. The back stab wound was minor
in consequences, with only soft tissue damage. The thoracic
stab wound on the other hand caused severe damage. The
wound was localised to the left side of the chest, about 3 cm
left of the median line and slightly above the left nipple.
This stab wound was associated with pericardium perfora-
tion, a right atrium perforation of slightly less than 1 cm, a
1.5 L haemothorax and a few mL haemopericardium. In
addition, organs were pale suggesting hypovolemic and
cardiogenic shocks.
Apart from those fire and stabbing lesions, there were
also several non-lethal blunt traumatisms, clearly showing
that the victim had been beaten: about a dozen of bruises,
a scalp laceration, fracture of the inferior mandible and
ribs fractures.

1353-1131/$ - see front matter Ó 2006 Elsevier Ltd and AFP. All rights reserved.
doi:10.1016/j.jcfm.2006.06.008
 A. Sauvageau et al. / Journal of Clinical Forensic Medicine 13 (2006) 344–348
Toxicological analyses demonstrated the presence of a
25% toxic level of carboxyhemoglobin in peripheral blood.
Haemothorax blood however had a non-lethal concentra-
tion of carboxyhemoglobin (less than 5%).
Cause of death was attributed to the combined effect of
cardiac stab wound and acute carbon monoxide intoxica-
tion in a house fire. Mode of death was ruled as homicide.
It was later found that the man was living alone except
for the last two months where he had been providing hous-
ing to a young woman. She was having drug problems and
a background in prostitution. One of her relatives had a
long criminal record and was under police investigation
at that time, including a wiretapped phone. Further inves-
tigation led to the young woman and her relative’s confes-
sions. Those confessions were corroborated with other
witnesses’ depositions as well as the data from the wire-
tapped phone, allowing reconstruction of the fatal event.
The man was first beaten and stabbed, then robbed
before the aggressors left the scene. Two hours later, they
came back to dispose of evidence left on the crime scene
when they realised the man was still alive. They set the
apartment on fire, leaving the victim behind.
2.2. Case 2
A 50-year-old man was found lying down on the kitchen
floor of his apartment, with a large incised wound on the
right side of the neck. He was wearing a winter coat, a t-
shirt, jeans and woollen socks. The body was lying close
to a large woollen blanket, an electric heater, an empty bot-
tle of water and a chair that was turned over. Blood-
drenched mirror fragments from a broken table were found
in the living-room over a large blood stain, next to a heav-
ily blood-stained dressing gown. Homicide was suspected
and a forensic pathologist was called on the scene, as well
as a forensic biologist. The forensic pathologist first
assessed the time of death and then examined the body.
External exam unveiled an 11 cm lesion on the right lateral
side of the neck. Wound exam was compatible with the
blood-stained mirror fragment and hesitation marks were
noted. No defense wound was found. Those observations,
combined with the absence of infraction signs, oriented the
forensic team towards a suicide.
While still on the scene, the investigation team learned
that the man was depressive. He apparently called his son
the previous evening to tell him not to be worried if he
had no news from him in the near future since he intended
to kill himself. All those elements were thus further sup-
porting suicide as mode of death. However, some crime
scene elements were still hard to explain. Most of the bleed-
ing occurred in the living-room, where was found a large
blood pool and the blood-drenched mirror fragments from
the broken table. Some traces of blood were present in the
doorway and in the snow outside the front door. On the
other hand, there were neither bloody footprints nor crawl-
ing traces between the living-room and the kitchen where
the body was found, despite the fact that the victim was
345
wearing heavily blood-stained woollen socks and bloody
jeans.
At autopsy, internal exam revealed a right jugular vein
perforation, whereas the right carotid and the left vessels
were intact. Organs were pale, especially the heart and kid-
neys, ascribable to hypovolemic shock. The scalp presented
a posterior haemorrhagic infiltration, which probably
occurred when the victim collapsed. Apart from a light to
moderate atherosclerotic cardiac disease, the body did
not present any other significant injury or disease.
Further investigation clearly established the following
time line and allowed comprehension of the scene. The
man was found dead around 11 o’clock in the morning.
On the previous night, he called his son and then broke
the mirror table at about 23 o’clock (neighbours of this
badly soundproofed apartment building clearly heard that
sound). A few minutes later, he cut his throat and fell on
the floor (another clearly overheard sound). He must
have stayed in the living room for a while, making the
large blood pool found there. Once the bleeding was a
lot slighter, he left the dressing gown in the living room,
dressed in warmer clothes and went outside, probably
looking for help. Blood drops found in the doorway
and the snow outside the front door were thus left
behind. He then went back in his apartment, walked over
and partly wiped the blood spots in the doorway and
increased the temperature of the heating system. Neigh-
bours from the apartment above related suffering from
an unusual overheat during that night. The victim must
still have felt chilly, so he rolled himself in a woollen
blanket and went to sit just next to the heating system
in the kitchen. By that time, blood was mostly dried,
therefore explaining absence of bloody footprint or crawl-
ing traces between the living room and kitchen. Hypovo-
lemic shock responses, in addition to coldness, probably
made him thirsty and he drank a bottle of water. On
the bottleneck and cap of this bottle, slight deposits of
dried blood were found. Death occurred around 7 o’clock
in the morning according to the time of death determina-
tion by the forensic pathologist.
In this case, there was clear evidence of physical activity
following neck vascular trauma and length of survival can
be roughly estimated to 8 h. The cause of death was hypo-
volemic shock following an incised wound to the neck.
3. Discussion
Length of survival is hard to evaluate and can be really
variable from one casualty to another, even with similar
wounds. In 1935, Strassmann emphasised that the activity
of victims following fatal injuries does not follow a defined
pattern, even in cases with identical damage to the same
organs.5 Therefore, physical activity of a fatally injured vic-
tim cannot be accurately predicted. The only exceptions are
cases of cervical spinal cord and medulla oblongata dam-
age; death being almost instantaneous in these instances.5
Nevertheless, forensic pathologists often have to pronounce
346 A. Sauvageau et al. / Journal of Clinical Forensic Medicine 13 (2006) 344–348

themselves regarding possible physical activity by the
injured victim and his probable length of survival.
Regarding incised or stab wounds involving severe vas-
cular or cardiac traumatisms, it is generally considered that
collapse and death are fairly rapid.1–4,6 However, several
authors have reported exceptions to this general statement.
Some authors have uncovered the infrequent occurrence
of physical activity and of delayed deaths after a deadly
injury within their case reviews of sharp weapon lesions.6–10
Elkin, in 1936, has revised 13 cases of heart stabbing, of
which only 5 were engaged in various physical activity
before fatal collapse: one victim ran 3 city blocks, another
was able to walk 75 ft, 2 went by themselves to the hospital
and one collapsed about 10 min after his stabbing. Four
other cases were immediately physically disabled, thought
they managed to survive for periods ranging from 30 min
to several hours.7
Later in 1961, Spitz et al. described 49 cases of fatal stab
wounds. From those, only 12 (24.5%) presented a delayed
disability of more than 5 min.8 Two other series found that
extended post-injury activity was an unusual phenomenon:
3 cases out of 31 in the series by Zimmer et al.9 and 3 such
cases were described in the 22 case review of Levy and
Rao.10
Thoresen and Rognum (1986) studied 109 fatal injuries
from sharp weapons and observed within them that only 24
victims were able to make physical effort after the lethal
wound, going from few steps to a several 100 m run. Sur-
vival time in this same study was surprisingly long in some
cases: of the 64 victims for which survival time could be
evaluated, 30 survived more than half-an-hour. Indeed, 7
victims survived between 0.5–1 h, 11 between 1 and 12 h
and 12 for more than 12 h. Among the 30 victims surviving
more than half-an-hour, 10 had heart lesions. Although
majority of non-survivors had heart damage (this was a
rather uncommon lesion in individuals surviving more than
12 h), it should be remembered that heart stabbing is not
synonymous of immediate death. Interestingly, 20% of
the non-disabled cases had heart stab with ventricular pen-
etration. However, it should be mentioned that in those
non-disabled heart stabbing cases, the greatest effort ful-
filled was to ascend a staircase.6
A literature research underlined different case reports
where more details about the survival delay and physical

Table 1
Physical activity and length of survival in fatal cardiovascular lesions
Reference Authors Age/gendera Site of lesionb Physical activity before collapse Survival length
11
Rehn 22/M RV Walked 300 paces after 3 h of unconsciousness 3 h
12
Keen – Pulmonary trunk 3 paces, fell, 5 steps, hospital 45 min
8
Spitz et al. 70/M Pulmonary artery Crawled about 6 ft –
34/M RV Crawled about 6 ft –
37/F RV Talked for 5 min 20 min
43/F Pulmonary artery Crawled 10 ft –
29/M RL Ran across the street 1 h 15 min
23/M Heart Ran 1 city block –
37/M RV Drove 4 city blocks 20 min
25/M LV Walked 1 city block 35 min
23/M LV and aorta Walked 358 ft –
25/M L subclavian artery Ran 4 city block 1h
32/F R femoral artery Conscious 24 h
26/M RA Staggered 3 city blocks 35 min
9
Zimmer et al. – Trachea – 30 min
– Heart Ran 100 m –
– Pericardial artery – 24 h
10
Levy and Rao 67/M RV Staggered 100 ft –
37/M RV and aorta Ran 40 ft 7 min
38/M RV and RA Ran 15 ft and stairs 1 h 15 min
13
Karger et al. 48/F Right ulnar artery Applied dressings, walked >6 h
42/M Left saphenous vein Took a bath 7 h
23/M RL, liver, pericardium Removed knife and walked 2h
46/M L carotid, vertebral arteries Walked 10 m Short
37/M LV Walked, concealed injury 2h
37/M RV Removed knife, sat down >1 h
22/M LV Collapsed after 3 min 20 min
32/M LV Talked, walked 10 m 2h
27/M LV Sat down, talked 20 min
36/M RV Removed knife 20 min
40/M RV Walked, talked 15 min
26/M LV Immediate collapse 30 min
a
M, male, F, female.
b
RV, right ventricle, LV, left ventricle, RA, right atrium, RL, right Lung.
 A. Sauvageau et al. / Journal of Clinical Forensic Medicine 13 (2006) 344–348
activity were available.8–13 They are compiled in Table 1. It
should be mentioned though that delayed deaths from late
complications of stab lesions were not revised here since
this is a different issue. Effectively, several authors have
reported cases of late tamponade or late haemothorax
occuring several days after the stabbing.14–19
Five factors have been proposed as outcome predictors
of sharp instrument lesions regarding post-injury physical
activity and survival length: site of injury, wound size,
number of lesions, amount of blood loss and cardiac
tamponade.
The first factor contributing to the ability of physical
activity and survival after fatal cardiovascular trauma-
tisms is the lesion site. It is generally considered that arte-
rial lesions will lead more quickly to death than venous
ones, as will do the large-vessel injuries compared to smal-
ler vessel.3 In that same line of thought, penetrating
lesions to the heart and great vessels are negative factors
to survival.1,6 Campbell’s study, considering cardiac inju-
ries, reported that right ventricular injury was three times
more common than left ventricular injury in survivors and
therefore, seems to confer a significant survival advantage
over left ventricular lesions. Moreover, there was no vic-
tim sustaining an atrium injury in the survivors.1 Survival
advantage of ventricles lesions over atrium ones could be
explained by the unique configuration of their wall. In
fact, the thick ventricular wall is made of intricate muscle
fibers, slowing down blood effusion and favouring clot
formation1,20 since clotting within the myocardial wound
is directly proportional to the thickness of the cardiac
wall.
Secondly, wound size was also noticed to have an
impact on survival delay. In myocardial wounds, 7–
10 mm lesion lengths were more commonly associated with
longer survival time (2–10 min), whereas 1.4–2 cm lesions
were related to periods of about 10 s.13 Likewise, small
heart perforations or small carotid artery incisions offered
a potential for considerable physical activity13 while larger
lesions of the same type will result in short-term survival.
Another negative factor is the multiple number of
lesions: victims with more than one cardiac chambers
involved and those with associated injuries at non-cardiac
site.1 In the 109 cases review by Thoresen and Rognum,
it was clearly demonstrated that heart or multiple organs
injuries significantly reduced possibility of post-injury
physical activity and that most of these victims were dead
within 1 h.6
In addition, the amount of internal or external bleeding
has to be considered in the survival time estimation.
According to different studies, the amount of blood loss
is an important biological factor determining death or sur-
vival.6,8 It was noticed that lowest amounts of internal
bleeding were found in non-survivors. This could be
explained by the probability that the victims died before
the amount of bleeding had reached a considerable level.
Thoresen and Rognum showed that persons with blood
loss as high as 2200 mL may stay alive for several hours.6
347
Therefore, a 1500 mL leakage is not synonymous with
unconsciousness since some victims had even show physical
capability despite their important haemorrhage. Further-
more, a pleural breach with haemothorax was associated
with a higher mortality rate in the cases review by Camp-
bell et al.1
Finally, there is some controversies around the effect of
cardiac tamponade. While Karger et al. have stated that
cardiac tamponade had a negative influence on survival13,
some authors have demonstrated the opposite.1,21 An
hypothesis was proposed to explain this surprising positive
effect of tamponade: its occurrence may be associated with
a less important exsanguination.
4. Conclusion
Final words, ironically, could not be better stated today
that they were over 40 years ago by Spitz et al.: ‘‘This
points out that the opinion of immediate disability so fre-
quently offered by the medical expert in the courtroom
may be too dogmatic’’. Nonetheless, in every day life,
forensic pathologists often have to pronounce themselves
on post-injury activity and survival length. To simply state
that there is no possible accurate estimation would be of no
help neither to police investigation nor the courtroom.
Therefore, medical experts must try to offer the best possi-
ble evaluation, keeping in mind that exceptions are
although possible. Furthermore, to do so, they may rely
themselves on the five factors exposed by thoughtful litera-
ture review.
Acknowledgements
The authors gratefully thank M. Yves Bob Dufour,
director of the Laboratoire de sciences judiciaires et de
médicine légale, as well as Mme Gabrielle Trépanier, chief
of the legal medicine section, for their support.
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