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The child crushed by a gate and the need for parental supervision

20 Oct 2021

  • Mandatory supervision of children essential when handling modern tech: Case report 
BY Ruwan Laknath Jayakody  Children, who can be both immature and inquisitive, should be closely monitored and supervised, especially when they are handling modern technology, as they can be victims of tragedies especially when unsupervised and due to the lack of awareness regarding safety mechanisms.  This observation was made in a case report on “A child death from the unsupervised handling of modern technology” which was authored by W.R.A.S. Rajapaksha and N.A.S.P. Wijerathna (both attached to the Kelaniya University’s Medical Faculty’s Forensic Medicine Department) and published in the Medico-Legal Journal of Sri Lanka’s First Volume’s First Issue in August 2014.  As Rajapaksha and Wijerathna reiterate, parents or guardians should be cautious when allowing children to handle modern technology and should therefore supervise young children thoroughly as little experiments or mischievous behaviour could lead to fatal injuries.  Case report A six-year-old boy who was active was found dead in his own house, wedged upright between a remote-controlled sliding gate and its post. Police investigations revealed that he was found facing the gate which was tightly pressed against his mid chest while his back was against the gate post. The remote control device was found on the floor beside him. Further investigations by the Police revealed that this child had kept the remote controlled key with him. He was unresponsive when found and was pronounced dead upon admission to the hospital.  Examination of the locus (a particular position or place where something occurs or is situated) revealed a 10 centimetre (cm) by seven cm size vertically placed, metal projection made of two parallel blades on the gate post, 90 cm above the ground. The post-mortem examination revealed a compatible patterned abrasion on the back of the chest, 90 cm above the heel, which Rajapaksha and Wijerathna opined, can be explained from the projection of the gate post.  There were conjunctival (a tissue that lines the inside of the eyelids and covers the white of the eye) petechiae (pinpoint, round spots that appear on the skin as a result of bleeding), and marked congestion of the upper chest and face. Internal examination was negative except for the marked congestion. The cause of death was concluded as traumatic asphyxia. The caretaker, the grandmother of the child, was unaware about the child’s whereabouts at the time and assumed that he was watching television at the neighbour’s house.  According to further investigations, the sliding gate is heavy and made up of iron bars. It was 15 feet in length and five feet in height. A remote controlled 350-watt electric motor supplied the force for the sliding movement of the gate. There was a safety mechanism to prevent the crushing effect. If there is an unexpected object that comes into contact, it automatically reverses the gate. But when it comes to the last six inches, the safety mechanism is not effective, and it stops with the compression of the object without reversing the gate.  Both “Traumatic asphyxia in New Mexico: A five-year experience” by D.P. Sklar, B. Baack, P. McFeeley, T. Osler, E. Marder and G. Demarest, and “Fatal unintentional traumatic asphyxia in childhood” by R.W. Byard, K.A. Hanson and R.A. James noted that traumatic asphyxia due to accidental entrapment in a remote controlled sliding gate is a rare finding. Moreover, in “An unusual case of thorax (chest) compression”, B. Eren, N. Turkmen and R. Fedakar pointed out that to find a case of traumatic asphyxia where the body is held in an upright position is more rare.  Traumatic asphyxia, as “Difficult airway management in a patient with traumatic asphyxia” by P. Ibarra, L.M. Capan, S. Wahlander and K.M. Sutin, “Negligent homicide by traumatic asphyxia” by S. Miyaishi, K. Yoshitome, Y. Yamamoto, T. Naka and H. Ishizu, “Traumatic asphyxia by un-witnessed cardiac arrest” by L.G. Koniaris, M.E. Kross, N. O'Malley and E.E. Cornwell, “Bilateral retrobulbar haemorrhage (rapidly progressive, sight threatening emergency that results in an accumulation of blood in the space located behind the globe of the eye) and visual loss following traumatic asphyxia” by Y.J. Choi, S.J. Lee, H.J. Kim and J.H. Yim, and “Traumatic asphyxia” by D. Moore, J.H. Mayer and O. Gago explained, it is caused by the crushing of the chest and the abdomen when severe compression forces are applied directly to the chest, thus hindering respiration.  It is, they noted, also associated with asthma, paroxysmal coughing (frequent and violent coughing that can make it hard for a person to breathe), protracted vomiting, and jugular (neck or throat) venous (veins) occlusion (blockage or closing of a blood vessel). They further added that a significant increase of venous pressure occurs only when the glottis (opening between the vocal folds in the larynx that is generally thought of as the primary valve between the lungs and the mouth) is closed during chest compression.  They also added that this is clinically characterised by cervico-facial (relating to, or affecting the neck and face) cyanosis (bluish purple hue to the skin), oedema (fluid retention), sub-conjunctival haemorrhages (the conjunctiva, the clear membrane that covers the eye, has a lot of tiny blood vessels, and when blood gets trapped beneath this layer, due to a broken blood vessel, it is called sub-conjunctival, and it is characterised by a red spot on the eye), and petechiae on the upper chest and face (per Ibarra et al., Koniaris et al., and Moore et al.).  It is due to the reflux of blood from the right heart, backward, through the valve-less superior vena cava (large vein that carries blood from other areas of the body such as the head, neck, arms and chest to the heart) and the great veins of the head and neck, that causes the engorgement of the capillaries (smallest and most numerous of the blood vessels which form the connection between the vessels that carry blood away from the heart which are the arteries and the vessels that return blood to the heart which are the veins) which will in turn lead to capillary atony (a condition in which a muscle has lost its strength), dilatation and stagnation, they observe.  In the cadaver of the boy in the instant case, there was massive congestion and bluish discolouration in the upper chest, upper limbs, neck and head regions (per Ibarra et al., Miyaishi et al., and Koniaris et al.). This child only had, they state, an imprint abrasion on the back of the chest and there were no major injuries caused to the chest wall or the internal chest organs. This, Rajapaksha and Wijerathna elaborate, is due to a pliable chest wall in children.  Furthermore, in traumatic asphyxia, internal injuries are, as emphasized by Ibarra et al. and Miyaishi et al., usually minimal. The common injuries expected with it, as per them, are rib fractures, pulmonary (lungs) contusion, pneumothorax (collapsed lung) and hemothorax (collection of blood in the space between the chest wall and the lung). The injury to the heart and great vessels are, they point out, rare. As in this case, traumatic asphyxia does not cause hydrostatic (of or relating to fluids at rest or to the pressures they exert or transmit) pulmonary edema (swelling that is caused by fluid trapped in one’s body tissues) because chest compression increases intravascular, interstitial (pressure gradient that transports material from the blood vessel across the interstitial space to a lymph node), and alveolar (relating to an alveolus or the alveoli of the lung or lungs) pressures to the same degree; thus, the pressure gradient is unchanged (per Ibarra et al).  The lower body is spared with the stigmata of increased venous pressure, possibly because, they explained, the inferior vena cava (a large blood vessel responsible for transporting deoxygenated blood from the lower extremities and abdomen back to the right atrium of the heart) is compressed and it prevents the reversal of the venous flow. Patient morbidity and mortality is usually determined by, Rajapaksha and Wijerathna, explained, the presence and severity of associated cardiovascular, pulmonary, and neurological injuries.  Investigation into the safety mechanism of the gate explained why this child was entrapped and held between the gate and the gate post, thus causing persistent pressure over the chest wall and death due to traumatic asphyxia. The unsupervised handling of the modern technology and the delay due to the unawareness of the safety mechanisms, had, Rajapaksha and Wijerathna noted, contributed to the death of this child. Therefore, it is mandatory to observe and supervise children closely, especially when they are handling modern technology.  Furthermore, Rajapaksha and Wijerathna called for the development of a safety mechanism in these gates which will cease to function only when the two points (gate and gate post) are in contact.


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