ࡱ> 5@ Objbj22 XXAGZT888$99dn::F::::::$҃R$ ::::: ::CCC:::C:CHCdC2wzl:: Z8=|.40d}>\C::: 15A5Asphyxia Contents: Definition Difference between asphyxia and anoxia Signs of asphyxia Types (causes of asphyxia) Definition of Asphyxia Asphyxia describes the situation in which the body is being deprived of oxygen. There will be either no air or insufficient air is getting into the body leading to low brain oxygen. Difference between Asphyxia and Anoxia Anoxia: is failure of oxygen that already present in the body to get to the tissues (e.g. shock, anemia, CO poisoning and heroin intoxication), whereas, asphyxia: describes the status of failure of oxygen to get into the body in the first place, which is usually due to mechanical obstruction. Signs of Asphyxia Congestion (non-specific) Cyanosis (non-specific) Edema of the face (non-specific) Petechial hemorrhage: always around the eyes, on eyelids, behind ear and inside the mouth. Types (Causes) of Asphyxia Environmental Crush asphyxia Suffocation (smothering) Positional asphyxia Chocking Compression of the neck Hanging BURNS AND FIRE DEATHS accident, suicide or crime? FIRE DEATHS CAN BE DIVIDED INTO DEATHS BEFORE THE FIRE, DEATHS DURING THE FIRE and DEATHS AFTER THE FIRE ACCIDENTAL FIRES The vulnerable people are: ALCOHOLICS SMOKERS CHILDREN THE ELDERLY EPILEPTICS SUICIDAL FIRES Self-immolation is not an uncommon method of suicide in some cultures CRIME 1) HOMICIDE 2)CONCEALMENT OF HOMICIDE 3)INSURANCE FRAUD 4)PYROMANIA FORENSIC INVESTIGATION OF FATAL FIRES THE LOCUS THE VICTIM The investigation involves examination of the fire scene itself, ideally with the body in situ, followed by postmortem examination and toxicological studies. This necessarily requires the presence at the locus of a number of personnel from different agencies, with different priorities. PERSONNEL AT THE LOCUS FIRE OFFICERS PROCURATOR FISCAL POLICE OFFICERS FORENSIC SCIENTISTS PHOTOGRAPHER PATHOLOGIST THE PATHOLOGISTS ROLE IDENTIFICATION CAUSE OF DEATH - documentation of injuries etc - ?alive during the fire - pre-existing natural disease - ?any factors preventing escape 3. COLLECTION OF SAMPLES - toxicology - forensic samples Other experts may be involved as part of the investigation ANTHROPOLOGIST ODONTOLOGISTS / RADIOLOGIST TOXICOLOGIST FIRE CASUALTIES The major causes of death are: inhalation of fire fumes burns and their complications other injuries other disease/complications of immobility BURNS A BURN RESULTS FROM THE DESTRUCTION OF TISSUE BY THE APPLICATION OF ANY FORM OF HEAT, OR OF ANY CHEMICAL SUBSTANCE. This can result from exposure to FLAME CONTACT with hot surfaces eg cooker rings RADIANT HEAT from hot objects eg electric or gas fires SCALDS bums due to hot liquids or steam eg water, hot oil CHEMICAL corrosive chemicals eg sulphuric acid RADIATION eg from X-rays ELECTRIC CURRENT Mammalian tissue can only survive within a narrow temperature range, approximately 20-40 C. With bums due to external heat, the degree of damage depends on: 1. THE APPLIED TEMPERATURE 2. THE ABILITY OF THE BODY SURFACE TO CONDUCT AWAY HEAT 3. THE TIME FOR WHICH THE HEAT WAS APPLIED Even a relatively low temperature can result in a bum if it is applied for a prolonged period. The lowest applied temperature found to cause bums was 44C (body temp 37C), though this required exposure for a period of five hours. The usual temperature of bath water is 36-42C. Bums can result from prolonged exposure to hot water bottles, usually in the elderly. 10 seconds exposure to water at 60C will cause partial thickness burns. At 70C 10 seconds exposure produces full thickness bums. There are different methods of assessing the extent and depth of bums, and the treatment regimes are different in different countries. Patients with severe and/or extensive bums are referred to specialized burns units for ventilatory support/intensive care/plastic surgery. EXTENT OF BURNS ASSESSED AS PERCENTAGE OF BODY SURFACE, USING RULES OF THUMB e.g RULE OF NINES' OR CHARTS eg LUND & BROWDER CHARTS More than 70% bums are likely to be fatal at any age. Elderly patients may succumb to 20%. DEPTH OF BURNS There are various classifications. The degree of severity varies from simple reddening of the skin to deep charring down to muscle and bone. Many of the deep charred bums seen on bodies recovered from fires are post-mortem, and postmortem bums can observe ante-mortem burns and other injuries. SUPERFICIAL BURNS There is minor damage to the surface cells only. There is reddening of the skin due to dilation of blood vessels, and the burned area is sensitive to touch. Heal completely without scarring. PARTIAL THICKNESS Some or all of the epidermis (surface layer) is destroyed. Epithelial elements remain in the hair follicles etc. within the dermis. The burned area is reddened with blistering/peeling, and is sensitive to touch. The epidermis regenerates from the centres of epithelium over about 2-6 weeks, depending on whether the skin loss is superficial or deep. With more superficial bums the new epithelium is normal, but with deeper burns there may be extensive hypertrophic scarring. FULL THICKNESS All the epithelial elements of the skin are destroyed, leaving a discoloured layer of leathery dead insensitive tissue, known as an eschar. There may be severe tissue swelling under the eschar, which can compromise blood flow. In hospitals the eschar may be incised to release pressure - an escharotomy. Full thickness bums can only heal from their edges, resulting in scars. DEEP CHARRING Fluid evaporates from the skin surface if the bum is moist. With extensive bums this fluid loss is substantial, and without treatment can result in hypovolemic shock. The exposed surface of partial and full thickness bums are an ideal growth medium for bacteria, and without treatment will rapidly become infected. BURNS - CAUSES OF DEATH 1. SHOCK (depends on extent of bums rather than depth severe pain may activate reflex cardiac arrest fall in circulating blood volume due to capillary wall dilatation associated with increased permeability of vessel wall together with fluid loss from the skin if the bum surface is moist treated by intravenous infusion of fluid if bums > 15% 2. ASSOCIATED SMOKE INHALATION IN FIRES carbon monoxide and other constituents of fumes airway damage from hot/irritant gases anoxia due to consumption of oxygen, particularly with fire in confined spaces lung damage /shock lung 3. INFECTION / SEPTICAEMIA wound infection from patient's own skin, patient's bowel, environment chest infections / shock lung septicaemia 4. MULTIPLE ORGAN FAILURE 5. IMMOBILITY FIRE FUMES IN MANY FIRE DEATHS, DEATH IS PRIMARILY DUE TO INHALATION OF SMOKE AND FIRE GASES, WHICH MAY OCCUR IN THE ABSENCE OF ANY BURNS TO THE SKIN SURFACE. BURNS TO AIR PASSAGES due to hot/irritant gases SOOT useful marker of smoke inhalation, visible in airways at pm PULMONARY OEDEMA reflects lung damage CARBON MONOXIDE due to partial combustion CYANIDE in some fires, particularly older types of furniture foam OTHER TOXIC CHEMICALS eg from burning plastics Carbon monoxide (CO) can easily be measured in the blood after death, or in samples taken in life. It readily diffuses into the bloodstream, and binds to haemoglobin, forming carboxyhaemoglobin. CO binds to Hb more strongly than oxygen, so that oxygen carrying capacity of the blood is thus reduced. CO levels are expressed as the percentage of the total Hb which is carrying CO. CO levels in fire fatalities are usually of the order of 50-60%. If death is solely due to CO poisoning, a blood saturation of at least 40% is required. The elderly and those with eg coronary disease are much more susceptible to CO poisoning than young adults and deaths have been reported at 25%. Bodies recovered from the same fire, even when lying side by side, can show greatly varying CO levels. Children often have much lower levels than adults in the same situation. Differences may be accounted for by eg local variation in draughts, differences above floor level and varying respiration rates. Smokers can normally have a blood CO saturation in life of up to 5-6% THE PROGNOSIS OF FIRE CASUALTIES depends on AGE much worse in the elderly EXTENT AND DEPTH OF BURNS these are assessed on admission to hospital SMOKE INHALATION/HYPOXIA. OTHER INJURIES eg from escaping OTHER DISEASE eg heart disease Elderly patients often die from natural causes e.g. stroke, the burns being contributory but not the main cause of death. Fire casualties suffering from pre-existing lung disease eg chronic obstructive pulmonary disease, are much more susceptible to the effects of smoke inhalation. FIRE DEATHS-IDENTIFICATION IS IT HUMAN? remains may be badly damaged or fragmentary VISUAL may not be feasible FINGERPRINTS DENTAL if records available (DOCUMENTS, JEWELLERY etc) X-RAYS old fractures etc DNA compare with relatives FACIAL RECONSTRUCTION ?ALIVE DURING FIRE ASSESSMENT OF A COMBINATION OF VITAL REACTION to burns. Difficult to assess. There may be a 'flare' around post-mortem burns, and conversely there may be no visible reaction to known ante mortem burns SOOT INHALATION soot in the trachea and main bronchi, indicating that smoke was breathed in CO LEVELS if CO is present in the blood, useful. If the CO is negative, it does NOT mean that the individual must have died before the fire. There have been reports of fire death victims, known to have been alive during the fire, who have died with no bum injuries, no evidence of inhaled soot and low CO levels. CO may be very low or absent in some situations, particularly flash fires with petrol or kerosene. In experimental flash fires oxygen levels fall to less than half the normal level, together with accumulation of high levels of carbon dioxide. These changes occur in advance of the peak levels of carbon monoxide. It has been proposed that the combined effects of oxygen deprivation, combined with high carbon dioxide levels and the inhalation of hot gases containing water vapour can overcome the victim very rapidly, and death may ensue before there is significant inhalation of soot and carbon monoxide. DEATHS BEFORE THE FIRE CONSIDER THE POSSIBILITY OF HOMICIDE NATURAL DISEASE eg heart disease. ALCOHOL INTOXICATION DEATHS DURING THE FIRE INHALATION OF FUMES BURNS HEAT HYPOXIA PHYSICAL INJURIES NATURAL DISEASE DEATHS AFTER THE FIRE BURNS AND THEIR COMPLICATIONS RESPIRATORY PROBLEMS INFECTIONS OTHER FACTORS eg other injuries, natural disease TIME OF DEATH? Is extremely difficult EXPOSURE TO FIRE AFFECTS ESTIMATION OF THE TIME OF DEATH TEMPERATURE METHODS ARE INVALID THE RATE OF ONSET OF RIGOR MORTIS IS ACCELERATED ARTEFACTS eg heat stiffening MOTOR VEHICLE FIRES OFTEN ASSOCIATED WITH SEVERE DESTRUCTION OF THE BODY HIGH TEMPERATURES FUELLED BY COMBUSTION OF PETROL, UPHOLSTERY, PLASTIC COMPONENTS ETC In fires following a crash, injuries may have caused death before the fire, or have prevented escape . BOMB EXPLOSION INJURIES 1. COMPLETE DISRUPTION: Victim must be in contact with bomb Pieces found up to 200m away 2. EXPLOSIVE INJURY Within one metre of bomb, parts of limbs etc blown off. Pattern of injury may show position of victim in relation to bomb There is a characteristic triad of - BRUISES - ABRASIONS - PUNCTATE LACERATIONS sometimes with dirt tattooing of exposed skin due to impact of minute fragments from the bomb & its surroundings 3. INJURY FROM SEPARATE FLYING FRAGMENTS 4. INJURIES FROM FALLING MASONRY 5. BURNS mainly from secondary ignition of clothing etc 6. BLAST INJURIES INVESTIGATION OF EXPLOSIONS RETRIEVAL OF BODIES IDENTIFICATION OF VICTIMS X-RAYS ASSESSMENT OF INJURIES RETRIEVAL OF BOMB FRAGMENTS DROWNING DROWNING CAN OCCUR IN A WIDE VARIETY OF SITUATIONS THE SEA RIVERS/LAKES CANALS QUARRIES MINESHAFTS BATHS/BOWLS OTHER LIQUIDS BODIES RECOVERED FROM WATER NOT ALL HAVE DROWNED! 1. DEATH BEFORE ENTERING THE WATER eg disposal of bodies in the Ganges 2.DEATH IN WATER FROM CAUSES OTHER THAN IMMERSION/DROWNING eg heart disease, trauma 3 .HYPOTHERMIA in cold water 4.'IMMERSION' - reflex cardiac arrest 5.TRUE DROWNING IMMERSION DEATHS REFLEX CARDIAC ARREST due to sudden immersion in cold water 1. WATER ENTERING NASOPHARYNX 2. COLD WATER ON THE SKIN THIS LEADS TO MASSIVE REFLEX STIMULATION OF THE VAGUS NERVE, WHICH CAUSES SLOWING OF THE HEART AND CARDIAC ARREST NO SIGNS OF DROWNING ARE SEEN POTENTIATION BY ALCOHOL. Many victims are drunk The diagnosis is usually one of exclusion, made by ruling out natural disease, trauma etc, combined with circumstantial evidence. TRUE DROWNING ASPHYXIA DILUTION OF THE BLOOD PHASES OF DROWNING BREATH HOLDING FOR VARIABLE LENGTHS OF TIME UNTIL ACCUMULATION OF CARBON DIOXIDE IN THE BLOOD AND TISSUES CAUSES STIMULATION OF THE RESPIRATORY CENTRE IN THE BRAINSTEM AND THE INHALATION OF LARGE VOLUMES OF WATER. SWALLOWING OF WATER, COUGHING, VOMITING AND LOSS OF CONSCIOSNESS FOLLOW IN RAPED SUCCESSION. THE REMAINING AIR IN THE LUNGS ESCAPES AND IS REPLACED BY WATER. PROFOUND UNCONSCIOSNESS AND CONVULSIONS WITH GASPING PRECEDE RESPIRATORY ARREST, FOLLOWING BY CARDIAC ARREST. IRREVERSIBLE BRAIN DAMAGE AND DEATH FOLLOW SHORTLY AFTERWARDS IF DROWNING IS INTERRUPTED BEFORE TERMINAL GASPING SETS IN, THE VICTIM SOMETIMES RECOVERS, AND THE EVENT IS REFERRED TO AS A NEAR DROWNING. SOME SURVIVORS DEVELOP INCREASING RESPIRATORY DISTRESS, ACCOMPANIED BY HYPOXIA AND HYPERCANPNIA. THIS PHENOMENON IS KNOWN AS SECONDARY DROWNING. ITS ONSET MAY BE DELAYED. IT IS DUE TO PULMONARY OEDEMA, FOLLOWED BY PNEUMONIA, AND IS OFTEN ASSOCIATED WITH ASPIRATION OF GASTRIC CONTENTS INTO THE LUNGS. THE MORTALITY RATE OF SECONDARY DROWNING IS HIGH. IN COLD WATER PROFOUND COOLING OF THE BODY LEADS TO SLOWING OF THE METABOLISM. THIS HAS A PROTECTIVE EFFECT ON THE BRAIN etc, AND RECOVERY HAS BEEN DOCUMENTED WITH RESUSCITATION AFTER PROLONGED SUBMERSION. (IN ONE CASE 20 MINUTES) FRESH WATER DROWNING Fresh water has a lower salt content than the blood THERE IS MASSIVE ABSORPTION OF FLUID INTO THE BLOODSTREAM THIS LEADS TO A LARGE EXPANSION OF CIRCULATING VOLUME AND HAEMOLYSIS (bursting of red blood cells) which causes: ACUTE HEART FAILURE due to volume overload. RELEASE OF POTASSIUM from ruptured red blood cells into the plasma. HIGH PLASMA POTASSIUM LEVELS ARE HIGHLY TOXIC TO THE HEART THERE IS ALSO A HYPOXIC ELEMENT DEATH IS EXTREMELY RAPID CARDIAC ARREST OCCURS IN AS LITTLE AS 2 -3 MINUTES Much of the experimental work on animals may not be directly applicable to the circumstances of human drowning, but there is good evidence that the blood is diluted. Dilution of the blood may reduce measured blood alcohol levels significantly. SEA WATER DROWNING SEA WATER HAS A HIGH SALT CONCENTRATION (> 3%) FLUID ENTERING LUNGS IS HYPERTRONIC, SO FLUID IS DRAWN FROM THE BLOOD INTO THE LUNG TISSUE. THERE IS NO MASSIVE FLUID TRANSFER INTO THE BLOOD DEATH IS SLOWER, PREDOMINANTLY ASPYXIAL CARDIAC ARREST USUALLY 4-8 MINS SURVIVAL MAY BE LONGER IN COLD WATER AUTOPSY SIGNS OF DROWNING CLASSICAL SIGNS ARE ONLY PRESENT IN APPROX 35% OF CASES. Where there is a delay before retrieval of the body, the positive signs of drowning progressively fade, and are also obscured by the development of decomposition. 1. FROTH IN NOSE/MOUTH sometimes forming a plume extruding from the nose and mouth. This froth is formed of a mixture of air, mucus, surfactant and water, mixed up by the attempts of the victim to breathe. It is sometimes slightly blood stained, due to tiny tears in the lung tissue as part of the drowning process. It is not in itself diagnostic of drowning (similar froth can be seen in natural deaths from heart disease). Not uncommonly, froth is present when the body is recovered, but has collapsed by the time of autopsy. 2. PULMONARY OEDEMA the lungs are waterlogged, and frothy fluid exudes from the cut surfaces on sectioning. The absence of oedema does not exclude drowning 3. OVERDISTENTION OF THE LUNGS in older texts referred to as emphysema aquosum. The lungs are over-inflated and crepitant. There may also be some areas of intrapulmonary hemorrhage 4. DRY DROWNING IN 10-20% OF CASES THE LUNGS APPEAR NORMAL This is thought to be as a result of the aspirated water being absorbed through the alveolar walls into the plasma. 5. MIDDLE EAR HAEMORRHAGES are not specific, and are seen in cases of natural death etc CHEMICAL TESTS based on electrolyte levels in the blood, and the differences in blood composition between the right and left sides of the heart were described in older texts, but have now been shown to be unreliable. NON-SPECIFIC CHANGES DUE TO IMMERSION MACERATION OF THE SKIN GOOSEFLESH due to cold PINK COLOURATION due to cold WATER IN STOMACH in turbulent waters, may enter after death. In still water, suggests water was swallowed during drowning FOREIGN MATERIAL IN AIR PASSAGES eg silt, sand, weed HOW LONG IN WATER? NO WRINKLING: A FEW HOURS WRINKLING: 12HRS -3 DAYS EARLY DECOMPOSITION: 4 - 10 DAYS BLOATING/MARBLING/SKIN SLIPPAGE: 2 -4 WEEKS Floating due to gas formation occurs after a variable time GROSS DECOMPOSITION: 1 - 2 MONTHS ADIPOCERE: MONTHS THE DECOMPOSITION RATE IS APPROX HALF THE AIR DECOMPOSITION OFTEN OBSCURES SIGNS OF DROWNING AND MAY MAKE IDENTIFICATION DIFFICULT: fingerprints dental scars, tattoos. etc THE DIATOM TEST FOR DROWNING DIATOMS ARE MICROSCOPIC ALGAE present in water When inhaled as part of the drowning process, they penetrate the walls of the alveoli, and are carried in the bloodstream to distant organs. CAN BE DETECTED IN TISSUES eg bone marrow METICULOUS TECHNIQUE REQUIRED MAY BE DETECTED IN NON DROWNING CASES UBIQUITOUS present in soil etc MAY BE HELPFUL, BUT NOT LEGAL PROOF OF DROWNING WAS IT ACCIDENTAL SUICIDE OR HOMICIDE ACCIDENT OFTEN IMMERSION RATHER THAN TRUE DROWNING ALCOHOL VOLATILE SOLVENT ABUSE EPILEPSY MAY OCCUR IN VERY SMALL AMOUNT OF WATER SUICIDE NOT UNCOMMON ELDERLY REMOVAL OF SHOES/HAT/HANDBAG ETC PRECAUTIONS TO PREVENT SURVIVAL eg tying of hands CIRCUMSTANTIAL EVIDENCE IMPORTANT MAY BE DIFFICULT TO ESTABLISH HOMICIDE UNCOMMON BRIDES IN THE BATH ELDERLY/CHILDREN PAGE  PAGE 1 Dr. A. 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