Documente Academic
Documente Profesional
Documente Cultură
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Written by:
Dr. Rana Faizan Ali
M.B.B.S (Dali University, Yunnan, P.R China)
PM&DC (I,II,III)
dr.rfa89@gmail.com
Javairia Zulfiqar
M.B.B.S (Dali University, Yunnan, P.R China)
Interne
Revised by:
Dr. Muhammad Shoaib
M.D (Kyrgyz-Russian Slavic University, Bishkek, Kyrgyzstan)
PM&DC (I,II,III)
=====================================
Forensic Medicine Curriculum given by PMDC for Step 1:
1. Medical Law
2.Traumatology
3. Poisoning
Division of Marks:
2 SEQ = 10 Marks (5 marks for each SEQ)
10 MCQs = 10 Marks (1 mark for each MCQ)
MEDICAL LAWS
Adult: A person who has reached age of 18 years (for males) or 16 years (for
females) or who has attained puberty, whichever is earlier.
Authorized Medical Officer: A medical officer or Medical board constituted by
provincial government is called authorized medical officer or board.
Qisas: means punishment by causing similar hurt at the same part of the body of
convict as he has caused to victim.
Diyat: means compensation specified in section 323 payable to heirs of victim by
the offender.
Arsh: means compensation specified in Qisas and Diyat Ordinance paid by the
offender to the victim or his heirs.
Daman: means compensation determined by the court to be paid by the offender
to victim for causing hurt liable to Arsh.
Wali: is legal heir of victim or deceased or victim himself, in case of qatl; wali is
heir of victim or if the victim is unknown then government.
Medical Practitioner: it is the one who possesses a recognized medical
qualification, as defined in Medical council Act.
1. Prohibition of use of word doctor and its abbreviation unless he/she is an RMP
or a person whom a doctor's degree other than a medical degree has been
confirmed.
2. Prohibition of use of medical degree or diploma unless issued by institution
recognized by PMDC.
3. Prohibition of surgical operations by an unqualified person (circumcisions and
injections and abscess drainage can be done)
4. Prohibition of prescription of some drugs (antibiotics) unnecessarily.
5. Restriction on the sale of medicines unless labeled and formula is written on
packing or within packing.
Functions OF PMDC:
1. Supervision of standards of proficiency for registration:
a. Recognition of basic register able medical and dental qualification in and
outside Pakistan.
b. Recognition of additional postgraduate qualification granted in and out of
Pakistan.
c. Power of having detailed information of courses of study and methods of
examination of all those institutes whose qualification is recognized.
d. Power of appointing inspectors to check the standards of teaching and
examination.
2. Maintenance of official register of medical and dental practitioners:
There are 3 parts of PMDC register:
Part 1: Provisional registration for one year. it continues till the members goes on
paying fee.
Part 2: Registration after completing MBBS.
Part 3: Registration for higher Post graduates degree this is open for public for
their interest.
3. To take disciplinary measures
Obligations of an RMP:
1. RMP must notify the change of his or her address to PMDC in 30 days.
2. RMP must not use any
-Name
-Title
-Symbol
-Any other qualification that is not in notice of PMDC.
Medical Ethics:
members of Medical profession in course of their practice & their dealing with
their patients and other members of profession.
The Geneva Declaration (1948):
The world medical association at its 3rd general assembly at Geneva in September
1948 adopted certain codes of ethics in the form of Oath to be taken by all
Members of medical profession, at the time of entering into medical profession.
Hippocratic code:
1. I solemnly pledge myself to devote my life to service of humanity
2. I will give my teachers due respect and gratitude.
3. I will serve my profession with devotion and dignity.
4. Health of my patient will be my first priority.
Duties of a Doctor:
-what a doctor must do?
-what a doctor must not do?
Duties in General: a doctor must have always maintained the highest standards of
professional conduct. Doctor should not practice by motives of profit. Following
practices are unethical:
1. Self advertisement.
2. Connection with non-qualified person.
3. Receiving any money from patient other than fee.
4. Any abuse of his skills etc.
Doctor-Patient Relationship:
Doctor-Doctor Relationship:
Basis of Doctor-Doctor relationship is
1. Cooperation
2. Understanding
3. Avoiding of Professional Jealousy.
Professional Secrecy:
& his patient. The doctor is obliged to keep secret; all that he comes to know
regarding the patient during treatment.
Following Points May Be Noted:
Should not disclose illness of his patient with or without consent of the patient.
In divorce cases, no information should be given without the consent of client.
In case of reporting medical journals, patients identity should not be disclose.
In case of examining dead body, certain facts found, the disclosure of which may
affect the reputation of the decreased or may cause mental suffering to relatives
in such cases doctors should maintain secrecy.
Civil Negligence.
Criminal Negligence.
Contributory Negligence
3rd Party Negligence
4. Failure to remove swab from abdominal cavity during operation which may
leads to complication or even death.
SWAB Cotton or piece of cloth used to clean the abdomen.
TRAUMATOLOGY
Classification of Injuries:
1. Mechanical injuries by physical violence.
2. Thermal injuries by heat or cold.
3. Chemical injuries
4. Electrical injuries
5. Firearm injuries
1. MECHANICAL INJURIES:
The injuries inflicted by mechanical force are generally divided into those caused
by blunt force and those due to sharp force. Injuries may be single or multiple.
There may be more than one type of skin injury to the body and they may be
localized or widespread. The effects of the injury on the body may be local (e.g. a
bruise on the breast), systemic (e.g. shock following a stabbed blood vessel in the
leg) or as a result of complications (e.g. kidney failure due to shock and infection).
It should be noted however, that the absence of external injury to the skin or
genitalia does not exclude the possibility of serious injury to the internal organs.
Bruises or Contusions: A bruise is an area of skin discoloration. A bruise occurs
when small blood vessels break and leak their contents into the soft tissue
beneath the skin. In bruise external surface may remain intact, only subcutaneous
surface is involved.
Factor modifying appearances of bruises are:
1. Vascularity: greater the vascularity greater will be the size of bruise.
2. Force: greater the striking force greater will be the bruise.
3. Age: old age people bruise easily.
4. Sex: females especially obese one bruises easily
5. Area: bony sites and lax skin bruise easily, while abdominal wall and scalp
does not bruise easily. Scalp of newborn bruise easily.
6. Texture: thin and delicate skin bruise easily.
7. Physical condition: Obese and unhealthy persons bruise easily.
8. Diseases: persons with coagulation disorders, liver and renal failure bruises
easily.
9. Complexion: bruises are well marked on persons with fair complexion.
10. Blisters: due to oblique blow or fractures of underlying bone blisters are
formed over bruise.
Age of Bruise:
Color changes:
1st day: red
2nd day: violet
3rd day: bluish black
4th day: livid red
5-6th day: greenish
8-12th day: yellowish
13-15th day: normal
There are no bluish or greenish stages in subconjunctival hemorrhage.
Medico legal Aspects:
1. identification of objects causing injury
2. degree of violence
3. time of injury
4. Purpose of injury: around neck=throttling, around nose and
mouth=smothering, on arms and face=sign of struggle, on
inner aspects of thighs and genitalia=sexual offence.
5. Is bruise true or false
6. is injury suicidal, homicidal or accidental
Antemortem Bruise
Postmortem Bruise
No swelling
No color changes
3. Epithelium abraded
Not so
5. It can be anywhere
True Bruise
False Bruise
No color changes
Not defined
3. Swelling is seen
No swelling
4. Extravasation of Blood
Not present
5. Blood Coagulation
No coagulation
7. No itching
Itching is present
Positive
Abrasion: An abrasion is a superficial injury to the skin in which the outer layer of
the skin is scraped off.
Excessive bleeding
Infection
Thrombosis
Secondary shock
Supervention of new disease
Acceleration of preexisting disease
Operational disorders
Neglect of patient
Indirect effect
Age of wound:
Naked eye examination:
6. Abrasion
7. Bruise
8. Aseptic wound
- Edges are red and swollen
- Scab formation
- Epithelium begins to grow
- Complete epithelial growth
- Scab goes off
9. Septic wound
-Edges red and swollen 12-24 hours
-Pus is formed
36 hours
-Granulation tissue is seen 7 days
12 hours
12-24 hours
24-36 hours
4-7days
8-10days
Antemortem wounds:
Postmortem wounds:
Not seen
No infiltrates.
2. THERMAL INJURIES:
Tissue injury resulting from the application of excessive heat and cold is called
thermal injury.
Cold: Exposure to cold produces hypothermia which is defined as temperature
less than 35 degree C. The body can tolerate dry cold much better than wet cold,
as wetness increases heat loss considerably.
The localized effects of cold are frost bite, trench foot and immersion foot.
Trench foot and immersion foot are result of prolonged exposure to severe cold
(5-8 degree C), typically seen in soldiers during winter warfare, especially in
trenches and in person exposure to prolonged immersion.
Frost bite occurs due to exposure to greater extremes of cold (-2.5 degree C),
develops more rapidly.
Heat:
Heat cramps: Caused by rapid dehydration of body through the loss of water and
salt in the sweat.
It is seen in workers in high temperature when sweating has been profuse. Severe
and painful paroxysmal cramps affecting the muscles of arms, legs and abdomen
occurs.
Heat stroke: It is a condition when rectal temperature greater than 41 degree C,
occurs when there has been direct exposure to the sun.
Causes of burn:
Dry heat: Flame and heated solids
Radiant heat
Friction
Corrosive chemicals: Solid and liquid
Lightning
Electric current
X-rays
Ultra-violet or infra-red light rays
Varieties of burns:
-Most chemicals that can cause moderate to severe chemical burns are strong
acids or bases (such as sulfuric acid and Nitric acid). Hydro sulfuric acid can cause
damage down to the bone and its burns are sometimes not immediately evident.
-Electrical burns: electric shock such injuries may lead to cardiac arrhythmias,
cardiac arrest, and unexpected falls with resultant fractures.
-Burns produced by flame may or may not produce vesiculation, but singeing of
the hair and blackening of the skin are always present.
-Radiation burns may be caused by over-exposure to UV light and X-rays. Burns
due to X-ray and radium vary from redness of the skin to dermatitis, with
shedding of hair and epidermis and pigmentation of the surrounding skin. Severe
exposure may produce burns with erythema, blistering with delayed healing and
ill-formed scars.
-Burns from corrosive substances show ulcerated patches and are usually free
from blisters, and hair is not singed
Classification of Burns:
Burns are often categorized as first-, second-, or third-degree burns, depending
on how badly the skin is damaged.
First-degree burns: burns affect only the outer layer of the skin.
They cause pain, redness, and swelling. The skin is dry without blisters.
Healing time: Healing time is about 3 to 6 days; the superficial skin layer over the
burn may peel off in 1 or 2 days.
Second-degree burns: (partial thickness) burns affect both the outer and
underlying layer of skin. They cause pain, redness, swelling, and blistering.
Healing time: Healing time varies depending on the severity of the burn.
Third-degree burns: (full thickness) burns extend into deeper tissues. They cause
white or blackened, charred skin.
There may be little or no pain or the area may feel numb at first because of nerve
damage.
Healing time: Healing time depends on the severity of the burn. Deep second- and
third-degree burns (called full-thickness burns) will likely need to be treated with
skin grafts, in which healthy skin is taken from another part of the body and
surgically placed over the burn wound to help the area heal.
B. Internal: Heat hematoma occurs when the head has been exposed to intense
heat and skull bones are charred. It is soft clot of light chocolate color and
resembles honey comb appearance.
Fracture of skull bones if death occurs from burns.
The brain is usually shrunken, firm and yellow to brown.
Coal particles can be traced in the respiratory tract, if death occurs from
suffocation. (Carbon soot)
Stomach and duodenum show inflammatory reaction with ulcers. (curling ulcers)
Blood shows cherry red in color.
Spleen and adrenal gland are congested.
Rupture of fatty cells may cause fat emboli.
Various visceral organs may be burnt with fractures of bones.
Burns activates coagulation mechanism and produces thrombosis especially in
coronary arteries.
Age of burns:
Redness: Immediate
Vesication: 2-3 hours
Pus formation: within weeks
Appearance of red granulating surface without any slough: 2 weeks
Medico-legal aspects of burn:
Grievous hurt: Grievous hurt is one which endangers life or which causes the
victim to be in severe bodily pain or unable to follow an ordinary pursuits for a
period of twenty days. The following injuries are grievous hurt.
i. Emasculation (loss of masculine power of a male. This includes excision,
injury of vertebral column leading to failure of erection)
ii. Permanent privation of sight of either eye
iii. Permanent privation of hearing of either ear.
iv. Privation of any member or joint: It includes eyes, ears, nose, mouth,
hands, feet etc.
v. Destruction or permanent impairing of the power of any member or
joint: The use of limbs and joints of the body are very essential for the
normal functions of the body, their deprivation causes lifelong crippling and
makes the person defense-less and miserable.
vi. Permanent disfiguration of the head or face: such as permanent scars
amount to disfigurement.
vii. Fracture or dislocation of a bone or tooth.
viii. Any hurt which endangers life or which causes the victim to be severe
bodily pain, or unable to follow his ordinary pursuits for a period of 20 days.
3. CHEMICAL INJURIES:
Injuries produced by the action of chemicals on body like acids and alkalis. These
also include vitriolage (throwing of acids on face). There is damage at the site of
application and below (as fluid flows down).
Chemicals may cause ulceration, may eat up the tissue and form cavities, color of
the affected part may tell us about the used chemical.
Black= H2SO4
Yellow= HNO3
White to Yellow= HCl
By the action of acids or alkalis tissues may be coagulated, dried, shrunken hard,
shriveled necrosed etc. Alkalis mostly cause liquefaction of tissues. Other
chemicals like castor oil seeds are vesicants they cause vesications, if contact
duration is deeper tissues are also involved.
Chemical Burns:
Superficial burns: only superficial tissues are involved and contact is short.
Deep burns: contact time is prolonged and deeper tissues are involved.
Death in Burns:
-Shock: Pain-Neurogenic shock
Fear-Psychogenic shock
Complications- Hypovolemic shock
-Suffocation by gases like carbon mono oxide, carbon di oxide and fumes of
the chemicals
-Inflammation
-Toxemia
Objectives to be obtained:
a. Identification of person.
b. Burns are either antemortem or postmortem, in
case of antemortem vital reaction is seen, red line
at the base of blister, repair signs, scar, scab,
granulations etc.
c. Determine cause of death is it burns or something
else.
d. Mode of death
e. Look at the clothes and identify the smell.
f. Look for the levels of co, co2, in the blood.
g.
h.
i.
j.
4. ELECTRICAL INJURIES:
Includes death from electricity, lightening and radiation.
Electricity: Electricity is a form of energy produced by the movement of electrons.
Under certain circumstances can injure the body and cause death.
Sources of electrocution:
Domestic sources
Industrial, commercial centers and transport system
Electricity distribution system
Lightening
Electrical injuries: An electrical injury occurs when a current passes through the
body, interfering with the function of an internal organ or sometimes burning
tissue.
Electrical injury may result from contact with faulty electrical appliances or
machinery or inadvertent contact with household wiring or electrical power lines.
Electrical injury can also occur from lightning.
The maximum amount of current passes through the blood vessels.
The current flow adopts the shortest route to the earth, to be neutralized in the
earth.
Features of electrocution:
-Lesion at the site of entrance in the body:
There will be crater formation (due to resistance offered by the skin), which is
tough on palpation and the margin is raised with the depressed floor.
There will be cracking of the skin.
The site of entrance has a metallic luster (due to atomization of metallic electric
wires) If it is high voltage current then burning of tissues, blackening and charring
may be seen.
-Lesion at the site of exit from the body:
Common at the bare soles, The tissues may be rupture giving deep laceration like
appearance. Due to heat production, burning may be seen.
-General features:
Moment of electrocution is painless.
Tingling and numbness is felt.
Severe involuntary muscular contractions, seizures, ventricular fibrillation, or
respiratory arrest due to CNS damage or muscle paralysis may occur.
Cardiac arrest may occur without burns in bathtub accidents (when a wet person
contacts a 110-V circuite.g. from a hairdryer or radio).
Suspended animation like state may be observed for a short period.
Unconsciousness, mental confusion, partial deafness, defective vision,
incontinence of urine may be seen.
Lightening Deaths:
A flash of lightning is due to an electric current discharge from thundercloud to
the earth. The electric current is direct with a potential of 100-1000 million volts
or more.
-Injuries may occur due to forceful tossing the body with the ground (blast effect)
-Dry skin and dry clothes are bad conductors, whereas wet skin and wet clothes
are good conductors.
-Common cutaneous findings associated with lightning strike include punctuate
full-thickness burns, linear burns, and contact burns from overlying metal objects
(if worn).
-Branching or ferning marks (zig zag) are an uncommon and unusual cutaneous
manifestation. These ferning patterns are called Lichtenberg figures.
These are due to dilatation and rupture of the smaller blood vessels at several
places giving rise to ecchymoses with an arborescent pattern.
Also called filigree marks.
-Some pericardial and sub-endocardial hemorrhages.
-Subserosal and mucosal hemorrhages of the respiratory and GI tracts.
-Fractured bones may be seen.
-If the electric discharge finds its way through the feet, the skin may be
ruptured at the point of exit and the shoes may be torn.
-Involvement of the central nervous system with paralysis of the heart or
the paralysis of the respiratory centre causes death.
Man Made:
Nuclear Radiation:
Types of ionizing radiation:
-The term ionizing radiation is applied to radiation which has the ability to
penetrate tissues and deposit its energy within them.
-Ionizing radiation may be classified as follows:
1. Electro-magnetic radiations: x-rays, Gamma rays.
2. Corpuscular radiations: Alpha-particles, Beta particles, Protons.
Effects of Radiation:
1. Biologic effects:
I. Somatic:
Immediate: Radiation sickness.
-Acute radiation syndrome.
Delayed: Leukemia.
- Carcinogenesis.
- Fetal developmental abnormalities.
- Shortening of life.
II. Genetic Chromosome mutation
- Point mutations
Chronic radio-dermitis.
Hyper-pigmentation.
De-pigmentation.
Atrophy.
Squamous cell carcinoma.
Basal cell carcinoma.
Acute Radiation Syndrome: A single exposure of a large dose of over 100 rads
penetrating radiation on the whole body within 1 to 2 days, results in a
progressive series of signs and symptoms known as acute radiation syndrome.
SPECIAL TRAUMA:
1. FIREARM INJURIES:
Mechanism of firearms:
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
Wound of Entrance: The wound of entrance is circular when the bullet strikes the
surface perpendicular. It is oval when the bullet strikes the body at an angle.
-The wound is smaller when the firing is from close range except in contact shots.
It is slightly larger when firing is from long distance.
-There may be some abrasions and contusions of the friction area around wound
of entrance by the bullet, is called as abraded or contused collar.
-Around the abraded or contused collar there is a dirt or grease collar made by a
metallic dust and grease from the surface of the bullet.
-Grease collar should not be confused with corona, which is blackish circular zone
around the wound caused by smoke in case of short from a near distance.
-The wound of entrance is inverted and no protrusion of fat through the wound.
Wound of Exit:
-Exit wounds are larger than the corresponding entrance wounds the skin edge
averted with protrusion of fat through the wound.
-The margin is irregular.
-Hemorrhage is more near the wound of exit.
-When the site of exit wound is in contact with the hard surface like wall then the
margins are abraded, so called as shored exit wounds.
-There may be multiple exit wounds due fragmentation of bullet or emergence of
fractured bone pieces.
Case of skull:
Punched in: wound of entrance.
Punched out: wound of exit.
II.
Ricochet Bullet: It is the bullet which by striking the body strikes some hard
surfaces like wall where it get bunched or reflected to take a different track
and then strikes the body of the person.
-Such a deform ricochet bullet causes more extensive wound of the
entrance, but its power of penetration is reduced.
Tandem Bullet (Piggy tail Bullet): First bullet which has been stuck inside
the barrel may be fired out when firing the second bullet and both the
bullets will enter the body at the same wound of entrance. When
postmortem is done there may be two bullets with only one wound of
entrance.
III.
IV.
V.
VI.
VII.
VIII.
Dum Dum Bullet: The bullet splits when it strikes the body is called dum
dum bullet.
Presence of more than one bullet in body: It may be tandem bullet. Two
bullets of two rapidly successive firing.
Single wound of entrance with more than one wound of exit:
With more than may one wound of entrance there may be one bullet
present in the body: Bullets getting into the arm and exiting from the
medial aspects of arm and again entering the chest with another wound of
entrance.
Multiple wound of entrance with multiple wounds of exit with no bullet
found inside the body: Entering from outer aspects of chest and exiting
from other aspects of chest then entering from medial aspects of arm and
exiting from the lateral aspects of the arm.
Kennedy Phenomena: When during autopsy it is difficult to distinguish
between firearms entry wound and exit wound.
American president PJK Kennedy sustained injury on neck, bullet entered
from back of neck and exit was from the front through trachea. The exit
wound was of small size difficult to say that was it entry or exit or another
entry from front. In fact the exit wound was small as the tight collar
supported the neck tissue. As he was taken to hospital, attempts were
made to save his life and during surgical manipulation it further became
difficult to distinguish between entry and exit wound.
Iv. The gun may be hold in a tight grip( state of cadaveric spasm).
v. Finger prints of a suicidal person may be in the trigger of the firearms.
B= Homicidal:
i. May be at anywhere in the body with contact, near shot or distant shot of
the wound.
ii. May be both short barreled or long barreled guns are used.
iii. The weapons are usually absent at the spot.
iv. Spot may be approachable to others. May be fingerprints of the
assailants (if weapon present at the spot).
C= Accidental:
i. May be due to wrong aiming or missing the target.
ii. May be due to playing with loaded guns or cleaning the loaded guns.
3: Distance of firing:
A= In case of shot gun firing:
i. Presence of fire, smoke, partially burnt or un burnt gun powder.
ii. The disc and wad causing abrasions at the wound of entrance.
iii. the diameter of the area of dispersion of pellets over the body.
iv. Impression of the muzzle in case of contact wounds.
B= In case of bullet injury (rifled guns):
i. Effects of fire, smoke, burnt and un burnt gun powder , when firing is
from short distance.
Entrance Wound
1- Size: smaller
2- Margin: inverted
3- Blackening, burning:
present.
4- Abraded or confused and
greeze color: present.
5- Foreign fabrics: enters the
wound.
6- Hemorrhages: less.
7- Dispersion of pellets in
short gun cases: present.
8- Protrusion of fats: absent.
9- Bright redness due to the
formation of COHb: present.
Exit Wound
1- Larger.
2- Averted.
3- Absent.
4- Absent.
5- Nothing such seen.
6- More.
7- Absent.
8- Present.
9- Absent.
10- Absent.
11- Absent.
12- Absent.
2. Blast/Explosion injuries:
These are due to house made bombs, explosions of shells, torpedoes, and mines
etc in wars and as well as in peace and also in cases of terrorism.
Explosion is mainly accompanied by blast waves, flame, fragments, secondary
missiles, fragments of vehicles, and falling buildings.
There definite waves are recognized:
a. Wave of positive pressure.
b. Wave of air displacement.
c. Wave of negative pressure.
Common types of explosives:
Nitroglycerine (40% dynamite)
PETN
TNT (2:4:6 Trinitrotoluene)
RDX (rapid detonating explosives)
Effects on Victims:
-Bodies are blown into pieces and instantaneous death occurs.
-Flame causes 1st, 2nd and 3rd degree burns.
-Sound effect may cause the rupture of the tympanic membrane.
Medico-Legal Aspects:
Try to count number of victims and try to put pieces of same person together.
Perform precipitin test to distinguish between the pieces of human and animal
bodies.
Investigation of RTA:
The investigation of RTA involves the following purposes:
1.
2.
3.
4.
Collection of history.
Examination of the deceased or the injured.
Examination of the vehicles involved in the accident.
Examination of the spot or place of occurrence of the accident.
-The marks on the body of the victim by the part of vehicle may give an idea
about the height of the vehicle.
2. Secondary Injuries:
-It is caused by the roadway, pavement or other objects like trees etc.
-These injuries are sustained by the victim after being knocked down by the
vehicle, due to fall and friction or impact with the ground.
-So, on examination, sand, soil, or gravel on the injuries area helps to link the
place of occurrence.
-Grazed abrasion and Stretched laceration are most common due to friction with
the ground.
Railway Accidents:
Railway injuries may be accidental or suicidal.
Fatal railway injuries may be sustained in the following ways:
-While walking along the rail or track.
-While crossing the rail or track.
-When a person is pushed suddenly in-front of a running train.
-When a person lies down on the railway track for a suicidal purposes, when the
train is coming.
-When a person accidently falls or intentionally jumps or is pushed from a running
train.
-When the head or some part of the body is extended out of the door or window
of a running train.
-When two train coming from the opposite direction collides.
-When the train is de-railed.
-When there is an outbreak of fire in a running train.
-When the passengers standing on the roof of train are electrocuted or struck
against and overhead structure or a over-bridge.
-Identification of a victim may become very difficult due to gross mutilation of the
body.
Aviation Accidents:
-Most challenging problem for identification of the victims.
-The bodies are often with gross mutilation or burnt that identification is nearly
impossible.
-Sometimes, the pocket articles, passports, letters, photographs, tattoo marks,
dentition, if un-burnt, may help for identification of victim.
-Now a days, DNA test is the mode of identification is such aviation accidents.
TOXICOLOGY/POISONING
Toxicology is a science dealing with properties, action, toxicity, fatal
dose, detection, estimation and treatment of poisons.
Forensic toxicology deals with the medical and legal aspect of the
harmful effects of chemicals on human being.
Toxicology refers to toxins produced by living organism which are
dangerous to man. Like poisonous plant, venom of snake, spider,
scorpion.
Poison is a substance, which if introduced in living body, or brought in
contact with any part through, will produce ill health or death, by its
constitutional or local effects or both.
Some poisons are harmless in small quantity but produce death if large
quantity is used.
Property of ideal homicidal poisons:
1. Cheap
2. Easily available
3. Colorless, odorless, tasteless.
4. Highly toxic and very small fatal dose.
5. Sign and symptoms should resemble of natural disease.
6. There should not be any antidote.
7. There should be no postmortem changes.
e.g. arsenic, aconite are commonly used homicidal poison.
C. Systemic:1. Cerebral:
a. CNS depressants:- alcohols, general anesthetics, opioid analgesic,
hypnotics, sedatives.
b. CNS stimulants: cyclic antidepressants, amphetamine.
c. Deliriant: Dhatura, belladonna, cannabis, cocaine.
2. Spinal: nux vomica (strychnine), gelsemium.
3. Peripheral: conium, curare.
4. Cardiovascular: aconite, quinine, tobacco, HCN, oleander, nicotine.
5. Nephrotoxic: Oxalic acid, mercury, cantharides.
6. Hepatotoxic: Phosphorous, carbon, tetrachloride, chloroform
2. Antihistamines
3. Food poisons:- Clostridium Botulism, Mushroom poisoning.
Action of poison:
1. Local: Result from direct action. (acids and alkalis)
a. Corrosion:- lesion by strong mineral acids.
b. Irritants:- gastritis by arsenic.
c. Nervous effects:- dilatation of pupil by Dhatura.
2. Remote:-Opium, barbiturates, tranquilizers, digitalis etc
a. Inhalation
b. Intravenous
c. Intramuscular, subcutaneous, intradermal,rectal
d. Oral
4. Condition of body:a. Age:
b. Habit:- action of certain poison decrease with habituate. An addict
can tolerate larger dose than a non addict. Like alcohol, morphine.
4. Serological antidote
The following principle should be followed in case of poisoning:1. Removal of unabsorbed poison from the body:a. If inhaled:-take pt. to fresh air. Give oxygen and artificial
respiration if necessary.
b. If bitten or injected:- immediately apply tight band above the
wound. Release in every 10 minutes for 20-30 second to prevent
gangrene.
c. If local application:- it should be washing with water.
d. If ingested:- stomach wash/ gastric lavage within 3 hr.
2. Administration of antidotes
3. Prevention of absorption into the system:- by
a. Renal excretion can be improved by plenty of fluid, diuretics.
b. Increasing diaphoresis ( Perspiration) using neostigmine,
pilocarpine
c. By dialysis.
d. By chelating agents
4. Treatment of general symptoms:Pain, shock, peripheral circulatory collapse, electrolyte imbalance.
Contraindication of Gastric Lavage:
1. Very old patients with esophageal varices.
2. Poisoning with corrosives: danger of perforation of stomach.
Contraindication of Emesis:
-Corrosives and volatile poisons.
-Comatose patients.
-Heart disease patients.
-Pregnant women.
-Kerosene : may cause aspiration pneumonia.
Chlorinated Hydrocarbons:
Many chloro compounds have been synthesized as insecticides from
dichloropropene to very complex modern synthetics. Commonly used
as pesticides.
Common chlorinated hydrocarbons are :-
DDT
Endrine
Gammexane
Dieldrin
7. Oils and fats are contraindicated but liquid paraffin may be given.
Post-mortem appearance:
1. Usual sign of asphyxia.
2. Smell of kerosene may be noticed from lungs and stomach.
3. Mucous membrane of stomach and intestine acutely inflamed
with sub mucous hemorrhage.
Nicotine like effect:1. Striated muscle:- muscle fasciculation, cramps, weakness, muscle
paralysis.
Opium:
Geographical distribution of opium:
-It is cultivated in India, china, turkey, Egypt, Russia, Yugoslavia and
England.
-Poppy seeds are white, harmless, nutritive and used as food.
-The oil from seeds are use for cooking purpose.
-It is dry juice obtained by incision from unripe capsule of white poppy
(papaver somniferum).
-By multiple longitudinal incision to the unripe poppy capsule, a milky
white juice is obtained, which on drying under atmospheric condition,
gives crude opium. It is reddish brown, characteristic odor and bitter
taste in fresh condition but hard, brittle, dark brown or even black on
keeping.
Opium alkaloids:
Crude opium contains a large number of alkaloids, about 25. these form
2 chemically different groups.
1. Phenanthrenes:-
morphine
10% of opium
codeine
0.5% of opium
Thebaine
0.3% of opium
2. Isoquinoline:Papaverine
1% of opium
Narcotine
6% of opium
Morphine:
-Morphine is a white shining crystals, has bitter taste and alkaline
reaction.
-The narcotic symptoms of opium poisoning are practically those of
morphine poisoning.
Classifications of narcotics:1. Natural:- morphine, codeine.
2. Semi-synthetic:-heroin, hydromorphine, oxymorphine.
3. Synthetis:-mepridine, methadone, levarphanol,fentanyl.
Action:Opiates exert their effects because of their chemical similarity to
natural substances called endorphins.
Fatal dose:- opium2 gm
codeine0.5 gm
morphine--0.2gm
Fatal period:- 6-12 hours.
Mode of death in opium poisoning:Opium depresses cortex, the respiratory and cough centers in medulla.
Reduces the responsiveness of the respiratory centers to co2 thus
cessation of respiration and causes death.
Sign and symptoms:A. Stage of excitement:This stage is of short duration, may absent if large dose is taken.
1. Increased sense of well being
2. Mental activity.
3. Free from anxiety.
4. Talkativeness
5. Restlessness
6. Flushing of face.
B. Stage of stupor:-
The nervous centers are depressed during this stage, which sometimes
comes on quite suddenly.
1. Headache and giddiness.
2. Nausea and vomiting.
3. Lethargy, drowsiness.
4. An uncontrollable desire to sleep from which the patient may be
roused by external stimuli but soon passes to stupor and coma.
5. Pupils are constricted.
6. Face and lips are cyanosed.
C. Stage of coma:Recovery takes place at this stage under prompt and proper treatment.
1. Patient passes into deep coma and can not roused.
2. Muscle are relaxed and reflexes are lost.
3. All secretion suspended except sweat.
4. Face is pale.
5. Pupil pin point and insensible to light.
6. Temperature subnormal.
7. Blood pressure falls.
8. Pulse and respiration are slow.
Treatment:
1. Stomach wash with a solution of 1:5000 potassium
permanganate.
2. A tablespoonful suspension of charcoal may be introduced into
the stomach.
3. Emetics usually fails due to depression of vomiting centers.
4. The intestine should be cleared out by enema twice daily for 2
days to prevent reabsorption.
5. Naloxone hydrochloride is a specific opoid antagonist.
6. Atropine is contraindicated, as it can cause death by paralyzing
the motor and sensory nerve.
Post-mortem appearances:
1. Face and nail cyanosed.
2. When chest is open smell of opium can found.
3. Tracheas and bronchus:- mucous membrane is congested and
covered with bloody secretion.
4. Lungs:- congested, edematous and frothy exudates.
5. Heart:- right side full and left side empty.
6. Stomach:- lump of opium can be found, and smell of opium can
found.
Cannabis indica:
Active principle
1. Cannabinol
2. Cannabidiol
3. Tetrahydrocannabinol isomer
Onset of action:Smoking:- Soon after smoking and last for 1-2 hours.
Swallowing:- 30 minute after swallowing & last for 2-3 hrs.
Snake poisoning:
There are more than 3500species of snakes, only about 250 are
poisonous.
SNAKE
POISONING
COLUBRIDAE OR
COBRA
ELAPIDAE OR LAND
SNAKES ( COBRA,
KING COBRA, KRAIT
ETC)
NONPOISONING
VIPERIDAE OR
VIPERS ( RUSSEL
VIPERS, PIT VIPERS,
ECHIS VIPERS ETC
HYDROPHINAE OR
SEA SNAKES
Poisonous
Non poisonous
1.Head scales
Usually large
2. Belly scales
Small or moderately
large, but do not cover
the entire breadth.
3. Fangs
4. Teeth
5. Tail
Compressed
6. Habits
Usually nocturnal
Not so
Trait
Cobra
Viper
Body
Short, narrow
neck
Head
Pupil
It is round
vertical
Maxillary bone
Carries only
poison fangs
Fangs
Tail
Round
Tapering
Eggs
Lay eggs
Venom
Neurotoxic
Haemotoxic
Snake venom:
Venom is the saliva of the snake. Cobra venom is the faint transparent
yellow and is slightly viscous.
Action of venom:
Elapidae venom is mainly neurotoxic. Viper venom mainly vasculotoxic
and hydrophinae venom is myotoxic.
1. A Neurotoxic venom causes muscular weakness of the legs and
paralysis involving the muscles of the face, throat and respiration. Local
symptoms and signs at the site of the bite are minimum. General
symptoms are due to local histamine release.
2. A Vasculotoxic venom produces enzymatic destruction of cell walls
and coagulation disorders.
3. A Myotoxic venom produces generalized muscular pain with
respiratory failure.
In viper bite:
-Locally, pain, swelling, discoloration and ecchymosis at the site of bite
and oozing of a bloody serum from the apertures caused by the bite.
-Abdominal pain, nausea, vomiting and signs of collapse such as cold
and clammy skin, feeble pulse.
-Complete unconsciousness follows.
-In case of recovery from these effects, haemorrhages occur from the
mucous membrane of the rectum and other orifices of the body.
Extensive local suppuration, sloughing and gangrene and malignant
oedema or tetanus or death may occur from septicemia.
Treatment:
once, at some distance above the site of wound, and should not be
kept more than half hour.
-The part should be immobilized.
-Free and deep incision should be made into puncture without injuring
any large vessels.
-The poisons should be neutralized by washing the wound with a weak
aqueous solution of potassium permanganate.
-In case of cobra or krait bite, local infiltration with a 5% solution of
carbolic soap round the site of bite, when anti venom is not available.
should be injected I/V as soon as possible after the bite and the dose
should be repeated 2 hours later or even earlier if symptoms of collapse
appear.
-In case of viper bite, some serum should be injected round about the
site of bite to prevent sloughing and gangrene.
-40-60ml of anti-snake venom serum may be injected sub-cutaneously
or I/M, but is not effective as I/V injections.
Section 6 (Forensic Medicine) of ALL in ONE for the PMDC Step 1 Preparation by
Faizan Ali & Ghulam Mohiudin
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