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Stari hipoanoxice

Definiie

Procese fiziopatologice caracterizate prin scaderea


oxigenului din sange

Hipoxemia
Scaderea ppO2 sanguin sub 60 mmHg SAU
Scaderea saturatiei in oxigen sub 90%

Asfixia = absenta oxigenului in sange sau


imposibilitatea celulelor de a utiliza oxigenul

*) cauza de deces versus proces agonic


Definiia medico-legal
ATENIE:
Agonic orice deces asociaz fenomene asfixice!!!
Sindroame asfixice sunt ntlnite n cauze extrem de
diverse de deces, att cu origine respiratorie (EPA, BP,
pneumonii, atelectazie) ct i cu origini
extrarespiratorii (ICA, hemoragii bulbopontine, etc)

DPDV ML: Deficitul de oxigen generat de


mecanisme traumatice specifice, care
determin direct apariia morii cerebrale
prin mecanism hipoxic-ischemic (Madea.
Handbook of forensic medicine)
Medicin clinic Medicin legal

Boli diverse (respiratorii, Traumatisme Strangulare/Sugrumare/Sp


cerebrale, cardiace, etc) Intoxicaii nzurare/Sufocare
Afectarea micrilor
respiratorii
IRA nec, etc
Afectarea transportului, utilizrii sau legrii O2
Hipotensiune arterial sau oc

Deficit indirect de O2 Deficit direct de O2

Ischemie/Hipoxemie

Hipoxie

Lez cerebrale hipoxic ischemice

Moarte cerebral hipoxic-


ischemic

Moarte cerebral hipoxic Asfixie mecanic


Clasificarea deceselor prin
mecanism asfixic
Anoxii de aport O2 nu ajunge la nivelul alveolelor
pulmonare

Alterarea membranei alveolo-capilare O2 nu trece


in sange

Anoxii de transport O2 nu ajunge la tesuturi

Anoxii de utilizare (histotoxice, citotoxice, tisulare)


O2 nu poate fi utilizat la nivel celular
Clasificarea deceselor prin mecanism
asfixic asfixii de aport
Violente Cu mainile si degetele (sugrumare)
Insuficienta O2 in aerul expirat Impiedicarea miscarilor resp:
Spatii inchise ermetic comprimare toraco-abd
Procese consumatoare de oxigen Pneumotorax traumatic
(fermentare, foc) Paralizia muschilor respiratori:
Altitudini mari Curarizante
Obstructia orificiilor respiratorii electrocutie
(sufocare)
Obstructia cailor respiratorii Neviolente
interna Obstructia CRS (tumori laringiene,
Inecare (inlocuirea coloanei de aer cu
bronsice, edem gloric
una de lichid) Obstructia CRI (pneumonii,
Obstructia CR cu alte obiecte (pietris, bronhopneumonii, AB, atelectazii)
nisip, pulberi, boabe cereale,
fragmente alimentare) Afectarea miscarilor resp (polio
Externa comprimarea externa a
pneumotorax, miastenia gravis,
regiunii cervicale distrofii musculare
Cu un lat actionat de propria greutate
(spanzurare)
Cu un lat actionat de o forta externa
(strangulare)
Clasificarea deceselor prin
mecanism asfixic alterarea mb
alv-cap
Violente
Toxice gazoase/volatile (O2, clor, fosgen)

Neviolente
Boala membranelor hialine

Intoxicatia cu O2 (pacienti ventilati


mecanic, NN)
Fosgen (CCl2O)
apare la 14 ore de expunere la aer cu O2 70% - Gaz incolor, miros de fan
(id la conc x4 fata de cele
AP: toxice
initial edem al pneumocitelor si a celulelor - Determina crosslinkari ale
endoteliale proteinelor de la nivelul
Ulterior congestie capilara, edem alveolar, MAC prin legarea de
hemoragii alveolare
gruparile NH2
Tardiv pseudomembrane (aspect de BMH) - Se neutralizeaza cu NH3
Clinic tahipnee, creste hipoxemia, hipoxie
tisulara
Clasificarea deceselor prin mecanism
asfixic transport
Violente
Cantitative: anemii posttraumatice, soc anafilactic (vasodil ->
extravazare plasmatica+hemoconcentratie)
Calitative: methHb, COHb, CNHb

Neviolente
Cantitative: anemie feripriva, megaloblastica
Calitative: drepanocitoza, talasemii
Clasificarea deceselor prin mecanism
asfixic citotoxic
Violente
Intoxicatii (alterarerea
enzimelor lantului
respirator)
Hipotermie (scaderea
met bazal)

Neviolente
ICC
hipoproteinemie
390
Tablou morfologic
Color Atlas of Forensic Medicine and Pathology

0
macroscopic extern
Color Atlas of Forensic Medicine and Pathology

Strangulation. Petechiael hemorrhages within the


mucosal surface of the mouth.

Strangulation. Petechiael hemorrhages within the


mucosal surface of the mouth.

Petechiael hemorrhages of the face.

Petechiael hemorrhages of the face.

Petesii
- Hemoragii punctiforme determinate de
rupturi vasculare (de ob venule
postcapilare)
- Semn nespecific de stare hipoanoxica
- Clasic in asfixii descrise la nivel scleral si
conjunctival
- Pot sa apara postmortem in ariile declive
Lividitati intens, violaceu albastrui
Petechiael hemorrhages at theofsurface of the heart Strangulation.
Strangulation. Petechiaelwithin
hemorrhages within the
echiael
ociated Petesii: sclerale, conjunctivale, in mucoasa sinusului sfenoid, epicardice, in mucoasa laringotraheala
hemorrhages
associated
at the surface
with asphyxia
with asphyxia due to chest
the heart
due compression.
to chest compression. mucosa of the
Petechiael hemorrhages
mucosa of and
tracheal the laryngeal
tracheal cartilage.
the
and laryngeal cartilage.
Tablou morfologic
macroscopic intern
Sange necoagulabil
Congestie pulmonara+alte organe interne
Emfizem pulmonar (mai ales in obstruciile
endoluminale
Tanatochimic:
- Creste hipoxantina in UV
- Creste cantitatea de lipoproteine in lichidul alveolar
- Creste LDH (in sp V) in ser
Etapele asfixiei mecanice
faza preasfixica (de latenta): cca 1 min
Clinic: apnee, agitatie , frica, sete de aer, cianoz
faza convulsiva: 1-2 min
Clinic: pierderea constientei, convulsii generalizate,
dispnee inspiratorie (sete de aer), horcait, tahicardie,
HTA, descarcari catecolaminice
faza asfixica (cca 4 min)
Clinic: decompensare, reducerea functiilor vitale,
bradicardie, moarte clinica
faza finala
Clinic: stop cardiorespirator
Tablou morfologic
Brain swelling and cerebral oedema are the common reac-
tions of the brain to injury of whatever aetiology. A con-
sequence of this is the formation of various intracranial
Histologically, congestion of intracerebral vessels with
perivascular haemorrhages (Figure 9.1) may be seen
Diffuse brain
Whist these may be seen in conditions such as suffocation

microscopic
herniations. or overlying in an infant, as well as asphyxial deaths in
If these are severe the non-perfused (respirator) brain, adults, they should not be taken as diagnostic for these
or cellular oedema
where there is cessation of cerebral perfusion, may be the conditions (see also Chapter 11, p. 1301).
final outcome.

llular oedemaAmprenta is defined as cellular


anoxica swelling
Spielmayer CONGESTIVE BRAIN SWELLING
a reduced extracellular space but, initially
BRAIN SWELLING
si Kernbach):
ct bloodbrain barrier (Klatzo 1967). This Congestive brain swelling can occur as a result of an
Simple swelling of the brain is a relatively common find- increase in intravascular blood, causing an increase in
is seen
ing inmost
deathscommonly
encountered ininmedicolegal
association withThe brain volume. It may occur very rapidly, particularly in
haemic
staza
conditions
pathophysiology
si edem in association
(including
is not clearly understood
practice.
but in simple children, as well as in patients who have sustained a head
terms there is an increase in the volume of the brain,
ntusions), although
usually related
generally it is eventually
y a Conditions
vasogenic
endotelioza
to an increase in intravascular blood.
in type
which of this oedema, with
is recognized break-
to occur include
asphyxial-type
oodbrain barrier deaths and others
(Bullock etwhere there mayAs
al. 1991). be a
congestive
prolonged rupturi capilare
phase.
ly more active cellular components
Confusion may arise at postmortem areininthat
examination
s type of oedemacanisoccur
misinterpretation more prominent
between in cerebral
this and true this
distrofie
oedema or congestive brain swelling with a raised intracra-
de and Pickard 2002).
of oedema hidropicnovacuolara
nial pressure. It is well recognized that the cerebellar tonsils
include:
descend and ascend within the foramen magnum with Figure 9.4 Histological appearances of oe
normal changes in respiration and blood pressure. It is
oedema, where the
not uncommon bloodbrain
to see is at particularly prominent in white matter.
barriertonsils
prominent cerebellar
re ispostmortem
a sudden rise in intravascular
examination pressure
this cannot necessarily be taken
as evidence
that there
inhas been alba;
a true rise
josinintracranial
be Sus
r to pressure.
driven edem
through subst
the capillary ruptura astrocytes appear swollen with later glio
bed
Minor uncal grooming may also be seen at post-
capilara intracerebrala
Sufocarea
Definitie: asfixie mecanica produsa prin astuparea concomitenta a
orificiilor nazale si bucal, ceea ce face imposibila patrunderea aerului
catre caile respiratorii inferioare.

Incadrare juridica de regula omucidere sau accidentala

Metode:
cu mana, direct
manual, indirect, prin aplicarea unor obiecte moi (perna, fular)
introducerea capului intr-un mediu moale (nisip) sau lichid (apa)
acoperirea fetei cu un cearsaf/carpa umeda
fixarea de benzi adezive de orificiile respiratorii
introducerea capului intr-o punga de plastic urmata de etanseizarea
acesteia (cea mai frecventa metoda in SUA)
SUDI apasarea accidenala a fetei sugarului cu bratul sau sanul mamei
This individual was

Sufocarea
abducted, bound, and
had multiple superficial
stab wounds associated
with a sexual assault.
Her head was wrapped
in multiple layers of
plastic that covered her
mouth and nose.

Morfologic
Sinucidere victima a luat o
- tablou clinic sarac supradoza medicamentoasa
dupa care si-a infasurat
- Urme degete in jurul punga peste cap
nasului/gurii Jos omucidere prin
aplicarea de benzi adezive la
nivelul orificiilor bucal si
- Echimoze/plagi in nazal)
vestibulul bucal
This individual committed suicide by taking multiple
pills and tying a plastic bag tightly over her head. It is

- Urme banda adeziva


the authors experience that it is better to pend these
cases for toxicology.

- Leziuni de aparare
Spanzurarea
Definitie: comprimarea gatului - Atipica (nodul in orice alta
cu un lat actionat de greutatea zona)
corpului persoanei spanzurate
- Functie de pozitia corpului:
Juridic: sinucidere (de regula); - Completa corpul atarna
mai rar accidental, omucidere, complet
pedeapsa capitala - Incompleta corpul are cel
putin 1 punct de sprijin
Clasificare medico-legala
- Functie de circulara
- functie de mobilitatea nodului - Completa (doar in spanzurari
- Cu nod fix complete)
- Cu nod culisant - Incompleta (in sp complete sau
incomplete)
- Functie de pozitia nodului
- Tipica (nodul la ceafa)
Spanzurarea
Mecanisme tanatogeneratoare carotic poate duce la deces
Compresiune pe carotida chiar daca forta este mica
intrerupe fluxul sanguin catre fracturi cervicale in
creier anoxie cerebrala in executii, cu dilacerarea MS,
minute BR sau a jonctiunii bulbo-
poate fi luata in discutie ca medulare
element izolat in cazul in care
forta aplicata este mica
compresiune pe CRS
insuficienta respiratorie
acuta
necesita o forta ceva mai mare
mecanism reflex
comprimarea bulbului
Spanzurare examen
clinic
Santul de spanzurare
- 1/3 superioara a gatului (intre cartilajul tiroid si mandibula)
- Traiect oblic, ascendent spre nod
- Adancime maxima in zona nodului
- Poate pastra patternul latului de spanzurare
- Asociaza:
- Banda excoriata inferior (prin frecarea santului de tegument)
- Dunga echimotica superior (rupturi microvasc la interfata sant-tesut
normal)
- Linie argintie sub sant (comprimarea tesutului adipos subcutanat)
- Daca lipseste mec mai probabil reflex vagal
- Tesutul subcutanat sau muscular infiltrate hematice
The rope pattern on this neck is very distinct
e rope. The pattern on the neck is wider than
e the folds of skin partially surrounded the

FIGURE 9.13 A shoestring wrapped twice around the neck


caused these pale marks with adjacent hemorrhage.

FIGURE 9.14 Sometimes determining manner of death is


Sp tipica
difficult. incompleta
This is probably an accident;accidentala
however, this cannot be
stated with certainty. The boy may have been experimenting
(baiatul a vrut sa vada cum e sa te
to see how it feels to choke.
sufoci)
Sp atipica incompleta accidentala medic pensionar cu
2000 CRC Press probleme
LLC cervicale pentru care facea exercitii.

A shoestring wrapped twice around the neck FIGURE 9.15


le marks with adjacent hemorrhage. This retired
physician had
neck problems for
which he used
traction to ease
the pain. Autopsy
revealed he had a
bad heart. There
Corespondenta sant-lat spanzurare was no reason to
believe he com-
Spanzurare examen
clinic
Alte semne:

- Lividitati la nivelul membrelor inferioare, a extremitatii inf a membrelor


superioare

- Cefalic: exoftalmie, protruzia limbii, hemoragii subconjunctivale

- Hemoragii cervicale musculare rare

- fracturi laringiene sau de hioid rare, incidenta creste cu varsta

- Leziuni artere carotide: rupturi intimale (s. Amussat), mansoane echimotice


pericarotidiene (s.Martin)

- Urme de saliv uscat (spnzurarea asociaz hipersalivaie)

- Hemoragii la nivelul anului -> apar cnd laul face mai multe circulare,
ntre care prinde pliuri cutanate

- Leziuni traumatice elementare pe diferite pri ale corpului apar prin


lovirea victimei de corpuri dure n cursul spnzurrii
Figure 21.11 Complete hanging suicide, with no petechiae and Figure 21.12 Incomplete hanging suicide, showing congestion
Spnzurare complet (st) versus incomplet (dr)
no congestion. syndrome above the ligature mark.

- n spnzurarea complet congestia superior de la este minim iar numrul de peteii


este extrem de redus (sunt determinate de congestia venoas care necesit ceva timp
pentru a sehanging
by incomplete produce)
may resemble the appearance of a
ligature strangulation (Bollinger 1889); thus, a differentia-
tion is problematic at best or may even prove impossible
388 PART III TRAUMATOLOGY AND VIOLENT DEATH

only rest upon several findings characteristic of hanging, and


relevant venous congestion in the upper regions of the body,
this is recognisable by the conspicuous intensive bluish or livid
not merely on a single finding. The pattern of findings should
be considered in the context of the overall circumstances. Fur-
Peteii, palpebral
discoloration of the skin. In cases of ligature strangulation or
incomplete hanging, this discoloration is frequently delineated
thermore, the inner sides of both arms should always be dis- superior (sp
sected to eliminate the presence of any haematomas due to
sharply from the ligature mark downwards.
finger marks. As a general rule, where the remains are in an incomplet)
advanced stage of putrefaction, it is not possible to rule out
Petechiae/congestion syndrome Within the congested body
definitively any external intervention. Toxicological examina-
regions, petechiae develop primarily in the capillary networks
tions are essential for the evaluation. If there are no inconsistent
of the conjunctivae tarsi, often also in the skin of the eyelids
findings, the hypothesis of suicide may be assumed based on
(Fig. 21.7). In addition, they are relatively common in the
the forensic evidence. In rare cases, the conclusion that it is
tunica conjunctiva bulbi. In rare cases, petechiae can be found
indeed suicide is supported by the evidence of recent self-
in the mucous membrane of the cheeks and lips. In cases of
inflicted injuries like practice slashes on the wrists.
11.2compression
severe Compression Trauma
of the jugular veinsto the
and Neckcompres-
thoracic
In isolated cases, a suicide hanging may be unsuccessful (e.g. 181
sion, petechiae also occur in the skin of the face and behind the
due to the ligature breaking). The suicide may remain capable
ears. Where petechiae are found in different regions of the skin
of action
Figure and even
21.7 Petechiae in leave the scene,ofwith
the conjunctiva deatheyelid
the upper not occurring
orTable
in the interior
11.3 ofFindings
the body, thison is commonly
externalreferred to as
examination and
(incomplete hanging).
until some time later, in some cases as a result of a second
congestion syndrome. In rare cases, severe blood congestion
autopsy
may lead to in compression
hyposphagma in thetrauma to the
conjuctivae (Fig.neck
21.8).and
More- their valid-
suicidal event (Holczabek 1964; Fechner et al. 1990). The cir-
ity retinal
over, as signs of vitality
haemorrhages and bleeding from the capillary net-
cumstances of the death subsequently give rise to suspicions of
cular deaths. For natural deaths, Prokop and Wabnitz (1970)
external intervention. Evaluation of such cases is only possible
works of the nose and eardrum may also occur (Ponsold 1938). identified this type of petechiae in frequencies of a maximum
External
Petechiae areexamination/autopsy
not specific to asphyxiation and can also be
on the basis of the medical and toxicological findings, the
of 7.6%. In rare cases, mild conjunctival petechiae can also be
results of the reconstructions and the police investigation.
findings
observed in other natural and non-natural Validity causes of death. observed in cases of sudden infant death syndrome (Kleemann
According to a study carried out by Rao and Wetli in 1988, et al. 1995). However, it is undisputed that petechiae in the head
Dried rivulet of saliva: often Defi nite vital sign! Homicide Where the hanging was the sole intent of foul play,
Hemoragii de tip Simon
Figure
petechial
from
discsone
21.15 Haemorrhages
haemorrhages
corner
of the of the
lumbar spine
on
may develop theinfront
overof70%
mouth hanging).
(incomplete
the of
intervertebral
cardiovas- and cervical region are significantly more common in different
the body of the unsuspecting victim bears very little evidence
of a struggle. Consequently, the constellation of findings could
(partea anterioar a
Swelling and cyanosis: only Definite vital sign! also be attributed to suicide. Such cases are, however, almost
abovefracture
the level ofpedicles
strangulation
discurilor intervetenrale, de
vertebra
including the
of both
is usually
or pars interarticularis of the axis unheard of. As a rule, they involve defenceless victims like small
face referred to as a hangmans fracture. Such children, the infirm or the elderly. In addition, victims of such
multe ori identificate la nivel
fractures are caused by hyperextension in combination homicides may also include people who, owing to intoxication,
Petechiae: in the sclerae,
with distraction. They are typically foundOften a definite
in judicial hang-vital are largely or wholly incapacitated. Defenceless victims may be
lombar
conjunctivae,
ings, where theoralknot
mucosa, andwas sign!
of the noose (Caution:
placed under the chin pulled up using the ligature or alternately pushed from a height
skin and
above the the
bodylevel
was dropped
of (Wood-Jones 1913). vibices
petechial This can in with the noose around their neck (Bhmer 1940).
- Determinate de asociere
lead to an avulsion of the spinal cord from the medulla
strangulation including the face theisarea of livor Occasionally, foul play may lead to death by hanging where
oblongata. Where
traciune extrem+spams
the trauma to the neck Hemoragii linguale n band
not particularly previousFig. did not Compression-related
trauma11.14 in the hemorrhage
prove fatal. The additional injuries
intense, the victim may survive the mortis hanging in the case
because the ofthata are nottongue
characteristic of hanging will usually cause external
- Mai frecvente la tineri i
vertebral canal expands due to the fracture head-downof the second- Apar n spnzurare prin congestie venoas
position)intervention to be suspected. Nevertheless, doubts may arise,
cervical vertebra, leading to a decompression of the spinal particularly if the primary trauma was directed towards the
Hemorrhagic
sp. Complete
strip of skin
cord. The anatomical Defithat
conditions are such nitefractures extensiv la baza limbii
vital sign!
of neck. It may prove difficult or even impossible to differentiate
between a double
the second cervicalorvertebra
multipleare not easy to diagnose during between previous trauma and subsequent findings from death
- Semn de vitalitate
ligature
autopsy. A computed tomography carried out prior to the by hanging. The presence of relevant haemorrhages in the soft
autopsy facilitates the diagnostic investigation. tissues of the neck, which are hardly ever found in cases of
InternalFractures
ligature of mark:
the lower cervical andNot uppera thoracic
vital sign!
spine hanging, is invariably an indication of additional trauma to the
There may be an abrasive collar around the marg
kratz et al. 1986).

Internal findings
1. Fractures of the larynx and hyoid bone: numero
have been carried out on the frequency of these
with highly diverse results and inadequate com
(Brinkmann 2004). Firstly, the discrepancies are d
predominantly retrospective, and rarely prospecti
of the examinations. Secondly, the dissection te
were not consistent. Occasionally, fine dissection
formed after the autopsy. In some cases, distinct
made between complete and incomplete hangin
in others.
It is an undisputed fact that thorough disse
identify fractures to the superior cornua of th
cartilage in up to 55% of cases. By contrast, th
Figure 21.14 Extravasation in the skin ridge between two majora of the hyoid bone are only fractured in a m
ligature marks (incomplete hanging with an electric cable).
Hemoragii la nivelul anului. Se observ trei of 42%. The thyroid cartilage laminae and cricoid
circulare de cordon
Strangularea
Definitie: comprimarea gatului printr-un cordon tras pe o
directie orizontala sau relativ orizontala (sau perpendiculara pe
axul lung al organismului), ce formeaza o circulara in jurul
gatului

Juridic: de regula omucidere

Morfologie:

- Santul de strangulare: circular, in 1/3 medie, adancime relativ


egala, de regula complet

- Fracturi hioid, cartilaje laringe


Macroscopic
Peteii superior de la mai intense dect n cazul spnzurrii
(comprimarea prin la de strangulare comprim cu precdere
venele->crete congestia venoas
Hemoragii la nivelul structurilor gtului, cu precdere la
nivelul esuturilor moi ale laringelui i ale m. cricoaritenoid
posterior
Hemoragii linguale (1) congestie venoas, (2) mucarea
limbii -> asociaz plgi linguale
Spum la nivelul CRS, alb sau rozat compresia laringelui
nu e complet aerul inspirat trece cu presiune prin laringele
obstruat parial (a fost descris stridor inspirator n cursul
strangulrii)
Emfizem pulmonar acut
8.48 8.50

St: lat strangulare In a review of 41 manual strangulation deaths, con-


Dr sus fractura corn hioid junctival/scleral petechiae were identified in 89 percent
Dr jos fractura unilaterala of cases. Fractures of the hyoid bone and/or thyroid car-
corn superior stang cartilaj tilage were identified in all 14 of the male victims and
hioid in half of the female victims.28 In the same study, in
48 ligature strangulation deaths, conjunctival/scleral
petechiae were identified in 86 percent of the cases, and
5 of the 21 male victims and 1 of the 27 female victims
11 Neck Trauma Maxeiner 1990). This normally r
inconsistent with the hypothesis o
evidence of foul play. Remarkably,
ture strangulation has been reporte

Accident The circumstances are


the accidental nature of such infreq
cases, accidents may also happen a
practices. For example, where bond
bent legs and neck together using p
lying position, the tension on the
self-strangulation.

Manual strangulation

Definition
Manual strangulation is a fatal com
by applying direct pressure of the h

Figure 21.18 Ligature strangulation homicide, showing Frequency/occurrence


petechiae under the fascia of the left musculus temporalis. Figure 21.19 Ligature strangulation homicide, showing Fig. 11.21 Petechial hemorrhage in laryngeal mucosa
Peteii, densitate mult crescut la nivel
Fig. 11.21 Petechial hemorrhage in laryngeal mucosa
intensive Hemoragie lingual
Fig.haemorrhages
11.20 Fracture in thehead
of the middle and
of the posterior
hyoid Hemoragii peteiale
bone duethird
Fatal
of the intense
to following
cases of manual strangulatio
strangulation
forensic pathology practice. Several
tongue.manual strangulation where surrounding hemorrhage rep-
epicranian
following intense strangulation
(congestie venoas)
resents a sign of vitality (freely dissected hyoid head;
same case as in Fig. 11.18)
intense la nivelul
by manual strangulation may be s
by ligature strangulation (Haarh
nape than at the front and lateral areas of the neck. There
Hemoragie mucoasei
Accordinglaringelui
to investigations by DiM
is substantial bleeding in the soft tissues of the larynxDifferentiation
andmay fade slowly, although they may remain
likely to be female than male. Man
between suicide, homicide
intens,
particularly in the posterior cricoarytenoid muscle. and accidentdetectable for up to several days (Figs. 11.23 and represents external intervention
conjunction with other traumatic
11.24).
4. Haemorrhages in the origins of bilateral, la Suicide Self-infl
the sternocleidomastoid icted ligature
The strangulation strangulation
device is still inwith sui-The suicide
place.
Where a multi-phase incident entai
manual strangulation may be eithe
muscles: this finding is infrequently
nivelul observed,
m notably in winds it around the neck several times. On
cidal
generally intent is possible using a device capable of occasion,
cause of death. In some cases, evide
locking in place and maintaining the constric-
the ligature is knotted at the front of the neck. Sometimes sui-
cases where tension has been applied to the neck during may constitute a secondary finding
strangulation. Therefore, wherecricoaritenoizi
tion exerted
cides insert objectsby the ligature.
under the loops Self-inflicted manual
to increase the compression
the ligature mark slants strangulation, however, is not possible
pressure. In rare cases, one end of the rope since mus-to a higher
is tied
victim survived for a certain period
(semnul
upwards, it is imperative that any posticus)
origin haemorrhagespointbe cles slacken on loss of consciousness and
and the other wound around the neck so that suicide by
constriction is released.
the actual homicide. Non-fatal cas
are observed relatively frequently
taken into consideration. ligature strangulation may end in death by hanging. If clear
Particularly in ligature strangulation, and sexual offences. It is important to
congestion syndrome is present, there can generally be no
5. Tongue haemorrhages: with its multitude of separate veins, depending on its intensity, significant hemor- manual strangulation may occur as
doubt as regards the vitality of the events. The hypothesis that
rhage in all layers of the neck muscles beneath sexual practices (Hkknen 2007).
the tongue is located in the anatomical vicinity of the venae
states that laryngeal and hyoid fractures are less common
the ligature mark can be seen; this is referred to
jugulares internae. Thus, congestion in the headin suicidal
and than homicidal ligature strangulation is evidently
as the internal strangulation mark. Extensive
unsubstantiated; therefore, it is irrelevant in evaluating indi- Classification of the circum
neck areas inevitably causes haemorrhaging of the tongue.internal injuries or hemorrhage are not seen in
Sugrumarea

En: manual strangulation

Comprimarea gtului cu mna/minile

Doar omucidere (auto-sugrumarea poate duce la


pierderea cunotinei dar nu duce la deces)

Morfologic:
Urme de degete la gtul victimei
Fracturi ale hioidului (coarne mari) i ale scheletului
cartilaginos al laringelui
Sus sugrumare, mici zone
semilunare coresp ungiilor
Jos excoriaii liniare,
sugestive pentru sugrumare cu
reacie de autoaprare a
victimei
St sus infiltrate hemoragice m cervicali
anteriori; st jos fractur cartilaje laringe
Dr fractur corn mare hioid
Asfixia mecanic prin obstrucie
endoluminal cu corpi strini
ATENIE!!! MOARTE VIOLENT, CHIAR DAC
PACIENTUL A FOST RESUSCITAT I A DECEDAT
ULTERIOR PRIN COMPLICAII

Forme:
Obstrucie cu un coninut extrinsec (bol alimentar, clu)
obstrucia este de regul la nivel laringean sau faringean
ingerior
Obstrucia este complet
Dac obstrucia este cu bol alimentar coresponden cu
coninutul gastric
General snge necoagulabil i hiperemie acut a organelor
interne
Aspirarea de materiale biologice intrinseci (snge,
coninut gastric)
Este obligatorie interesarea bronhiolelor mici/alveolelor
n caz contrar fenomen agonal/postmortem
Differentiation between suicide, homicide,
accident and natural death
Suicide In principle, a bolus mechanism as a method of
suicide would appear to be possible. Forster and Schulz (1964)
documented a case of self-inflicted gagging by a schizophrenic
subject, which evidently triggered a bolus mechanism.

Homicide If elderly or handicapped patients with dysphagia


suffer a bolus death after being wrongly given foods that have
not been sufficiently broken down, it could be questioned
whether this is criminal assault resulting in death. The same
applies to the hurried feeding of such patients.

Natural death Since obstructions of the larynx are predomi-


nantly due to varying causes of dysphagia, a natural death may
be assumed in many cases.

Obstruction of the trachea and bronchia

Definition
Asphyxiation due to obstruction of the trachea and/or bronchia
ure 21.27 Bolus death, showing compressed chyme with a is caused by aspiration of material originating in the body or a Figure
ce of meat in the larynx and in the lowest section of the Figure 21.28
foreign body.Foreign
Not only asbody aspiration
the cause due tois obstruction
of death, aspiration also of the
trachea of an infantas aby
vitalasign.
peanut. fractu
Obstrucia laringelui cu
rynx.
Aspirarea unei alune (copil), identificat imediat
of great relevance
aspira
bol alimentar (carne
homorphology superior
Forms de bifurcaia traheei pulmo
Aspiration of material originating in the body A particularly lung.
ernal findings Petechiae only occur very rarely in the con-
ctivae or not at all. significant role is played by the aspiration of chyme and blood.
Only in cases where at least the small bronchi on both sides are
rnal findings obstructed by the aspirate up to the periphery is the evaluation
of aspiration of chyme or blood as the cause of death justified.
Site of the bolus: this is located in the larynx and/or in the
Some of these cases are accompanied by the development of
is a re
lowest section of the pharynx (Fig. 21.27). The laryngeal
inlet is usually completely obstructed. Bolus death is evi- areas of chyme and blood aspiration. An acute pulmonary Sudde
denced by the presence of the foreign body. It should be emphysema may frequently be observed. If aspirated material
noted that the bolus material may have been removed is only found in the trachea and the primary bronchia, and this varicea
as a result of resuscitation measures or shifted during section of the airways is not completely obstructed, death by sis, ul
intubation. asphyxiation may not be assumed. These findings may be inter-
Stomach contents: in approximately two-thirds of cases, preted as agonal aspiration with another underlying cause of Howev
Aspirarea de snge secundar unei fracturi craniene. Se observ snge la nivelul
bronhiilor principale dar i pe suprafaa de seciune i subpleural, asociat cu
Figure 21.30 Aspiration of blood following a craniofacial
aspecte de emfizem acut al unui plmn anemic
fracture. Blood is present in the right primary bronchus; blood
Aspirare de coninut gastric la un heroinoman (arii verzui maronii, evidente dup
compresia
Figure 21.29plmnului)
Chyme aspiration areas in the case of heroin
Culoarea este dat de digestia parial a parenchimului pulmonar de coninutul acid
intoxication.
gastric The
(sindromul areas exhibit greenish-brown discoloration.
Mendelson)
Inecarea
Definitie: asfixie mecanica determinata de inlocuirea coloanei de
aer din CR cu o coloana de lichide

Etape fiziopatologice:

apnee voluntara (1-3 minute); depinde de varsta, antrenament si


temperatura apei (creste cu scadere temperaturii datorita scaderii
vitezei reactiilor enzimatice si cu scaderea varstei a fost descrisa
resuscitarea unui sugar ce a stat 66 min in apa rece)

inspir involuntar; apare atunci cand ppCO2 in sange >55mmHg


sau cand PaO2 scade sub 100 mmHg asociat cu hipercapnie

tuse, urmata de un nou inspir involuntar; dupa 2-3 repetari


individul devine inconstient, apar convulsii anoxice (de
decerebrare) si deces
Inecarea
Tanatogeneza
mecanic anoxie de aport
neuroreflex
laringospasm, determinat de contactul lichidului cu faringele-laringele
hidrocutie (sincopa termo-diferentiala sau reflexul de plonjon)
vasoconstrictie pulmonara, mecanism asociat in initierea FV prin agravarea hipoxiei
traumatism mecanic plonjare in apa de adancime redusa, cu aparitia altor leziuni ce
pot explica decesul (fractura de baza de craniu cu afectarea centrilor bulbari
cardiorespiratori)
duc la incapacitatea victimei de a respira normal
mecanism hemodinamic
in apa dulce (dureaza cca 4 min) apa din alveole trece in vasele din sange
perialveolare -> hipervolemie cu hemodilutie -> liza hematica -> hiperpotasemie -> FV
in apa sarata (dureaza cca 8 min) hiperconcentratie in alveolele pulmonare -> atrage
lichidul din sange -> hemoconcentratie + edem pulmonar, deseori hemoragic
alterarea surfactantului -> risc de EPA pana la 7 zile de la accident necesita
supraveghere atenta
hipotermie: mentinerea corpului in apa rece timp mai indelungat -> hipotermie (apa
conduce mai bine caldura decat aerul -> rezistenta scazuta la hipotermie);
hipertermie: apare in submersia in apa fierbinte (sau in alte lichide fierbinti)
mecanismul otogen perforarea timpanului -> patrunde apa in UM-> afectarea UI
(otoliti) -> pierdere echilibru -> inotatorul nu se mai poate orienta sa iasa la suprafata
Inecarea - morfologie
Semne datorate sederii prelungite petesii asfixice
in apa
plamanul inecatului (plaman umflat
Pielea de gaina (cutis anserina) 3- cu pompa)
4h (piloerectie)
Mana de spalatoreasa inima asfixica (D dilatate, pline cu
sange, S golite de sange)
Manusa mortii (detasarea pielii)
Detasarea fanerelor (10-20z stat in Fisuri gastrice pe mica curbura
apa) Plancton (diatomee) in organele-
Adipoceara filtru si in oase,
Putrefactia Cresterea punctului crioscopic in
ventriculul stng (prin
Semne de inec (leziuni intravitale) hemodilutie)
Cresterea peptidului natriuretic
ciuperca inecatilor (semn de atrial
vitalitate) spuma (albicioasa,
infiltrate sanguine in muschii
rozata, hemoragica), densa, perlata,
gatului, trunchiului si membrelor
in jurul orificiului bucal
superioare
Plmn necat n ap dulce
versus srat
Caracteristic Ap dulce Apsrat

Mrime i greutate Mare, uor Mare, greu (pn la 2


kg)
Culoare Roz palid Albstrui, purpuriu

Consisten Aspect emfizematos Moale, aspect


gelatinos
Form dup scoaterea i reine forma; nu Nu i reine forma;
din cadavru colapseaz colapseaz
Secionare Lichid puin sau Lichid n cantitate
absent mare, spum
Crepitaii prezente absente
Diatomee
Alge cu perete bogat n compui silicai;
Perete celular extrem de rezistent (inclusiv la
tratamentul termic)
Prezena a peste 20 diatomee/20g plmn sau
prezena lor n organe terminale (MO, splin,
rinichi)-> semn de vitalitate
Utile pentru
Evidenierea caracterului vital al necului
Identificarea locului necului (diatomeele au caractere
specifice funcie de localizarea geografic)
a b

!
g. 15.17 (a) Foam at the mouth and nostrils in a case of death by drowning. (b) Aspiration of chyme particles
e St ciuperca
upper inecatului
half of the spum
trachea and extrem content
watery/foamy de fin,innecesit dg dig cu spuma din EPA/boli
the airways
cardiace, etc situaie n care bulele sunt mult mai mari (vezi dr jos)
Dr sus fragment pulmonar pe care se exteriorizeaza o spuma albicioasa (sursa pentru
able 15.5 The
ciuperca inecatului Freshwater Saltwater Near drowning
athophysiological
Dr jos seciune la nivelulHypotonic
ATB cu spum rozat, cu bule mari (secundar unui aspirat
Hypertonic gastric)
Adipocere is a waxy decomposition product formed from
bacterial hydrolysis and hydrogenation of fat tissue, which
occurs in bodies under water or in moist soil, in a warm
and anaerobic environment. Adipocere biochemistry has been
extensively investigated (Takatori 2001). Adipocere appear
usually after approximately 3 months postmortem, but som
case studies have shown its early formation within 34 weeks
Late decomposition is influenced by factors such as wate
temperature and bacterial content, and the victims injuries
Algal colonisation gives soft tissues a green or black discolora
tion. Body colonisation by marine scavengers can start befor
the onset of putrefactive changes. Later scavengers cause post
mortem artefacts, which can modify existing injuries and
mimic antemortem lesions, and quicken the course of th
bodys skeletonisation. The corpses movement in the wate
(a)
(c) limbs disarticulate first distall
enhances joint disarticulation:
due to the higher torsion forces and sinovial joints such as th
Figure areSkin
21.32
shoulder macerationbefore
disconnected of thefibrous
hands injoints
drowning
suchvictims.
as interver
The chronology
tebral of these 1993).
ones (Haglund changes depends upon different factors,
primarily the temperature of the water in which the corpse in
Site of death
submerged. Postmortem submersion times in these cases were:
(a)
The3 days (water
site of temperature
death can be close56C), (b) 6place
to the days,where
(waterthe body i
temperature 56C)aquatic
Mna
found, a remote and
de(c)spltoreas:
9 days (water
setting, temperature
or, in the 67C).
case of the cadaver
disposal ina-3
water, dry land. Awareness concerning the behav
zile
iour of human bodies in water is crucial for the assessment o
B-6 zile
the site of death.
C-9 zile
Cadaver buoyancy

The buoyancy of corpses follows basic laws of physics an


(b) depends on environmental and individual factors (Fig. 21.33)
into the blood, while proteins and fluid are
ported in the opposite direction, causing h
tonic hyperhydration. Thus, in addition
aspirated water, the lungs also collect fluid
surrounding tissue, producing the findi
edema aquosum: macroscopically, the
are massively distended, heavy, and w
logged. Overextension of lung tissue may
subpleural hemorrhage per rhexis (Fig. 15.

15.1.3
St Diagnosing Death
corp gsit n ap cu
by Drowning
numeroase arii de descuamare i
alge verzi pe suprafa
The external finding of cyanosis of the face,
and Dr leziuni
shoulders is postmortem
occasionally produse
made after
de fauna
postmortem acvaticahowever, these are as u
intervals;
cific as goose flesh, shrinking of the pe
nipples, excretion, or biting of the tongue.
heart dilatation, the absence of postmortem
coagulation, and anemic spleen are seen at au
in the case of death by drowning. Linear subf
hemorrhage in the superficial neck and ches
251

Plmni hiperinflai
Fig. 15.10 Emphysema aquosum with(umflai
sharply overex- cu pompa,
panded lungs that overlap at the body midline
emphysema aquosum) - nec n ap dulce Aort de culoare
rou intens, datorat
hemolizei sngelui
din circulaia mare
(dg dif cu autoliza
vezi fig). Pulmonara
are un spect normal
Elasticitate sczut
Fig. 15.11 Distinct emphysema aquosuma parenchimului
with residual pulmonar n
emphysema aquosum se vede urma lsat prin
imprints following blunt pressure (arrows)

digitopresiune
hemorrhage (Paltaufs spots), foamy content in the
Peteii mari, de tip Paltauf; produse prin
microrupturi la nivelul septurilor alveolare

Peteii Tardieu; produse prin


microrupturi capilare secundare
creterii presiunii hidrostatice: a nu
se confunda cu petele de antracoz
pulmonar (inlet)
Fig. 15.16 Wydlers sign: layer with clear watery fluid
(arrow)

cerebral insult, as well as due to intoxication,


craniocerebral trauma, or electrocution. For this
reason, atypical drowning fits only awkwardly
into the classification shown in Table 15.1. In
particular, drowning in a bathtub or in a puddle
is commonly classified as atypical drowning.
Fig. 15.15 Lacerations in the gastric mucosa after swal-
lowing of water in a case of fatal drowning Semnul Wydler coninutul gastric, vrsat
Rupturi ale mucoasei 15.2.3 Near Drowning
ntr-un
and Mycotic recipient
Infection de sticl, se separ n trei
gastrice Fig. 15.16 Wydlers sign: layer with clear watery fluid
Immersion syndrome remains at best a
partially understood phenomenon, possibly of
subcomponente:
Near drowning (arrow)
describes cases where a pre-
multifactorial etiology. It can also be assumed viously submerged - individual
Superior spum
dies within at
that preexisting cardiovascular disease plays a least 24 h of being rescued. Fungal infections
predisposing role alongside acute strain on the -effectMijlociu
can be a rare late cerebral coninut
in near insult,
drowning as
with wellclar
as due to intoxication,
circulatory system. - Inferior
aspiration of water, in particular coninut alimentar propriu-zis
involving
St - Emphysema aquosum, HE
Jos coeficient bronhoalveolar. Normal,
group. Radiologically, 20% of the Distention of stomach and duodenum
plume of froth, which was con- bronhiile au lumenul cu circa 25-30% mai
4). The average volume mare
of thedect
stomacharterele
in MSCT nvecinate
was 470 ml,(dr jos). n
ranging from 50 tostnga
1,200 mljos(Fig.
se 6). Autopsyun
observ confirmed
raport subunitar, ce
an average volume of stomach of 480 ml. Interestingly the
sugereaz
control group showed fie bronhospasm
only about fie hemodiluie
half of this volume
(276 ml, Table 1). (ca n cazul necului n ap dulce)
n average blood density at the right The content of the stomach in the drowning group
ound (Fig. 5), whereas the control measured an average of 20 HU and in the control group of
ficantly higher mean density of 39 HU (Table 1).
was a less significant difference in In 90% of the drowning cases, a distension of the
the drowning victims had mean duodenum by watery content was found. But also the
cause sudden and unex- Hering reflex (carotid sinus reflex): Bradycardia
the control group 60
er while producing no, or
HU.
due to chemical or thermal stimulation of
f drowning. Controversy the nasal mucosa. Possibly relevant in bath-
cho- syndrome can be
ersion tub homicides following sudden forced sub-
ral causes. Immersion in
ning mersion of the head in water by pulling on
mpredisposing factor in the legs
however, a number of It is assumed that, due to prior ingestion of a
ery,
ors need to be present for significant volume of food, blood flow in the
yse-
vagal inhibition to occur; gastrointestinal tract is redistributed, possibly
s such as hyperthermia, a due to peripheral hyperthermia. A lack of blood
l consumption, and sud- ensues if vagal stimulation causes additional
th a
n predisposition to death strain on the circulatory system. Alcohol may
e present. lead to further peripheral vasodilation, while
is an umbrella term for alcohol-related changes in cardiac stimulus con-
water due to vagal inhi- duction could be relevant in terms of cause of
presents a diagnosis of death.
be made when a body Furthermore, other reactions in terms of acute
s no signs of drowning, shock states have been associated with sudden
changes to explain the death following immersion in water:
sence of signs of water Cold shock: Massive redistribution of blood
as led to the use of the due to peripheral vasoconstriction.
Pain shock: Intense stimulation of, e.g., the
eflexes have been pro- solar plexus in the case of a belly flop; blood
th: sinks to the visceral vessels, slackened due to
Diferite
422 specii de diatomee PART III TRAUMATOLOGY AND VIOLENT DEATH

organs. Concerning the number of diatoms reaching closed


organs, some authors speak in terms of dozens and others of
single diatoms. While some authors have set the diagnostic
limit at 20 diatoms/slide per 100 L pellet for lungs and 5
diatoms/slide per 100 L for internal organs as a reliable criteria
for the diagnosis of drowning (Ludes et al. 1999), others have
proposed separation values up to 2040 diatoms/5 g in bone
marrow (Hrlimann et al. 2000).

False positives
The main critique of the diatom method is the finding of
diatoms in non-drowned corpses. Due to the ubiquity of
diatoms, false positives can be related to antemortem penetra-
tion, postmortem penetration during submersion or contami-
nation during sample collection and preparation.
Gastroenteric absorption may, in principle, occur as a result
Figure 21.37 A diatom (Thalassiosiria baltica) on the external of ingestion of diatom-laden beverages or food such as vegeta-
surface of the pleura in a cadaver with advanced postmortem bles and shellfish. Investigations performed during the 1960s
changes (experimental conditions, SEM 2000).
on gastroenteric absorption of diatoms using animals fed with
diatom suspensions have revealed some diatoms in internal
organs. Conversely, if a corpse is submerged after death, diatoms, organs, but others studies yielded negative results. Antemortem
due to the lack of cardiac activity, will not be transported to contamination may also, in principle, be due to diatom inhala-
closed organs. SEM and TEM studies have demonstrated the tion, which may involve aerophilic species, or be a consequence
penetration of diatoms from the alveoli into the blood stream of repeated swallowing or aspiration of water by divers or
during experimental drowning (Lunetta et al. 1998). swimmers.
Diatoms are eukaryotic unicellular or colonial algae, which Postmortem diatom penetration may occur during post-
are detectable in water, air and soil. The diatoms cell wall con- mortem submersion at high hydrostatic pressure, and through
tains a high quantity of silica and comprises two interconnected antemortem wound and postmortem artefacts. Experimental
units (valves). Diatom sizes range from 2 m to over 500 m, studies suggest the possibility of contamination, related to the
but those passing from the lungs into the blood stream gener- postmortem submersion time and depth as well as during post-
ally have a size <60 m. The valve structure represents the basis mortem submersion of isolated bones. Data on humans are
for taxonomic classification. It has either a pattern of radial much scantier than for animals due to the lack of systematic
symmetry or an elongated one, which provides the first distinc- studies on bodies submersed after death where the death
tion between centric and pinnate diatoms. Quantitative analysis occurred on land.
and taxonomic comparison of diatoms in the putative drown- Quantitative data on diatoms in organs of the non-drowned
ing media and the victims organs can assist in the diagnosis are contradictory. Most studies report few diatoms in the
of drowning, in differentiating between fresh- and saltwater peripheral organs of the non-drowned and studies performed
drowning, in estimating the site of drowning and in excluding with protocols aiming to avoid postmortem contamination
sources of contamination. found no diatoms in control cases (Auer and Mttnen 1988;
Ludes et al. 1994). A study from Denmark, published in the
1980s, reported in non-drowned bodies up to 194 valves/cm3
diameter of pulmonary artery) in drown
Fig. 6 a, b Distention of stom- (Fig. 2), whereas in the control group a
ach. a Swallowed water in a
distended stomach with an air average of 1.04 was measured (Table
fluid level (arrowhead) and was confirmed histologically (Fig. 3): t
alimentary leavings swimming
close to the top (arrow). Note had a significantly lower coefficient (0.
the hypodense liver indicating group (0.97); P=0.02 (Wilcoxon-test).
fatty liver as an additional find-
ing (31 HU). b Autopsy image The posterior distance between the
of the stomach fluid content show any significant difference betwee
A mosaic pattern of hypo- and hyper
was present in 60% of the drowning ca
and MSCT (Fig. 2), but only in 10% o

Heart failure
St sus lichid n bronhiile principale
(sgei),
spots in special sequences. Further CTRcu
The studies on nivel
did this show
not hidroaeric
issue a significant (vrf
The stomach dif
are necessary. sgeat) i aspect mozaicat al pl,on
interestingly,
drowning
Otherwise we found all thecaracteristic groupsigns
typical forensic (0.47) and the showed
victims control
pentru of aspiratul hidric
30%
wet drowning in MSCT, suchintrapulmonarof drowning
as aspiration, emphysema cases showed
non-drowning anc
(zonele albicioase
aquosum, mosaic pulmonary edema, MSCT; 40% at autopsy. The size of th
=ap)stomach swallowed fluid
and distented
hiperdense
and duodenum. Additionally we increased in 60% ofand
could document the cases,
in the the size io
stomach
St jos n zonele hipodense lumentul
directly measure bronchospasm,inwater40%, in were 40%rather
the paranasal
values and 20%, denseresp
co
vascular are diametrul mai
or showed mare
sinuses and haemodilution whichIniscomparison,
rather complicated
(sgeat) dect
the
n
control
zonele
groupanshowe
hiperdense
aver
impossible at the classical autopsy. content of stoma
The pathophysiological hypo-
atrium
(vrf
in
andsgeat)
70%.
hyperperfused areas Although the
in the lung (mosaic pattern)Drwith The left heart
narrow or dilated
hiperinflaie side was
hidricspecific,increased
gastric those
cu c
pulmonary arteries is much betterdrowning
nivelvisualised
ininMSCT
hidroaeric the (one
axial
(vrfuri
case). emphys
airways,
sgeat)
The inferior
images of the MSCT than during classical autopsy.caval vein lungwasin a enlarg
victim
drowning
The bronchial-arterial coefficient as well asde-
is significantly the control cases.
highly suspiciou
creased in the drowning cases in MSCT and histology; it is of these findings