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Asphyxial conditions

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Asphyxial conditions

  2. 2. DEFINITIONS Asphyxia (Greek, 'pulsenessne ss' or 'absence of pulse') means restriction of oxygen due to mechanical interference with respiration.
  3. 3. ASPHYXIAL CONDITIONS- DEFINITIONS Suicide (Latin suicidium, ‘to kill oneself’) is the act of intentionally causing one's own death.
  4. 4. ASPHYXIAL CONDITIONS- DEFINITIONS Failed suicide attempt (Latin: tentamen suicidii) refers to a suicide that did not result in death. Some are regarded as not true attempts at all, but rather parasuicide.
  5. 5. ASPHYXIAL CONDITIONS- DEFINITIONS Hanging or 'self- suspension' is a form of asphyxia caused by suspension of the body by a ligature which encircles the neck, the constricting force being at least part of the weight of the body. It may be either complete (feet are not touching the ground) or partial (feet are touching the ground).
  6. 6. ASPHYXIAL CONDITIONS- DEFINITIONS Strangulation is a form of asphyxia caused by mechanical disruption of blood flow through the vessels of the neck and/or blockage of air passage through the trachea by means of a ligature or by any means other than suspension of the body.
  7. 7. CLASSIFICATION OF STRANGULATION Ligature strangulation: When ligature material is used to compress the neck. It includes the use of any type of cord-like object, such as an electrical cord or purse strap.
  8. 8. CLASSIFICATION OF STRANGULATION Manual strangulation or throttling: When human fingers, palms or hands are used to compress the neck.
  9. 9. CLASSIFICATION OF STRANGULATION Mugging: Strangulation caused by holding the neck of the victim in the bend of elbow (i.e. the ‘sleeper hold’) or knee of the assailant.
  10. 10. CLASSIFICATION OF STRANGULATION Garroting: Strangulation is caused by compression of the neck by a ligature which is quickly tightened by twisting it with a lever (rod, stick or ruler) known as Spanish windlass which results in sudden loss of consciousness and collapse.
  11. 11. ASPHYXIAL CONDITIONS- DEFINITIONS Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid.
  12. 12. ASPHYXIAL CONDITIONS- DEFINITIONS Suffocation is a form of asphyxia caused by mechanical obstruction to the passage of air into the respiratory tract by means other than constriction of neck or drowning.
  13. 13. CLASSIFICATION OF SUFFOCATION Smothering is caused by mechanical occlusion of external air passages from outside, i.e. the nose and mouth by hand, cloth, pillow, pla stic bag or other material
  14. 14. CLASSIFICATION OF SUFFOCATION Choking is caused by an obstruction within the trachea, either partially or completely, from inside by a foreign body, like coin, fruit seed, toffees, candies, fish or any other material.
  15. 15. CLASSIFICATION OF SUFFOCATION Gagging results from pushing a gag (rolled up cloth or paper balls) into the mouth, sufficiently deep to block the pharynx. It combines the features of smothering and choking.
  16. 16. CLASSIFICATION OF SUFFOCATION Overlaying results from compression of the chest, nose and mouth, so as to prevent breathing.
  17. 17. CLASSIFICATION OF SUFFOCATION Traumatic asphyxia results from respiratory arrest due to mechanical fixation of chest, so that the normal movements of chest wall are prevented.
  18. 18. CLASSIFICATION OF SUFFOCATION Confined space entrapment occurs when there is inadequate oxygen in the enclosed space due to consumption or displacement by other gases.
  19. 19. CLASSIFICATION OF SUFFOCATION Burking is a combination of homicidal smothering and traumatic asphyxia.
  20. 20. EPIDEMIOLOGY  The rate of suicide is far higher in men than in women (3-4: 1) with suicidal hangings more common. However, recent trends suggest that women are gradually using hanging than other methods of suicide.  Women are more likely than men to be victims of strangulation (domestic violence or sexual assault).  Nearly all reported autoerotic strangulation incidents involve men.  Accidental strangulation may occur in both men and women.
  21. 21. CAUSES  Several populations are at risk of hanging or strangulation.  Toddlers: The neck may get caught and strangled in ill- constructed cribs as they put their heads out. Window cords have also been implicated in such deaths.
  22. 22. CAUSES  Adolescents: Incidence of accidental hanging, throttling or strangulation due to ‘choking game’ (voluntary asphyxia in order to enjoy the altered sensations due to cerebral hypoxia). Playground slide tie rope has been implicated in accidental strangulation. Emulating TV shows and depression can also lead to hanging.
  23. 23. CAUSES  Adults: Autoerotic accidents, assaults, and suicidal depression are common causes (e.g. prisons, where hanging is easier and available method). Accidental strangulation from scarfs and ‘chunni’ (in females) and by cotton cloth entangled in the rotor of a machine (in males) have been reported.  Elderly: Depression can lead to hanging.
  24. 24. CAUSES Isadora Duncan syndrome: The world famous dancer Isadora Duncan died on 14 September 1929 as a result of her long scarf which she was wearing got caught in the wire wheels of her Buggati car. She died at the scene and was later found to have sustained a fractured larynx and carotid artery injury.
  25. 25. PATHOPHYSIOLOGY The proposed mechanisms of the observed features seen in most of the asphyxial conditions (whether by hanging, manual strangulation, application of ligature, or postural asphyxiation (in children whose necks are caught in an object such as a crib) includes the following:
  26. 26. PATHOPHYSIOLOGY Venous obstruction leading to cerebral congestion, hypoxia and unconsciousness, which in turn, produces loss of muscle tone leading to airway obstruction, occurs if ligature is made up of broad and soft material. For manual strangulation and suicidal near- hanging victims, it is a significant factor that produces loss of consciousness.
  27. 27. PATHOPHYSIOLOGY Arterial blockage due to pressure on carotid artery, leading to cerebral anemia and collapse due to low cerebral blood flow occurs when ligature is made of thin cord.
  28. 28. PATHOPHYSIOLOGY Reflex vagal inhibition caused by pressure to the carotid sinuses and increased parasympathetic tone leading to sudden cardiac arrest (less common)
  29. 29. PATHOPHYSIOLOGY Most experts agree that regardless of the events occurring in any given hanging or strangulation, death ultimately occurs from cerebral hypoxia and ischemic neuronal death. Notably, none of the proposed mechanisms advocates airway compromise as the immediate cause of signs and symptoms observed in such cases. In fact, although mechanical airway compromise occurs and ultimately complicates patient management, it appears to play a minimal role in the immediate death of victims.
  30. 30. CLINICAL EFFECTS OF ASPHYXIA Sphincter Voiding of Asphyxia relaxation urine, stools, semen Capillary Decreased endothelium oxygen tension damage and reduced Hb Increased Cyanosis capillary Tardieu’s permeability spots Unconscious ness Pulmonary edema Capillary rupture Loss of Capillary Increased muscle stasis and intracapillary power engorgement pressure
  31. 31. Triad of asphyxial stigmata may be seen Cyanosis: Bluish discoloration of skin, face (particularly in the lips, tip of nose, ears lobules), nailbeds and mucous membranes
  32. 32. Triad of asphyxial stigmata may be seen Petechial hemorrhages (Tardieu’s spots) are found in those parts where capillaries are least supported, e.g. conjunctiva, face, epiglottis, on the face. They tend to be better made out in fair skinned persons.
  33. 33. Triad of asphyxial stigmata may be seen Congestion and edema of the face due to raised venous pressure.
  34. 34. EVALUATION AND DOCUMENTATION HISTORY In practice, it has been observed that manually strangled or garroted or suicidal hanging victims are brought to the hospital in unconscious state for the purposes of treatment. Such cases are brought to the emergency department after being found by strangers, friends, family members or sometimes police. On many occasions the exact history may not be disclosed by the relatives. The history in such cases is lacking, vague or cooked up. In such cases, the doctor must try to extract the history from different sources available.
  35. 35. EVALUATION AND DOCUMENTATION Even if the victim is conscious, she may not always report the attempted strangulation episode. As is common with cases of domestic violence, the victim may be hesitant to fully describe what happened or will minimize the severity of the attack. Moreover, visual evidence of force applied to the neck during such incident is often absent or minimal on initial medical evaluation. The lack of physical findings may lead authorities to discount the patient’s report. Hence, specific questions often are required to elucidate the history.
  36. 36. EVALUATION AND DOCUMENTATION The victim should be asked about the method or manner of strangulation, whether hands, elbow and forearm, knee, ligature or any other method was used. Whether the victim attempted hanging? The number of such episodes, whether single, multiple or repeated with different methods. Other circumstances should also be enquired like whether the victim also smothered, shaken, knocked or pounded into a wall or the ground? Was the victim also hit or physically sexually or assaulted? Whether the victim has consumed any alcohol, drug or any other poison (any smell from breath)?
  37. 37. EVALUATION AND DOCUMENTATION The practitioner has to enquire about specific symptoms like whether the victim lost consciousness, if there is any neck pain, any difficulty in breathing or swallowing, any change of voice, headache, and if there was any urinary and/or fecal incontinence.
  38. 38. EVALUATION AND DOCUMENTATION Hanging victims are more likely to arrive in the emergency department with a depressed level of consciousness than are victims of manual strangulation. This is presumably due to the more intensive and prolonged compressive force applied to the neck due to hanging than is typically seen with manual pressure.
  39. 39. CLINICAL PRESENTATION The victim may present with deceptively harmless signs and symptoms with no or minimal external signs of soft tissue injury because of the slowly compressive nature of forces involved in non-lethal strangulation. The upper airway may also appear normal beneath intact mucosa, despite hyoid bone or laryngeal fractures. It takes time for hemorrhage and edema to develop after compressive injuries (may take 36 hours after the episode), and the patient can develop edema of the supraglottic and oropharyngeal soft tissue, leading to airway obstruction.
  40. 40. SIGNS AND SYMPTOMS The clinical presentations can vary according to the method, force and duration of asphyxiation. The following specific clinical manifestations are possible in asphyxiation victims:
  41. 41. SIGNS AND SYMPTOMS Dysphonia or hoarseness of voice is commonly seen. Patient may sometimes present with aphonia.
  42. 42. SIGNS AND SYMPTOMS Dysphagia or swallowing difficulty may occur due to injury to larynx or hyoid bone which is not common symptom on initial assessment, but may be reported subsequently in 2 weeks. Sometimes it may be painful (odynophagia).
  43. 43. SIGNS AND SYMPTOMS Dyspnea is very common, but often a late development. Respiratory distress is seen in 2 weeks which may be due hyperventilation or psychogenic (anxiety, fear, depression). Difficulty breathing can also be due to laryngeal edema or hemorrhage, although those injuries are less common in surviving victims.
  44. 44. SIGNS AND SYMPTOMS Pain and swelling in the throat or neck is common after attempted strangulation. The patient may be able to localize it to a specific area of injury, or it may be diffuse and poorly localized. Edema may be caused by internal hemorrhage, injury to underlying neck structures or fracture of the. Laryngeal fracture can manifest as severe pain on gentle palpation of the larynx or subcutaneous emphysema over or around the laryngeal cartilage.
  45. 45. SIGNS AND SYMPTOMS Altered mental status: Restlessness, confusion, loss of orientation or combativeness due to cerebral hypoxia or from concomitant intracranial injury or ingestion of drugs or ethanol.
  46. 46. SIGNS AND SYMPTOMS Neurologic symptoms include changes in vision, tinnitus, ptosis, facial droop, or unilateral weakness, paralysis or loss of sensation. In many patients, the findings are transient and believed to be caused by focal cerebral ischemia produced by the strangulation process that resolves with time. In rare cases, damage to the internal carotid artery may induce thrombosis with a delayed neurologic presentation.
  47. 47. SIGNS AND SYMPTOMS Petechiae can occur at or above the area of compression and are most frequently seen on the face, periorbital region, eyelids, scalp and conjunctiva. Facial and conjunctival petechiae are evidence of prolonged elevated venous pressure. It has been found that the jugular vein needs to be occluded for at least 15-30 seconds for the development of facial petechiae. Subconjunctival hemorrhage is usually seen after a vigorous struggle between the victim and assailant.
  48. 48. SIGNS AND SYMPTOMS Neck: Injury to the soft tissues in the neck may manifest with abrasions (scratches), hyperemia, e cchymoses and edema. The hyperemia may be transient and not visible by the time of assessment. Ecchymoses and swelling may take time to develop and may not be visible on initial assessment.
  49. 49. SIGNS AND SYMPTOMS Attempted throttling: Fingertips may produce faint oval or round bruises 1.5-2 cm in size (may be more in case of continued bleeding). A grip from right hand produces a bruising due to bulb of pressing thumb over the cornue of hyoid/thyroid on anterolateral surface of right side of victim's neck and several fingertip bruising marks and overlying nail scratch abrasions over left side. A single bruise on the victim’s neck is most frequently caused by the assailant’s thumb as bruises made by tips of thumbs are more prominent than with other fingers.
  50. 50. SIGNS AND SYMPTOMS Multiple abrasions on the neck may be defensive in nature from use of victim's own fingernails in an effort to dislodge the assailant's grip but commonly are a combination of lesions caused by both the victim and the assailant’s fingernails.
  51. 51. SIGNS AND SYMPTOMS Chin abrasions may also occur from the defensive actions as the victim tries to protect their necks from the manual strangulation of the assailant.
  52. 52. LIGATURE MARK (‘FURROW’) IN ATTEMPTED HANGING AND STRANGULATION S. No. Features Hanging Strangulation 1. Direction Oblique Transverse 2. Continuity Non-continuous Continuous 3. Level in the neck Above thyroid At or below thyroid 4. Base Pale, hard, Soft and reddish parchment-like
  53. 53. SIGNS AND SYMPTOMS Attempted throttling: Fingertips may produce faint oval or round bruises 1.5-2 cm in size (may be more in case of continued bleeding). A grip from right hand produces a bruising due to bulb of pressing thumb over the cornue of hyoid/thyroid on anterolateral surface of right side of victim's neck and several fingertip bruising marks and overlying nail scratch abrasions over left side. A single bruise on the victim’s neck is most frequently caused by the assailant’s thumb as bruises made by tips of thumbs are more prominent than with other fingers.
  54. 54. SIGNS AND SYMPTOMS Lungs: Aspiration pneumonitis may occur due to inhalation of vomitus during the episode. Pulmonary edema is a seen generally in comatose hanging victims. The cause of the pulmonary edema can either be due to anoxic injury to the central nervous system (neurogenic pulmonary edema) or from the large negative intrathoracic pressures seen when the victim struggles to breathe in against an occluded airway (obstructive pulmonary edema).
  55. 55. SIGNS AND SYMPTOMS Involuntary urination or defecation, expulsi on of fetus (if pregnant) may occur.
  56. 56. SIGNS AND SYMPTOMS Fractures of the thyroid cartilage or hyoid bone in victims of accidental strangulation and direct injury to the trachea is rare with strangulation. Carotid artery injury is also uncommon after attempted hanging and strangulation.
  57. 57. SIGNS AND SYMPTOMS Injury to other organ systems from strangulation is uncommon. Case reports of diaphragmatic injury, multiple organ failure, and thyroid storm after attempted strangulation; cricotracheal separation and common carotid artery dissection, and laryngotracheal separation after attempted hanging; and laryngeal rupture and carotid artery stenosis after accidental strangulation have appeared in the medical literature.
  58. 58. SIGNS AND SYMPTOMS Examination for other associated injuries in cases female patients regarding injuries on lips, face, cheeks, abdom en, back, genital organs and breast (if there is any history suggesting sexual abuse). In such cases complete examination of genital organs is of vital importance.
  59. 59. Diagnosis The majority of the victims present with some common features, a combination of these findings should be taken into consideration for diagnosis: Hyperemia and/or ecchymosis Facial or conjunctival petechiae Change of voice or difficulty in breathing Marks on the neck Loss of consciousness or altered mental status
  60. 60. DIAGRAMS AND PHOTOGRAPHS It is important to document the injuries through diagrams and photograph that may be seen at the time of examination for evidence purpose. The injuries should be mentioned in the pictograph given along with the medico-legal report. The following photographs may also be taken: Distance photo: Full body photograph to identify the victim and location of injury. Close-up photo: Photographs of injuries along with a ruler from different angles to maximize visibility and to document the size. Follow-up photo: As the injuries may take time to develop, taking follow-up photographs at different time intervals will document injuries as they evolve.
  61. 61. LABORATORY AND IMAGING Arterial blood gases (ABGs) analysis should be done in all patients who require intubation, for subsequent ventilator management.
  62. 62. LABORATORY AND IMAGING Pulse oximetery is indicated in patients with altered mental status and respiratory distress. It also makes ABGs unnecessary in patients who do not require endotracheal intubation.
  63. 63. LABORATORY AND IMAGING Neck X-ray should be done in nearly all strangulation victims and patients with a mechanism consistent with hanging. It is useful to detect fractured hyoid bone and for evaluation of subcutaneous emphysema due to fractured larynx. Fractures of the cervical vertebrae are extremely rare in strangulation injuries unless there has been a hanging with a free-fall drop of the body. Generally, a fractured hyoid bone indicates a severe, occult soft- tissue injury, even in a patient whose medical condition is otherwise stable.
  64. 64. LABORATORY AND IMAGING Chest X-ray is indicated after endotracheal intubation for placement confirmation, diagnosi s of pulmonary edema, aspiration pneumonitis and acute respiratory distress syndrome (ARDS).
  65. 65. LABORATORY AND IMAGING CT scan is indicated to detect hyoid bone and laryngeal fractures, injury to carotid arteries and other soft-tissue abnormalities that may not be apparent on plain radiographs. CT head is done to evaluate neurological status. CT is more sensitive for bony injuries, subcutaneous emphysema, soft-tissue edema, and internal hemorrhage.
  66. 66. LABORATORY AND IMAGING Doppler vascular imaging, CT angiography or arteriography is useful to detect injury to the carotid arteries (in patients with unilateral neurological findings). The current ‘gold standard’ for blunt carotid artery injury is four-vessel selective angiography.
  67. 67. LABORATORY AND IMAGING MRI is the most useful imaging modality for the majority of such victims because of its highest sensitivity for deep soft-tissue injury including the larynx and vessels.
  68. 68. LABORATORY AND IMAGING Fiberoptic laryngoscopy is indicated for visualization of the laryngeal structures (vocal cords) and adjacent structures for edema and hemorrhage.
  69. 69. MANAGEMENT Like any other traumatic injuries, the management of a strangulation victim starts with the ABCs  Airway  Breathing  Circulation Fluid resuscitation must be done judiciously as there is risk of subsequent ARDS and cerebral edema.
  70. 70. MANAGEMENT The choice and sequence of imaging is dependent on patient’s clinical condition, suspected injuries and availability of the specific modalities in that set-up. An ENT consultation can establish both the need for, and the timing of, these studies.
  71. 71. MANAGEMENT Like any other traumatic injuries, the management of a strangulation victim starts with the ABCs— airway, breathing, circu lation. Fluid resuscitation must be done judiciously as there is risk of subsequent ARDS and cerebral edema.
  72. 72. MANAGEMENT Orotracheal intubation should be done preferably by an anesthetist. It can be difficult if laryngeal edema is present or if direct traumatic disruption of the larynx has occurred. Cricothyroidotomy is indicated for any patient with severe respiratory distress and completely obstructed airway. If associated neck injuries render cricothyroidotomy difficult, percutaneous translaryngeal ventilation may be used to temporarily oxygenate a patient.
  73. 73. MANAGEMENT The definitive airway management is laryngotomy which must be done at the earliest
  74. 74. COMPLICATIONS Respiratory system: Both aspiration pneumonia and ARDS may develop; tracheal stenosis in case of rupture.
  75. 75. COMPLICATIONS Neurologic sequelae including muscle spasms, transient hemiplegia, central cord syndrome and seizures. Long- term paraplegia or quadriplegia and short-term autonomic dysfunction may be seen in spinal cord injury.
  76. 76. COMPLICATIONS Psychiatric symptoms: Encephalopathy, insomnia, nightmares and anxiety and an inclination for violence are seen in such victims. Psychosis, depression, suicidal ideation, Korsakoff syndrome, amnesia and progressive dementia may develop.
  77. 77. PROGNOSIS The prognosis for survivors of hanging and strangulations arriving to the emergency department is widely variable. The outcome is determined by the presence of cardiopulmonary arrest (as indicated by a requirement for cardiopulmonary resuscitation and/or invasive airway management) and degree of anoxic brain injury (as correlated with a low Glasgow Coma Score and cerebral edema on initial CT scan). In general, the emergency room disposition of such victims is primarily determined by their clinical condition and evidence of injury to their deep neck structures.
  78. 78. MEDICO-LEGAL FORMALITIES WHILE DEALING WITH ATTEMPTED STRANGULATION OR HANGING Medical practitioners who examine such cases in the emergency have to follow a protocol regarding the documentation of medico-legal formalities; besides imparting treatment in order to save the life of patient. Injuries due to assault are required to be informed to the police (if police is not accompanying) to ensure safe disposition of the patient. In case of suspected child abuse, child protective agency should be notified. The preparation of medico-legal report is guided as per the protocol .
  79. 79. LEGAL PROVISIONS In India, attempt to commit suicide is an offence punishable under Sec. 309 IPC. It states that whoever attempts to commit suicide and does any act towards the commission of such offence, shall be punished with simple imprisonment for a term which may extend to 1 year or with fine, or with both. Attempt to commit suicide is an offence punishable under Sec. 309 IPC
  80. 80. LEGAL PROVISIONS Abetment of suicide: As per Sec. 306 IPC, any person who abets the commission of suicide shall be punished for a term which may extent to 10 years imprisonment and shall also be liable to fine. GOPAL KANDA, THE SIRSA MLA IS THE MAIN ACCUSED OF A CASE UNDER SECTION 306 IPC
  81. 81. The Protection of Women from Domestic Violence Act, 2005 Salient features of the Act: The term 'domestic violence' covers all forms of physical, sexual, verba l, emotional and economic abuse that can harm, cause injury to, endanger the health, safety, life, limb or well-being, either mental or physical of the aggrieved person.
  82. 82. The Protection of Women from Domestic Violence Act, 2005 Salient features of the Act: ‘Aggrieved' person' is not just the wife but a woman who is the sexual partner of the male irrespective of whether she is his legal wife or not. It includes daughter, mother, sister, child (male or female), widowed relative, or any woman residing in the household who is related in some way to the respondent.
  83. 83. The Protection of Women from Domestic Violence Act, 2005 Salient features of the Act: ‘Respondent’ is any male, adult person who is, or has been, in a domestic relationship with the aggrieved person that includes his mother, sister and other relatives; the case can also be filed against relatives of the husband or male partner.
  84. 84. THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005 Information to Protection Officer: The information regarding any acts of domestic violence does not necessarily have to be lodged by the aggrieved party but by any person who has reason to believe that such an act has been or is being committed. Any medical officer, neighbors, social workers or relatives can all take initiative on behalf of the victim.
  85. 85. THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005 Duties of medical facilities: If an aggrieved person or a Protection Officer or a service provider requests the medical practitioner to provide any medical aid to the victim, the doctor should provide medical aid to the aggrieved person in the medical facility.
  86. 86. THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005 Penalties: The magistrate can impose a penalty up to 1 year of imprisonment and/or a fine up to Rs. 20,000/- for an offence under this Act. The offence is also considered cognizable and non-bailable. The decision can be taken under the sole testimony of the aggrieved person; the court may conclude that an offence has been committed by the accused.
  87. 87. THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005 The magistrate can impose monetary relief and monthly payments of maintenance. The respondent can also be made to meet the expenses incurred and losses suffered by the aggrieved person as a result of domestic violence and can also cover loss of earnings, medical expenses, loss or damage to property and can also cover the maintenance of the victim. The Act also allows the magistrate to make the respondent pay compensation and damages for injuries including mental torture and emotional distress caused by acts of domestic violence.
  88. 88. KEY ELEMENTS OF STRANGULATION AND SUFFOCATION STATUTE The Strangulation and Suffocation Law in the Unites States defines and provides penalties for a person who engages in intentional strangulation and suffocation. The states of Iowa, South Dakota, California, Wisconsin, Tennessee, Virginia and New York have passed laws making it a felony (a crime punishable by death or imprisonment in excess of 1 year) under certain conditions to knowingly impede someone’s breathing.
  89. 89. ‘Dangerous weapon’ means any firearm, whether loaded or unloaded; any device designed as a weapon and capable of producing death or great bodily harm; any ligature or other instrumentality used on the throat, neck, nose, or mouth of another person to impede, partially or completely, breathing or circulation or blood; any electric weapon, or any other device or instrumentality which, in the manner it is used or intended to be used, is calculated or likely to produce death or great bodily harm. ‘Substantial bodily harm’ means bodily injury that causes a laceration that requires stitches, staples, or a tissue adhesive; and fracture of a bone; a broken nose; a burn; a petechia; a temporary loose of consciousness, sight or hearing; a concussion; or a loss or fracture of a tooth.
  90. 90. SAMPLE CASE REPORT Domestic violence: A lady 29 years was admitted in Medicine unit in emergency as a suspected case of poisoning with history of found unconscious at her residence; alleged by her husband to have taken some drugs at her home. On examination, the lady was cyanosed. She was managed and treated as a case of suspected poisoning. Next day, the department of Forensic Medicine was approached for review of the case and on thorough examination, a ligature mark was found all around the neck which was circular, and horizontally placed below the level of thyroid cartilage (Fig. 1). The patient was immediately shifted to ICU where it was confirmed that the patient had developed pulmonary edema. On detailed investigation by the investigating officer, it was confirmed that the husband had tried to strangulate her over some dispute but could not succeed.
  91. 91. SAMPLE CASE REPORT Sexual assault with manual strangulation: A young girl aged 13 years was found from an abandoned street in semi- unconscious condition. She was shifted to Govt. Medical College Jammu for treatment. During examination, cresentric abrasions along with multiple oval shaped bruises were found over the neck and nasal region. Two days after, when she regained her consciousness fully; her statement was recorded by the police. It was revealed in the statement that she was kidnapped by her close relative and then taken to abandoned street and was sexually assaulted there and when she tried to cry, she was throttled and smothered by the accused, thereafter she fell unconscious.
  92. 92. SAMPLE CASE REPORT Traumatic asphyxia: A truck conductor was brought to the emergency in Govt. Medical College Jammu in semi- conscious condition with labored breathing, intense cyanosis, and tachycardia. The history revealed by the police that he was helping the driver by standing at the back side of truck for the purpose of parking. However, the driver could not control the truck while reversing the same that lead to fixation of the conductor in between the backside of truck and the wall resulting in traumatic asphyxia. On examination, multiple bruises and contusions over the chest with fracture of ribs were found. Patient was immediately shifted to ICU but could not survive and died after two days.
  93. 93. THANKX FOR Y0UR PATIENCE... IT IS A SUZY WORK...................
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