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A POWER POINT PRESENTATION
                     BY
         DR.SANGEETA CHOWDHRY &
              DR.SUNIL SHARMA
DEPARTMENT OF FORENSIC MEDICINE & TOXICOLOGY
       GOVT. MEDICAL COLLEGE, JAMMU




 ASPHYXIAL
 CONDITIONS
DEFINITIONS


Asphyxia
 (Greek, 'pulsenessne
 ss' or 'absence of
 pulse')        means
 restriction of oxygen
 due to mechanical
 interference      with
 respiration.
ASPHYXIAL CONDITIONS-
             DEFINITIONS



Suicide           (Latin
 suicidium, ‘to kill
 oneself’) is the act of
 intentionally causing
 one's own death.
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.
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).
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.
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.
CLASSIFICATION OF STRANGULATION




Manual strangulation
or throttling: When
human fingers, palms
or hands are used to
compress the neck.
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.
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.
ASPHYXIAL CONDITIONS-
             DEFINITIONS


Drowning is the process
 of         experiencing
 respiratory impairment
 from
 submersion/immersion
 in liquid.
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.
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
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.
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.
CLASSIFICATION OF SUFFOCATION



Overlaying      results
from compression of
the chest, nose and
mouth, so as to
prevent breathing.
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.
CLASSIFICATION OF SUFFOCATION


Confined        space
entrapment      occurs
when      there     is
inadequate oxygen in
the enclosed space
due to consumption or
displacement by other
gases.
CLASSIFICATION OF SUFFOCATION



Burking      is     a
 combination       of
 homicidal
 smothering      and
 traumatic asphyxia.
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.
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.
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.
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.
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.
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:
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.
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.
PATHOPHYSIOLOGY
Reflex          vagal
 inhibition caused
 by pressure to the
 carotid sinuses and
 increased
 parasympathetic
 tone    leading    to
 sudden        cardiac
 arrest          (less
 common)
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.
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
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
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.
Triad of asphyxial stigmata may be seen




Congestion        and
 edema of the face
 due to raised venous
 pressure.
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.
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.
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)?
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.
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.
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.
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:
SIGNS AND SYMPTOMS

Dysphonia         or
 hoarseness of voice
 is commonly seen.
 Patient        may
 sometimes present
 with aphonia.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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).
SIGNS AND SYMPTOMS


Involuntary urination
 or
 defecation, expulsi
 on of fetus (if
 pregnant) may occur.
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.
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.
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.
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
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.
LABORATORY AND IMAGING
Arterial     blood
gases      (ABGs)
analysis should be
done in all patients
who          require
intubation,      for
subsequent
ventilator
management.
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.
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.
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).
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.
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.
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.
LABORATORY AND IMAGING

Fiberoptic
laryngoscopy       is
indicated         for
visualization of the
laryngeal structures
(vocal cords) and
adjacent structures
for    edema     and
hemorrhage.
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.
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.
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.
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.
MANAGEMENT


The definitive airway
management         is
laryngotomy
which must be done
at the earliest
COMPLICATIONS

Respiratory
 system:        Both
 aspiration
 pneumonia        and
 ARDS may develop;
 tracheal stenosis in
 case of rupture.
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.
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.
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.
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 .
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
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
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.
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.
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.
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.
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.
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.
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.
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.
‘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.
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.
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.
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.
THANKX FOR Y0UR PATIENCE...




 IT IS A SUZY
WORK...................

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ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 

Asphyxial conditions

  • 1. A POWER POINT PRESENTATION BY DR.SANGEETA CHOWDHRY & DR.SUNIL SHARMA DEPARTMENT OF FORENSIC MEDICINE & TOXICOLOGY GOVT. MEDICAL COLLEGE, JAMMU ASPHYXIAL CONDITIONS
  • 2. DEFINITIONS Asphyxia (Greek, 'pulsenessne ss' or 'absence of pulse') means restriction of oxygen due to mechanical interference with respiration.
  • 3. ASPHYXIAL CONDITIONS- DEFINITIONS Suicide (Latin suicidium, ‘to kill oneself’) is the act of intentionally causing one's own death.
  • 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. 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. 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. 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. CLASSIFICATION OF STRANGULATION Manual strangulation or throttling: When human fingers, palms or hands are used to compress the neck.
  • 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. 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. ASPHYXIAL CONDITIONS- DEFINITIONS Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid.
  • 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. 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. 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. 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. CLASSIFICATION OF SUFFOCATION Overlaying results from compression of the chest, nose and mouth, so as to prevent breathing.
  • 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. 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. CLASSIFICATION OF SUFFOCATION Burking is a combination of homicidal smothering and traumatic asphyxia.
  • 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. 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. 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. 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. 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. 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. 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. 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. PATHOPHYSIOLOGY Reflex vagal inhibition caused by pressure to the carotid sinuses and increased parasympathetic tone leading to sudden cardiac arrest (less common)
  • 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. 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. 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. 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. Triad of asphyxial stigmata may be seen Congestion and edema of the face due to raised venous pressure.
  • 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. 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. 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. 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. 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. 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. 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. SIGNS AND SYMPTOMS Dysphonia or hoarseness of voice is commonly seen. Patient may sometimes present with aphonia.
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. SIGNS AND SYMPTOMS Involuntary urination or defecation, expulsi on of fetus (if pregnant) may occur.
  • 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. 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. 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. 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. 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. LABORATORY AND IMAGING Arterial blood gases (ABGs) analysis should be done in all patients who require intubation, for subsequent ventilator management.
  • 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. 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. 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. 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. 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. 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. LABORATORY AND IMAGING Fiberoptic laryngoscopy is indicated for visualization of the laryngeal structures (vocal cords) and adjacent structures for edema and hemorrhage.
  • 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. 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. 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. 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. MANAGEMENT The definitive airway management is laryngotomy which must be done at the earliest
  • 74. COMPLICATIONS Respiratory system: Both aspiration pneumonia and ARDS may develop; tracheal stenosis in case of rupture.
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. ‘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. 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. 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. 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. THANKX FOR Y0UR PATIENCE... IT IS A SUZY WORK...................