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The mechanism of death in [[asphyxial death]]s seems to be an exam favourite. | The mechanism of death in [[asphyxial death]]s seems to be an exam favourite. | ||
===Short answer=== | |||
*Brain stem hypoxia due to ischemia caused by venous obstruction in the neck.<ref>URL: [http://www.forensicmed.co.uk/pathology/mechanisms-of-death/ http://www.forensicmed.co.uk/pathology/mechanisms-of-death/]. Accessed on: 1 May 2012.</ref><ref>URL: [http://www.forensicmed.co.uk/pathology/pressure-to-the-neck/ http://www.forensicmed.co.uk/pathology/pressure-to-the-neck/]. Accessed on: 1 May 2012.</ref> | *Brain stem hypoxia due to ischemia caused by venous obstruction in the neck.<ref>URL: [http://www.forensicmed.co.uk/pathology/mechanisms-of-death/ http://www.forensicmed.co.uk/pathology/mechanisms-of-death/]. Accessed on: 1 May 2012.</ref><ref>URL: [http://www.forensicmed.co.uk/pathology/pressure-to-the-neck/ http://www.forensicmed.co.uk/pathology/pressure-to-the-neck/]. Accessed on: 1 May 2012.</ref><ref name=pmid20456578/> | ||
===Long answer=== | |||
*It depends on who one asks. Other explanations include | *It depends on who one asks. | ||
*Other explanations include:<ref name=pmid20456578>{{Cite journal | last1 = Clément | first1 = R. | last2 = Redpath | first2 = M. | last3 = Sauvageau | first3 = A. | title = Mechanism of death in hanging: a historical review of the evolution of pathophysiological hypotheses. | journal = J Forensic Sci | volume = 55 | issue = 5 | pages = 1268-71 | month = Sep | year = 2010 | doi = 10.1111/j.1556-4029.2010.01435.x | PMID = 20456578 }}</ref> | |||
**"Cardiac inhibition secondary to nerve stimulation". | |||
**"Respiratory asphyxia". | |||
==The obsolete asphyxia quintet== | ==The obsolete asphyxia quintet== | ||
| Line 88: | Line 91: | ||
Associations: | Associations: | ||
*Ethanol intoxication.<ref name=pmid20666919>{{Cite journal | last1 = Nikolić | first1 = S. | last2 = Zivković | first2 = V. | last3 = Dragan | first3 = B. | last4 = Juković | first4 = F. | title = Laryngeal choking on food and acute ethanol intoxication in adults--An autopsy study. | journal = J Forensic Sci | volume = 56 | issue = 1 | pages = 128-31 | month = Jan | year = 2011 | doi = 10.1111/j.1556-4029.2010.01510.x | PMID = 20666919 }}</ref> | *[[Ethanol]] intoxication.<ref name=pmid20666919>{{Cite journal | last1 = Nikolić | first1 = S. | last2 = Zivković | first2 = V. | last3 = Dragan | first3 = B. | last4 = Juković | first4 = F. | title = Laryngeal choking on food and acute ethanol intoxication in adults--An autopsy study. | journal = J Forensic Sci | volume = 56 | issue = 1 | pages = 128-31 | month = Jan | year = 2011 | doi = 10.1111/j.1556-4029.2010.01510.x | PMID = 20666919 }}</ref> | ||
*Neurologic disease.<ref name=pmid17209932>{{Cite journal | last1 = Dolkas | first1 = L. | last2 = Stanley | first2 = C. | last3 = Smith | first3 = AM. | last4 = Vilke | first4 = GM. | title = Deaths associated with choking in San Diego county. | journal = J Forensic Sci | volume = 52 | issue = 1 | pages = 176-9 | month = Jan | year = 2007 | doi = 10.1111/j.1556-4029.2006.00297.x | PMID = 17209932 }}</ref> | *Neurologic disease.<ref name=pmid17209932>{{Cite journal | last1 = Dolkas | first1 = L. | last2 = Stanley | first2 = C. | last3 = Smith | first3 = AM. | last4 = Vilke | first4 = GM. | title = Deaths associated with choking in San Diego county. | journal = J Forensic Sci | volume = 52 | issue = 1 | pages = 176-9 | month = Jan | year = 2007 | doi = 10.1111/j.1556-4029.2006.00297.x | PMID = 17209932 }}</ref> | ||
Epidemiology: | Epidemiology: | ||
*Extremes of age.<ref name=pmid17209932/> | *Extremes of age.<ref name=pmid17209932/> | ||
**Old - often | **Old - often associated with neurologic disease or [[alcohol]]. | ||
**Young - may be foreign body ingestion. | **Young - may be foreign body ingestion. | ||
| Line 103: | Line 106: | ||
==Drowning== | ==Drowning== | ||
===General=== | ===General=== | ||
*Drowning is difficult to prove on autopsy.<ref name=pmid16378701>{{cite journal |author=Piette MH, De Letter EA |title=Drowning: still a difficult autopsy diagnosis |journal=Forensic Sci. Int. |volume=163 |issue=1-2 |pages=1–9 |year=2006 |month=November |pmid=16378701 |doi=10.1016/j.forsciint.2004.10.027 |url=}}</ref> The diagnosis is often based on circumstance, i.e. the scene. | |||
* | **The [[autopsy]] is often negative, i.e. there is [[negative autopsy|no anatomical cause of death]]. | ||
====Laboratory==== | |||
There are a few tests of debated value:<ref name=pmid16378701/> | |||
*Diffusion of particulates into the blood (left ventricle) from the water. | |||
**Diatom test. | |||
*Haemodilution. | |||
**Mostly useless - CPR interferes with it, not reliable if there putrefaction or autolysis. | |||
*Transport of aveolar element into blood circulation. | |||
=== | ===Gross=== | ||
External | ====External findings==== | ||
*''[[Plume of froth]]'' ([[AKA]] ''cone of foam'') at the mouth/nostrils (fresh drowning only).<ref name=pmid16378701/><ref name=pmid12134758>{{cite journal |author=Bohnert M, Ropohl D, Pollak S |title=[Forensic medicine significance of the fluid content of the sphenoid sinuses] |language=German |journal=Arch Kriminol |volume=209 |issue=5-6 |pages=158–64 |year=2002 |pmid=12134758 |doi= |url=}}</ref> | *''[[Plume of froth]]'' ([[AKA]] ''cone of foam'') at the mouth/nostrils (fresh drowning only).<ref name=pmid16378701/><ref name=pmid12134758>{{cite journal |author=Bohnert M, Ropohl D, Pollak S |title=[Forensic medicine significance of the fluid content of the sphenoid sinuses] |language=German |journal=Arch Kriminol |volume=209 |issue=5-6 |pages=158–64 |year=2002 |pmid=12134758 |doi= |url=}}</ref> | ||
**Classic DDx for this finding is: narcotics, [[congestive heart failure]]. | **Classic DDx for this finding is: narcotics, [[congestive heart failure]]. | ||
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*Wrinkled skin ([[AKA]] ''washerwoman skin'' and ''hydration changes'') - changes due to water immersion; changes may be present in the context of immersion post-mortem.<ref name=pmid6741294>{{cite journal |author=Reh H |title=[Early postmortem course of washerwoman's skin of the fingers] |language=German |journal=Z. Rechtsmed. |volume=92 |issue=3 |pages=183–8 |year=1984 |pmid=6741294 |doi= |url=}}</ref> | *Wrinkled skin ([[AKA]] ''washerwoman skin'' and ''hydration changes'') - changes due to water immersion; changes may be present in the context of immersion post-mortem.<ref name=pmid6741294>{{cite journal |author=Reh H |title=[Early postmortem course of washerwoman's skin of the fingers] |language=German |journal=Z. Rechtsmed. |volume=92 |issue=3 |pages=183–8 |year=1984 |pmid=6741294 |doi= |url=}}</ref> | ||
Internal:<ref name=pmid12134758>{{cite journal |author=Bohnert M, Ropohl D, Pollak S |title=[Forensic medicine significance of the fluid content of the sphenoid sinuses] |language=German |journal=Arch Kriminol |volume=209 |issue=5-6 |pages=158–64 |year=2002 |pmid=12134758 |doi= |url=}}</ref><ref>URL: [http://netk.net.au/Forensic/Drowning.pdf http://netk.net.au/Forensic/Drowning.pdf]. Accessed on: 20 September 2010.</ref> | ====Internal findings==== | ||
Features:<ref name=pmid12134758>{{cite journal |author=Bohnert M, Ropohl D, Pollak S |title=[Forensic medicine significance of the fluid content of the sphenoid sinuses] |language=German |journal=Arch Kriminol |volume=209 |issue=5-6 |pages=158–64 |year=2002 |pmid=12134758 |doi= |url=}}</ref><ref>URL: [http://netk.net.au/Forensic/Drowning.pdf http://netk.net.au/Forensic/Drowning.pdf]. Accessed on: 20 September 2010.</ref> | |||
*Lung emphysema; "kissing lungs" = lungs touch one another -- on opening the chest. | *Lung emphysema; "kissing lungs" = lungs touch one another -- on opening the chest. | ||
*Froth in the trachea. | *Froth in the [[trachea]]. | ||
*Paltauf spots -- light-red washed-out appearing fingertip-sized spots.<ref>URL: [http://www.mijnwoordenboek.nl/EN/theme/ME/EN/DE/P/3 http://www.mijnwoordenboek.nl/EN/theme/ME/EN/DE/P/3]. Accessed on: 20 September 2010.</ref> | *Paltauf spots -- light-red washed-out appearing fingertip-sized spots.<ref>URL: [http://www.mijnwoordenboek.nl/EN/theme/ME/EN/DE/P/3 http://www.mijnwoordenboek.nl/EN/theme/ME/EN/DE/P/3]. Accessed on: 20 September 2010.</ref> | ||
**Thought to arise from hemolysis + fluid decedent drown in. | **Thought to arise from hemolysis + fluid decedent drown in. | ||
*Fluid in the paranasal sinuses.<ref name=pmid8643988>{{cite journal |author=Hottmar P |title=[The presence of fluid in the paranasal sinuses in comparison with other diagnostic signs of drowning] |language=Czech |journal=Soud Lek |volume=40 |issue=4 |pages=34–6 |year=1995 |month=December |pmid=8643988 |doi= |url=}}</ref> | *Fluid in the paranasal sinuses.<ref name=pmid8643988>{{cite journal |author=Hottmar P |title=[The presence of fluid in the paranasal sinuses in comparison with other diagnostic signs of drowning] |language=Czech |journal=Soud Lek |volume=40 |issue=4 |pages=34–6 |year=1995 |month=December |pmid=8643988 |doi= |url=}}</ref> | ||
===Microscopic | ===Microscopic=== | ||
*None that are specific. | |||
==Carbon monoxide toxicity== | ==Carbon monoxide toxicity== | ||
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*CO binds to myoglobin. | *CO binds to myoglobin. | ||
===Gross | ===Gross=== | ||
External | ====External findings==== | ||
*Salmon pink skin. | *Salmon pink skin. | ||
Internal | |||
DDx of pink skin includes: | |||
*[[Hypothermia]]. | |||
*Cyanide poisoning. | |||
*Fluoroacetate poisoning. | |||
====Internal findings==== | |||
*General: organs pink hue. | *General: organs pink hue. | ||
*Brain: globus pallidus [[necrosis]] - bilateral.<ref name=pmid21150349>{{Cite journal | last1 = Fielding | first1 = J. | last2 = Lang | first2 = W. | last3 = White | first3 = OB. | title = Carbon monoxide poisoning: impact on ocular motility. | journal = Cogn Behav Neurol | volume = 23 | issue = 4 | pages = 256-61 | month = Dec | year = 2010 | doi = 10.1097/WNN.0b013e3181c5e2c1 | PMID = 21150349 }}</ref> | *Brain: globus pallidus [[necrosis]] - bilateral.<ref name=pmid21150349>{{Cite journal | last1 = Fielding | first1 = J. | last2 = Lang | first2 = W. | last3 = White | first3 = OB. | title = Carbon monoxide poisoning: impact on ocular motility. | journal = Cogn Behav Neurol | volume = 23 | issue = 4 | pages = 256-61 | month = Dec | year = 2010 | doi = 10.1097/WNN.0b013e3181c5e2c1 | PMID = 21150349 }}</ref> | ||
Notes: | Notes: | ||
*Bilateral necrosis of the putamen is seen in [[methanol toxicity]]. | *Bilateral necrosis of the putamen is seen in [[methanol toxicity]]. | ||
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===Toxicology=== | ===Toxicology=== | ||
*Classically has the smell of "rotten eggs".<ref name=pmid20920221>{{cite journal |author=Morii D, Miyagatani Y, Nakamae N, Murao M, Taniyama K |title=Japanese experience of hydrogen sulfide: the suicide craze in 2008 |journal=J Occup Med Toxicol |volume=5 |issue= |pages=28 |year=2010 |pmid=20920221 |pmc=2954931 |doi=10.1186/1745-6673-5-28 |url=}}</ref> | *Classically has the smell of "rotten eggs".<ref name=pmid20920221>{{cite journal |author=Morii D, Miyagatani Y, Nakamae N, Murao M, Taniyama K |title=Japanese experience of hydrogen sulfide: the suicide craze in 2008 |journal=J Occup Med Toxicol |volume=5 |issue= |pages=28 |year=2010 |pmid=20920221 |pmc=2954931 |doi=10.1186/1745-6673-5-28 |url=}}</ref> | ||
*Lab: ''thiosulfate'' | *Lab: ''thiosulfate''. | ||
===Gross=== | ===Gross=== | ||
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*Patterned ovoid contusions (from the fingers). | *Patterned ovoid contusions (from the fingers). | ||
*+/-Defensive-type injuries. | *+/-Defensive-type injuries. | ||
====Image==== | |||
<gallery> | |||
Image:Hofmann_Lehrbuch_suidide_hanging.jpg | Drawing of suicide by hanging. (WC/National Library of Medicine) | |||
</gallery> | |||
===Microscopic=== | ===Microscopic=== | ||