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An introduction to forensic pathology is in the ''[[forensic pathology]]'' article. | An introduction to forensic pathology is in the ''[[forensic pathology]]'' article. | ||
== | =Overview= | ||
==Classification== | |||
===DiMaio classification<ref>{{Ref HoFP|155-64}}</ref>=== | ===DiMaio classification<ref>{{Ref HoFP|155-64}}</ref>=== | ||
{{familytree/start}} | {{familytree/start}} | ||
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{{familytree | C01 | | C02 | | C03 | | | | C05 | | C07 | | | | | |C01=Hanging|C02=Ligature|C03=Manual|C05=Abnormal<br>skin colour|C07=No abnormality|}} | {{familytree | C01 | | C02 | | C03 | | | | C05 | | C07 | | | | | |C01=Hanging|C02=Ligature|C03=Manual|C05=Abnormal<br>skin colour|C07=No abnormality|}} | ||
{{familytree/end}} | {{familytree/end}} | ||
==Mechanism of death== | |||
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><ref name=pmid20456578/> | |||
===Long answer=== | |||
*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== | ||
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*''Fluid blood'' is considered totally useless as a sign of anything. | *''Fluid blood'' is considered totally useless as a sign of anything. | ||
=Specific types of asphyxial deaths= | |||
==Hanging== | ==Hanging== | ||
===General=== | ===General=== | ||
*Common way to suicide. | *Common way to suicide. | ||
*May be accidental in the context of adolescents playing - see ''[[choking]]''. | |||
===Gross | ===Gross=== | ||
Classic findings: | |||
*V-shaped furrow on the neck. | *V-shaped furrow on the neck. | ||
*V " | **V "opens" at the point of suspension. | ||
*+/-Tongue sticking-out. | |||
Note: | |||
*Hyoid bone fracture - uncommon in hanging.<ref name=pmid20206574>{{Cite journal | last1 = Mukhopadhyay | first1 = PP. | title = Predictors of hyoid fracture in hanging: Discriminant function analysis of morphometric variables. | journal = Leg Med (Tokyo) | volume = 12 | issue = 3 | pages = 113-6 | month = May | year = 2010 | doi = 10.1016/j.legalmed.2010.01.002 | PMID = 20206574 }}</ref> | |||
Documentation (The Rose method):<ref> | Documentation (The Rose method):<ref>Rose, T. 28 September 2010.</ref> | ||
*Anterior mid-line: | *Anterior mid-line: | ||
**Measure distance from angle of neck to superior aspect of ligature mark. | **Measure distance from angle of neck to superior aspect of ligature mark. | ||
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**Measure distance from C7 (???) to inferior aspect of ligature mark. | **Measure distance from C7 (???) to inferior aspect of ligature mark. | ||
**Measure width of ligature mark. | **Measure width of ligature mark. | ||
DDx: | |||
*[[Ligature strangulation]]. | |||
==Choking== | |||
===General=== | |||
*Typical accidental. | |||
*May be part of game adolescents play known as the ''choking game''.<ref name=pmid19190276>{{Cite journal | last1 = Macnab | first1 = AJ. | last2 = Deevska | first2 = M. | last3 = Gagnon | first3 = F. | last4 = Cannon | first4 = WG. | last5 = Andrew | first5 = T. | title = Asphyxial games or the choking game: a potentially fatal risk behaviour. | journal = Inj Prev | volume = 15 | issue = 1 | pages = 45-9 | month = Feb | year = 2009 | doi = 10.1136/ip.2008.018523 | PMID = 19190276 }}</ref> | |||
**Known by many synonyms, e.g. ''asphyxial game'', ''fainting game'', ''black-out game''. | |||
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> | |||
*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: | |||
*Extremes of age.<ref name=pmid17209932/> | |||
**Old - often associated with neurologic disease or [[alcohol]]. | |||
**Young - may be foreign body ingestion. | |||
===Gross=== | |||
Features: | |||
*Foreign object that obstructs the airway. | |||
**Usually a large laryngeal bolus of food - typically meat.<ref name=pmid17209932/> | |||
==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 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]]. | ||
**Underlying etiology of this finding: pulmonary edema (as may be seen in a cerebral vascular malformation<ref name=pmid8454093>{{cite journal |author=Bilotti A |title=Noncardiogenic pulmonary edema: a certain etiology? |journal=Del Med J |volume=65 |issue=1 |pages=25–7 |year=1993 |month=January |pmid=8454093 |doi= |url=}}</ref>). | **Underlying etiology of this finding: pulmonary edema (as may be seen in a cerebral vascular malformation<ref name=pmid8454093>{{cite journal |author=Bilotti A |title=Noncardiogenic pulmonary edema: a certain etiology? |journal=Del Med J |volume=65 |issue=1 |pages=25–7 |year=1993 |month=January |pmid=8454093 |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> | *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=== | ||
*None that are specific. | |||
==Carbon monoxide toxicity== | ==Carbon monoxide toxicity== | ||
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*CO binds to myoglobin. | *CO binds to myoglobin. | ||
===Gross findings=== | ===Gross=== | ||
* | ====External findings==== | ||
*Internal | *Salmon pink skin. | ||
DDx of pink skin includes: | |||
*[[Hypothermia]]. | |||
*Cyanide poisoning. | |||
*Fluoroacetate poisoning. | |||
====Internal findings==== | |||
*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> | |||
Notes: | |||
*Bilateral necrosis of the putamen is seen in [[methanol toxicity]]. | |||
Image: | |||
* | *[http://i.dailymail.co.uk/i/pix/2011/02/14/article-1357042-0D0AEDBC000005DC-598_468x286.jpg CO toxicity of the brain (dailymail.co.uk)]. | ||
===Microscopic=== | ===Microscopic=== | ||
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===General=== | ===General=== | ||
Many artefactual findings: | Many artefactual findings: | ||
*Postmortem epidural hematoma.<ref>{{Cite journal | last1 = Ritter | first1 = C. | title = [A heat gelatinized subdural hematoma in a burned cadaver as an indication of a vital accident]. | journal = Z Rechtsmed | volume = 103 | issue = 3 | pages = 227-30 | month = | year = 1990 | doi = | PMID = 2309533 }}</ref> | *Postmortem [[epidural hematoma]].<ref name=pmid2309533>{{Cite journal | last1 = Ritter | first1 = C. | title = [A heat gelatinized subdural hematoma in a burned cadaver as an indication of a vital accident]. | journal = Z Rechtsmed | volume = 103 | issue = 3 | pages = 227-30 | month = | year = 1990 | doi = | PMID = 2309533 }}</ref> | ||
**[[Subdural hematoma]]s are ''not'' considered artefactual. | |||
*Pugilistic attitude (boxer's position/stance).<ref>{{Cite journal | last1 = Levy | first1 = AD. | last2 = Harcke | first2 = HT. | last3 = Getz | first3 = JM. | last4 = Mallak | first4 = CT. | title = Multidetector computed tomography findings in deaths with severe burns. | journal = Am J Forensic Med Pathol | volume = 30 | issue = 2 | pages = 137-41 | month = Jun | year = 2009 | doi = 10.1097/PAF.0b013e3181879cc9 | PMID = 19465802 }}</ref> | *Pugilistic attitude (boxer's position/stance).<ref>{{Cite journal | last1 = Levy | first1 = AD. | last2 = Harcke | first2 = HT. | last3 = Getz | first3 = JM. | last4 = Mallak | first4 = CT. | title = Multidetector computed tomography findings in deaths with severe burns. | journal = Am J Forensic Med Pathol | volume = 30 | issue = 2 | pages = 137-41 | month = Jun | year = 2009 | doi = 10.1097/PAF.0b013e3181879cc9 | PMID = 19465802 }}</ref> | ||
*Heat fractures. | *Heat fractures. | ||
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*Carboxyhemoglobin.<ref>{{Ref OPMfP|18}}</ref> | *Carboxyhemoglobin.<ref>{{Ref OPMfP|18}}</ref> | ||
==Hydrogen sulfide== | ==Hydrogen sulfide toxicity== | ||
===General=== | ===General=== | ||
*Fashionable for suicides; has high mortality and may be toxic to responders/death investors.<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> | *Fashionable for suicides; has high mortality and may be toxic to responders/death investors.<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> | ||
**Can be generated by mixing a source of sulfide with an acid ''or'' ingesting the sulfide which will then react with stomach acid. | **Can be generated by mixing a source of sulfide with an acid ''or'' ingesting the sulfide which will then react with stomach acid. | ||
*Mechanism: bonds to mitochondrial cytochrome enzymes.<ref name=pmid18695173>{{cite journal |author=Truscott A |title=Suicide fad threatens neighbours, rescuers |journal=CMAJ |volume=179 |issue=4 |pages=312–3 |year=2008 |month=August |pmid=18695173 |pmc=2492967 |doi=10.1503/cmaj.080878 |url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492967/?tool=pubmed}}</ref> | *Mechanism: bonds to mitochondrial cytochrome enzymes.<ref name=pmid18695173>{{cite journal |author=Truscott A |title=Suicide fad threatens neighbours, rescuers |journal=CMAJ |volume=179 |issue=4 |pages=312–3 |year=2008 |month=August |pmid=18695173 |pmc=2492967 |doi=10.1503/cmaj.080878 |url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492967/?tool=pubmed}}</ref> | ||
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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=== | |||
*Green discolourization of the skin.<ref name=Ref_Shkrum33>{{Ref Shkrum|33}}</ref> | |||
==Manual strangulation== | ==Manual strangulation== | ||
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*Hyoid bone fracture. | *Hyoid bone fracture. | ||
*Thyroid cartilage fracture. | *Thyroid cartilage fracture. | ||
* | *Hemorrhage in strap muscles of the neck. | ||
*Patterned ovoid contusions (from the fingers). | |||
*+/-Defensive-type injuries. | |||
====Image==== | |||
<gallery> | |||
Image:Hofmann_Lehrbuch_suidide_hanging.jpg | Drawing of suicide by hanging. (WC/National Library of Medicine) | |||
</gallery> | |||
===Microscopic=== | ===Microscopic=== | ||
*Usually not contributory. | *Usually not contributory. | ||
==See also | Features: | ||
*+/-Siderophages. | |||
*+/-Inflammation - esp. [[neutrophil]]s. | |||
==Ligature strangulation== | |||
===General=== | |||
*May be suicide ''or'' homicide. | |||
*In females may be associated with a sexual assault.<ref name=pmid10739219/> | |||
*More likely to be a homicide than a [[hanging]]. | |||
===Gross=== | |||
Features: | |||
*Horizontal furrow/depression on the neck - due to ligature. | |||
*Petechiae - very common.<ref name=pmid10739219>{{Cite journal | last1 = DiMaio | first1 = VJ. | title = Homicidal asphyxia. | journal = Am J Forensic Med Pathol | volume = 21 | issue = 1 | pages = 1-4 | month = Mar | year = 2000 | doi = | PMID = 10739219 }}</ref> | |||
*+/-Fractures of the hyoid, thyroid or cricoid cartilage - more common in males.<ref name=pmid10739219/> | |||
DDx: | |||
*[[Hanging]] - furrow/depression typically rises to a point of suspension. | |||
=See also= | |||
*[[Forensic pathology]]. | *[[Forensic pathology]]. | ||
=References= | |||
{{reflist|2}} | {{reflist|2}} | ||
=External links= | |||
*[http://failuremag.com/index.php/feature/article/the_game_that_makes_parents_gasp/ The choking game (failuremag.com)]. | |||
[[Category:Forensic pathology]] | [[Category:Forensic pathology]] |
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