CC BY
10
CONCEPT FOR THE FORMULATION OF FORENSIC MEDICAL DIAGNOSIS IN CASE OF DEATH WITH HYPOTHERMIA
Kostadinov Sergey Deyanov1,
'Assist. professor in Sector Forensic Medicine and Deontology, Faculty of Public health, MU - Pleven,
Bulgaria.
Kostadinov Stefan Sergeev2
Medical student 6th grade(trainee doctor), MU - Pleven, Bulgaria.
Ivanova Simoneta Krasimirova.3
Medical student 2ndgrade, MU - Pleven, Bulgaria.
SUMMARY:
The aim of the study is to review the regulatory requirements and to present a concept for the formulation of forensic medical diagnosis in case of death with hypothermia, which can serve as a basis for consensus and unification of the expert practice.Material and method: The requirements for the formulation / construction of the diagnosis of fatal hypothermia have been reviewed by: 1. the available literature on the forensic medical expertise of hypothermia and the ICD 10 regulation; 2. the written forensic medical conclusions for the cases of fatal hypothermia for a 6-year period (2011-2016, a total of 128 cases) of the specialists from four regional departments of Forensic Medicine in the Republic of Bulgaria. The information is analyzed and summarized.Results and Discussion: The analysis of the written forensic medical conclusions justifies the conclusion that for the formulation of the diagnosis of hypothermia and the cause of death there is a lack of a generally accepted statement, the requirements of ICD 10 (for specifying the cause and specificities of the trauma) are not being kept, for the diagnosis only the effect (hypothermia / overcooling) is written or there is a lack of diagnosis and in that case only the signs found in the body examination are listed. A concept for the formulation of forensic medical diagnosis in case of death with hypothermia is presented, which can serve as a basis for consensus and unification of the expert prac-tice.Conclusion: We believe that the exposed scheme of constructing the diagnosis of death of hypothermia requires and implies a deeper approach to the expertise and its conclusion, which would lead to an increase in its quality (credibility, unification, comparability, etc.).
Key words: hypothermia, forensic diagnosis, ICD 10.
Introduction:
The topicality of the subject comes from the problems of forensic medical expertise in cases of death with hypothermia, resulting from:
- difficulties related to the diagnosis of the lesion: multifactorial determination (multiple combination of external and internal factors), mainly of a functional character (lack of pathognomonic and sometimes more significant signs of the autopsy find), expressed patomorphosis;
- lack of an established standard of forensic medicine in the Republic of Bulgaria, lack of protocols for the expertise on the individual nosological units, deficiency of specialized Bulgarian literature on the forensic expertise of hypothermia, individualism and professional partiality in knowing and recognizing the signs of hypothermia and their informative value, differences in the criteria for acceptance of the diagnosis, etc.
Objective:
The aim of the study is to review the requirements and to present a concept for the formulation of forensic medical diagnosis in case of death with hypothermia, which can serve as a basis for consensus and unification of the expert practice.
Material and method:
The requirements for the formulation / construction of the diagnosis of fatal hypothermia have been reviewed by:
- the available literature on the forensic medical expertise of hypothermia and the ICD 10 regulation;
- the written forensic medical conclusions for the cases of fatal hypothermia for a 6-year period (2011-2016, a total of 128 cases) of the specialists from four regional departments of Forensic Medicine in the Republic of Bulgaria. The information is analyzed and summarized.
Results and discussion:
The analysis of the written conclusions shows that the generally accepted scheme is observed (exposed in the textbooks and manuals of forensic medicine), as their final part is schematically divided into two subparts: medical forensic diagnosis and answer to the questions asked (expert's conclusions). However, for the formulation of the diagnosis of hypothermia and the cause of death there is a lack of a generally accepted statement, the requirements of ICD 10 (for specifying the cause and specificities of the trauma) are not being kept, for the diagnosis only the effect (hypothermia / overcooling) is written or there is a lack of diagnosis and in that case only the signs found in the body examination are listed. (look at examples 1, 2, 3) Example 1: „... CONCLUSION:
During the inspection and the autopsy of the corpse of....... 37 years old, it was established: Hypothermia - Vishnevsky's spots /stress ulcers /on the gastric mucosa, cerebral and pulmonary oedema, acute blood stasis in the internal organs, wrinkled spleen capsule /their detailed description is above/. Concomitant diseases and condition - chronic calculous cholecystitis, mild degree of generalized atherosclerosis of vessels, faecal incontinence.
The cause of the death of...... is a general over-
cooling of the body (hypothermia). Death has occurred gradually, slowly. At a certain stage of hypothermia, the injured person could have been inadequate and disoriented.
During the examination of the corpse no injuries were found which could not be explained by the stated mechanism. There are no signs of fight or violence found. There are traces of old cuts in the left elbow - a possible previous suicide attempt.
The condition of the corpse corresponds to death most probably on......
Expert: ......... "
Example 2:
„... DISCUSSION OF THE DATA AND CONCLUSION:
From the data contained in the inspection and autopsy on the corpse of....... - 77years old, it was established: severe cerebral and coronary sclerosis, chronic ischaemic heart disease, emaciation of the corpse, raspberry-red post-mortem spots, wounds on the nose and forehead, wounds on the knees.
The death of....... is due to acute cardiovascular
and respiratory failure as a result of general overcool-ing of the body. The described wounds are superficial and are not related to the onset of death, they are caused terminally by falling on the ground.
The diagnosis and the cause of death are clarified and there is no need for a blood test for presence of ethyl alcohol.
No other traumatic injuries and bone fractures are found on the corpse.
The data from the corpse corresponds to death in the first day.
EXPERT:......."
Example 3:
„... CONCLUSION
During the inspection and the autopsy of the
corpse of....... were found: highly advanced rotting
post-mortem changes, spots of Vishnevsky on the gas-tral mucosa.
The cause of death of....... is the overcooling, for
which we judge from the autopsy find, the conditions of the localization of the corpse.
No traumatic injuries to explain the onset of death were found during the examination of the corpse.
The corpse's condition corresponds to death from around the third to fourth day.
Expert:.... "
In order to overcome individualism and unify the expert practice in making the diagnosis of cases of death with hypothermia, we present a concept for the formulation of the forensic diagnosis in compliance with the ICD 10 regulation and our understanding of the informative content of routine morphological diagnostic signs. Concept for the formulation of forensic medical diagnosis in case of death with hypothermia:
The diagnostic analysis is completed and can be considered as final when an explanation is found for all identified signs.
The conclusion of theforensic medical examination on death with hypothermia includes:
- diagnosis of hypothermia and its peculiarities (rapid or slow type, accidental or induced, dry, wet, mixed, etc.);
- diagnosis of other pathological conditions, differential diagnosis;
- diagnosis of the cause of death, comment on the tanatogenesis;
- term of death;
- other questions referred to the expertise (lifetime on the cold exposure / trauma; possible duration of the cold exposure; role of the predisposing factors in the particular case; degree of alcohol abuse; timeliness and regularity of the medical action; possibility to prevent death, etc.
General sequence of exposure of the findings in subpart "forensic medical diagnosis" of the conclusion:
1. Competing injuries (self-deadly);
2. Combining injuries (e.g. pneumonia, stroke, severe alcohol abuse);
3. Background injuries/conditions (e.g. average alcoholic abuse, emaciation);
4. General cold trauma (ICD 10);
5. Concomitant injuries/conditions;
This set of findings in the conclusion is appropriate for the following reasons:
- hypothermia is a precarious diagnosis and should be considered as a sole main cause of death only when excluding other possible main causes of death (i.e. competing);
- hypothermia is a condition/injury that is often combined with other non-lethal injuries in combined major cause of death or complication of another major cause;
- hypothermia is rarely the result only of cold exposure, and most often occurs in situations of background conditions/injuries, which predispose and/or aggravate it;
- the concomitant conditions/injuries have no relation to hypothermia and to death, so they should be last exposed when arranging the pathological findings.
Formulation of the diagnosis of hypothermia: I. Setting according to ICD 10 regulation (X31,T68)
II. Sequential exposure of the established data for the diagnosis, as it follows:
1. Cause and predisposing factors (the particularities of the exposure determined by the external and internal factors)
2. Effects of cold exposure/trauma (grouped by informative content):
2.1. During lifetime:
A. General cold trauma:
a. signs of lifetime exposure to cold (do not proof cooling and overcooling);
b. sign of cooling (i.e. loss of body heat at normal central/inner body temperature);
c. signs of overcooling:
- macroscopically (internal and external);
- histological;
B. Local cold trauma (indirect evidence, it may be unrelated to the circumstances of the death);
2.2.Post-mortem (i.e. staying on cold after death)
An example of formulation of diagnosis according to the scheme presented: „... CONCLUSION:
After the inspection, autopsy and laboratory tests of the corpse of.......it was found:
■ emaciation;
■ data of extreme low temperature impact - general cold trauma from cold air ("dry" hypothermia, overcooling):
- reason and predisposing factors (the atmosphere at the place, where the corpse was find - cold room, on the floor; emaciation, advance age);
- sign of lifetime cooling of the body (tempera-ture-preservingposture, "shivering man");
- signs of overcooling - overfilling of the heart and the magistral vessels with blood and blood clots, emphysematous lungs, characteristic haemorrhages in the gastral mucosa (Vishnevsky's spots), fat necrosis and haemorrhages in the pancreas, spotted haemorrhages in the mucous membrane of the renal pelvis (Fabrikantov's spots); from the histological examination: diffuse changes in the microcirculation with venous stasis, sludge (agglutination of the erythrocytes), perivascular haemorrhages, sign of Osminkin (folding of the bronchial mucosa, activated secretion of mucous in the bronchioles, emphysema), acute venous stasis in the internal organs, cerebral and inceptive lumbar oedema;
■ blood supply on the inner surface of the soft cranial meninges of the nape, lack of other traumatic injuries;
■ concomitant, chronic lesions - generalized atherosclerosis; hypertonic disease (with cardiomeg-aly and atherosclerotic nephrocirrhosis; pleural adhesions in the left side; condition after surgical intervention of the abdomen with peritoneal adhesions;
■ lack of ethyl alcohol in the blood;
Based on the available data, excluding other reasons, we assume that the death of...... is due to overcooling (hypothermia), a result of the influence of excessively low natural temperature on the background of emaciation, which contributed to the cold trauma.
УДК: 618.175
The overcooling is a result of the action of dry, cold air (on the floor ofan unheated, not closed room at a minus external temperature). As predisposing factors in this case, it is possible to be pointed out the advanced age and the emaciation, associated with weakened resistance forces of the organism.
The blood supply of the soft cranial meninges of nape, according to its character and localization can be explained by a fall under their own height (i.e. on the standing surface), including the place where the corpse was found, its health significance leads to pain and suffering.
The state of the corpse at the scene of the accident corresponds to death from a first day. Expert...... "
Conclusion:
We believe that the exposed scheme of constructing the diagnosis of death from hypothermia requires and implies a deeper approach to the expertise and its conclusion, which would lead to an increase in its quality (credibility, unification, comparability, etc.).
Bibliography:
1. Forensic medicine and medical deontology. Textbook for medical students . 3rd ed. Ed. on St. Radanov. Sofia, "Siela". 2006:176-178.
2. ICD 10. WHO.
3. Madea B, Tsokos M, Preuß J. Death due to hypothermia. Morphological findings, their pathogenesis and diagnostic value. In: Tsokos M. (ed.), Forensic pathology reviews. Totowa, New Jersey, Humana Press. 2008; 5:3-24. DOI 10.1007/978-1-59745-110-9_1.
4. Palmiere C, Teresinski G, Hejna P. Postmortem diagnosis of hypothermia. Int J Legal Med. 2014; 128:607-614. DOI 10.1007/s00414-014-0977-1.
5. Shigeev V, Shigeev S, Koludarova E. Death from the cold. Moscow, "News". 2004.
6. Shigeev V, Shigeev S. Essays on the cold trauma. Moscow, „August Borg", 2016.
7. Türk E. Hypothermia. Forensic Sci Med Pathol. 2010 Jun.;6(2):106-15. DOI: 10.1007/s12024-010-9142-4.
8. Viter V, Pudovkin V, Yurasov V. et al. Morphological diagnosis of cold trauma. Practical manual. Moscow," Korina-offset", 2012.
ПРОБЛЕМА ДИАГНОСТИКИ _ЭКСТРАГЕНИТАЛЬНОГО ЭНДОМЕТРИОЗА_
Махмудова С.Э.1
1студентка VI курса ФГБОУ ВО
«ПГМУ им. академика Е.А. Вагнера», г. Пермь, Российская Федерация
АННОТАЦИЯ.
На сегодняшний день экстрагенитальный эндометриоз является сложной мультидисциплинарной проблемой. Нередко, при появлении патологических геморрагических выделений из пораженного органа не обращают внимания на связь данного симптома с менструацией, не уточняя акушерско-гинекологиче-
