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МЕАИиИНСКИЕ НАУКИ
DIFFERENTIATION OF THE MORPHOLOGICAL SIGNS OF _HYPOTHERMIA, DIAGNOSTIC POSITIONS_
Kostadinov Sergey Deyanov1, Kostadinov Stefan Sergeev2, Ivanova Simoneta Krasimirova.3
'Assist. professor in Sector Forensic Medicine and Deontology, Faculty of Public health, MU - Pleven, Bulgaria.
Medical student 6th grade(trainee doctor), MU - Pleven, Bulgaria.
Medical student 2ndgrade, MU - Pleven, Bulgaria.
SUMMARY:
The post-death diagnosis of death from hypothermia is a complex problem of modern forensic medicine. Despite the many studies, the problems are ambiguous and the diagnosis is uncertain.
The goals of the study are: 1. to differentiate and group the morphological features of hypothermia according to their relationship to the stages of cold exposure (staying on cold, cooling, overcooling); 2. to define diagnostic positions / principles of acceptance of the diagnosis.
Material and method: A review of the informative content of the routine morphological diagnostic features of fatal hypothermia is made, and for that aim the following is studied: 1. the accessible literature on forensic expertise on hypothermia; 2. written forensic conclusions for 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: An individualism was identified regarding the diagnosis of fatal hypothermia, the understanding of the diagnostic significance of the morphological signs and the criteria for acceptance of the diagnosis.
There are presented: 1. Differentiation and grouping of the morphological signs of hypothermia, according to their relation to the stages of the cold exposure; 2. Our positions / criteria for accepting the diagnosis.
Conclusion: The hypopothermia pathomorphosis is a circumstance that hinders its forensic expertise. We believe that it could be confined to the objective reasons that imply it by unifying the methodology of expertise, but also by knowing and understanding the diagnostic significance of its features.
Key words: hypothermia, morphological signs, diagnostic positions.
Introduction:
The post-death diagnosis of death from hypothermia is a complex problem of modern forensic medicine. Despite the many studies, the problems of diagnosing this cause of death are ambiguous and sometimes obstructive. [8]
The identification of hypothermia has always been problematic in forensic medicine due to the non-specificity and inconsistency of known macroscopic and microscopic findings. Today, there are no definite morphological signs of fatal hypothermia, which does not allow to manage an unambiguous diagnosis of the cause of death. [4]
There is a general consensus in the literature that the presence of cold erythema with Vishnevsky's spots are classic, highly indicative signs which support the diagnosis. Combining them with hemorrhages in the synovial membrane, bloody synovial fluid in the knee joints and basal vacuolization of the tubular epithelium are shown as a significant diagnostic criterion in favor of fatal hypothermia, but their absence does not exclude the diagnosis. [3, 4]
To date, there is no comprehensive morphological picture describing the amendments qualitatively and quantitatively and suitable for forensic medical expertise. This is due to an isolated study of organs and systems by the majority of authors. [2]
All authors agree that the complex morphological picture and its pathomorphosis depend on the multiple combination of external and internal factors related to
the specifics of cold exposure, the health status of the injured persons, the applied treatment (in case of death after discontinuation of exposure).
In a differential-diagnosis plan, it should be considered that hypothermia may be an element contributing to death in case of illnesses, traumas and water incidents, alcohol and drug abuse, mistreatment and / or non-assistance to the homeless, and helpless (sick, elderly, small children). [7]
The diagnosis of cold trauma could not be based on reduced data, its accuracy depends on the set of established signs, the most important of which are the characteristic macro- and microscopic morphological signs, but also the changes in a number of biochemical indicators. [5, 6]
The diagnostic validity of signs depends not only on their specificity and frequency, but also on the understanding of their pathogenesis.
According to her understandings, Asmolova H. [1] differentiates the macromorphological signs of the hypothermia to:
1. signs of cooling: goose bumps, a sign of Shter (pose of shivering person), chilblains, a sign of Puparev (wrinkled scrotum with testicles lifting in the direction of the inguinal canals), a sign of Rayski (frost on the eyelashes, icicles in the openings of the nose and mouth), cold erythema, absence of autolysis in the pancreas, sign of Puhnarevich (an empty stomach with a folded mucous membrane covered with vitreous mucus);
2. sings of overcooling: Vishnevsky's spots, Fabrikantov's spots (spotted haemorrhages in the mucous membrane of the renal pelvis), overflow with blood and blood clots on the left side of heart, lighter blood in the left half of the heart and lungs compared to the right half and the hollow veins.
Regardless of the possible disagreements regarding the affinities of the different signs of this differentiation arising from different perceptions of their pathogenic origin, as well as about the semantics of the terms cooling and overcooling, the same is useful and practical. However, in view of the critical perception of existing assessments and differentiations, it is worth noting the following:
- the indication "goose bumps" is observed in death for various reasons and in cadavers, which have stayed under different temperature conditions. Today it is explained as a rigor mortis of mm. arrectores pi-lorum. Theoretically, the sign may display cooling only until the rigor mortis occurs;
- chilblains are variation of local cold trauma, proving live local effects of cold, but it is questionable whether their origin is related to general cooling of the body;
- the sign of Rayski certifes for living in cold (at a minus temperature) but is not necessarily related to cooling (i.e. increasing the amount of body heat);
- the absence of autolysis in the pancreas can be explained by agonal death and does not exclude overcooling, as not all cases of fatal hypothermia are demonstrated with pancreatic lesions. On the other hand, the reduced body temperature could delay the autolysis;
- the cold erythema for many authors is a sign of overcooling, especially in correlation with Vishnevsky's spots;
- Puhnarevich's sign alone is of no diagnostic value and could only be of diagnostic significance if relevant preliminary information is available, e.g. the time and type of food consumed;
- Fabrikantov's spots are a sign that occurs in many other conditions and with other names, e.g. spotted hemorrhages in the mucous membrane of the renal pelvis in case of asphyxial / hypoxic death (Tardyo's spots).
Objective:
The objectives of the study are:
1. To differentiate and group the morphological features of hypothermia according to their relation to the stages of cold exposure (staying on cold, cooling, overcooling), which implies a better understanding of their diagnostic significance;
2. To define diagnostic positions / principles of acceptance of the diagnosis.
Material and method:
A review of the informative content of the routine morphological diagnostic features of fatal hypothermia was made, and for this purpose, the following were studied:
- the accessible literature for the questions on the forensic expertise of hypothermia
- the written forensic medical conclusions for cases of fatal hypothermia for the 6-year period (20112016, 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 literature survey and review of written forensic conclusions did not provide consensus to the authors on the informative content and diagnostic significance of routine morphological signs of fatal hypothermia.
The analysis of the written conclusions shows:
- formalism to the expertise, including a site inspection of the place of accident, autopsy and chemical examination of blood and urine from the cadaver for using ethyl alcohol. (This approach allows to identify and exclude only the macroscopic signs of diseases and traumas at death with preliminary evidence of possible cold trauma.);
- deficiency (limited number and uniformity) of established signs associated with hypothermia and diagnostic proclivity of experts for some of the signs manifested by their higher frequency;
- the еstablished morphological signs do not differ in their informative content, i.e. on their evidence of belonging to the different stages of cold exposure, but all of them are shown as signs of hypothermia.
Differentiation of the morphological signs of hypothermia:
The complex nature of the forensic expertise of hypothermia assigns variety of data and signs. The discussion includes the systematization of the causes and signs to:
- cold trauma / hypothermia;
- other pathological conditions in the specific case (competing; combining; complications; background, concomitant).
For didactic measures and practical purpose, the data on cold trauma collected during the expertise could be differentiated and grouped generally, as it follows:
I. Data suggesting local and general cold trauma (must meet the requirement of necessity and sufficiency):
1. Reason/s (ambient temperature below the temperature comfort zone and/or conditions that cause secondary hypothermia).
2. Predisposing/risk factors (belonging to/arising from the environment and/or the individual, i.e external and internal).
II. Signs testifying to local and general cold trauma (i.e. effects of the action of cold):
1. Lifetime:
1.1. Local cold trauma (proves the local lifetime action of cold; it is possible to not be related to the conditions and circumstances of the death);
1.2. General cold trauma:
A. proving only the lifetime general action of cold: Rayski's sign:
B. cooling (i.e. loss of body heat at normal central/inner body temperature): a sign of Shter (pose
of shivering person); "goose bumps" (until stiffness occurs); Pouparev's sign;
C. overcooling:
a) macroscopically
- external: "terminal burrowing" / "hide-and-die"; "paradoxical undressing"; cold erythema; superficial mechanical damage of certain sites (when there are no other causes of falling and creeping, e.g. alcohol abuse);
- internal: scarlet musculature, haemorrhages in the muscles of the border surface/core (e.g. m. iliopsoas); haemorrhages in the knee joints (in the capsule, synovial fluid); scarlet blood with blood clots; overflowing with blood in the heart and vessels from and to it; lighter blood in the left heart half; light emphysema-tous lungs; Fabrikantov's spots; full bladder; Vishnevsky's spots; acute pancreatic lesions (haemorrhages, necrosis, pancreatitis); greater death term determined from the body temperature of the cadaver than determined by other methods;
b) microscopic / histological:
- diffuse changes in microcirculation (disparity of blood vessel caliber, stasis, sludge, microthrombosis, plasma and cell division, perivasal edema and haemorrhages);
- sign of Asmolova - Rivenson, Koludarova (heart - prevalence of the cardiomyocytes' oedema over that of the intramuscular stroma with its compression from motley, homogeneous muscle layers with unclear boundaries between the muscle fibers); swelling, ho-mogenization, motley of muscle fibers; metachromasy with differently expressed, diffuse small-ranged fuccinophilic degeneration);
- Osminikin's sign (lung - broncho- and bron-chio-spasm with high curved mucosa, increased mucus secretion, lack of desquamated epithelium; atelectasis at the periphery of spasmodic bronchi, diffuse emphysema; absent or minor oedema.)
- Armanni-Ebstein phenomenon (kidney -basal, subunuclear vacuolization of the tubular epithelium /due to lipid deposition/);
- reduction to glycogen deficiency in the liver, heart and skeletal muscle.
Post-mortem (staying on cold after death): generally bright, pink-like skin and red-like post-death spots; Belin's sign (wrinkled/macerated skin of the hands and feet in wet cold exposure); decreased dynamics of the cadaver's changes; freezing and damages caused by a freezing of the cadaver (Blosfeld stripes - visible / due to imbibition after thawing / skin blood vessels, cold cataracts, cranial bone diastasis and fracture, damage to internal organs caused by freezing) etc.
Note: Belin's sign, pink-like skin, and red-like post-mortem spots may be result of both lifetime and post-mortem action of cold. Since they do not prove lifetime signs, they are only stated as post-mortem changes.
Diagnostic statements:
The literature data and our personal experience allow us to expose the following diagnostic statements / principles for the forensic diagnosis of hypothermia:
1. The assessment of the signs and the general cadaver picture is made in each specific case on the basis of a comprehensive analysis of all data; From the signs of overcooling, none is pathognomonic, they come out (or similar to them) and in other conditions and causes of death, each of them may be absent.
2. Due to the lack of required and specific morphological features, i.e. those that happen obligatory and/or only under overcooling, the diagnostic value of the signs depends and by default increases in combination;
3. The lack of obligatory and specific morphological features of hypothermia (i.e. those that undoubtedly prove it) determines the need for an approach of identifying characteristic complexes (combinations of characteristic signs);
4. The signs of overcooling alone have no diagnostic value, but only in correlation with each other and with the other details of the case (e.g. the conditions and circumstances of death and/or not finding the cadaver);
5. For the diagnosis/conclusion, it is important to have a characteristic set of signs of overcooling, combined with preliminary evidence of causality (i.e. reason/s and predisposing factors explaining them);
6. When there is absence of a convincing set of evidences from the cadaver study, which are relevant to the preliminary information of cold exposure, the diagnosis of hypothermia is uncertain. The conclusion can not be categorical and it is of a probabilistic nature;
7. There are no specific morphological features of fatal hypothermia, i.e. such as those, which prove that the cause of death is overcooling;
8. Establishing hypothermia does not prove the cause of death. As an independent cause, death from hypothermia can only be accepted if other possible causes of death are excluded.
Conclusion:
The pathomorphosis of hypothermia is a circumstance that hinders its forensic expertise. We believe that it could be confined to the objective reasons that imply it by unifying the methodology of the expertise, but also by understanding the diagnostic significance of the established signs.
Bibliography:
1. Asmolova N. Pathomorphology of overcooling of the body and death from hypothermia. FR Forensic library. [04.09.2016] http://www.forens-med.ru/book.php?id=38
2. Koludarova E. Thermoregulatory and her morphology from positions of formation of functional system of an organism in case of death from action of a cold. Problems of expertise in medicine. 2006;06(21-1) [04.09.2017]
http://cyberleninka.ru/article/n7termoregulyatsiya -i-ee-morfologicheskiy-sled-s-pozitsiy-formirovaniya-funktsionalnoy-sistemy-organizma-v-sluchayah-smertelnoy
3. Madea B, Tsokos M, Preuft 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 B, Pudovkin B, Yurasov B. et al. Morphological diagnosis of cold trauma. Practical tool. Moscow, "Corina-offset", 2012.
УДК 616.24-02:616.233-002.2-007.272]-008.4_
ГИПЕРВЕНТИЛЯЦИОННЫЕ НАРУШЕНИЯ РЕГУЛЯЦИИ ДЫХАНИЯ У
БОЛЬНЫХ ХОБЛ
Заболевания органов дыхания и, прежде всего, ХОБЛ представляют собой значительную медицинскую проблему [1, С.112]. Ряд исследований указывает на то, что при бронхиальной астме и ХОБЛ происходит дизадаптация дыхательного центра, что приводит к дополнительным проблемам в лечении и реабилитации данного контингента больных [2, С.53], [3, С. 159]. В основном одышка при ХОБЛ связана с гиперинфляцией [4, С. 70], [5, С. 17], [6, С. 57] [7, С. 20]. Ранее нами [3, С. 163] показана стадийность изменений деятельности нервной системы в зависимости от степени компенсации вентиляции легких при хроническом бронхите и бронхиальной астме. Одним из важнейших регуляторов дыхательного центра является углекислый газ. По его концентрации в выдыхаемом воздухе можно судить о нарушениях деятельности дыхательного центра[7, С. 126], [8, С. 78].
Цель исследования: На основании тестирования и капнографии изучить особенности гипервентиляционных нарушений регуляции дыхания у больных ХОБЛ.
Материал и методы
Обследовано 60 больных ХОБЛ в возрасте от 35 до 60 лет; 13 женщин и 47 мужчин. Все больные были в фазе ремиссии заболевания. Легкое течение заболевания было у 12, среднетяжелое - у 22, тяжелое - у 26 человек. Больных с крайне тяжелым течением заболевания в исследование не включали. Контрольная группа состояла из 17 человек, набранная из практически здоровых людей в возрасте от 34 до 59 лет. Диагностика ХОБЛ проводилась в соответствии с рекомендациями рабочей группы GOLD - пересмотр 2011 года [9, С. 23].
При выполнении работы проводилось общеклиническое обследование больных, ведение карт самонаблюдения с регистрацией результатов пикфлоуметрии. Спирометрия проводилась при помощи аппаратно - программного комплекса «Ва-лента». Измеряли легочные объемы и емкости: жизненная емкость легких (ЖЕЛ, л.), объем форсированного выдоха за первую секунду (ОФВ1, л.), индекс Тиффно (отношение ОФВ1 к ФЖЕЛ в процентах).
Барламов П. Н.1, Махмудова С. Э.2
Д.м.н., доцент, 2 студентка ¥1курса ФГБОУ ВО «ПГМУ им. академика Е.А. Вагнера», г. Пермь Российская Федерация
Гипервентиляционные нарушения регуляции дыхания диагностировались на основании Найме-генского вопросника (НВ) и капнометрического исследования, которое включало определение конечного значения СО2 в объемных процентах (об.%) в конце выдоха с помощью капнометра TIDAL WAVE Sp™ Модель 615 (диапазон 0-19.7%). Кап-нографическое исследование является основным в подтверждении гипокапнических нарушений газообмена - основного диагностического критерия гипервентиляции [10, с.16]. О гипокапнии, а значит о гипервентиляционных нарушениях стабильного течения [10, с. 25] судили в тех случаях, когда концентрация СО2 в конечной части выдыхаемого воздуха была ниже 4.8 об.%СО2. Проба с произвольной гипервентиляцией (I IIII В) позволяла выделить гипервентиляционный синдром лабильного течения [10, с. 26]: регистрация показателей исходной кап-нометрии в течение 3-5 минут. Если показатели капнограммы оказывались нормальными, то затем пациенту предлагалось дышать в течение одной минуты максимально глубоко и часто (приблизительно 30 дыханий в минуту). Если уровень CO2 (об.%) к пятой минуте восстановительного периода не достигал 66% исходного (менее 4.8 об%), то регистрировали гипервентиляционный синдром латентного типа (ГВС).
Статистическая обработка материалов исследования: проводилась с использованием программного пакета «Statistica 9.0» c применением методов параметрической и непараметрической статистики. Изучаемые количественные признаки в зависимости от вида распределения представлены в виде среднего со средним квадратичным отклонением М±с, где М - среднее, с - одно стандартное отклонение или при ненормальном распределении - медианы с интерквартильным размахом (Me, 25-75 процентиль). Межгрупповое сравнение полученных данных для проверки гипотезы о равенстве средних для двух групп использовался критерий Стьюдента, для трех групп и более - однофактор-ный дисперсионный анализ и при отвержении нулевой гипотезы для анализа различий между тремя группами использовали критерий Стьюдента с по-
