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МЕаииПНСКПЕ НАУКИ
METHODOLOGY OF FORENSIC EXAMINATION AND CERTIFICATION OF _DEATH IN FATAL HYPOTHERMIA_
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.
2Medical student 6th grade, MU - Pleven, Bulgaria.
Medical student 1th grade, MU - Pleven, Bulgaria.
SUMMARY:
A review of available literature on the state of forensic examination and requirements for certification of death in fatal hypothermia.
What is presented: 1. A functional scheme of the methodology of the expertise that can serve as a concept for forensic examination of the corpse in the preparation of forensic standard; 2. specific requirements and form of construction of diagnosis in forensic conclusion and the certificate („message") of death.
Key words: hypothermia, forensic examination, death certificate
Introduction:
One of the current trends of the researches in fo-rensics continues to be the expertise of death from the common low-temperature action (overcooling, hypothermia).
Despite numerous research, problems and results are ambiguous, and the diagnosis uncertain. [1] Due to the predominantly functional nature of the disability, the lack of pathognomonic and sometimes more significant signs of the autopsy find, the forensic expertise is difficult and labor intensive and requires the collection and the compliance of a complex of data (predisposing factors, clinical course, autopsy find, laboratory tests). The conclusion is of a probabilistic nature and is based on the data set and excluding other possible causes of death.
Particularly challenging are the cases where hypothermia is a contributing factor to death - diseases, trauma incidents, water immersion, alcohol and drug use, maltreatment and / or non-assistance and not caring for helpless (sick, elderly, young children).
- Nowadays, the research interest is directed to an in-depth study and introduction into the expert practice of the possibilities and results of instrumental and laboratory analysis:
- postmortem imaging diagnosis;
- micromorphology of general cold trauma (by the methods of histo- and immunohistochemistry);
- post-mortem biochemistry (establishment of characteristic biochemical markers and constellations that are indicative of the adaptation response and metabolic changes resulting from cold stress);
- post-mortem blood-gas analysis (oxyhemom-etry);
- molecular pathology and others.
Promising results are reported, but there are still
no pathognomonic signs of fatal hypothermia. Studies of the problem have led to the accumulation of data whose knowledge provides a deeper understanding of the conditions, mechanisms and signs of overcooling death and increases the potentialities and quality of expertise.
The lack of an established medical standard in forensic medicine in the Republic of Bulgaria reflects in the volume of research on the different types of expertise, the quality and reliability of the expert conclusions, which is particularly valid for the expertise of fatal hypothermia.
Purpose:
The purpose of the study is to present a summarized functional scheme of the methodology of the expertise and the rules for the certification of death through a review of the current possibilities of the forensic examination and the requirements for the certification of death in fatal hypothermia.
Material and method:
An accessible, up-to-date (until 2015) literature is studied on:
- the forensic examination of fatal hypothermia;
- the certification of death.
The information is analyzed and summarized.
Results:
On the methodology of forensic examination of fatal hypothermia:
The general course of the forensic research can be differentiated into four stages that are not strictly chronologically and functionally distinct (fig. 1):
A. Collection and examination of preliminary information:
Preliminary data shall include all data other than those of the autopsy and laboratory tests of the corpse.
The collection of preliminary information includes:
a) Inspection of the site of the scene and of the corpse at the place of its finding;
b) Acquaintance with the data of the materials in the case;
c) Clinical study (in case of discontinued cold exposure to death).
B. Forensic autopsy:
According to the morphological signs of the general cold trauma, in case of suspicion of death from overcooling, the following general scheme of forensic examination of the corpse is recommended:
a) repeated external inspection (of clothing and corpse), fixation (schemes, photographing, notes);
b) non-invasive procedures - post-mortem diagnosis;
Post-mortem imaging diagnosis allows for a more specific pre-targeting and narrowing of the differential diagnosis, hence correct autopsy planning and necessary additional research.
With nuclear magnetic resonance imaging (MRI) have been established the so described, when there is a death due to overcooling, haemorrhages in the hip muscles (mm. iliopsoas) and in back muscles. [5] Computer tomography (CT): diffuse hyperaeration in relatively "dry" lungs (resembling the image of pulmonary emphysema) and filling the heart, the aorta and the pulmonary arteries with blood [7]; Filled urinary bladder, which corresponds to the autopsy finding.
c) an internal view of the corpse, including section the knee joint and the deep (hip, dorsal) muscles to detect the presence of haemorhages.
C. Instrumental and laboratory tests:
a) histology and histochemistry:
- tissue samples from places with local cold trauma - frosts, perniones, etc. (colored with HE);
- tissue samples from internal organs (HE coloring);
- tissue samples from liver, myocardium, skeletal muscle (glycogen coloring);
- tissue samples from the lung (to detect capillary fat embolism) and kidney (Armani-Ebstein phenomenon);
b) post-mortem blood-gas analysis (oxyhemom-etry, oximetry profile);
The analysis of hemoglobin and its derivatives by CO-oximeter is an accessible, easy and fast method. For the diagnosis of fatal hypothermia, it is applicable in combination with conventional methods to exclude other causes of death and to take into account results with data on:
- lifetime or post-mortem warming;
- cardiopulmonary resuscitation (CPR);
- the term of death.
In summary, the oxymetric diagnostic features in favor of hypothermia are: tO2Hb, tSO2, L-O2Hb > R-O2Hb. ( O2Hb - Oxyhemoglobin; SO2 - Saturation of hemoglobin with oxygen; L-O2Hb - Concentration of oxyhemoglobin in the left heart ventricle; R-O2Hb -Concentration of oxyhemoglobin in the right heart ventricle).
c) post-mortem biochemistry:
- tissue samples of liver, myocardium and skeletal muscle to determine the glycogen content;
- blood (from thigh, portal, liver vein) and urine to determine glucose content;
At present, with greater diagnostic relevance in the case of overcooling death, there are some indicators of the carbohydrate metabolism.
Diagnostically significant signs of overcooled death are:
- Significant decrease to complete disappearance of glycogen in the myocardium, skeletal muscles and liver (Depending on the duration of lethal hypothermia, the expression of the complete depletion of energy resources);
- hypoglycaemia or lack of blood glucose from a femoral vein;
- a higher blood glucose content of the liver than the portal vein resulting from enhanced glycogenolysis. (Normally, the blood glucose concentration of the portal vein is higher);
- lack of glucose in the urine.
In summary, it is believed that the reduction and disappearance of blood glucose and glycogen in the liver, heart and skeletal muscle is a sufficiently reliable indication of death from hypothermia. To adequately evaluate the results of a carbohydrate metabolism study, it is necessary to take into account the characteristics of overcooling - slow or fast type.
d) forensic chemistry:
- blood and urine to determine the ethyl alcohol content;
- in case of suspicion of drug use - urine sample (urine screening);
- if necessary, developed toxicological analysis;
e) microbiological study (if there is a death data from infectious-inflammatory complications of cold trauma).
D. Discussion of the data and conclusion (forensic diagnosis, answer to the questions).
About Forensic Diagnosis of Fatal Hypothermia:
The forensic diagnosis is a medical conclusion about the nature of the trauma, specifying its nosology, etiology, pathogenesis and morphological manifestations, according to the classes, headings and terms of ICD 10.
According to the requirements of ICD 10, in the diagnosis of fatal hypothermia resulting from low natural temperature, the "cause" and "effect" should be stated as follows:
1. the characteristics of the accident, conditions and circumstances as a cause of the trauma - class XX, rubric X31 Impact of excessively low natural temperature and specification: Total cold trauma from cold air / water (similar to dull, explosive, electro- or other type trauma);
2. the condition / lesion resulting from the accident and its features - in this case class XIX, rubric T68 Hypothermia (accidental hypothermia) with subsequent differentiated indication of signs of general cold trauma (for lifetime exposure of cold, cooling, over-cooling) .
When:
■ Cold trauma is caused by an artificial source of cold, the same is denoted by the W93 rubric Impact of excessive cold of artificial origin and specifying, for example Common cold trauma from long standing in a freezer;
■ Hypothermia is not related to low ambient temperature, depending on the case may be the headings:
- R68.0 Hypothermia not related to low ambient temperature (for example secondary hypothermia);
- T88.5 Other complications of anesthesia. Hypothermia accompanying anesthesia;
- P80. - Newborn Hypothermia.
With regard to the certification of death from hypothermia:
According to the requirements of ICD 10, in case of confirmation of overcooling death due to low natural
temperature, the doctor shall enter in the medical certificate ("Death Note"):
■ direct cause of death:
Rubric T68 Hypothermia or rubric corresponding to the nasal unit leading immediately to death, which is a direct complication / consequence of hypothermia or a preceding complication;
■ Preceding cause:
Rubric T68 Hypothermia or rubric corresponding to a nosological unit that is its direct complication / consequence and a direct cause of the immediate cause of death. (When T68 is the immediate cause of death, there is no intermediate preceding cause);
■ the primary cause of death:
Heading X31 Impact of Extremely Low Natural Temperature and Specification - Total cold trauma from cold air / water.
Compliance with these requirements is important because, based on death reports, mortality is investigated and calculated by reasons, ie. one of the indicators of health status and health policy. In addition, these documents are usually also applied as written evidence, ie. the need to meet the requirements for defining the diagnosis and the cause of death and in the expert conclusions is obvious, and they also discuss the tanato-genesis.
When discussing the tanatogenesis of the hypothermia, as the immediate cause of death, it should be borne in mind that it leads to and is manifested by a complex disruption of vital functions, and today there is no generally accepted immediate tanatogenetic mechanism, although clinical and experimental observations point out as the most common the ventricular fibrillation.
Cold trauma:
1.Local:
2. Common- signs of:
- staying in cold:
- cooling
- overcooling
Lifetime
■" lesions t
M а с г ошогр liology
("Corpse picture")
Other pathological conditions lesions:
1. Risk factors:
2. Competing:
3. Ead^gcaiBii^K.
Inspection of the scene:
1. Overview of the situation:
2. Inspection of the corpse
PreLiuiiuan evi-deuce (for cold trail ma)
(cacamnestic data).
J L
Clinical study.
Case materials: 1. Infection Protocol:
Medical Documentât on:
3. Witness. Testimonies:
4. Meteorological report, etc.
Discussion (Analysts and -data synthesis)
Conclusion:
1. Diagnosis of hypothermia:
2. Diagnoas of other pathological conditions, DD
3. Diagnosis of the cause of death:
4. Term of death:
5. Other issues.
A. Preliminary information
B. Autopsy
C. Instrumental and laboratory tests
D. Data discussing and conclusion
Cold trauma
Corpse changes
Post-mortem changes.
Other:
From animals, etc.
Non-invasive: Imaging research
Instrumental and lab ora tor*" tests
Invasive;
1. Histology and hi stodiemi stry :
2. Biochemistry:
3. Toxicology:
4. Microbiology:
5. Post-death oxyhemometry:
6. Other
Fig. 1 Functional scbeuie of the examinatioii of fatal bypotbeiuiia.
Discussion, conclusions:
Based on our practical experience and the data from the review of the literature, comes the conclusion of the incomplete use, and possibly the lack of knowledge of the actual possibilities of the expertise, as well as the failure to comply with the requirements of establishing the forensic diagnosis and the certification of the cause of death due to hypothermia.
The literary review did not provide data on the scientific interest of Bulgarian authors with developments and publications on the problems of fatal hypothermia and its forensic medical expertise. Bulgarian-language literature on this topic is presented only by textbooks and practical guides in forensic medicine, in which, for understandable reasons, the exhibition is limited in volume.
In order to optimize the expertise of fatal hypothermia and to standardize the expert practice, it is appropriate to update the specialized Bulgarian-language literature, but especially to elaborate and adopt a standard of forensic medicine and protocols for forensic study of the various nosological units, which would also solve a number of other problems stemming from its financing and related material and personnel provision.
Bibliography:
1. Витер В, Пудовкин В, Юрасов В. и др. Морфологическая диагностика холодовой травмы. Практическо пособие. Москва, „Корина-офсет", 2012.
2. МКБ 10. СЗО.
3. Кузнецова И. Диагностическое значение определения гликогена, глюкозы и гликозилиро-ванного гемоглобина в биологических жидкостях и
тканях трупа. Нормы содержания гликогена, глюкозы и гликозилированного гемоглобина в тканях и жидких средах трупа. Информационное письмо, Кировского областного бюро судебно-медицинской экспертизы, 2004. [08.04.2014.]
http://www.forens-med.ru/book.php?id=538
4. Шигеев В, Шигеев С, Колударова Е. Холо-довая смерть. Москва, „Новости". 2004.
5. Aghayev E, Thali M, Jackowski C, et al. MRI detects hemorrhages in the muscles of the back in hypothermia. Forensic Science International. 2008;176:183-186.
6. DiMaio V, DiMaio D. Hyperthermia and Hypothermia: the Effects of Heat and Cold. Chapter 17 in: Forensic Pathology. 2nd ed. CRC Press LLC, 2001.
7. Hyodoh H, Watanabe S, Katada R, et al. Postmortem computed tomography lung findings in fatal of hypothermia. Forensic Science International. 2013; 231:190-194.
8. 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.
9. 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
10. Yajima D, Asari M, Okuda K, et al. An objective approach using three indexes for determining fatal hypothermia due to cold exposure; statistical analysis of oxyhemoglobin saturation data. Legal Medicine. Tokyo, 2015;17:451-458.
APPLICATION OF VACUUM ASSISTED CLOSURE THERAPY FOR _TREATMENT OF DIFFICULT TO HEAL WOUNDS_
Elena Krasteva, Elean Zanzov, Stancho Prodanov, Penka Stefanova
Department of Propaedeutics of Surgical Diseases, Medical University-Plovdiv University Hospital "St. George "- Plovdiv
ABSTRACT
Vacuum assisted closure technique (VAT) is a modern form of wound treatment, which uses the creation of a negative pressure within the wound dressing. The introduction of VAT in our clinic has become a method of choice for treating difficult to heal wounds over the last five years. The primary disease leading to the formation of difficult to heal wounds is uncompensated diabetes mellitus with diabetic micro- and macro-angiopathy. This disease is ranked to varying degrees based on either chronic venous or chronic arterial insufficiency . The aim of our team was to apply a vacuum technique to chronic wounds and by doing so we could possibly reduce complications and mortalities .The VAT technique could hence aid specialized treatment.
Material and Methods 11 patients with chronic non healing wounds of the lower leg and foot for a period of two years. In each patient there was a different depth and area of affected structures. In some patients the response orchestrated was epithelialization while others were undergoing surgery involving different types of plastic surgery.
Results In some patients total recovery of the skin defect was observed, others have registered some complications. Rapid and positive treatment contributes to better control of concomitant diseases.
Conclusion Patients with diabetic foot and those with difficult healing wounds result from chronic arterial or venous insufficiency require a multidisciplinary approach to treatment. Our intention was always to use a body sparing method of treatment.
Keywords : vacuum assisted technique, treatment, difficult healing wounds
