Doble mecanismo de estrangulación. A propósito de un caso / Double mechanism of strangulation. Apropos of a case

RESUMEN Las asfixias mecánicas son aquellas que resultan del impedimento mecánico a la penetración del aire en las vías respiratorias, suelen clasificarse atendiendo a la naturaleza del medio mecánico que las origina y a su modo de actuar. La estrangulación puede definirse como la constricción del cuello mediante la aplicación de una fuerza activa, ajena al peso del cuerpo, que actúa por intermedio de un lazo, las manos, el antebrazo o cualquier otra estructura rígida. En la estrangulación antebraquial, la constricción del cuello se lleva a cabo normalmente rodeando al individuo con el brazo y el antebrazo. Cuando el mecanismo de la compresión del cuello es lateral, no se afectan las vías aéreas, la compresión de las arterias carótidas hace que se produzca una isquemia cerebral y pérdida de conocimiento en 10-15 segundos. El mecanismo de muerte en estos casos será la anoxia cefálica. Si la compresión del cuello es anterior, actúa ocluyendo las vías aéreas, la presión sobre los cartílagos tiroides y cricoides puede producir fracturas y el mecanismo de muerte será la obstrucción respiratoria. El presente trabajo constituyó un caso poco común de estrangulación, donde se utilizó un mecanismo combinado que llevó al occiso al deceso final. Para la realización de la discusión del caso se tuvo en cuenta los elementos del lugar del hecho, el examen del exterior y el interior del cadáver (AU).

ABSTRACT Mechanical asphyxias are those resulting from the mechanical obstruction of the air penetration in the airways. They are usually classified according to the nature of the mechanical mean producing it and the way it performs. Strangulation may be defined as neck constriction through the application of an active force not proper to the body weight, acting by means of a knot, hands, forearm or any stiff structure. In ante brachial strangulation, neck constriction is normally performed surrounding the individual with the arm and forearm. When the neck constriction mechanism is lateral, the airways are not affected: carotid arteries constriction produces a brain stroke and loss of consciousness in 10-15 s. The death mechanism in these cases will be cephalic anoxia. If the neck compression is anterior, it occludes the airways; the pressure on thyroidal and cricoid cartilages may produce fractures and death mechanism will be respiratory obstruction. The current work deals with an uncommon strangulation case, where a combined mechanism led the person to the final decease. For the case discussion the authors took into account the elements of the place, and the examination of the exterior and the inside of the corpse (AU).

Suicide pact by hanging: A case report.

Suicides are more likely to occur during periods of socioeconomic, family and individual crisis. A suicide pact is an agreement between two people to end their lives. Most suicides are solitary and private; but few results from a pact between 2 people to die together. It is predominantly made by male-female partners and by less violent methods. Suicide pact between people of the same gender is an unusual event. We discussed a case of a suicide pact where a 19-year-old male and a 20-year-old male who were friends committed suicide by hanging because of drug addiction and poverty. Two young adult male made a pact to commit suicide by hanging themselves from a ceiling hook. It is unique case in this regard. Suicide pact is also very interesting from the perspective of medical examiners. They need to make comprehensive postmortem examination to finally conclude the proper cause and the manner of death.

Exhumation and identification: A case report.

The term exhumation is restricted to legally digging out the body from the grave after burial. The objectives of disinterment can vary in various cultures as well as countries and requirements vary from place to place However, most cases of exhumation occur because there is a request from a magistrate to carry out an autopsy to gain essential forensic evidence. The paper discusses such a case of 10 year old girl who was buried after committing sexual assault and strangulation. After the passage of about two years the victim’s body was retrieved from the place identified by the accused persons who confessed to the crime. The body of the victim was identified by her mother from a small piece of under slip and other articles she was wearing. The paper discusses various aspects of exhumation and also stresses the importance of careful examination and recording of personal articles, belongings etc of the victim recovered from/with the body during autopsy examination.

Rape, sodomy and murder of a minor girl.

In this short case of article on typical sexual assault, a 14 year old minor girl was killed and found in a ditch of a jungle nearby her house. The minor girl has died as a consequence of barbarous act of sexual assault, sustained bruises on labia, recent hymnal tears, and tears around anus with signs of ligature strangulation besides the generalized signs of asphyxia. The wearing garments were found torn at places with the presence of stains of mad and sand particles. The laboratory findings confirm presence of spermatozoa. The presence of marks of violence on the genitals of the child, when an early examination is made is the strong evidence that the sexual assault has been committed. The psychiatric analysis of all the accused of this kind of cases should be made mandatory for better assessment of the cases besides an active legislative and judicial actions, comprehensive quick approaches of investigative officers and healthcare providers.

Asphyxial deaths at District Hospital, Tumkur A retrospective study.

Asphyxial death forms one of the modes of death which may be suicidal, homicidal or accidental in nature. A retrospective study of autopsies conducted between years 2006 - 2010 is an attempt to know the incidence of asphyxial deaths at district hospital, Tumkur. During this period there were 2288 deaths, out of which 438 deaths were of asphyxial deaths. The most common form of asphyxial death was hanging followed by drowning. The incidences of asphyxial deaths were more in males than females in the ratio of 1.4:1. These cases were studied to know age and sex distribution of the victims. In this study, we found that among asphyxial deaths hanging were more 268 (61.18%) followed by drowning 140 (31.96%), strangulation 19 (4.33%) and others respectively. Appropriate education, influencing the media in their portrayal of suicidal news, reporting method, involvement of young generations in encouraging activities may reduce the rate of suicidal death by hanging in future.

Pattern of ligature mark in cases of compressed neck in Rajkot region: a prospective study.

Ligature mark may be the only evidence available in cases of asphyxial deaths due to either hanging or strangulation. A through examination of the ligature mark and analysis of the information provided by it is therefore, a must to arrive at the most probable cause of death and differentiate between hanging and the ligature strangulation. A prospective study was conducted at the Department of Forensic Medicine, P.D.U. Medical College & Hospital, Rajkot from January 2008 to December 2008. During that period out of 2159 cases, 90 cases of hanging and 7 cases of ligature strangulation were selected for the present study. We found that deaths due to hanging constituted 4.17% of the total unnatural deaths subjected to medicolegal autopsy; young adults of the age group 21 to 30 years accounted for the maximum cases 40% and the male: female ratio was 2:1. Chunni (34.44%) was the most common ligature material used. The mark was obliquely placed (100% cases) above thyroid cartilage (80% cases). In all the cases of ligature strangulation the mark was transverse and below the level of thyroid cartilage.

Newer trends in hanging death.

A total of 105 cases of deaths due to hanging were studied in a span of 5 years time. This present study throws some light on the emerging trends that Hanging is increasingly being adopted by a relatively younger age group who are mostly illiterate and of poor socio-economic status. Hanging being viewed as giving swift painless death and without much expenses and without arousing much suspicion, this mode is increasingly adopted to commit suicide. Dribbling saliva mark, which was a hallmark of Ante-mortem hanging, is increasingly seen in less number of cases. No incidence of fracture of Hyoid bone being seen in this study, due to the fact that most cases were of lower age group and also may be due to most of the victims adopting soft ligatures and low suspension points. Transverse tears in the Carotid arteries were not seen here and on subjecting to Histo-pathological study, we could detect disruption of intimal layer of Carotid artery. Effect of pressure on layers of skin were seen on Histo-pathological study showing vital reaction changes useful for labelling Ante-mortem hanging.

Nomenclature for knot position in hanging A study of 200 cases.

Hanging is one of the common methods of committing suicide world wide. Position of the knot, in hanging cases is important as it determines the post-mortem findings of the head and face and can also be used to predict the expected autopsy findings. Although hanging has been described in forensic literature since ages, there has been no proper scientific nomenclature for classifying the position of knot in hanging cases. This paper describes a new nomenclature of exact knot position on the neck based on commonly used anatomical landmarks with self explanatory terms of classification, so that it can be understood and used by the autopsy surgeons and the pathologists with ease. In the present study 200 cases of hanging were studied retrospectively and position of knot is classified according to a newly described nomenclature. The new nomenclature classifies the position of knot into 6 major classes each of which are further subdivided into 3 subcategories thus making 18 different positions on each side of neck. The most common position of knot was found at occipitomastoid region (32%) and the least common position being at mental region (2%).

Pattern of neck findings in suicidal hanging A study in Manipur.

Deaths due to hanging are common among suicides. In a study on 84 cases of suicidal hanging brought for autopsy to the mortuary of the Regional Institute of Medical Sciences, Imphal during 2004 to 2008, it was observed that 77.38% of the cases were males and 22.62% were females. The highest number of victims was in the age range of 21-40 years. 73.81% of the cases committed suicide indoors and 57.14% of them used ropes as ligature material. 85.75% of the victims had fixed knots with a single turn and 10.71% had slip knots. Complete atypical hanging constituted 88.10% of the cases. 23.81% of the cases had tear of the carotid artery and 3.57% had hyoid fractures. None of the cases had cricoid or trachea fractures. The neck findings vary depending upon the composition, multiplicity and tightness of the ligature material used, the suspension time, type of hanging, etc. Hence, the possible findings in a suspected case of hanging must be always anticipated so as to avoid any erroneous opinion.

A drop of saliva de-codes the mystery of hanging body.

A Forensic Expert sometimes asked to provide his opinion from the documents alone, particularly when the allegations were raised on the investigations, and the postmortem. Spot examinations were carried out by other doctor(s) and Forensic Scientists respectively. In the instant case there were allegations made on the fellow sports student, coach, and the investigating agencies all in connivance to pronounce the death as of suicidal hanging instead of murder. It is well known that the criminals first kill the person and then hang him to simulate it as hanging. Whenever, alcohol is detected in the blood than it creates a lot of doubts, which result into allegations from the relatives. Beside the examination of clothes, the injuries like ligature mark, their shape, size and location etc., thorough reviewing of documents & photographs plays a pivotal role in reconstructing the scene of crime. This has an importance in forming a conclusive opinion as to the cause and manner of death. In this paper, opinion regarding cause and manner of death to be of ante-mortem hanging was ascertained on reviewing the post-mortem report, photographs showing dribbling of saliva and Forensic Science Laboratory reports.

Tratamiento quirúrgico de fractura cervical en el Hospital Regional Rancagua: análisis de un periodo de 4 años / Surgical treatment of cervical fracture in the Rancagua Regional Hospital: analysis of a period of 4 years

Introducción: La gravedad, las implicancias neurológicas y el alto costo del tratamiento de la fractura cervical, hacen de esta lesión un tema de suma importancia. Esta injuria provoca graves limitaciones e invalidez a los afectados, en su mayoría en plena actividad laboral, impactando en lo médico, social y económico. Objetivos: Describir los pacientes tratados quirúrgicamente de fractura cervical traumática en el Hospital Regional Rancagua, por el equipo de Neurocirugía dentro de un periodo de 4 años. Materiales y Métodos: Se evaluó - 24 pacientes con antecedente de fractura cervical el mecanismo del trauma, el tiempo transcurrido desde el ingreso hospitalario hasta la cirugía, nivel y compromiso de la lesión medular, tipo de abordaje quirúrgico, complicaciones médicas, quirúrgicas y seguimiento post-operatorio, entre otros. Resultados: 5 mujeres y 19 hombres, edad promedio 39 años (rango de edad 14 a 75 años), principales mecanismos de trauma fueron los accidentes automovilísticos-atropello (58 por ciento). El nivel medular más frecuentemente lesionado fue C4-C5 (25 por ciento). En el 50 por ciento de los pacientes se clasificó de entrada como Frankel A, por lo que un 50 por ciento de todos los pacientes ingresaron tetrapléjicos, y de estos, un 33 por ciento egresó tetraparéticos. Del ingreso a cirugía hubo un tiempo de espera promedio 5 días. Dentro de las complicaciones médicas la causa respiratoria (46 por ciento) fue la más frecuente, necesitando 64 por ciento de estos pacientes ventilación mecánica. Se registró 1 infección de herida operatoria donde el abordaje fue posterior. El Índice de Barthel promedio de 14 pacientes fue de 49 puntos. De 6 pacientes con puntaje Cero, 85 por ciento de estos ingresaron como Frankel A y 50 por ciento egresaron tetrapléjicos. Los pacientes se rehabilitaron en promedio de 2.5 meses. Discusión: Logramos objetivar nuestra realidad. La técnica quirúrgica fue prácticamente uniforme entre los pacientes, sin complicaciones...

Introduction: Gravity, neurological implications and high costs of treating cervical fracture, makes of this injury an issue of most importance. This injury causes severe limitations and disability to those affected, mostly in full working activity, impacting on the medical, social and economic. Objectives: To describe patients surgically treated for traumatic cervical fracture at the Rancagua Regional Hospital, by the team of Neurosurgery Department, within a period of 4 years. Materials and Methods: We evaluated 24 patients with an history of cervical fracture mechanism of trauma, the time from hospital admission to surgery, and commitment level of spinal cord injury, type of surgery, medical and surgical complications and follow-up post -operation, among others. Results: 5 women and 19 men, average age 39 years (ranging age from 14 to 75 years), major trauma mechanisms were motor vehicle accidents (58 percent). The most frequently injured spinal level was C4-C5 (25 percent). 50 percent of patients were classified as Frankel A at the admission, so that 50 percent of all patients admitted were quadriplegics, and of these, 33 percent were discharged as tetraparétic. Admission to the surgery were an average of 5 days. Within cause respiratory medical complications (46 percent) was the most frequent, requiring 64 percent of these patients mechanical ventilation. There was only 1 wound infection where the approach was posterior. The average Barthel Index of 14 patients was 49 points. In 6 patients with zero score, 85 percent were admitted as Frankel A and 50 percent egressed as tetraplejic. Patients were rehabilitated an average of 2.5 months. Conclusions: We were able to objectify our reality. The surgical technique was nearly uniform among patients without severe postoperative surgical complications...

Fatores prognósticos nos ferimentos cervicais penetrantes / Prognostic factors of penetrating neck trauma

O pescoço é vulnerável a traumatismos devido à grande quantidade de estruturas vitais, podendo ocorrer lesões importantes e com alta morbimortalidade. OBJETIVO: Avaliar resultados em pacientes vítimas de ferimentos penetrantes cervicais. MÉTODOS: Foram analisados retrospectivamente prontuários de 39 pacientes entre 2001 e 2009. Ferimentos penetrantes foram definidos como lesões que penetravam além do músculo platisma. Foram analisados idade, gênero, etiologia, localização dos ferimentos, estruturas lesadas, tratamento e desfecho. Foi verificada a associação entre essas variáveis e o desfecho (alta ou óbito) por meio do teste exato de Fisher. RESULTADOS: Dos 39 pacientes analisados, 33 (84,62 por cento) eram homens, com média de 28 anos. A principal causa de ferimento cervical penetrante foi projétil de arma de fogo, com 19 (48,72 por cento) casos e a zona mais acometida foi a zona II, com 29 (74,36 por cento). Foram observados 13 (33,3 por cento) casos de instabilidade hemodinâmica e o tempo médio de internação dos pacientes foi de 14 (1-99) dias. A principal indicação da exploração cirúrgica foi a presença de hemorragia profusa em oito (20,5 por cento) dos casos. As principais estruturas acometidas foram veias cervicais (20,5 por cento). Ocorreram oito (20,51 por cento) óbitos. Pacientes jovens apresentaram melhor prognóstico. CONCLUSÃO: A mortalidade foi de 20,51 por cento. Pacientes com menos de 26 anos apresentaram melhor prognóstico.

The neck is vulnerable to trauma because of vital structures and possible major injuries with high morbidity and mortality rates. AIM: To evaluate the outcome in patients with penetrating cervical wounds. METHODS: The medical registries of 39 patients were analyzed retrospectively from 2001 to 2009. Penetrating wounds were defined as injuries that penetrated beyond the platysma muscle. Age, gender, etiology, wound site, injured structures, treatment, and outcome were analyzed. Fisher's exact test was adopted to establish the link between these variables and the outcome (discharge or death). RESULTS: Of 39 patients, 33 (84.62 percent) were men with a mean age of 28 years. The main cause was firearm projectiles - 19 (48.72 percent) cases; the most frequently affected zone was zone II - 29 (74.36 percent). Thirteen (33.3 percent) cases of hemodynamic instability were observed, and the average hospital stay was 14 (1-99) days. The main indication for surgical intervention was the presence of profuse hemorrhage, in eight (20.5 percent) cases. The main structures affected were the cervical veins (20.5 percent). There were eight (20.51 percent) deaths. Younger patients had a better prognosis. CONCLUSION: The mortality rate was 20.51 percent. Patients below age 26 years had a better prognosis.

Fracture of hyoid bone in cases of asphyxial deaths resulting from constricting force round the neck.

When any case of hanging, strangulation or throttling comes to the Department of Forensic Medicine for Post-mortem examination, the hyoid bone becomes the most integral part of internal examination at the autopsy table. Many authors and workers in this field have seriously highlighted fracture of hyoid bone. Some have claimed hyoid bone fracture in about 20% cases of hanging. Some have claimed hyoid bone fracture in about 68% cases of hanging. They also claimed that hyoid bone fracture increases with age above 40 years due to calcification and immobilization of joints. Some also claimed that hyoid bone fracture increases with using hard ligature for hanging and strangulation. Fracture of hyoid bone has been ascribed to many factors like manners of constriction, level of application of ligature or force of constriction, long drop or short drop suspension, age of victim, sex of victim etc. Besides getting hyoid bone fracture at autopsy table, it is also very important to check whether it is ante-mortem or post-mortem in nature or just an artifact. For this difficulty some have even advised preautopsy X-ray of the neck structures to detect ante-mortem hyoid bone fracture. Observing the importance given to hyoid bone fracture in hanging, ligature strangulation and throttling cases by many authors at the past and present days, the present authors have taken up the study in 257 cases of hanging, 7 cases of ligature strangulation and 5 cases of throttling to notice that hyoid bone fracture is nil or very rare in hanging where as it is very common in both forms of strangulation.