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ASPHYXIA

Dr. GUNAWAN ARSYADI, SpF, SpPA (K)

ASPHYXIA
A

condition where the disturbance


of air exchange respiration
occured
- Obstruction of respiratory tract
mechanical asphyxia
- Circulation arrested

HYPOXIA
Failure

of cell to keep the metabolism


eficiently

- Hypoxic, hypoxia
Failure of O2 to enter blood circulation
- Anemic hypoxia
Insufficient of adequate O2 by blood for tissue
metabolism
- Stagnant hypoxia
Circulation failure
- Histotoxic hipoxia
Oxygen in erythrocyte can not be used in the
tissue

Histotoxic Hipoxia
A. Extracellular
Respiratory tissue enzyme poisoned (CO
intoxication)
B. Pericelullar
Dicrease of cell membrane permeability which
cause O2 cannot enter the cell (ether imtoxication)
C. Substrate
Insufficient nutrient for efficient metabolism.
(Hypoglicaemia)
D. Metabolic
End product from cellular metabolism cannot be
eliminated and inhibit the next metabolism
(Uremia, CO2 poisoning)

Sign which can determine a


respiratory obstruction :
1.
2.
3.
4.
5.

Cyanosis: bluish at lips and finger


tips
Congestion: systemic obstruction
(lung obstruction, heart dilatation)
Still diluted blood
Lung oedema (not specific)
Tardius Spot

3 phase before asphyxial death


Dyspneu phase: high concentrate
C02 Kussmaul respiratory
2. Convulsive phase seizure
3. Apnea phase:
- Weakened breath/ bradipneu
- Loss of conciousness
- Pupil dilatation death
1.

Mechanical Asphyxia
1.

2.
3.
4.
5.

Squeeze
a. Hanging
b. Strangulation
c. Throttling
Smothering
Choking
Drowning
Compression

D R O W N I NG
Dr. GUNAWAN ARSYADI, SpF, SpPA
(K)

Drowning
Type of suffocation where respiratory
tract is blocked by water/ fluid air /
fluid is sucked into respiratory tract &
alveoly

DROWNING DEFINITION
Drowning is the effect of sinked body
partially or totally. Death is cause by
fluid in the lung, generally water,
which cause difficulty in breathing
and cause death by the effect of
asphyxia

INTRODUCTION
Mechanism of death in drowning generally
cause by asphyxia, vagal inhibition and
larynx spasm. Death of asphyxia by
electrolite exchange in blood in fresh water
drowning and salt water drowning.
Drowning is especially happened by
accidentally, rather than murder and suicide

MECHANISM OF DROWNING
Victim is sinked cause by gravitation
specific gravity of body is smaller
than specific gravity of fluid, victim
would floating early reaction,
victim try to breath, fluid inhaled
specific gravity of victim > specific
gravity of water drowning.

Dry drowning process


Some of water enter larynx or
trachea larynx spasm
Concentrated mucus, bubble is
formed and obstruct fluid cant
enter into lung brain hypoxia
(fatal) not cause by respiratory
occlusion by water but larynx
spasm(dry drowning)

Autopsy Examination
Outer Examination :
a. No diagnostic available
b. Several invention can enlighten
drowning diagnosis

Intravital sign in drowning


cases
Cadaveric

spasm
Middle ear bleeding
Watery particle (grass, mud, etc.) at
respiratory tract
Paltauf rash
Net weight of right heart is different
than net weight of left heart
Diatome (+) in lung/ bone marrow

Outer examination in drowing


cases :

Decrease of corpse temperature (algor mortis) is held


faster, (livor mortis) light red colour.
Goose-flesh apperance (cutis anserina)
Spasm of the erector pilae muscles/ rigor mortis
Washer womans hand
The deceased has been in the water for more than 1 -2
hours.
Mush room-like mass, appear at mouth or nose or both.
Petechial haemorrhages at eyelids especially lower
part.

Outer examination in drowing


cases :
For men, their genital : become
shrinkage, erection, which especially
semi-erection is found.
Theres a bruise or bite at the tongue.
Cadaveric Spasme
Bleeding / Injury at the face, hand and
posterior extremity as the effect of
touched by surrounding.

Outer examination in drowing


cases :
Examination

especially focused to
respiratory system.
Particle (Corpus Alienum), bubble in
trachea is seen either by
macroscopic & microscopic.
Pleura can be reddish and contain
petechia.
Large bleeding rash (diameter 3 -5
cm) is called paltauf rash .

Outer examination in drowing


cases :
Congestion

at larynx is an essential
finding, lungs usually too expanded.
Edema and lung congestion (700
-1000 g)
Emphysema Aquosum or
Emphysema Hydroaerique.
Middle ear bleeding.

Lab. Examination in drowing


cases:
I. Chemistry Test in drowning cases
Gettler, shows the difference of Cl level in blood,
between right and left heart.
The blood was analysed from the right
and left sides of the heart
If the chloride levels was less on the right then on the
left drowned in salt watter
if the chloride level was elevated on the right side of
the heart drowned in fresh water
Durlacher, determine the difference of plasma specific
gravity between right and left heart .
II. Examination of watery particles in lungs
In microscopic way, particle like cylicate crystal, mud,
worm egg and algae is found at alveoly (subpleura
part).

Lab. Examination in drowing


cases:
III. Diatomae analysis and
stomach contain
Diatomae (+) examination : diatomae
5/HPF at lung; or 1/HPF bone
marrow .
Diatomes are unicellular algae.
Stomach contain : Sand or mud or
watery micro organism is found

To exams there is particles in lungs:


a. Subpleural

lungs duct is examined.


b. Object/tools that used is glass object,
cover glass and microscope.
c. Condition : Lungs is still not rotted
d. Objective is to find a particle which
orginally from surrounding water
such as sand, mud, water grass, egg
worm.

Examination of watery particles in


Lungs
Procedure:
Lungs surface is scratched with clean
knife then washed. Lung surface is cut,
secretes wich will come out is dipped
on glass object, closed with cover
glass and seen under the microscope.

Several probability conclusion from


exmination of watery particles in lungs
1.

Lungs test (+), other Victim death cause by drowning


cause of death is not
found

2.

Lungs test (+) other


cause of death is
found

a.

Lungs test (-)

a.

3.

b.
c.

b.
c.
d.

Maybe death because of drowning


Death cause by other causes
Death cause both by drowning /
other cause
Maybe death in clean water
Maybe death because of vagal
reflex
Maybe death because of larynx
spasm
Victim maybe put in to water after
death, which in this case the other
cause of death is found

Special examination
Destruction Test
Procedure:
Peripheral lung tissue is destruct with
H2SO4, then put with HNO3
sentrifuge sediment is put on glass
object seen under microscope to
detect diatome.
2.

Condition of diatome test ( Destruction Test)


Lung

must be fresh
Part which would be exammed must
at right part of peripher
Type of diatome that found must be
same with diatome at that water
surrounding
Total of diatome at lungs 5/ HFP
Bone marrow 1/ HFP

Drowning in fresh water


I.

Drowning in fresh water


Mechanism : Fresh water (hypotonic)
drain process in osmosis
hemodilution
hyperkaliemia ventricle fibrillation
anoxia cerebri death (5 minutes)

Drowning in fresh water


On exmination to the that drowned
in fresh water will found :
Lung become bigger/, relatively dry,
reguler shape, pale red/
emphysematous. Die in 5 minutes
(40 ml/ kgBB)

Drowning in fresh water


Usually die in 5 minutes
Hyperkaliemia occur ventricle fibrillation
Can be followed by lungs edema
Lungs
* Relative dry
* Pale colour
* Reguler/ normal shape
* Lots of buble
* Crepitation (+)
Hemodilution / net weight reduce

Drowning in salt water


II. Drowning in salt water
Mecanism : Salt water
(hemoconcentration) circulation
fluid is carried out to lungs tissue
(Na , Hmt ) pulmonum edema
miocardium anoxia and increase of
blood viscosity heart failure

Drowning in salt water


On examination to the victim will found:
Lungs is bigger and heavy, relatively
wet, big, usually overlapping, purple
blue/smooth surface, no crepitation, lots
of fluid, when carried out from thorax,
lung looks flat / when pressed =>
convex, death in 5-10 minutes (20 ml /
kgBB)

Drowning in salt
water

Hemoconcentration
Lungs

(Net weight increase)

edema
Dead in 5 10 minutes
Lungs
* Wet appereance/ heavy
* Big
* Lot of fluid, lack of bubble
Blood net weight : 1.0595 1.060,
difference of 0.005 is exceptional

Manner of Death in Drowning


Accidentally
Suicide

(usually body is tied with


heavy object)
Murder (victim is found tied which
imposibily done by victim himself)