A S P H Y X I ADr. GUNAWAN ARSYADI, SpF, SpPA (K)

A S P H Y X I AA condition where the disturbance of air exchange respiration occured - Obstruction of respiratory tract mechanical asphyxia- Circulation arrested

HYPOXIAFailure 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 HipoxiaA. ExtracellularRespiratory tissue enzyme poisoned (CO intoxication)B. PericelullarDicrease of cell membrane permeability which cause O2 cannot enter the cell (ether imtoxication) C. SubstrateInsufficient nutrient for efficient metabolism. (Hypoglicaemia)D. MetabolicEnd product from cellular metabolism cannot be eliminated and inhibit the next metabolism (Uremia, CO2 poisoning)

Sign which can determine a respiratory obstruction :Cyanosis: bluish at lips and finger tipsCongestion: systemic obstruction (lung obstruction, heart dilatation)Still diluted bloodLung oedema (not specific)Tardius Spot

3 phase before asphyxial deathDyspneu phase: high concentrate C02 Kussmaul respiratoryConvulsive phase seizureApnea phase:- Weakened breath/ bradipneu- Loss of conciousness- Pupil dilatation death

Mechanical AsphyxiaSqueezea. Hangingb. Strangulationc. ThrottlingSmotheringChokingDrowningCompression

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

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

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 processSome 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)

Outer Examination :No diagnostic availableSeveral invention can enlighten drowning diagnosisAutopsy Examination

Intravital sign in drowning casesCadaveric spasmMiddle ear bleedingWatery particle (grass, mud, etc.) at respiratory tractPaltauf rashNet weight of right heart is different than net weight of left heartDiatome (+) 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 mortisWasher womans handThe 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.

For men, their genital : become shrinkage, erection, which especially semi-erection is found.Theres a bruise or bite at the tongue.Cadaveric SpasmeBleeding / 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.Outer examination in drowing cases :

Lab. Examination in drowing cases: I. Chemistry Test in drowning casesGettler, 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 heartIf the chloride levels was less on the right then on the left drowned in salt watterif 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).

III. Diatomae analysis and stomach containDiatomae (+) 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 Lab. Examination in drowing cases:

Subpleural lungs duct is examined.Object/tools that used is glass object, cover glass and microscope.Condition : Lungs is still not rottedObjective is to find a particle which orginally from surrounding water such as sand, mud, water grass, egg worm.To exams there is 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.Examination of watery particles in Lungs

Several probability conclusion from exmination of watery particles in lungs

1.Lungs test (+), other cause of death is not foundVictim death cause by drowning2.Lungs test (+) other cause of death is foundMaybe death because of drowningDeath cause by other causes Death cause both by drowning / other cause3.Lungs test (-)Maybe death in clean waterMaybe death because of vagal reflexMaybe death because of larynx spasmVictim maybe put in to water after death, which in this case the other cause of death is found

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. Special examination

Lung must be freshPart which would be exammed must at right part of peripherType of diatome that found must be same with diatome at that water surroundingTotal of diatome at lungs 5/ HFP Bone marrow 1/ HFPCondition of diatome test ( Destruction Test)

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

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 minutesHyperkaliemia occur ventricle fibrillationCan be followed by lungs edemaLungs * Relative dry* Pale colour* Reguler/ normal shape* Lots of buble* Crepitation (+)Hemodilution / net weight reduceDrowning in fresh water

Drowning in salt waterII. 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

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 (Net weight increase)Lungs edema Dead in 5 10 minutesLungs* Wet appereance/ heavy* Big* Lot of fluid, lack of bubbleBlood net weight : 1.0595 1.060, difference of 0.005 is exceptionalDrowning in salt water

AccidentallySuicide (usually body is tied with heavy object)Murder (victim is found tied which imposibily done by victim himself)Manner of Death in Drowning