Asphyxial conditions


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Asphyxial conditions

  2. 2. DEFINITIONSAsphyxia (Greek, pulsenessne ss or absence of pulse) means restriction of oxygen due to mechanical interference with respiration.
  3. 3. ASPHYXIAL CONDITIONS- DEFINITIONSSuicide (Latin suicidium, ‘to kill oneself’) is the act of intentionally causing ones own death.
  4. 4. ASPHYXIAL CONDITIONS- DEFINITIONSFailed suicide attempt (Latin: tentamen suicidii) refers to a suicide that did not result in death. Some are regarded as not true attempts at all, but rather parasuicide.
  5. 5. ASPHYXIAL CONDITIONS- DEFINITIONSHanging or self- suspension is a form of asphyxia caused by suspension of the body by a ligature which encircles the neck, the constricting force being at least part of the weight of the body. It may be either complete (feet are not touching the ground) or partial (feet are touching the ground).
  6. 6. ASPHYXIAL CONDITIONS- DEFINITIONSStrangulation is a form of asphyxia caused by mechanical disruption of blood flow through the vessels of the neck and/or blockage of air passage through the trachea by means of a ligature or by any means other than suspension of the body.
  7. 7. CLASSIFICATION OF STRANGULATIONLigature strangulation: When ligature material is used to compress the neck. It includes the use of any type of cord-like object, such as an electrical cord or purse strap.
  8. 8. CLASSIFICATION OF STRANGULATIONManual strangulationor throttling: Whenhuman fingers, palmsor hands are used tocompress the neck.
  9. 9. CLASSIFICATION OF STRANGULATIONMugging: Strangulation caused by holding the neck of the victim in the bend of elbow (i.e. the ‘sleeper hold’) or knee of the assailant.
  10. 10. CLASSIFICATION OF STRANGULATIONGarroting: Strangulation is caused by compression of the neck by a ligature which is quickly tightened by twisting it with a lever (rod, stick or ruler) known as Spanish windlass which results in sudden loss of consciousness and collapse.
  11. 11. ASPHYXIAL CONDITIONS- DEFINITIONSDrowning is the process of experiencing respiratory impairment from submersion/immersion in liquid.
  12. 12. ASPHYXIAL CONDITIONS- DEFINITIONSSuffocation is a form of asphyxia caused by mechanical obstruction to the passage of air into the respiratory tract by means other than constriction of neck or drowning.
  13. 13. CLASSIFICATION OF SUFFOCATIONSmothering is causedby mechanicalocclusion of externalair passages fromoutside, i.e. the noseand mouth byhand, cloth, pillow, plastic bag or othermaterial
  14. 14. CLASSIFICATION OF SUFFOCATIONChoking is caused byan obstruction withinthe trachea, eitherpartially or completely,from inside by aforeign body, like coin,fruit seed, toffees,candies, fish or anyother material.
  15. 15. CLASSIFICATION OF SUFFOCATIONGagging results frompushing a gag (rolledup cloth or paper balls)into the mouth,sufficiently deep toblock the pharynx. Itcombines the featuresof smothering andchoking.
  16. 16. CLASSIFICATION OF SUFFOCATIONOverlaying resultsfrom compression ofthe chest, nose andmouth, so as toprevent breathing.
  17. 17. CLASSIFICATION OF SUFFOCATIONTraumatic asphyxiaresults from respiratoryarrest due tomechanical fixation ofchest, so that thenormal movements ofchest wall areprevented.
  18. 18. CLASSIFICATION OF SUFFOCATIONConfined spaceentrapment occurswhen there isinadequate oxygen inthe enclosed spacedue to consumption ordisplacement by othergases.
  19. 19. CLASSIFICATION OF SUFFOCATIONBurking is a combination of homicidal smothering and traumatic asphyxia.
  20. 20. EPIDEMIOLOGY The rate of suicide is far higher in men than in women (3-4: 1) with suicidal hangings more common. However, recent trends suggest that women are gradually using hanging than other methods of suicide. Women are more likely than men to be victims of strangulation (domestic violence or sexual assault). Nearly all reported autoerotic strangulation incidents involve men. Accidental strangulation may occur in both men and women.
  21. 21. CAUSES Several populations are at risk of hanging or strangulation. Toddlers: The neck may get caught and strangled in ill- constructed cribs as they put their heads out. Window cords have also been implicated in such deaths.
  22. 22. CAUSES Adolescents: Incidence of accidental hanging, throttling or strangulation due to ‘choking game’ (voluntary asphyxia in order to enjoy the altered sensations due to cerebral hypoxia). Playground slide tie rope has been implicated in accidental strangulation. Emulating TV shows and depression can also lead to hanging.
  23. 23. CAUSES Adults: Autoerotic accidents, assaults, and suicidal depression are common causes (e.g. prisons, where hanging is easier and available method). Accidental strangulation from scarfs and ‘chunni’ (in females) and by cotton cloth entangled in the rotor of a machine (in males) have been reported. Elderly: Depression can lead to hanging.
  24. 24. CAUSESIsadora Duncan syndrome: The world famous dancer Isadora Duncan died on 14 September 1929 as a result of her long scarf which she was wearing got caught in the wire wheels of her Buggati car. She died at the scene and was later found to have sustained a fractured larynx and carotid artery injury.
  25. 25. PATHOPHYSIOLOGYThe proposedmechanisms of theobserved featuresseen in most of theasphyxial conditions(whether by hanging,manual strangulation,application of ligature,or posturalasphyxiation (inchildren whose necksare caught in an objectsuch as a crib)includes the following:
  26. 26. PATHOPHYSIOLOGYVenous obstruction leading to cerebral congestion, hypoxia and unconsciousness, which in turn, produces loss of muscle tone leading to airway obstruction, occurs if ligature is made up of broad and soft material. For manual strangulation and suicidal near- hanging victims, it is a significant factor that produces loss of consciousness.
  27. 27. PATHOPHYSIOLOGYArterial blockage due to pressure on carotid artery, leading to cerebral anemia and collapse due to low cerebral blood flow occurs when ligature is made of thin cord.
  28. 28. PATHOPHYSIOLOGYReflex vagal inhibition caused by pressure to the carotid sinuses and increased parasympathetic tone leading to sudden cardiac arrest (less common)
  29. 29. PATHOPHYSIOLOGYMost experts agree that regardless of the events occurring in any given hanging or strangulation, death ultimately occurs from cerebral hypoxia and ischemic neuronal death. Notably, none of the proposed mechanisms advocates airway compromise as the immediate cause of signs and symptoms observed in such cases. In fact, although mechanical airway compromise occurs and ultimately complicates patient management, it appears to play a minimal role in the immediate death of victims.
  30. 30. CLINICAL EFFECTS OF ASPHYXIA Sphincter Voiding of Asphyxia relaxation urine, stools, semen Capillary Decreased endotheliumoxygen tension damageand reduced Hb Increased Cyanosis capillary Tardieu’s permeability spots Unconscious ness Pulmonary edema Capillary rupture Loss of Capillary Increased muscle stasis and intracapillary power engorgement pressure
  31. 31. Triad of asphyxial stigmata may be seenCyanosis: Bluish discoloration of skin, face (particularly in the lips, tip of nose, ears lobules), nailbeds and mucous membranes
  32. 32. Triad of asphyxial stigmata may be seenPetechial hemorrhages (Tardieu’s spots) are found in those parts where capillaries are least supported, e.g. conjunctiva, face, epiglottis, on the face. They tend to be better made out in fair skinned persons.
  33. 33. Triad of asphyxial stigmata may be seenCongestion and edema of the face due to raised venous pressure.
  34. 34. EVALUATION AND DOCUMENTATIONHISTORYIn practice, it has been observed that manually strangled or garroted or suicidal hanging victims are brought to the hospital in unconscious state for the purposes of treatment. Such cases are brought to the emergency department after being found by strangers, friends, family members or sometimes police. On many occasions the exact history may not be disclosed by the relatives. The history in such cases is lacking, vague or cooked up. In such cases, the doctor must try to extract the history from different sources available.
  35. 35. EVALUATION AND DOCUMENTATIONEven if the victim is conscious, she may not always report the attempted strangulation episode. As is common with cases of domestic violence, the victim may be hesitant to fully describe what happened or will minimize the severity of the attack. Moreover, visual evidence of force applied to the neck during such incident is often absent or minimal on initial medical evaluation. The lack of physical findings may lead authorities to discount the patient’s report. Hence, specific questions often are required to elucidate the history.
  36. 36. EVALUATION AND DOCUMENTATIONThe victim should be asked about the method or manner of strangulation, whether hands, elbow and forearm, knee, ligature or any other method was used. Whether the victim attempted hanging? The number of such episodes, whether single, multiple or repeated with different methods. Other circumstances should also be enquired like whether the victim also smothered, shaken, knocked or pounded into a wall or the ground? Was the victim also hit or physically sexually or assaulted? Whether the victim has consumed any alcohol, drug or any other poison (any smell from breath)?
  37. 37. EVALUATION AND DOCUMENTATIONThe practitioner has to enquire about specific symptoms like whether the victim lost consciousness, if there is any neck pain, any difficulty in breathing or swallowing, any change of voice, headache, and if there was any urinary and/or fecal incontinence.
  38. 38. EVALUATION AND DOCUMENTATIONHanging victims are morelikely to arrive in theemergency departmentwith a depressed level ofconsciousness than arevictims of manualstrangulation. This ispresumably due to themore intensive andprolonged compressiveforce applied to the neckdue to hanging than istypically seen withmanual pressure.
  39. 39. CLINICAL PRESENTATIONThe victim may present with deceptively harmless signs and symptoms with no or minimal external signs of soft tissue injury because of the slowly compressive nature of forces involved in non-lethal strangulation. The upper airway may also appear normal beneath intact mucosa, despite hyoid bone or laryngeal fractures. It takes time for hemorrhage and edema to develop after compressive injuries (may take 36 hours after the episode), and the patient can develop edema of the supraglottic and oropharyngeal soft tissue, leading to airway obstruction.
  40. 40. SIGNS AND SYMPTOMSThe clinical presentations can vary according to the method, force and duration of asphyxiation. The following specific clinical manifestations are possible in asphyxiation victims:
  41. 41. SIGNS AND SYMPTOMSDysphonia or hoarseness of voice is commonly seen. Patient may sometimes present with aphonia.
  42. 42. SIGNS AND SYMPTOMSDysphagia or swallowing difficulty may occur due to injury to larynx or hyoid bone which is not common symptom on initial assessment, but may be reported subsequently in 2 weeks. Sometimes it may be painful (odynophagia).
  43. 43. SIGNS AND SYMPTOMSDyspnea is very common, but often a late development. Respiratory distress is seen in 2 weeks which may be due hyperventilation or psychogenic (anxiety, fear, depression). Difficulty breathing can also be due to laryngeal edema or hemorrhage, although those injuries are less common in surviving victims.
  44. 44. SIGNS AND SYMPTOMSPain and swelling in the throat or neck is common after attempted strangulation. The patient may be able to localize it to a specific area of injury, or it may be diffuse and poorly localized. Edema may be caused by internal hemorrhage, injury to underlying neck structures or fracture of the. Laryngeal fracture can manifest as severe pain on gentle palpation of the larynx or subcutaneous emphysema over or around the laryngeal cartilage.
  45. 45. SIGNS AND SYMPTOMSAltered mental status: Restlessness, confusion, loss of orientation or combativeness due to cerebral hypoxia or from concomitant intracranial injury or ingestion of drugs or ethanol.
  46. 46. SIGNS AND SYMPTOMSNeurologic symptoms include changes in vision, tinnitus, ptosis, facial droop, or unilateral weakness, paralysis or loss of sensation. In many patients, the findings are transient and believed to be caused by focal cerebral ischemia produced by the strangulation process that resolves with time. In rare cases, damage to the internal carotid artery may induce thrombosis with a delayed neurologic presentation.
  47. 47. SIGNS AND SYMPTOMSPetechiae can occur at or above the area of compression and are most frequently seen on the face, periorbital region, eyelids, scalp and conjunctiva. Facial and conjunctival petechiae are evidence of prolonged elevated venous pressure. It has been found that the jugular vein needs to be occluded for at least 15-30 seconds for the development of facial petechiae. Subconjunctival hemorrhage is usually seen after a vigorous struggle between the victim and assailant.
  48. 48. SIGNS AND SYMPTOMSNeck: Injury to the soft tissues in the neck may manifest with abrasions (scratches), hyperemia, e cchymoses and edema. The hyperemia may be transient and not visible by the time of assessment. Ecchymoses and swelling may take time to develop and may not be visible on initial assessment.
  49. 49. SIGNS AND SYMPTOMSAttemptedthrottling: Fingertips mayproduce faint oval or roundbruises 1.5-2 cm in size (may bemore in case of continuedbleeding). A grip from right handproduces a bruising due to bulb ofpressing thumb over the cornue ofhyoid/thyroid on anterolateralsurface of right side of victimsneck and several fingertip bruisingmarks and overlying nail scratchabrasions over left side. A singlebruise on the victim’s neck is mostfrequently caused by theassailant’s thumb as bruises madeby tips of thumbs are moreprominent than with other fingers.
  50. 50. SIGNS AND SYMPTOMSMultiple abrasions on the neck may be defensive in nature from use of victims own fingernails in an effort to dislodge the assailants grip but commonly are a combination of lesions caused by both the victim and the assailant’s fingernails.
  51. 51. SIGNS AND SYMPTOMSChin abrasions may also occur from the defensive actions as the victim tries to protect their necks from the manual strangulation of the assailant.
  52. 52. LIGATURE MARK (‘FURROW’) IN ATTEMPTED HANGING AND STRANGULATIONS. No. Features Hanging Strangulation 1. Direction Oblique Transverse 2. Continuity Non-continuous Continuous 3. Level in the neck Above thyroid At or below thyroid 4. Base Pale, hard, Soft and reddish parchment-like
  53. 53. SIGNS AND SYMPTOMSAttemptedthrottling: Fingertips mayproduce faint oval or roundbruises 1.5-2 cm in size (may bemore in case of continuedbleeding). A grip from right handproduces a bruising due to bulb ofpressing thumb over the cornue ofhyoid/thyroid on anterolateralsurface of right side of victimsneck and several fingertip bruisingmarks and overlying nail scratchabrasions over left side. A singlebruise on the victim’s neck is mostfrequently caused by theassailant’s thumb as bruises madeby tips of thumbs are moreprominent than with other fingers.
  54. 54. SIGNS AND SYMPTOMS Lungs: Aspirationpneumonitis may occur due toinhalation of vomitus duringthe episode. Pulmonaryedema is a seen generally incomatose hanging victims.The cause of the pulmonaryedema can either be due toanoxic injury to the centralnervous system (neurogenicpulmonary edema) or from thelarge negative intrathoracicpressures seen when thevictim struggles to breathe inagainst an occluded airway(obstructive pulmonaryedema).
  55. 55. SIGNS AND SYMPTOMSInvoluntary urination or defecation, expulsi on of fetus (if pregnant) may occur.
  56. 56. SIGNS AND SYMPTOMSFractures of thethyroid cartilage orhyoid bone invictims of accidentalstrangulation anddirect injury to thetrachea is rare withstrangulation. Carotidartery injury is alsouncommon afterattempted hanging andstrangulation.
  57. 57. SIGNS AND SYMPTOMSInjury to other organ systems from strangulation is uncommon. Case reports ofdiaphragmaticinjury, multiple organfailure, and thyroid stormafter attemptedstrangulation; cricotrachealseparation and commoncarotid artery dissection, andlaryngotracheal separationafter attempted hanging; andlaryngeal rupture and carotidartery stenosis afteraccidental strangulation haveappeared in the medicalliterature.
  58. 58. SIGNS AND SYMPTOMSExamination for otherassociated injuries incases femalepatients regardinginjuries onlips, face, cheeks, abdomen, back, genitalorgans and breast (ifthere is any historysuggesting sexualabuse). In such casescomplete examination ofgenital organs is of vitalimportance.
  59. 59. DiagnosisThe majority of the victims present withsome common features, a combination ofthese findings should be taken intoconsideration for diagnosis: Hyperemia and/or ecchymosis Facial or conjunctival petechiae Change of voice or difficulty in breathing Marks on the neck Loss of consciousness or altered mental status
  60. 60. DIAGRAMS AND PHOTOGRAPHSIt is important to document the injuries throughdiagrams and photograph that may be seen at the timeof examination for evidence purpose. The injuries shouldbe mentioned in the pictograph given along with themedico-legal report. The following photographs mayalso be taken:Distance photo: Full body photograph to identify thevictim and location of injury.Close-up photo: Photographs of injuries along with aruler from different angles to maximize visibility and todocument the size.Follow-up photo: As the injuries may take time todevelop, taking follow-up photographs at different timeintervals will document injuries as they evolve.
  61. 61. LABORATORY AND IMAGINGArterial bloodgases (ABGs)analysis should bedone in all patientswho requireintubation, forsubsequentventilatormanagement.
  62. 62. LABORATORY AND IMAGINGPulse oximeteryis indicated inpatients with alteredmental status andrespiratory distress.It also makes ABGsunnecessary inpatients who do notrequire endotrachealintubation.
  63. 63. LABORATORY AND IMAGINGNeck X-ray should be donein nearly all strangulation victimsand patients with a mechanismconsistent with hanging. It isuseful to detect fractured hyoidbone and for evaluation ofsubcutaneous emphysema due tofractured larynx. Fractures of thecervical vertebrae are extremelyrare in strangulation injuriesunless there has been a hangingwith a free-fall drop of the body.Generally, a fractured hyoid boneindicates a severe, occult soft-tissue injury, even in a patientwhose medical condition isotherwise stable.
  64. 64. LABORATORY AND IMAGINGChest X-ray isindicated afterendotrachealintubation forplacementconfirmation, diagnosis of pulmonaryedema, aspirationpneumonitis and acuterespiratory distresssyndrome (ARDS).
  65. 65. LABORATORY AND IMAGINGCT scan is indicated to detect hyoid bone and laryngeal fractures, injury to carotid arteries and other soft-tissue abnormalities that may not be apparent on plain radiographs. CT head is done to evaluate neurological status. CT is more sensitive for bony injuries, subcutaneous emphysema, soft-tissue edema, and internal hemorrhage.
  66. 66. LABORATORY AND IMAGINGDoppler vascularimaging, CTangiography orarteriography is usefulto detect injury to thecarotid arteries (inpatients with unilateralneurological findings).The current ‘goldstandard’ for bluntcarotid artery injury isfour-vessel selectiveangiography.
  67. 67. LABORATORY AND IMAGINGMRI is the mostuseful imagingmodality for themajority of suchvictims because ofits highest sensitivityfor deep soft-tissueinjury including thelarynx and vessels.
  68. 68. LABORATORY AND IMAGINGFiberopticlaryngoscopy isindicated forvisualization of thelaryngeal structures(vocal cords) andadjacent structuresfor edema andhemorrhage.
  69. 69. MANAGEMENTLike any other traumatic injuries, the management of a strangulation victim starts with the ABCs Airway Breathing Circulation Fluid resuscitation must be done judiciously as there is risk of subsequent ARDS and cerebral edema.
  70. 70. MANAGEMENTThe choice and sequence of imaging is dependent on patient’s clinical condition, suspected injuries and availability of the specific modalities in that set-up. An ENT consultation can establish both the need for, and the timing of, these studies.
  71. 71. MANAGEMENTLike any other traumatic injuries, the management of a strangulation victim starts with the ABCs— airway, breathing, circu lation. Fluid resuscitation must be done judiciously as there is risk of subsequent ARDS and cerebral edema.
  72. 72. MANAGEMENT Orotrachealintubation should bedone preferably by ananesthetist. It can be difficult iflaryngeal edema is present orif direct traumatic disruption ofthe larynx has occurred.Cricothyroidotomy is indicatedfor any patient with severerespiratory distress andcompletely obstructed airway.If associated neck injuriesrender cricothyroidotomydifficult, percutaneoustranslaryngeal ventilation maybe used to temporarilyoxygenate a patient.
  73. 73. MANAGEMENTThe definitive airwaymanagement islaryngotomywhich must be doneat the earliest
  74. 74. COMPLICATIONSRespiratory system: Both aspiration pneumonia and ARDS may develop; tracheal stenosis in case of rupture.
  75. 75. COMPLICATIONSNeurologic sequelaeincluding musclespasms, transienthemiplegia, centralcord syndrome andseizures. Long-term paraplegiaor quadriplegiaand short-termautonomic dysfunctionmay be seen in spinalcord injury.
  76. 76. COMPLICATIONSPsychiatric symptoms:Encephalopathy,insomnia, nightmaresand anxiety and aninclination for violenceare seen in such victims.Psychosis, depression,suicidal ideation,Korsakoff syndrome,amnesia and progressivedementia may develop.
  77. 77. PROGNOSISThe prognosis for survivors ofhanging and strangulationsarriving to the emergencydepartment is widely variable. Theoutcome is determined by thepresence of cardiopulmonaryarrest (as indicated by arequirement for cardiopulmonaryresuscitation and/or invasiveairway management) and degreeof anoxic brain injury (ascorrelated with a lowGlasgow ComaScore and cerebral edema oninitial CT scan). In general, theemergency room disposition ofsuch victims is primarilydetermined by their clinicalcondition and evidence of injury totheir deep neck structures.
  78. 78. MEDICO-LEGAL FORMALITIES WHILE DEALING WITH ATTEMPTED STRANGULATION OR HANGINGMedicalpractitioners whoexamine such cases in theemergency have to follow aprotocol regarding thedocumentation of medico-legalformalities; besides impartingtreatment in order to save the lifeof patient. Injuries due to assaultare required to be informed to thepolice (if police is notaccompanying) to ensure safedisposition of the patient. In caseof suspected child abuse, childprotective agency should benotified. The preparation ofmedico-legal report is guided asper the protocol .
  79. 79. LEGAL PROVISIONSIn India, attempt to commit suicide is an offencepunishable underSec. 309 IPC. Itstates that whoeverattempts to commit suicideand does any act towardsthe commission of suchoffence, shall be punishedwith simple imprisonmentfor a term which mayextend to 1 year or withfine, or with both. Attempt to commit suicide is an offence punishable under Sec. 309 IPC
  80. 80. LEGAL PROVISIONSAbetment ofsuicide: As perSec. 306 IPC, anyperson who abets thecommission of suicideshall be punished for aterm which may extentto 10 yearsimprisonment andshall also be liable tofine. GOPAL KANDA, THE SIRSA MLA IS THE MAIN ACCUSED OF A CASE UNDER SECTION 306 IPC
  81. 81. The Protection of Women from Domestic Violence Act, 2005 Salient features of the Act:The term domestic violence covers all forms of physical, sexual, verba l, emotional and economic abuse that can harm, cause injury to, endanger the health, safety, life, limb or well-being, either mental or physical of the aggrieved person.
  82. 82. The Protection of Women from Domestic Violence Act, 2005Salient features of the Act: ‘Aggrieved person is not just the wife but a woman who is the sexual partner of the male irrespective of whether she is his legal wife or not. It includes daughter, mother, sister, child (male or female), widowed relative, or any woman residing in the household who is related in some way to the respondent.
  83. 83. The Protection of Women from Domestic Violence Act, 2005Salient features of the Act: ‘Respondent’ is anymale, adult person whois, or has been, in adomestic relationshipwith the aggrievedperson that includeshis mother, sister andother relatives; thecase can also be filedagainst relatives of thehusband or malepartner.
  84. 84. THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005 Information to ProtectionOfficer: The informationregarding any acts of domesticviolence does not necessarilyhave to be lodged by theaggrieved party but by anyperson who has reason tobelieve that such an act hasbeen or is being committed.Any medicalofficer, neighbors, socialworkers or relatives can alltake initiative on behalf of thevictim.
  85. 85. THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005Duties of medical facilities:If an aggrieved person or aProtection Officer or aservice provider requeststhe medical practitioner toprovide any medical aid tothe victim, the doctorshould provide medical aidto the aggrieved person inthe medical facility.
  86. 86. THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005Penalties: The magistrate canimpose a penalty up to 1 yearof imprisonment and/or a fineup to Rs. 20,000/- for anoffence under this Act. Theoffence is also consideredcognizable and non-bailable.The decision can be takenunder the sole testimony of theaggrieved person; the courtmay conclude that an offencehas been committed by theaccused.
  87. 87. THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005The magistrate can imposemonetary relief and monthlypayments of maintenance. Therespondent can also be made tomeet the expenses incurred andlosses suffered by the aggrievedperson as a result of domesticviolence and can also cover lossof earnings, medicalexpenses, loss or damage toproperty and can also cover themaintenance of the victim. The Actalso allows the magistrate to makethe respondent pay compensationand damages for injuries includingmental torture and emotionaldistress caused by acts ofdomestic violence.
  88. 88. KEY ELEMENTS OF STRANGULATION AND SUFFOCATION STATUTEThe Strangulation and Suffocation Law in the UnitesStates defines and provides penalties for a personwho engages in intentional strangulation andsuffocation. The states of Iowa, South Dakota,California, Wisconsin, Tennessee, Virginia and NewYork have passed laws making it a felony (a crimepunishable by death or imprisonment in excess of 1year) under certain conditions to knowingly impedesomeone’s breathing.
  89. 89. ‘Dangerous weapon’ means any firearm, whether loaded orunloaded; any device designed as a weapon and capable ofproducing death or great bodily harm; any ligature or otherinstrumentality used on the throat, neck, nose, or mouth ofanother person to impede, partially or completely, breathing orcirculation or blood; any electric weapon, or any other device orinstrumentality which, in the manner it is used or intended to beused, is calculated or likely to produce death or great bodilyharm.‘Substantial bodily harm’ means bodily injury that causes alaceration that requires stitches, staples, or a tissue adhesive;and fracture of a bone; a broken nose; a burn; a petechia; atemporary loose of consciousness, sight or hearing; aconcussion; or a loss or fracture of a tooth.
  90. 90. SAMPLE CASE REPORTDomestic violence: A lady 29 years was admitted in Medicineunit in emergency as a suspected case of poisoning with history offound unconscious at her residence; alleged by her husband tohave taken some drugs at her home. On examination, the ladywas cyanosed. She was managed and treated as a case ofsuspected poisoning. Next day, the department of ForensicMedicine was approached for review of the case and on thoroughexamination, a ligature mark was found all around the neck whichwas circular, and horizontally placed below the level of thyroidcartilage (Fig. 1). The patient was immediately shifted to ICUwhere it was confirmed that the patient had developed pulmonaryedema. On detailed investigation by the investigating officer, itwas confirmed that the husband had tried to strangulate her oversome dispute but could not succeed.
  91. 91. SAMPLE CASE REPORTSexual assault with manual strangulation: A young girl aged13 years was found from an abandoned street in semi-unconscious condition. She was shifted to Govt. MedicalCollege Jammu for treatment. During examination, cresentricabrasions along with multiple oval shaped bruises werefound over the neck and nasal region. Two days after, whenshe regained her consciousness fully; her statement wasrecorded by the police. It was revealed in the statement thatshe was kidnapped by her close relative and then taken toabandoned street and was sexually assaulted there and whenshe tried to cry, she was throttled and smothered by theaccused, thereafter she fell unconscious.
  92. 92. SAMPLE CASE REPORTTraumatic asphyxia: A truck conductor was brought to theemergency in Govt. Medical College Jammu in semi-conscious condition with labored breathing, intensecyanosis, and tachycardia. The history revealed by the policethat he was helping the driver by standing at the back side oftruck for the purpose of parking. However, the driver couldnot control the truck while reversing the same that lead tofixation of the conductor in between the backside of truckand the wall resulting in traumatic asphyxia. On examination,multiple bruises and contusions over the chest with fractureof ribs were found. Patient was immediately shifted to ICU butcould not survive and died after two days.
  93. 93. THANKX FOR Y0UR PATIENCE... IT IS A SUZYWORK...................