J. Ugrasal. State University of New York College Maritime College at Fort Schuyler.
Chemical asphyxia 229 230 Forensic Pathology These deaths might be accidental order propecia paypal hair loss 9 year old, suicidal or homicidal in manner order propecia with american express hair loss viviscal. Com- pared with other causes of homicide purchase propecia 5mg online hair loss cure stem cell, homicides via asphyxia are relatively uncommon in the U. In the last ten years, murders ascribed to stran- gulation have averaged 286 a year, with a range of 366 to 211. There seems to have been a gradual decrease in the number of such cases over the years. Murders caused by “asphyxiation” (no further description but excluding strangulation) have averaged 107 a year, with this number being fairly con- stant over the ten-year period. Suffocating gases Entrapment / Environmental Suffocation In suffocation by entrapment or environmental hazard, asphyxia is caused by inadequate oxygen in the environment. In entrapment, individuals ﬁnd themselves trapped in an air-tight or relatively air-tight enclosure. Fortunately, this speciﬁc form of death by entrapment is becoming rare, as modern refrigerators do not have a latch system of locking and can be pushed open from the interior. In environmental suffocation, an individual inadvertently enters an area where there is gross deﬁciency of oxygen. This deﬁciency is not due to displacement of the oxygen by suffocating gases, which will be discussed in another section, but rather that the oxygen has been depleted by some mech- anism. Thus, the authors reported two deaths caused by lack of oxygen in an underground chamber. This lethal atmosphere was caused by fungus-like organisms and Asphyxia 231 low forms of plant life present on the vault walls and in the sediment on the ﬂoor. The metabolic processes of the fungi and plant life resulted in depletion of oxygen by these organisms, with production of carbon dioxide. The increased quantity of carbon dioxide, however, was insufﬁcient in itself to have caused death by displacement of oxygen. At oxygen concentrations of 10 to 15%, there is impairment in judgment and coordination. At oxygen concentrations of 4 to 6%, there is loss of consciousness in 40 sec and death within a few min. In deaths due to entrapment or environmental suffocation, the cause of death cannot be determined by autopsy alone, because there are no speciﬁc ﬁndings. It is only by an analysis of the circumstances leading up to and surrounding death, and the exclusion of other causes, that one can make a determination as to the cause of death. Smothering Asphyxia by smothering is caused by the mechanical obstruction or occlusion of the external airways, i. Deaths such as these are usually either homicide or suicide, very rarely accident (Figure 8. The most common form of suicidal smothering is the placing of a plastic bag over an individual’s head (Figure 8. Here, there is often no necessity to secure the bag at the neck, because it clings to the face, occluding the airways. These ﬁlmy plastic bags also account for the rare accidental deaths by smothering when these bags are used to cover a mattress or pillow in a crib of a young child. In all the deaths that the authors have seen in which plastic bags have been placed over the head, there have been no speciﬁc autopsy ﬁndings. Petechiae of the epicardium or pleural surfaces of the lung were sometimes present, but these are so nonspeciﬁc that the authors do not give any weight to them. If an individual commits suicide by use of a plastic bag and the bag is removed prior to notiﬁcation of the authorities, a medical examiner cannot determine the cause of death by the autopsy. There are occasional allegations of infants smothering in their cribs because of heavy blankets or bedding placed over them. One can pile a number of blankets on an infant without causing any respiratory difﬁculty. Cir- cumferential oral and nasal pallor is noted and death is attributed to smothering. This pallor, however, can be caused post mortem by passive pressure of the dependent head on the pillow. Alcoholic coma, however, puts them in grave danger of death anyway and this is more likely the cause of death, rather than the alleged suffocation. Here, an infant is trapped either between a too-small mattress and the frame of the crib, or between a defective crib and mattress, with the face wedged against the mattress (Figure 8. Such deaths, though unintentional, are still homicides if the victims die during the commission of a crime. Typically, a gag is placed around the face obstructing the mouth and nose (Figure 8. Victims are usually elderly individuals who are either unable to struggle sufﬁciently to move the gag or who are unusually susceptible to the anoxia by virtue of natural disease. Mucus and ﬂuids may accumulate in the nasal cavities and airways, contrib- uting to asphyxia. This has not been the case in young individuals in whom petechiae are usually absent. It is the discovery of the gag obstructing the airways that makes the diagnosis, not alleged signs of asphyxia. In homicide by smothering, the implements used are usually pillows, bedding, and the hands. The victims tend to be very young, very old, debilitated, or incapacitated by restraints, disease or drugs. The face is not congested and there are no petechiae of the sclerae or conjunctivae (Figure 8. Abrasion injuries of the face will occur only if the victim puts up a vigorous resistance. In a review of 15 smothering deaths involving children below the age of 2 years, of the 13 who could be evaluated for the presence of petechiae, only one had ﬁndings. This child had a single petechia of the conjunctiva and a single area of scleral hemorrhage. Because of the circumstances of this case, there was the possibility that the child might also have been choked. The nose is pinched off with one hand, while the other hand is used to push the jaw closed. In infants and adults unable to put up any effective resistance, an autopsy will fail to disclose any injury due to this process. In adults, even those who can muster only a minimal struggle, there may be abrasions on the nose or chin from the ﬁn- gernails, and contusions of the lips from pressure of the palm (Figure 8. Violent struggles with increased utilization of oxygen can speed up this sequence of events, just as natural disease could make the individual more susceptible to the effects of hypoxia. Natural deaths are seen in individuals with acute fulminating epiglottitis, where there is obstruction of the airway by the inﬂamed epiglottis and adjacent soft tissue. Such individuals represent medical emergencies and can die literally in front of a physician. The individual develops a sore throat, hoarseness, respiratory difﬁculty, inability to speak and then suddenly collapses as the airway is completely obstructed.
Tertiary syphilis discount propecia 1 mg with amex hair loss stages, now a rare disease in the developed world cheap propecia 1 mg on line hair loss 7 keto, can cause aortitis buy genuine propecia online hair loss solutions, that is, inflammation of the aortic adventitia, weakening of the walls, and subsequent development of descending aortic aneurysms and dissections. Rarely, other systemic arteritides, such as giant cell arteritis, can also cause aneurysm formation in the ascending aorta. An aortic dissection flap on echocardiography appears as a linear or thin serpiginous tissue plane extending parallel (in the long-axis plane) (Fig. An acute, unthrombosed flap will undulate independently and usually bulge outward from the true lumen in pulsatile fashion during systole. These characteristics can be demonstrated by M-mode and can be used to distinguish true disease from reverberation artifact. If color Doppler is used to sweep along the flap, one may occasionally be able to identify the site of the primary tear as a communication between the false and true lumen (Video 14. The false lumen may be seen to contain more spontaneous echocardiographic contrast or even formed thrombus. By color and spectral Doppler, forward flow in systole can also help identify the true lumen (Fig. C, M-mode illustrating systolic pulsation of the dissection flap (arrow) outward from the true aortic lumen. D, Low-velocity spectral Doppler flow without clear cyclic variation in the false lumen. Aortic transection occurs as a result of severe deceleration injury and consists of complete shearing of the aorta at the isthmus, with the severed ends of the aorta floating freely within hematoma. Aortic intramural hematoma is an accumulation of blood that remains contained within the aortic media; it accounts for approximately 5% to 20% of acute aortic syndromes (see Fig. On echocardiography, intramural hematoma appears as a smooth, homogeneously echogenic bulge within the medial layer of aortic wall. It is hypothesized to arise from rupture of a penetrating atherosclerotic ulcer, spontaneous rupture of the vasa vasorum, or more frequently, blunt trauma. Intramural hematomas are distinguished from the typically focal, echobright, and irregular plaque in that they lie within the aortic wall and extend smoothly and longitudinally along the aorta. On cross-sectional views the hematoma appears as a crescentic or circular area of homogeneous thickening around the central aortic lumen. Unlike dissection, the intimal layer is still intact and is not mobilized, so there is no detectable intimal tear and no blood flow communication with the aortic lumen. Intramural hematomas can arise in either ascending or descending locations and may enlarge or progress to frank aortic dissection and may have similar mortality rates. Thus the principles of medical and surgical management are essentially the 72 same as for typical aortic dissections. Pulmonary Embolism Echocardiography can be extremely useful in the diagnosis and management of acute pulmonary embolism (see Chapter 84). Echocardiography performed for other indications, including dyspnea, chest pain, and hypotension, also occasionally leads to the incidental discovery of pulmonary embolus. Thrombi that result in pulmonary embolism generally arise from the deep venous system in the legs; echocardiography can be used to directly visualize thrombus anywhere from the vena cava to the pulmonary arteries (Fig. The pulmonary artery bifurcation should be carefully assessed from the short-axis views in patients with suspected pulmonary embolism, and it is not uncommon for so-called saddle emboli to become lodged at the bifurcation (Fig. Putative thrombi need to be distinguished from other cardiac masses, including myxomas, fibroelastomas, and vegetations (see later, Cardiac Masses). In these patients, pulmonary pressure will ultimately rise, and the right ventricle may not show evidence of dilation or dysfunction in acute pulmonary embolism. Infective Endocarditis Echocardiography is the first-line modality for the detection, evaluation, and management of endocarditis (see Chapter 73). Infective endocarditis is definitively diagnosed by culture or pathologic examination of a vegetation (in situ or embolized) or intracardiac abscess. However, many cases are diagnosed on clinical grounds by using the modified Duke criteria as a guideline. The first criterion is positive blood cultures consistent with infective endocarditis. The second major criterion is an echocardiogram demonstrating (1) a vegetation (Fig. The suboptimal sensitivity often results from physical imaging factors causing poor image quality and acoustic shadowing and also depends on the size of the vegetation. An additional vegetation (orange arrow) in the superior vena cava associated with a previous indwelling catheter is noted, and the eustachian valve was also infected in this patient with a history of intravenous drug abuse. Vegetations appear as discrete echogenic masses that are adherent to but distinct from the leaflet itself. Characteristics of vegetations that aid in distinguishing them from other masses include localization, texture, motion, shape, and associated abnormalities. Vegetations are typically located on the upstream, or low-pressure, side of the valve, in the path of any regurgitant bloodstream (i. The echodensity of a vegetation is usually similar to that of myocardium, although advanced vegetations can be inhomogeneous, with findings indicative of liquefaction (which is echolucent) or calcification (which is echodense or bright). Large vegetations can prolapse into the upstream chamber and create a “ball-and-chain” effect that causes leaflet flail and regurgitation. Vegetations vary tremendously in shape but often appear as compact multilobulated or pedunculated, amorphous, and friable agglomerations compared with tumor tissue or thrombus. The vegetation can extend some distance from the valve to which it is tethered and may occur in multiples on the same or different valves. Associated abnormalities such as regurgitation, abscesses, and intracardiac channels can accompany advanced endocarditis. There are no distinguishing characteristics that are organism specific, although staphylococcal infections (particularly methicillin-resistant Staphylococcus aureus and S. Vegetations devoid of microorganisms are the hallmark of noninfectious endocarditis, also called “nonbacterial thrombotic” or “nonbacterial marantic” endocarditis (see Chapter 73). The typical lesions are small (1 to 5 mm), verrucous, nondestructive nodules that adhere to the upstream side of the valve (typically mitral or aortic) along the line of closure and contain only cellular and fibrin elements. These also occur in patients with advanced neoplasms, sepsis, and prothrombotic tendencies in association with 78 clinical features indistinguishable from those of typical infective endocarditis (see later, Systemic Diseases and Echocardiography). Of note, the presence of preexisting thickening and degenerative changes in leaflets can render the diagnosis challenging. On occasion, myxomatous leaflets, ruptured chordae, calcified structures, and fibrin strands can either mask or mimic a vegetation. In these circumstances, clinical correlation with other Duke diagnostic criteria is important. Comparison with previous echocardiograms should also be undertaken; a stable finding over years is unlikely to represent a vegetation. Among patients with endocarditis, 66% to 75% have risk factors for infection, and echocardiography should be used to scrutinize the relevant structures at risk especially carefully. Patients with prosthetic valves, complex cyanotic congenital heart disease, surgical systemic-pulmonary shunts, bicuspid aortic valves, rheumatic heart disease, or mitral valve prolapse are at higher risk. Echocardiographic characteristics associated with a poorer prognosis and embolization include vegetation size greater than 1. The natural history of vegetations after medical therapy is of interest because most will still be apparent on follow-up echocardiography in 1 to 2 months, even after successful medical treatment.
Sedation or general anesthesia should be offered to supplement the regional technique propecia 1mg with visa endometriosis hair loss cure. Lumbar epidural block (initial dose of 10–15 mL 2% lidocaine with epinephrine 1:200 cheap 1 mg propecia amex hair loss cure found,000 buy generic propecia 5mg online hair loss 8 year old, administered over 10 min) has the advantage of slow onset, allowing time to treat the induced cardiovascular changes. For patients with a high opioid tolerance, the use of a continuous epidural anesthetic (for either hip replacement or knee replacement) should be considered. In an effort to reduce adverse events associated with perioperative opioid consumption, there is emerging interest from the orthopaedic community in eliminating the routine use of opioids in spinal anesthetics. In elderly patients, the fracture occurs through osteoporotic bone in the femoral neck, intertrochanteric, or subtrochanteric area (Fig. Nondisplaced or minimally displaced femoral neck fractures are usually treated by closed reduction and percutaneous pinning of the fracture. Elderly patients frequently have numerous medical problems, which means that the fractures require prompt internal fixation/prosthetic replacement to facilitate early mobilization. These are normally much higher energy fractures, often associated with multiple traumas. Moja L, Piatti A, Pecoraro V, et al: Timing matters in hip fracture surgery: patients operated within 48 hours have better outcomes. It is indicated for virtually any fracture, from the lesser trochanter to the distal femur, within 7 cm of the articular surface. The procedure also is used for the treatment of nonunions and malunions of the femoral shaft. There are, however, indications in which the nail is inserted in a retrograde fashion from distal to proximal (e. Early fixation of femoral shaft fractures in severe polytrauma has several benefits. The advantages of early fixation of long bones include improved pain control, early mobilization, improved pulmonary function, and decreased morbidity and mortality. This situation may be exacerbated in the polytrauma patient with pulmonary injury and may produce posttraumatic pulmonary failure. Hemorrhage up to 1 L may be contained in the thigh following a femur fracture; therefore, patients may be hypovolemic at the start of the procedure. Because the procedure is essentially percutaneous, apparent blood loss may be underestimated because of the hemorrhaged blood contained in the thigh. The patient is placed in the supine or lateral decubitus position on either a radiolucent table or a fracture table. Ante-grade insertion of the nail requires a lateral incision several cm in length proximal to the greater trochanter. The hip abductors are split, and portal into the femoral canal is created in the piriformis fossa. The intramedullary nail is then inserted into the intramedullary canal with gentle taps, using a hammer. Retrograde insertion of the nail is performed through an incision several cm long over the anterior aspect of the knee. The knee joint is entered and the portal to the intramedullary canal is made in the non-weight-bearing portion of the intercondylar notch. Variant procedure or approaches: The application of femoral nailing has been expanded to treat nonunions, malunions, posttraumatic deformities of the femur, and leg-length differences. Specialized additional equipment, such as an intramedullary saw or an external fixator, may be required for these procedures. In young patients (< 50 yr) in whom early osteoarthritis of the hip spares some of the cartilage, the hip may be realigned with proximal femoral osteotomy. This entails cutting the bone at the level of the lesser trochanter, realigning the hip, and stabilizing the osteotomy with internal fixation. The pins for the external fixator are inserted percutaneously or through small incisions. Suggested Viewing Links are available online to the following videos: Hip Fractures, Types and Fixation – Everything you Need to Know – Dr. The femur, patella, and tibia are exposed; cartilage and minimal bone are excised with a saw. Alternatively, arthroplasty may be performed on only one compartment of the knee (i. In revision procedures, one or more components of the old joint are removed, and new components are placed. In resection or excision arthroplasty of the knee (usually for infection of the prosthesis), the components are removed, but not replaced. Ganapathy S: Wound/intra-articular infiltration or peripheral nerve blocks for orthopedic joint surgery: efficacy and safety issues. Kuper M, Rosenstein A: Infection prevention in total knee and total hip arthroplasties. Through a midline incision and anterior or median parapatellar arthrotomy, the cartilage surface and a small amount of bone are excised. The bones are stabilized with plates, screws, an intramedullary rod, or an external fixator. Because this is generally an intraarticular fracture, the fragments should be reduced precisely. Part or all of the patella may be excised; pins, wires, and/or screws are normally used to fix the patellar fragments together internally. Cruciate tears are generally repaired only if bone is avulsed at one end of the ligament, again with direct suture, staples, or screws. For collateral ligament repair, a longitudinal incision is made directly over the ligament medially or laterally. The torn ligament is repaired by direct suture or by fixing it to bone with a screw or staple. Cruciate ligament reconstruction is performed for instability 2° intrasubstance tears of these ligaments. Homografts, such as a portion of the patellar tendon or semitendinosus tendon, normally are used, but allografts or synthetics also are available. Dwyer T, Whelan D: Anatomical considerations in multiligament knee injury and surgery. Siegel L, Vandenakker-Albanese C, Siegel D: Anterior cruciate ligament injuries: anatomy, physiology, biomechanics, and management. Soft-tissue components of the surgery include incision (release) of the lateral patellar retinaculum and reefing or tightening of the medial retinaculum (Fig. In cases of severe malalignment of the extensor mechanism, the insertion of the patellar tendon may be moved to a new, more medial location (tibial tubercle transfer). In this procedure, the tibial tubercle generally is detached with a saw or osteotomes, leaving a bone pedicle attached distally. The tubercle is then rotated medially on the pedicle and fixed in its new position with a screw. Many surgeons routinely perform an anterior compartment fasciotomy to prevent postop compartment syndrome. In knee arthroscopy, multiple portals or entry points for the arthroscope and instruments generally are used.