Forensic Medicine and Toxicology(FMT) - AIM4PG

EFFACEMENT OR OBLITERATION OF IDENTITY: The identity of a dead body may be destroyed by the following methods. (l) Purposive removal of the identifying features, e.g, fingerprints, tattoo marks, scars, moles, teeth, hair, etc. and articles of clothing. (2) Animals, e.g., rats, dogs, jackals and hyenas and birds, such as vultures may attack a dead body and mutilate it in a very short time, when the body is exposed in an open place. (3) Burning or incineration. (4) Advanced putrefaction. (5) Dismemberment and burying or throwing different parts in different places. (6) Chemical destruction of the body in corrosive acids or alkalis. Alkaline hydrolysis uses lye, 150°C heat and 60 pounds of pressure a square inch to destroy bodies in big stainless steel cylinders that are similar to pressure cookers. The process leaves a dry bone residue similar in appearance and volume to cremated remains. (7) Dismemberment by moving vehicles, like trains or by machinery. (8) Bomb explosions. which may disintegrate the body.

EFFACEMENT OR OBLITERATION OF IDENTITY: The identity of a dead body may be destroyed by the following methods. (l) Purposive removal of the identifying features, e.g, fingerprints, tattoo marks, scars, moles, teeth, hair, etc. and articles of clothing. (2) Animals, e.g., rats, dogs, jackals and hyenas and birds, such as vultures may attack a dead body and mutilate it in a very short time, when the body is exposed in an open place. (3) Burning or incineration. (4) Advanced putrefaction. (5) Dismemberment and burying or throwing different parts in different places. (6) Chemical destruction of the body in corrosive acids or alkalis. Alkaline hydrolysis uses lye, 150°C heat and 60 pounds of pressure a square inch to destroy bodies in big stainless steel cylinders that are similar to pressure cookers. The process leaves a dry bone residue similar in appearance and volume to cremated remains. (7) Dismemberment by moving vehicles, like trains or by machinery. (8) Bomb explosions. which may disintegrate the body.

NATIONAL HUMAN RIGHTS COMMISSION'S RECOMMENDATIONS ON AUTOPSY: The following is the brief account of the procedure to be carried out. The doctors who have access to the scene of death should: (1) Photograph the body. (2) Record body position. (3) Determine time of death. (4) Protect deceased's hands with paper bags. (5) Examine the scene for blood. (5) Obtain information from scene witnesses, friends or relatives, hospital records, etc. (6) Place the body in a body pouch. (7) Become familiar with the types of torture or violence Autopsy: (1) Record the names of all persons present during autopsy. (2) One doctor should be designated as principal prosector. (3) Photograph full frontal aspect and right and left profiles of the face. ( 4) Colour photographs should be comprehensive in scope and must confirm the presence of all demonstrable signs of injury or disease. (5) Radiograph the body. (6) Obtain dental X-rays. (7) Examine clothing and photograph. (8) Photograph 100% of body area. (9) Determine the time of death. (10) Photograph all injuries. (11) Photograph scars, keloids, moles, etc. (12) Identify and label any foreign object that is recovered. (13) The length of the back, the buttocks and extremities, including wrists and ankles must be systematically incised to look for deep injuries. The shoulders, elbows, hips and knee joints must also be incised to look for ligamentous inury. (14) Conduct a thorough and complete autopsy. (15) Take colour photographs of all injuries and abnormalities, found during internal examination. (17) Send viscera for chemical examination. Preserve all foreign objects, all clothes and personal ects. finger nails and nail scrapings; foreign and pubic in cases of sexual assault. (19) At the end of the autopsy report should be a summary of the frndings and cause of death. By: Dr Nayana For more notes join www.aim4pg.com/study-group

AGONAL THROMBI: In case of a person dying slowly with circulatory failure, a firm, stringy, tough, pale-yellow thrombus forms in the cavities, usually on the right side of the heart. The process may begin in the atrial appendage, in the apex of the ventricle or in the angles of the ventricular surfaces of tricuspid valve. It extends and fills the right auricle and ventricle and spreads into the pulmonary artery and its branches like a tree-like cast. In the left ventricle, agonal thrombi are not so big. POSTMORTEM CLOTS: Two types are seen: (1) when blood clots rapidly, a soft, lumpy, uniformly dark-red, slippery, moist clot is produced ("red currant- jelly"). (2) When red cells sediment before blood coagulates, the red cells produce a clot similar to the first type. Above this, a pale or bright-yellow layer of serum and fibrin is seen ("chicken-fat"). The fibrin clot may be soft or jelly-like, but is elastic, when the amount of fibrin is greater. Usually, a mixture of the two types of clot is seen. Postmortem clots are moist, smooth, shiny, rubbery, homogeneous, loosely or not at all attached to the underlying wall, and there are no fme white lines of fibrin (striae of Zahn). Postmortem fibrinous clots in heart are known as cardiac polyps. By: Dr Nayana For more notes join www.aim4pg.com/study-group

Scars Characteristics:- Scars may indicate the type of injury which produced them. ( 1) Incised wounds produce linear scars. If healing is secondary, the scar is wider and thicker in the centre than in the periphery. (2) Scars from lacerated wounds, and from wounds which have suppurated are firmer, irregular, more prominent, and are adherent to the deeper tissues. (3) Stab wound due to a knife-blade produces oval, elliptical. triangular, or irregular scars which are depressed but may be elevated due to keloid formation. (4) A bullet wound causes a circular depressed scar. (5) Scars from scalds are spotted in appearance. tend to be continuous, often run downwards and show evidence of splashing about the main injury. (6) Scars clue to corrosive acids. burns or radiation, cause irregular scars, and keloid may develop in the scar tissue, especially in Negroes. (7) Vaccination scars are circular or oval, flat or slightly depressed. (8) Many skin diseases, smallpox. syphilis, etc., cause multiple scars on the skin. Erasure : The scar can be erased by excision and skin grafting, or suture of the edges of the excised area. This results in a scar which is less clearly seen. Medicolegal Importance : (1) They form important marks for identification of a person. (2) The shape of the scar may indicate the nature of weapon or agent that caused the injury. (3) The age of the scar is important in a criminal offence. If the age of a wound corresponds with the elate of the attack it may have value as circumstantial evidence. (4) Linea albicantes may indicate previous pregnancy. (5) If a person is disfigured clue to scars, it becomes a grievous hurt. (6) Scar causing contracture at or around a joint restricting movement or functions of the joint becomes grievous hurt. (7) The accused may attribute scars of wounds to disease or therapeutic procedures. (8) Scar of various operative procedures also help in identification. (9) To charge an enemy with assault, a person may claim that scars clue to disease are those of wounds. By: Dr Nayana For more notes join www.aim4pg.com/study-group

SYNCOPE: Syncope is sudden stoppage of action of the heart, which may prove fatal. This term is also not used as a cuase of death. Syncope or fainting is due to vasovagal attacks resulting from reflex parasympathetic stimulation. Syncope is caused by reflex bradycardia or asystole, or by reflex splanchnic vasodilation. Due to the acute reflex circulatory changes, blood pressure falls suddenly causing cerebral anaemia and rapid unconsciousness. Recovery is common. CAUSES: (1) Anaemia due to sudden and excessive haemorrhage. (2) Asthenia from deficient power of heart muscle as in fatty degeneration of the heart, myocardial infarction and certain poisons (3) Vagal inhibition. (4) Exhausting diseases. AUTOPSY: The heart is contracted and the chambers are empty when death has occurred from anaemia, but chambers contain blood when death occurs due to asthenia. The lungs, brain and abdominal organs are usually pale. Splanchnic pooling of blood occurs. By: Dr Nayana For more notes join www.aim4pg.com/study-group

COMA: It is a state ofunarousable unconsciousness determined by the absence of any psychologically understandable response to external stimuli or inner need. It involves the central portion of the brain stem. Coma is a clinical symptom and not a cause of death. CAUSES: (1) Compression of the brain, e.g., effusion of blood on or in the brain, inflammation, abscess or neoplasm of brain. (2) Drugs; opium, hypnotics, cocaine, alcohol, anaesthetics, cyanide, atropine, phenol, oxalic acid, CO, etc. (3) Metabolic disorders and infections: uraemia, cholaemia, eclampsia, diabetes, pneumonia, infectious fevers, heat stroke, etc. (4) Other causes: embolism and thrombosis in the cerebral vessels, epilepsy, hysteria, etc. AUTOPSY: Injuries or disease of the brain may be present as noted in the causes of coma. The lungs, brain and the meninges are congested. Splanchnic pooling of blood occurs. By Dr Nayana For more notes join www.aim4pg.com/study-group

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Diagnosis of Brainstem Death: Exclusions: (1) Where the patient may be under the effects of drugs, e.g. therapeutic drugs or overdoses. (2) Where the core temperature of the body is below 35°C. (3) Where the patient is suffering from severe metabolic or endocline disturbances which may lead to severe but reversible coma, e.g. diabetes. Preconditions of diagnosis: (i) Patient must be deeply comatose. (ii) Patient must be maintained on a ventilator. (iii) Cause of the coma must be known. Personnel who should perform the tests: (1) Brainstem death tests must be performed by two medical practitioners. (2) Doctors involved. should be experts in this field. Under no circumstances are brainstem death tests performed by transplant surgeons. (3) At least one of the doctors should be of consultant status. Junior doctors are not permitted to perform these tests. (4) Each doctor should perform the tests twice.

CRITERIA FOR DETERMINING BRAIN DEATH: Harvard Criteria: (1) Unreceptivity and unresponsivity: Total unawareness to externally applied stimuli and inner need and complete unresponsiveness to even the most intense painful stimuli. (2) No movements: No spontaneous muscular moverments in response to stimuli such as pain. touch, sound or light for a period of at least one hour. (3) Apnoea: Absence of spontaneous breathing for at least one hour and when patient is on ventilator, the total absence of spontaneous breathing may be established by turning off the respirator for 3 minutes and observing whether there is any effort on the part of the subject to breathe spontaneously. (4) Absence of elicitable reflexes: Irreversible coma with abolition of central nervous system activity is evidenced in part by the absence of elicitable reflexes. The pupils are fixed and dilated and do not respond to a direct source of bright light. Ocular movement and blinking are absent. There is no evidence of postural activity. Corneal and pharyngeal reflexes are also absent. Stretch tendon reflexes also cannot be elicited. (5) IsoelectricEEG: It has confirmatory value. By: Dr Nayana For more notes join www.aim4pg.com/study-group

CRITERIA FOR DETERMINING BRAIN DEATH: MINNESOTA CRITERIA (1971): The criteria for brainstem death was formulated by Mohan Dass and Chou as follows: (1) Known but irreparable intracranial lesion. (2) No spontaneous movement. (3) Apnoea when tested for a period of 4 minutes at a time. (4) Absence of brainstem reflexes: (a) dilated and fixed pupils, (b) absent corneal reflexes, (c) absent Doll's head phenomenon, (d) absent ciliospinal reflexes, (e) absent gag reflex, (f) absent vestibular response to caloric stimulation, (g) absent tonic neck reflex, (5) EEG not mandatory. (6) Spinal reflex not important. (7) All the findings above remain unchanged for at least 12 hours. Brainstem death can be pronounced only if the pathological process responsible for states (1) to ( 4) above are deemed irreparable with presently available means.

CRITERIA FOR DETERMINING BRAIN DEATH: PHILADELPHIA PROTOCOL (1969): (1) It detennined death on the basis of Lack of responsiveness to internal and external environment. (2) Absence of spontaneous breathing movements for 3 minutes, in the absence of hypocarbia and while breathing room air. (3) No muscular movements with generalised flaccidity and no evidence of postural activity or shivering. (4) Reflexes and responses: (a) Pupils fixed, dilated, and nonreactive to strong stimuli. (b) Absence of corneal reflexes. (c) Supraorbital or other pressure responses absent (both pain response and decerebrate posturing). (d) Absence of snouting and sucking responses. (e) No reflex response to upper and lower airway stimulation. (f) No ocular response to ice-water stimulation of inner ear. (g) No superficial and deep tendon reflexes. (h) No plantar responses. (5) Falling arterial pressure without support by drugs or other means. (6) lsoelectric EEG {in the absence of hypothermia, anaesthetic deaths, and drug intoxication) recorded spontaneously and during auditory and tactile stimulation. These criteria shall have been present for at least 2 hours and two physicians other than the physician of a potential organ recipient should certify death. As the protocol insists on a two hour delay, this precludes the use of any organs for transplantation.

VIRTUAL AUTOPSY (VIRTOPSY): It is a non-invasive technique of examining dead bodies to find out the cause of death. It does not destroy some important evidence which may be destroyed in the usual autopsy. It is a combination of CT and MR imaging. CT images give information about morbid anatomical findings and MR imaging demonstrates soft tissue injury, organ trauma, state of blood vessels, tissue and bones. MR spectroscopy measures metabolites formed due to decomposition, which help to estimate time since death. Two dimensional and three dimensional imaging is done with multi slice CT. Emphysema, air embolism, pneumothorax, hyperbaric trauma and decompression effects can be better appreciated. When an injury is caused by a weapon, using a computer software, virtual model of an injury with the 30 image of a simulation can be created by using a similar weapon. In a firearm injury entrance and exit wounds can be determined based on fracture pattern with inward and outward bevelling of the bone. The track of the projectile inside the brain or other internal organs with haemorrhage and damage to tissues can be viewed with CT scanning.

Medicolegal Importance of Hair (1) Hair is important in crime investigation, for it remains identifiable on the clothes, body and the alleged weapons in crimes committed long before. It often provides the only connection between a weapon or even the accused and the victim of an assault. (a) Motor vehicles responsible for injuries may be identified by the detection of hair on the vehicle. (b) In rape and sodomy, the pubic hair of the accused may be found on the victim or vice versa. In bestiality, animal hair may be found on the body or underclothing of the accused, or his pubic hair may be found about the genitals of the animal. (c) Stains on the hair may indicate the nature of the assault, e.g., mud stains in struggle, seminal stains in exual offences, salivary stains in asphyxial deaths, blood stains in injury, etc. Stains may be got from Ihe walls, doors, furniture, etc., and may indicate the cene of crime. (2) Nature of weapon can be made out from the injuries to the hair, and hair bulb. (3) Hair is useful in identification especially when there has been some known peculiarity of the hair, dyeing, bleaching or artificial waving. (4) Age of a person may be determined from the growth of hair on different parts of body. (5) Sex may be determined from their distribution on body, texture and from Barr bodies. (6) Singeing of the hair indicates burns or a close range firearm injury. (7) It is helpful in differentiating scalds from burns. (8) In chronic poisoning with heavy metals, e.g., arsenic, the poison can be detected in the hair. (9) The time of death can sometimes be determined from the length of the hair on the face.

Approach To Nephritic Syndrome By: Dr Richa Aggarwal , MD Internal Medicine Watch Lecture Is Live https://youtu.be/pPqGsJJQd1w Listen To Lecture Podcast https://anchor.fm/aim4pg/episodes/Approach-To-Nephritic-Syndrome-e1bu5rp Download Lecture Pdf www.aim4pg.com/pdf More Lectures Of Faculty Coming Soon Stay Tuned

A doctor is not liable : (I) For an error of judgement or of diagnosis, if he has acted with ordinary care and secured all necessary data on which to base a sound judgement. For the treatment of a disease or injury, the doctor may adopt the one which in his judgement, will be more effective and appropriate. In such case, the doctor is not liable for an injury resulting from an error in his judgement. (2) For failure to cure or for bad result that may follow, if he has exercised reasonable care and skill. (3) If he exercises reasonable care and skill, provided that his judgement conforms to the accepted medical practice, and does not result in the failure to do something or doing something contrary to accepted medical practice. No doctor ensures success either in his diagnosis or in his treatment. There is always room for a difference of opinion among doctors. Bad results are not necessarily due to negligence, e.g. some patients may be keloid formers. The Law considers the doctor negligent only when (1) he did not consider the possibility that such a complication might occur, (2) that he failed to watch for it carefully or to recognise it promptly, or (3) to treat in a timely and appropriate fashion.

Cocaine Magnan's symptom or cocaine bugs is characteristic, in which there is a feeling as if grains of sand are lying under the skin or some small insects are creeping on the skin giving rise to itching sensation (formication, tactile hallucination) with resultant excoriation, leading to irregular scratches and ulcers Sometimes a manic, paranoid or depressive psychosis develops (cocaine psychosis or excited delirium). Cocaine Habit: It is also known as cocainism, cocainophagia or cocainomania. Chronic abusers can tolerate ten grams a day. It causes digestive disturbances, anorexia, salivation, tachycardia, tachyapnoea and insomnia. The face is pale, eyes sunken, pupils dilated, and the gaze 'shifty'. The tongue and teeth are black.

INFORMED CONSENT : Informed consent implies an understanding by the patient of (1) the nature of his condition, (2) the nature of the proposed treatment or procedure, (3) expectations of the recommended treatment and the likelihood of success, ( 4) the details of the alternative courses of treatment that are available, (5) the risks and benefits involved in both the proposed and alternative procedure, (6) the potential risks of not receiving treatment, and the relative chances of success or failure of both procedures, (7) particular known inherent risks that are material to the informed dicision, so that he may accept or reject the procedure. All disclosures must be in language the patient can understand. Physicians have a legal, moral and ethical duty to provide all relevant information that enables a patient to either accept or reject treatment. This disclosure will very much reduce litigation, when the results are unsatisfactory or unexpected. The patient must show that the doctor did not adhere to accepted medical standards to prove liability for lack of informed consent. Exceptions to informed consent: (1) Emergency. (2) Therapeutic privilege. (3) When a patient waives his right to informed consent and delegates the right to the doctor or a close relative. Informed Refusal : The physician has a duty to disclose adequately and appropriately to the patient, the risks or possible consequences of refusal to undergo a test or treatment. After understanding all the facts, the patient can refuse to submit to treatment or an operation. Examination may reveal findings which when used in the process of investigation can damage the party examined. If later on the party is proved to be innocent, the damage sustained cannot be undone. This is why the right to deny consent to examination is generally given to the party. For Daily Subject Wise Notes Join www.aim4pg.com/study-group

FORMED CONSENT : Informed consent implies an understanding by the patient of (1) the nature of his condition, (2) the nature of the proposed treatment or procedure, (3) expectations of the recommended treatment and the likelihood of success, ( 4) the details of the alternative courses of treatment that are available, (5) the risks and benefits involved in both the proposed and alternative procedure, (6) the potential risks of not receiving treatment, and the relative chances of success or failure of both procedures, (7) particular known inherent risks that are material to the informed dicision, so that he may accept or reject the procedure. All disclosures must be in language the patient can understand. Physicians have a legal, moral and ethical duty to provide all relevant information that enables a patient to either accept or reject treatment. This disclosure will very much reduce litigation, when the results are unsatisfactory or unexpected. The patient must show that the doctor did not adhere to accepted medical standards to prove liability for lack of informed consent. Exceptions to informed consent: (1) Emergency. (2) Therapeutic privilege. (3) When a patient waives his right to informed consent and delegates the right to the doctor or a close relative. Informed Refusal : The physician has a duty to disclose adequately and appropriately to the patient, the risks or possible consequences of refusal to undergo a test or treatment. After understanding all the facts, the patient can refuse to submit to treatment or an operation. Examination may reveal findings which when used in the process of investigation can damage the party examined. If later on the party is proved to be innocent, the damage sustained cannot be undone. This is why the right to deny consent to examination is generally given to the party.

Monk's hood / mitha bish/blue rocket./aconite All parts are poisonous.Root is most poisonous followed by seed. It has sweet taste ,that's y it's called mitha bish. CLINICAL FEATURES -CVS:- cardiac block, hypertension,arrhythmias,Av block,chest pain, initially theres tachycardia followed by bradycardia. -GIT:-hypersalivation,nausea ,vomiting and diarrhea -CNS:- Aconite initially stimulates CNS and then depresses CNS.Headache,giddiness ,ataxia ,slurred speech ,diplopia and convulsions . -Muscular system:- muscle weakness with twitching ,darting pains,cramps and convulsions. Death may be because of cardiac cause or respiratory cause. Treatment:- 1. Gastric lavage with warm water and weak solution of iodine in potassium iodide or tannic acid to precipitate alkoloids. 2. Atropine is antidote,used to treat bradycardia. 3. Activated charcoal