All about asphyxia in forensic medicine.1.pptx

All about asphyxia in forensic medicine.

1. Asphyxia Dr.M Qadeer Naqvi

2. ASPHYXIA It is a condition in which oxygen supply to the blood and tissues is reduced because of interference with respiration. It can lead to Anoxia\Anoxaemia\Hypoxia.

3. Causes of asphyxia Obstruction to the air passages due to hanging,strangulation or throttling. Occlusion of the air passages as in drowning or laryngeal spasm. Pressure on the chest,as in traumatic asphyxia Inhalation of irrespirable gases like carbon monoxide. Spasm of the respiratory muscles,as in strychnine poisoning. Paralysis of the respiratory center,as by narcotics and anesthetics. Obstruction to the upper respiratory passage in cases of angioneurotic oedema.

4. Features of asphyxia Cyanosis,capillary dilatation,capillary stasis,rise of capillary pressure. Increased capillary permeability

5. Mechanical asphyxial deaths or Violent asphyxial deaths Hanging Strangulation Suffocation D rowning

6. Hanging 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).

7. Types Complete hanging. Partial hanging. Typical hanging. Atypical hanging.

8. Complete hanging When feet do not touch the ground and the weight of the body acts as a constricting force. Partial hanging When the weight of the head and not the whole body acts as a constricting force is known as partial hanging.

9. Typical hanging The ligature is situated in the midline above the thyroid cartilage and runs symmetrically upwards on both sides of the neck to the occipital region. Atypical hanging Any variation of this standard position.

10. Symptoms So rapid that they are rarely observed. Flashes of lights before the eyes,ringing in the ears. Unconsciousness and death. Respiration stops before the heart which may continue for 10-15min.

11. Causes of death Asphyxia Ligature forces the tongue up and occludes air,15kg tension occludes the trachea. Cerebral congestion Obstruction of jugular veins by compression with 2kg wt tension.

12. Cerebral anoxia Carotid artery occludes with 4-5kgs tension and vertebral artery with 20kgs tension. Reflex vagal inhibition. Fracture dislocation of cervical spine at the level of 2,3,and 4 vertebrae. Combination of any of the above.

13. Diagnosis Ligature mark around the neck. Presence of abrasions,echymosis and redness around the ligature mark. Trickling saliva from the mouth. Echymosis of larynx and trachea. Rupture of intima of carotids. Signs of asphyxia.

14. Medico-Legal Aspects Was the death due to hanging? Whether hanging was suicidal,homicidal or accidental? Typical oblique,non-continuous,high up ligature mark. Abrasions and echymosis above and below the ligature mark. Extravasation-tear of the intima of the carotids. Saliva and signs of asphyxia.

15. Suicidal Usually full suspension. Ligature tied to beam,hook,fan,tree etc. Suspension without any platform is unusual in suicide. Occasional nail mark-may be self inflicted while trying to free him\herself. Suicidal note.

16. Homicidal Extremely rare,except in case of lynching. Difficult,unless the victim is unconscious by injury or by drugs. Marks of violence may be seen on the body.

17. Postmortem hanging\Suspension Person murdered and the dead body suspended to simulate suicide. Usually the rope is tied first to the neck and then around the beam\hook. Ligature mark may be produced if the body is suspended within 2hrs after death.

18. Judicial hanging Drop of 5-7meters. Fracture dislocation at cervical 2-3 or 3-4. Transection of spinal cord. Tear of intima of carotid artery. Injury to pons and medulla

19. Causes of death Asphyxia Anoxia Congestion Vagal inhibition Combination of any of the above

20. Homicide Common form of murder-associated with sexual offences. Infanticide-by strangulation with umbilical cord. Evidence of struggle,surprise attack,under intoxication,weak personality.

21. Strangulation 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.

22. CLASSIFICATION OF STRANGULATION Manual strangulation or throttling : When human fingers, palms or hands are used to compress the neck.

23. CLASSIFICATION OF STRANGULATION Ligature 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. 

24. CLASSIFICATION OF STRANGULATION Mugging: Strangulation caused by holding the neck of the victim in the bend of elbow (i.e. the ‘sleeper hold’) or knee of the assailant.

25. CLASSIFICATION OF STRANGULATION Garroting: 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.

26. Common methods of Homicidal strangulation Throttling Compression of neck by hands. Bruises produced by tips of fingers. More force is used than is necessary. Marks of thumb on one side and fingers on other side. Pressure of nails produce crescentic marks with or without incision. Hyoid bone fracture and bruising can be seen with careful neck dissection.

27. Accidental strangulation Children may get entangled during play. Infants are strangled in their cots,when the neck is caught in sidebars. Alcoholics,epileptics and insane persons are susceptible for accidental strangulation.

28. ASPHYXIAL CONDITIONS-DEFINITIONS Suffocation 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. It can also caused by lack of oxygen in the environment or

29. CLASSIFICATION OF SUFFOCATION Smothering is caused by mechanical occlusion of external air passages from outside, i.e. the nose and mouth by hand, cloth, pillow, plastic bag or other material

30. CLASSIFICATION OF SUFFOCATION Choking is caused by an obstruction within the trachea, either partially or completely, from inside by a foreign body, like coin, fruit seed, toffees, candies, fish or any other material.

31. CLASSIFICATION OF SUFFOCATION Gagging results from pushing a gag (rolled up cloth or paper balls) into the mouth, sufficiently deep to block the pharynx. It combines the features of smothering and choking.

32. CLASSIFICATION OF SUFFOCATION Overlaying results from compression of the chest, nose and mouth, so as to prevent breathing.

33. CLASSIFICATION OF SUFFOCATION Traumatic asphyxia results from respiratory arrest due to mechanical fixation of chest, so that the normal movements of chest wall are prevented.

34. CLASSIFICATION OF SUFFOCATION Confined space entrapment occurs when there is inadequate oxygen in the enclosed space due to consumption or displacement by other gases.

35. CLASSIFICATION OF SUFFOCATION Burking is a combination of homicidal smothering and traumatic asphyxia.

36. Café coronary Impaction of food in the larynx causes sudden death Healthy intoxicated person in hotel while eating suddenly turns blue,coughs violently-collapses and dies. At autopsy a large food bolus seen in the respiratory tract-larynx obstructing air passage. Post-mortem appearance-the foreign body is embedded in a thick mucus in the trachea.

37. Traumatic asphyxia Its due to respiratory arrest due to mechanical fixation of chest so that the respiratory movements are prevented. E.g.:Stampede in a theatre or in places where crowded gatherings are there.Fall of earth-coal mines,tunneling accidents etc. Post-mortem appearances An intense deep purple red colour of the head,neck and upper part of chest above the level of constriction.

38. 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.

39. 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.

40. 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.

41. 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 by cotton cloth entangled in the rotor of a machine have been reported. Elderly: Depression can lead to hanging.

42. CAUSES Isadora 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 spoke wheels of her car . She was declared dead in the hospital.

43. PATHOPHYSIOLOGY The proposed mechanisms of the observed features seen in most of the asphyxial conditions (whether by hanging, manual strangulation, application of ligature, or postural asphyxiation (in children whose necks are caught in an object such as a crib) includes the following:

44. PATHOPHYSIOLOGY Venous 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.

45. PATHOPHYSIOLOGY Arterial blockage due to pressure on carotid artery, leading to cerebral anoxia and collapse due to low cerebral blood flow.

46. PATHOPHYSIOLOGY Reflex vagal inhibition caused by pressure to the carotid sinuses and increased parasympathetic tone leading to sudden cardiac arrest (less common)

47. Hyoid bone fracture Inward fracture. Antero-posterior fracture. Avulsion fracture.

48. Inward fracture Seen in throttling-main force is an inward compression on the hyoid bone. Fingers squeeze the greater horns towards each other,due to which the bone may be fractured and post fragments displaced inwards.

49. Antero-posterior compression fracture In case of hanging,the hyoid bone is forced directly backwards due to which,the divergence of greater horns is increased which may fracture with outward displacement of the posterior small fragments. Ligature strangulation,run over accidents.

50. Avulsion fracture Very rare and is due to over activity of neck muscles without direct action or injury to hyoid bone. Incidence - Hanging 15-20% above 40yrs age. Very common in throttling.

51. Drowning Drowning is a form of asphyxial death due to aspiration of fluid into the air passages by submersion of the body in water or fluid medium. Complete submersion not necessary,submersion of nose and mouth is enough.

52. Classification Typical Atypical Typical drowning Obstruction of air passages and lungs by inhalation of fluid and is known as “Wet drowning”. Typical signs are found at autopsy.

53. Atypical drowning Conditions in which there is very little or no inhalation of water or fluid in the air passages. Dry drowning.

54. Vicious cycle of drowning Deep inspiration Need for air Water enters resp.passage Air driven out of lungs Cough reflex

55. SEQUENCE OF EVENTS IN DROWNING 1. SENSE OF PANIC Expressed by: Violent struggle Automatic swimming movements Usually followed by: 2. PERIOD OF VOLUNTARY APNOEA Duration: 1-2 minutes. Hypoxemia, hypercapnia , R & M acidosis.

56. 3. ATTEMPT AT TAKING A BREATH WATER: May be freely inhaled Or, may cause glottic spasm due to impingement. In 10-15 % victims: glottic spasm severe asphyxia water may not enter the lungs unless subcouncious . Dry drowning In 85-90 % victims: water is swallowed inducing vomiting, gasping & aspiration of water into lungs. When expiratory effort is made : fine froth, sometimes blood stained (due to overdistension of liquid coloumn ) Wet drowning

57. 4. Cessation of constant struggling 5. Stage of convulsive spasms, twitching, dilation of pupils 6. Clinical death

58. Freshwater Drowning The Mechanism + Resp Pathophysiology

59. More liquid in the circulation Hemodilution, decrease in Na+, Cl & Ca conc. Liquid/ water goes inside RBCs Hemolysis Release of K+ Increase in K+ conc.

60. Marked Ventilation perfusion mismatch Shift Acute hypervolemia Experimental Vs Reality Increase in K+ irritates myocardium Arrythmias (VF) occurs

61. Effect on CVS Increase in circulatory volume but till plateau. Decrease in blood density Dec in Na, Cl

62. Salt water Drowning Pulling out of water  Hemoconc. Inc. in Na, Cl and Mg No hemolysis, No VF Death within 5-12 minutes (later than freshwater)

63. Pulmonary edema within minutes Shift Hypovolemia Hypertonic liquid Draws water out through mb Into pulmonary alveoli Damage to basement mb + Dilution & washing out of Surfactant compliance decreased

64. Pulmonary edema X ray

65. Effect on CVS CVS effects are secondary to: 1. Changes in arterial oxygen tension 2. Changes in acid base balance. Acute hypoxemia  Catecholamine release Transient tachycardia and hypertension. Followed by bradycardia and hypotension as hypoxemia intensifies. Hypoxemia may directly reduce myocardial contractility Hypoxia + Acidosis:  increase the risk for arrythmias ( VT, VF, Asystole ) Note: VF as an immediate cause of death is uncommon in both forms of human drowning.

66. Effects on Brain Hypoxia  ischemic damage to brain Window period of 4-6 minutes before irreversible neuronal damage.

67. Effects on other organs Acute renal and hepatic insufficiency GI injuries DIC

68. Complications Immediate Complications Cardiac Arrhythmias (VF, Asystole) Cardiogenic Shock Delayed Complications Liquid damages pulmonary ARDS Primary pulmonary edema 2. Cerebral hypoxia Neurogenic pulm edema Hypoxic encephalopathy  Brain death Pneumonia (aspiration, chemical, bacterial) Sepsis Multi Organ failure

69. Medico legal aspects Whether the death was due to drowning or other cause? Length of time the body was in water. Whether it was accidental/suicidal/homicide?

70. Postmortem findings External findings Fine froth at the nose and mouth.its white or rarely blood stained,leather-like,abundant and increases in amount with compression of the chest. Rarely the presence of weeds,mud etc in the tightly clinched hand.

71. MACRO-MORPHOLOGICAL CHANGES 1. FOAM/ FROTH: 1. Mushroom like froth from mouth, nostrils. 2. Foam inside mouth, in upper airways. Drowning liquid+ edema liquid+ fine air bubbles (resistant to collapse) Blood stained: mechanism? 3. External foam: most valuable finding D/D: 1. Cardiogenic PE 2. Epilepsy 3. Drug intoxication 4. Electrical shock

72. Tongue : may be protruded or swollen Cutis Anserina : goose flesh? Reaction Phenomenon ? Weed, grass, gravel in hand : due to cadaveric spasm. Soddening of skin of hands, feet/ shoes.  Wrinkling Bleaching of epidermis in 4-8 hrs  Washerwoman’s hands and feet 24-48 hrs.

73. Comparison of forensic pathology of lungs Trait Fresh water drowning Sea water drowning 1. Size and weight Balloned but light Balloned and heavy; weight upto 2kg 2. Color Pale pink Purplish or bluish 3. Consistency Emphysematous Soft and jelly like 4. Shape after removal from the body Retained but do not collapse Not retained; tend to flatten out 5. Sectioning Crepitus is heard. Little froth and no fluid No crepitus . Copius fluid and froth.

74. Cause of death Asphyxia Ventricular fibrillation Laryngeal spasm. Vagal inhibition. Exhaustion. Injuries. Fatal period 4-8min.

75. Diagnosis of drowning Froth Weeds & gravel/soil in hand. Voluminous lungs. .

76. Asphyxia CLINICAL EFFECTS OF ASPHYXIA Sphincter relaxation Voiding of urine, stools, semen Decreased oxygen tension and reduced Hb Cyanosis Capillary endothelium damage Increased capillary permeability Pulmonary edema Unconsciousness Loss of muscle power Capillary stasis and engorgement Increased intracapillary pressure Capillary rupture Tardieu’s spots

77. Triad of asphyxial stigmata may be seen Cyanosis: Bluish discoloration of skin, face (particularly in the lips, tip of nose, ears lobules), nailbeds and mucous membranes

78. Triad of asphyxial stigmata may be seen Petechial 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.

79. Triad of asphyxial stigmata may be seen Congestion and edema of the face due to raised venous pressure.

80. EVALUATION AND DOCUMENTATION HISTORY In 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.

81. EVALUATION AND DOCUMENTATION Even 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.

82. EVALUATION AND DOCUMENTATION The 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)?

83. EVALUATION AND DOCUMENTATION The 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.

84. EVALUATION AND DOCUMENTATION Hanging victims are more likely to arrive in the emergency department with a depressed level of consciousness than are victims of manual strangulation. This is presumably due to the more intensive and prolonged compressive force applied to the neck due to hanging than is typically seen with manual pressure .

85. CLINICAL PRESENTATION The 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.

86. SIGNS AND SYMPTOMS The clinical presentations can vary according to the method, force and duration of asphyxiation. The following specific clinical manifestations are possible in asphyxiation victims:

87. SIGNS AND SYMPTOMS Dysphonia or hoarseness of voice is commonly seen. Patient may sometimes present with aphonia.

88. SIGNS AND SYMPTOMS Dyspnea 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.

89. SIGNS AND SYMPTOMS Dysphagia 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).

90. SIGNS AND SYMPTOMS Pain 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.

91. SIGNS AND SYMPTOMS Altered mental status : Restlessness, confusion, loss of orientation or combativeness due to cerebral hypoxia or from concomitant intracranial injury or ingestion of drugs or ethanol.

92. SIGNS AND SYMPTOMS Neurologic 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.

93. SIGNS AND SYMPTOMS Petechiae 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.

94. SIGNS AND SYMPTOMS Neck : Injury to the soft tissues in the neck may manifest with abrasions (scratches), hyperemia, ecchymoses 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.

95. SIGNS AND SYMPTOMS Attempted throttling : Fingertips may produce faint oval or round bruises 1.5-2 cm in size (may be more in case of continued bleeding). A grip from right hand produces a bruising due to bulb of pressing thumb over the cornue of hyoid/thyroid on anterolateral surface of right side of victim's neck and several fingertip bruising marks and overlying nail scratch abrasions over left side. A single bruise on the victim’s neck is most frequently caused by the assailant’s thumb as bruises made by tips of thumbs are more prominent than with other fingers.

96. SIGNS AND SYMPTOMS Multiple abrasions on the neck may be defensive in nature from use of victim's own fingernails in an effort to dislodge the assailant's grip but commonly are a combination of lesions caused by both the victim and the assailant’s fingernails.

97. SIGNS AND SYMPTOMS Chin abrasions may also occur from the defensive actions as the victim tries to protect their necks from the manual strangulation of the assailant.

98. SIGNS AND SYMPTOMS Attempted throttling : Fingertips may produce faint oval or round bruises 1.5-2 cm in size (may be more in case of continued bleeding). A grip from right hand produces a bruising due to bulb of pressing thumb over the cornue of hyoid/thyroid on anterolateral surface of right side of victim's neck and several fingertip bruising marks and overlying nail scratch abrasions over left side. A single bruise on the victim’s neck is most frequently caused by the assailant’s thumb as bruises made by tips of thumbs are more prominent than with other fingers.

99. SIGNS AND SYMPTOMS Lungs: Aspiration pneumonitis may occur due to inhalation of vomitus during the episode. Pulmonary edema is a seen generally in comatose hanging victims. The cause of the pulmonary edema can either be due to anoxic injury to the central nervous system (neurogenic pulmonary edema) or from the large negative intrathoracic pressures seen when the victim struggles to breathe in against an occluded airway (obstructive pulmonary edema).

100. SIGNS AND SYMPTOMS Involuntary urination or defecation, expulsion of fetus (if pregnant) may occur.

101. SIGNS AND SYMPTOMS Fractures of the thyroid cartilage or hyoid bone in victims of accidental strangulation and direct injury to the trachea is rare with strangulation. Carotid artery injury is also uncommon after attempted hanging and strangulation.

102. LIGATURE MARK (‘FURROW’) IN ATTEMPTED HANGING AND STRANGULATION S. 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, parchment-like Soft and reddish

103. Diagnosis The majority of the victims present with some common features, a combination of these findings should be taken into consideration 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

104. DIAGRAMS AND PHOTOGRAPHS It is important to document the injuries through diagrams and photograph that may be seen at the time of examination for evidence purpose. The injuries should be mentioned in the pictograph given along with the medico-legal report. The following photographs may also be taken: Distance photo: Full body photograph to identify the victim and location of injury . Close-up photo: Photographs of injuries along with a ruler from different angles to maximize visibility and to document the size. Follow-up photo: As the injuries may take time to develop, taking follow-up photographs at different time intervals will document injuries as they evolve .

105. MANAGEMENT Like 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.

106. MANAGEMENT The 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.

107. MANAGEMENT Like 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.

108. MANAGEMENT Orotracheal intubation should be done preferably by an anesthetist. It can be difficult if laryngeal edema is present or if direct traumatic disruption of the larynx has occurred. Cricothyroidotomy is indicated for any patient with severe respiratory distress and completely obstructed airway. If associated neck injuries render cricothyroidotomy difficult, percutaneous translaryngeal ventilation may be used to temporarily oxygenate a patient.

109. MANAGEMENT The definitive airway management is laryngotomy which must be done at the earliest

110. COMPLICATIONS Respiratory system: Both aspiration pneumonia and ARDS may develop ; tracheal stenosis in case of rupture.

111. COMPLICATIONS Neurologic sequelae including muscle spasms, transient hemiplegia, central cord syndrome and seizures. Long-term paraplegia or quadriplegia and short-term autonomic dysfunction may be seen in spinal cord injury.

112. COMPLICATIONS Psychiatric symptoms : Encephalopathy, insomnia , nightmares and anxiety and an inclination for violence are seen in such victims. Psychosis, depression, suicidal ideation, Korsakoff syndrome, amnesia and progressive dementia may develop.