و
1
Wounds ه كلية طب اا
ا/ د يوسف سلي
.
Definition OF A WOUND
Any break in the continuity of the
body tissues whether skin, blood
vessels, or internal organ.
Medicolegal Classification: 1. Abrasions-------( سحجا )
2. Contusions (bruises)(echymosis) (ض (كدما) (رض 3. Contused (lacerated) wound (جرح كدمي) laceration 4. Incised (cut/slashed) wound جرح قطعي) )
5. chopping wound (طيعي ( جرح ت 5. Stab wound جرح طعني) ) 6. Firearm wound جرح ط ناري) ) 7. Burns حر) ) 8.Fractures ر (كس ) اص معين خاص ا دال خاص ح ذا خ جر
. Fabricated wounds ( جرح مصطنع ) . Defense wounds ح دفاعي (جر )
. Bite marks , punching
. Legal Classification Of Wounds
a. Simple wounds: these are wounds that heal in less
than 20 days without causing any permanent infirmity
b. Dangerous wounds: these are wounds which heal
in more than 20 days and or which leave a
permanent infirmity .
c. Fatal wounds: these are wounds which cause death
either immediately or within a short time. ية بشر عاقة الس
Permanent Infirmity :
It Is loss of functioning organ or loss
of its function.
disfigurement .
is the state of having one's
appearance deeply and persistently
harmedmedically, such as from
a disease, birth defect, or wound.
Abrasions ( Definition )
Destruction ( اتاف ) or scraping (قشط ) of the
superficial layer of the skin or mucous membrane
caused by rough blunt object .
they are of great importance from the medicolegal
aspect.
They may be the only evidence of struggle in many
crimes or accidents.
Types of abrasions 1. Sliding abrasions: A) Linear abrasion due to sliding of
localized rough objects e.g. pin or fingernails on the
skin producing line or parallel lines due to destruction of
the ( epidermis ) cuticle. د ي ال ة ع تحريك ا سحب الة خشنة مدب B) Dragging [brush] abrasions : dragging of broad rough
surface against the body as in street accidents. They are
broad and multiple .
ي سطح عريض خشن ا العكس سم ع سحب ا جرجر ال
2. Pressure [imprint, impact, pattern] abrasions: due to
pressure by rough object on cuticle leaving its pattern or
shape on the skin( rope marks in hanging ) د ي ال ع شك ع د فيط ي ال ة ع ضغط االة المس
Dragging abrasions
Patterned bruises & abrasions
.
.
.
. .
Fire arm inlet – collar abrasion & patterned
bruise of the barell
fingernail abrasions : when nails
indulge ) تتغرس imbedded) in skin they
take the shape of semi-lunar )))))))))
abrasions (pressure nails abrasions)
fingernail abrasions : when nails
scratch or sliding on skin they make
parallel lines (sliding linear abrasions)
Ligature or rope abrasions :
taking the same shape and
breadth of the Ligature or rope
example:
abrasions in hanging (الشنق )
and strangulation ل لح (الخنق ب ).
يعرف ( patterned abrasions)
Medicolegal importance of abrasions
1. shape gives idea about the causative
instrument
2. site gives idea about the type of crime
3. degree of healing gives idea about the time
passed since abrasion occurred
4. It helps to identify assailant
• 5 .Give an evidence of nature of the crime,
MLI. Of abrasions 1. Shape. Give an idea about the causative
instrument:
a. It is crescent(semi-lunar ) in shape in
pressure nail abrasion.
b. Parallel lines in sliding nail abrasions.
c. Broad and wide in dragging abrasions.
d. It has the same pattern of the rope in rope pattern
abrasions. when it is tied around neck or wrist .
e. Two curved lines elliptical ( ي (بي in shape in
human bite taking the same shape and breadth as
human teeth.
Medicolegal importance of abrasions
Human bites
2- Site gives idea about type of crime
a. finger nail abrasions on the neck suggest
throttling.(الخن باليد}
b. around mouth and nose openings suggest
smothering.(س (كت الن
c. rope mark pattern abrasions on the neck
suggest strangulation and hanging.
D . abrasion on private parts suggest rape
3. healing gives idea about the time passed since
abrasion occurred.
• ƒfirst day: it is red with oozing serum due to
slight capillary bleeding.
The 2nd day: a soft yellow scab is formed.
ƒThe 3rd day: the scab is dried (brown).
ƒ The first week: the scab falls leaving a pink surface.
The third week: it disappears (heals by new growth
of epithelium) without leaving a scar.
4. It helps to identify assailant:
• The assailant may be scratched as signs of
struggle.
• nail abrasions on assailant coinciding with
date of crime.
• DNA detection from epithelial tissues under
finger nail of victim or assailant obtain as a
results of abrasions
• Shape of bite fits with the teeth of the victim.
5-Give an evidence of nature of
the crime suicidal or homicidal.
• In case of struggle and resistance
• abrasions give important
evidence of crime homicidal;
because this is absent in suicidal.
abrasion postmortem Antemotrem abrasion
Absent
Microscopic examination (inflammatory cells and fibrin)
(cellular infiltrations) Present
Absent
Healing Present
Absent
Present Sepsis
Absent
Vital reaction Present
Absent
Accompanied with bruises may be Present
(Bruises) Contusions
• it is extravasations of blood into the tissues due to
rupture of blood vessels . It may occur under the skin, any deep tissue or internal organs.
• It results from a blow by a blunt instrument. e.g. stick ,stone, pressure by the tips of fingers as in case of throttling.
• Pressure of soft tissues against hard object even (bone) The force of a blow is enough to rupture of underlying blood vessels , but not enough to tear skin or mucous membrane.
bruise
.
Black eye
Factors affecting degree (extent) of bruising
• 1. Type of tissue: • loose skin e.g. (fatty areas ) and (eye
lids) bruises easily than fibrous tough skin (e.g. palms of the hands) 2. Age: • Infants bruise easily, because of their
delicates skin. elderly bruise easily (due to fragility of blood vessels and atheromatous changes). .
3. Sex: women bruise easily than men
because they have much
subcutaneous fat.
4. Color of skin: blondes bruise more obviously than
dark skin people in whom it is better
to be felt as a slight elevation of
tissues.
5.Effect of Gravity:
leading to shift of blood to a place
remote of (away of) point of injury.
6 Rapidity of death:
if death occurs rapidly e.g. injuries
leading to cardiac inhibition, bruises
may be absent or very slight.
7. blood diseased persons:
vitamin deficiency,
liver diseases and
Alcoholics bruise
easily.
Medicolegal importance of bruise
1. shape gives idea about the causative instrument
2. site gives idea about the type of crime
3. degree of healing gives idea about the time passed since bruise occurred.
• 4 .Give an evidence of manner of the
death suicidal or homicidal.
•
Medicolegal importance of bruises
• 1- Shape gives idea about the causative instrument
• blow by a stick leads to elongated broad
bruise with the same breadth of the stick
• Whip produce two thin parallel bruises,
which continuous with body curvature
• Human bites gives two curved rows of
bruises that may be accompanied by
abrasions
site of bruises gives idea about
1 ) type of crime 2) exception sites 1) type of crime
a. finger bruises & abrasions on the neck suggest
throttling.
b. bruises & abrasions around mouth and nose
openings suggest smothering.
C . Bruises & abrasions due to rope mark on the neck
suggest strangulation and hanging.
D . Bruises & abrasions on private parts suggest rape
.
pressure bruises & abrasions
2) exception Site of bruises:
effect of gravity e.g.
- blow to the forehead may appear as a
black eye owing to gravitation of effused
blood from tough scalp to loose tissue of
the lids.
- A blow to the temple may find its way to
the cheeks or behind the ear (battle sign).
-Also a blow to the calf may find its way
around the ankle.
Black eye
Temporal bruise migrate behind the ear, Subaponeurotic (subgaleal) Blood
collects under the aponeurosis and so is diffuse behind the ear. :
„
.
3. A Color of bruise gives idea about Age
of the bruise:( 30% - 40%) accurecy
this can be estimated from the color
changes that occur from the periphery to
the center of the bruise.
Certain stages of hemoglobin
disintegration occur by the action of
tissue enzymes and histocytes.
These changes are:
a. bright red in color-----(oxyhemoglobin)
b. Blue in color-----(deoxygenated blood)
c. green in color----------------- (biliverdin)
d. yellowish in color----------------(bilirubin) It completely fades away (engulfment by phagocytes).
Each change takes 3 - 4 days until color fades in 2-3 weeks.
Dating of Bruises:
• common question can you date bruises.
• The short answer is no.
• Many experts will still attempt to date
bruises based on colour, tenderness
and/or swelling.
• but the literature shows that this is only
accurate between 30-40% of the time.
Other studies show varying ages
based on colour:
• red, the color commonly associated with a new
bruise, can be up to a week old.
• Blue and purple, also associated with recent
bruises, can show up anytime between Day 1
and Day 14.
• Despite being yellow colour which is associated
ith old ruises, a e see as soon as 24
hours and green colour as soon as 48 hours.
• It difficult to date bruises accurately.
a). Subconjunctival bruises, retain their bright color
until they are completely absorbed.
Because conjunctiva is rich in oxygenation and
hemoglobin is kept oxygenated by air
conjunctiva is rich in phagocytic cells .
So, it is not always easy to give an approximate age
for bruise and this point must be taken with caution.
a). Deep bruises of thick tissue e.g.
buttocks, may first appear few days after
injury thus first appearing bluish color, as
the blood tracks from deeper tissue to the
surface.
Infrared photography can demonstrate
them in early stage.
4. Size or extent of the bruise is
not related to the size of the
causative object only .
But it depends on:
a-severity of the blow the
b- density, laxity and vascularity of
the tissues.
c-rapidity of death.
Finger bruises:
They are disc shaped bruises few
centimeter in size, finger nail abrasions
are usually associated, as in throttling,
they are frequently on the front and sides
of the neck on both sides of laryngeal
prominence, but movement of hands may
cause large irregular patches of bruises
and linear scratches that may be from the
assailant and the victim ( from victim in
strangulation to untie the rope.)
Contused Wound (Lacerated Wounds) جر كدمي ا رضي
Definition
It is an irregular splitting of the skin or mucus membrane accompanied with subcutaneous extravasations of blood.
caused by impact(blow) of heavy blunt force, heavy stick, big stone, fall from height, motor car accident, blow by a hammer on scalp.
Contused wound
Characters of contused wounds
• 1. Edges:
a. Irregular
b. Surrounded with bruises and abrasions
c. Hair is crushed -------------- (hand lens)
d. There is bridging of tissues crossing the
edges because it is not cleanly cut .
e. Little external bleeding due to crushing of
blood vessels.
Contused wound
Characters of contused wounds بع ) (ت
2. They are liable to sepsis
due to tissue destruction.
3. They heal by secondary intention
take longer time to heal
N.B. In cases of stretched skin over bones
as in scalp over skull, elbow, or knee, and skin
over tibia), the edges appear more or less
regular simulating incised wounds.
In close examination (with hand lens),
irregular edges with abrasions and contusions
at the edges and the hair is crushed.
-contused wound
Contused wound Cut wound Irregular with multiple
angles Edges Cleanly cut, sharp
regular and
Multiple and irregular
Angles 2 acute angles
Present Bridging of tissues
Absent Crushed Hair Sharply cut
Little external bleeding
Free external bleeding
More liable to infection Less liable to infection
Delayed by secondary intention Healing Rapid by primary intention
Cut (Incised / Slashed Wounds)
These are produced by sharp instrument
drawing the edge of a sharp instrument
along the surface of the skin
( knifes, razor, or sharp edge of a glass).
Characters of a cut wound
1- It is longer than deep. At the beginning the tissues are divided more deeply
than at the termination (wound tail)
2- It has acute angles
3- Edges are sharp and regular. except if the skin is corrugated as in axilla and
scrotum, the edges are irregular.
Also if the instrument have corrugated edge as in
broken glass, or sharp edge of broken bottle.
4- Hair is sharply cut at the edges.
5- No tissues bridging across the edges.
6- Free external bleeding.
7- No abrasion or contusions at the edges
when examined by hand lens.
Cut wound
No gaping - Edges gap widely -
- No hemorrhage or very little
Accompanied by hemorrhage
No blood clot Blood clot at the base –
No swelling Edges are swollen
No evidence - Evidence of healing or sepsis
No cellular reaction - Polymorphonuclear leukocytes and threads of fibrin may be present
Antemortem cut wound Postmortem cut wound
Aging of cut wound (healing of cut wound)
It is estimated from the rate of healing: • - After 12 hours: Edges are red and swollen.
- After 24 hours: Proliferation of the vascular endothelium with beginning of vascular capillary network - After 48 hours: New vessels grow from the deeper layers towards the surface and pus may be seen if wound is infected - After 5 days: Obliteration of blood vessels begins - After 10 days: Healing by primary intention - After 3 weeks: A red scar is formed - After 3 months: Scar becomes coppery - After 6 months: The scar becomes pale and hardly detected
Stab Wound عني جر • Definition
These are wounds which are caused by pushing
(thrusting) sharp pointed instrument into the
depth of the body, e.g. sharp edged blade,
as knife, sword, or dagger.(خنجر)
If the instrument has a pointed end but has no
sharp edge
e.g. nail, closed scissors ل ص م ,سيخ poker ,م
screw driver( the wound is called ,(الم
punctured stab wound خزي جرح
Characters of a stab wound
• 1. It is deeper than wide: depth is related to the length of the blade. 2. The width of the wound is relative to the breadth of the instrument: ل ا س عرض الساح ا اط ن اقصر a. It may be equal to the breadth of the instrument. b. It may be enlarged a little during withdrawing of the instrument. c. It may be smaller due to tissue recoil. 3. Edges of the wound: are cleanly cut without surrounding abrasions, except in case of punctured
خزي ماعدا ال wounds using a blunt edged instrument, where abrasions may surround the wound
Characters of a stab wound ( بع ) ت4. Shape of the wound has a relation to the instrument
لسا المستخد ر له عاقة ب ر )شكل ال ص سيخ ا مسم ر م ( سكينة خن
a. A knife has o e sharp edge → ou d ith one acute
angle the other angle is rounded (triangular or wedge-shaped).
b. Double bladed knife dagger.(ر .two acute angle wound → (خن
c. Closed scissors → quadrangular rhomboid shape,
surrounded by bruises.
d. Ope s issors → pairs of ou ds o e is al a s
above the other and is oblique to the first one. The
distance between the scissor blades is variable
unless the scissors is in the locked position.
e. Nail „ , stellate shape, surrounded by bruises.
Common examples of stab wounds are stab
wound in chest or abdomen which may be
homicidal (most common) ,suicidal or
accidental.
Postmortem stabbing differentiated from
AM stab by( gaping, hemorrhage, clotted
blood, healing and sepsis).
Cut or stab ( double blades)
chopping wounds
Axe
Meat cleavers
.
• These represent injuries caused by relatively
• sharp heavy edged objects, such as:
• hatchet فأس, • meat cleaver ر ,ساط
• sword سيف,
• spade ف ري -جار ك ,
• matchete منج
• axe. ط ب
.
• The target for chopping attacks is found to be
mainly the head and neck region, followed by
the trunk (the most common site for stab
wounds), and the majority of victims have
sustained more than 5 wounds.
They are also more likely to have defensive
wounds whilst trying to avoid and block
blows to the body.
.
• The edges of the wounds is sharply cut.
• Underlying tissues is similarly cleanly divided,
and underlying bone is cut or chipped.
• I so e ases pie es of o e had ee sha ed off. • Where the skull receives an impact, the outer
table of the skull is sometimes cleanly cut.
• the inner table is fractured with inwardly
directed bone chips.
• Linear fractures were also found radiating from
injured bones.
.
.
.
.
.
Special Types of Injuries: Punching: ة اليد ر ب ال• This is a blow with clenched fist.
• Common directed to the upper part of the body.
1. Bruising and abrasions are the most common result.
2. Lacerations may occur over bony prominences as
the brow or cheek.
3. Blows in the mouth may lacerate lips against teeth.
fracture nose, jaws or maxilla and detach teeth.
4. Punching to abdomen may lead to rupture liver or
intestine particularly children.
•
Black eye • It bruises around the eye
• Direct trauma to the eye
• trauma to forehead, and percolation of
blood of the bruises by the effect of gravity.
• Fractured base of skull of anterior cranial
fossa. and percolation of blood by the effect
of gravity. it has no posterior end,
• eye movement is limited,
it is often unilateral and may be bilateral.
•
II. Kicking:
• It is kicking by shoes or boot or by bare feet. . The victim is usually lying on the ground. The common targets for kicking are face, neck, side of the chest and abdomen, and perineum: ƒ It is a mixture of abrasions, bruises and sometimes lacerations . ƒ Injuries are usually severe due to heaviness of
oot or shoes e e soft shoes as trai ers a cause severe injuries due to the strength of muscles of the legs. ة عضا الرجل نظرا لƒ
ƒ Kicking: ( (بع ت
.Injuries on the face , abrasions ,contusions ,
laceration and fracture of the face bones or teeth
may occur.
. Deep injuries to the abdominal organs( contusions or
rupture organs), and fracture of ribs and sternum can
occur from grinding of a heel on the body.( الدهس الكعب ( الطحن ا الفر ب
ƒ In kicking, the pattern of the footwear may be imprinted on
the skin and the pattern must be recorded preferably by
photography.
III. Bite Marks:
•
Mostly they are seen in sexual assault, child
abuse or fighting.
• Bites may cause abrasions, bruises or
lacerated wounds.
• It appears as pair of curved bruises on the
skin.
•
ƒ
When bites are found, they should be
recorded carefully,
preferably by color photography, or
by accurate sketch.
ƒ If bites are fresh, they are gently
rubbed by a saline , damped swab to
obtain saliva for DNA detection, or for
blood grouped if the assailant is
secretor.
The shape of the tooth pattern must be
compared with that of the assailant and
can be compared with the tooth pattern
kept at the family dentist.
ƒ A forensic dentist should be called if
possible to examine the mark, and to
determine the tooth pattern of the
assailant. to resolve any allegation of bite
by animal (e.g. the family dog).
.
.
.
.
• .
.
• .
.
.
.
Dog bite
• .
IV. Defense Injuries:
• These are injuries sustained by the victim to
defend himself.
• In case of punching, kicking there will be
abrasion or bruises on the outer side of the
forearm, back of hands
Fingers may be broken in an attempt by the
victim to shield himself.
Defense Injuries sites
ƒ
ƒ In kicking,
defend bruises may occur on the
outer side of the thigh as the victim
tries to protect his genital region.
ƒ In attacks by knife, its blade may be
gripped by the victim,
so that cut wounds may occur across the
flexors of the fingers and in the palm.
Fabricated (Self-Inflicted) Wounds
Definition
These are simple wounds which
are self inflicted (or fabricated)
by the person on his body.
The objectives are:
ƒ To pretend that a crime was
committed in self defense or to
allege bad treatment by other
persons or authorities.
ƒ
ƒ
Characters of fabricated wounds
1. Superficial and not dangerous.
2. Within the reach of the hand and in a
safe site e.g. e tre ities, forehead…et .
3. They are inflicted on bare skin, so no
corresponding tear on clothes.
4. Usually they are superficial multiple parallel .
5. The age of the wound does not usually
correlate with the date stated by the fabricator.
6. Careful examination and interrogation
وا ( اإست ) about the manner of the assault, or
type of weapon will prove that allegation was
false.
Complications of Wounds
causes of death from wounds
• 1 - Haemorrhage ( external or internal)
• 2 - Air embolism (arterial – venous )
•
• 3 - fat embolism
--
4-Infection
5-Disseminated intravascular coagulation DIC
6-Adult respiratory distress syndrome –ARDS
7- Traumatic shock (sympathetic)
( parasympathetic)
1 - Haemorrhage
• External haemorrhage is less dangerous than internal hge., because it is apparent ,easily diagnosed but it is important to know that about 2000 ml. blood loss is fatal ( 1/3 of total blood volum.
• 200 ml. into pericardium is fatal
• 5oo ml. in peritoneum
• 500ml. Pleura
• Few ml. in the brain
1 – Haemorrhage ( بع ( ت
• blood loss from veins less dangerous than
artery because it is in the form of jets, So rate
of loss is faster
• Bleeding from big artery e.g. femoral highly
dangerous than bleeding piles
• Females tolerate bleeding more than males
•
Symptoms and signs of Haemorrhage
• Low blood pressure
• Rapid weak pulse
• Rapid shallow respiration
• Subnormal temperature
• Cold clammy sweat.
• pallor
2 - Air embolism
• A ) Venous air embolism (more common ).
• less dangerous
• It occurs in
• cut throat
• Criminal abortion.
• Tubal insufflations.
• B ) Arterial air embolism. (Less common).
• more dangerous
•
-- • venous air embolism • It occurs in cut throat(opening of big vein),
• ,e.g. jugular vein.
• 1 - In cut throat , decrease of venous pressure, air is sucked in the open neck vein during inspiration due to negative intra-thoracic pressure.
• 2- In tubal insufflations air is pushed under pressure, and in criminal abortion when using the douching method.
• When more than 200 ml.is injected leading to failure of pulmonary circulation filling right side and pulmonary artery with failure of systemic circulation.
-- Arterial air embolism Stab wound of chest communicating between bronchus
and pulmonary veins
The embolus passes from left ventricle to aorta, and then to a smaller artery causing ischemic effects on Kid e , rai , heart, reti a…et .
Lethal volume: few milliliters are enough to occlude an artery supplying a vital organ. (cerebral or coronary )
-- • 3 - Fat embolism(Liquid fat globules pass to
venous circulation through torn veins in)
• Fracture long bone
• Burns
• Trauma to fatty area
• Hysterosalpingography ( libiodol )
• Which passes to the right side of the heart and block pulmonary arterioles and may pass to pulmonary veins to the left side then to retinal or cerebral arterioles.
•
-- • 4-Infection • Delayed cause of death
• Cellulitis
• Gas gangrene
• Tetanus
• Pneumonia and pneumonitis
• Septicemia
• Meningitis ( traumatic meningitis )
• empyema
5-Disseminated intravascular
coagulation DIC The coagulation system in the body
consists of clotting mechanisms to
prevent excessive blood loss.
Whereas fibrinolytic mechanisms (which
generates plasmin) are to ensure
circulation within the vasculature.
.
DIC like syndrome, there is widespread
activation of the blood coagulation system
leading to excessive generation and
disseminated deposition of fibrin clots in
small and midsize vessel.
which alters the microcirculation leading to
ischaemic necrosis in various organs
particularly in kidney and lung
Resulting in organ failure
-- • 5-Disseminated intravascular coagulation DIC
thromboplastin
• Prothrombin thrombin
thrombin
• Fibrinogen fibrin
. widespread activation of the blood
coagulation system leads to consumption of platelets and coagulation factors resulting in serious haemorrhagic complications which sometimes may be the most striking clinical presentation.
Hence, a patient with DIC can present as thrombotic and bleeding problem simultaneously
Any tissue insult (damage)sufficient enough to
release tissue products or toxins into the
circulation can result in DIC.
. • Trauma & huge hematoma( release of phospholipids and fat (major fractures) into the circulation can cause haemolysis, endothelial damage and activation of the coagulation cascade.
• Sepsis.(due to either cell membrane components of the microorganism or bacterial exotoxins).
• obstetric disorders (premature separation of placenta + amniotic fluid embolism)
• snake bites(exogenous toxins)
• Malignancy.
• liver disease.
• vascular anomalies
• major transfusion reactions
--- • Excess thrombin generation, as a result
of bacteraemia or endotoxaemia,this
results in excess fibrin generation and
deposition in the vascular system.
• In the early phase of DIC, plasmin
(naturally occurring fibrinolytic agent)
causes fibrinolysis to maintain circulation
• Bleeding manifestation, seen in some
forms of DIC, is due to the excess
fibrinolytic activity.
6-Adult respiratory distress syndrome --ARDS
• CAUSES ائي يصا ال اد غريب داخل الح ل م :دخ
• Near drowning persons اذه ت ان مياه في الرئ
• Aspiration of gastric content ي في المعدة ااكل ال
• shock hypoxia, decrease vitality of alveoli, alveolar damage (transudation into alveoli)
• Irritant gases يصا ح ل غازا غريب ضارة ل دخ
• ص اكسجين ن
• Infection (exudation into alveoli)
• Severe trauma to the chest (dyspnea ص اكسجين ) نارتشاحا
Pathophysiology
diffuse alveolar damage
severe oedema into lungs
stiff (hard) lung
Clinical picture
1. Dyspnea 1-2 days after trauma
2. Plain chest X-ray shows pulmonary
edema and diffuse alveolar collapse
7 - Parasympathetic shock
(vagal shock – reflex cardiac inhibition)
Excessive vagal sensory stimulation may cause
cardiac arrest.
1-Trauma to the sensitive area e.g. testes
2-Cervical dilatation during criminal abortion
2-Sudden immersion in ice water
3- Cold water or foods striking the glottis
4- Sudden pressure on the neck.
5- pressure on the neck in violent asphyxia
-- • Clinical picture of parasympathetic
shock( non specific)
1. Pallor
2. Hypotension
3. Loss of consciousness due to
4. Slow pulse
5. Deep irregular respiration
6. Complete cardiac standstill and
death occur