Forensic Outline Outline Final PDF

Wounds and Patterns of Injury (Wounds I) 1. Introduction to Wounds o Definition→ Circumscribed injury which is caused by an external force. 1. It can involve any tissue or organ. 2. Can be surgical and traumatic or accidental. o Types of tiss...

Wounds and Patterns of Injury (Wounds I) 1. Introduction to Wounds o Definition→ Circumscribed injury which is caused by an external force. 1. It can involve any tissue or organ. 2. Can be surgical and traumatic or accidental. o Types of tissue damage 1. It is caused by an external damage such as mechanical that leads to cellular and / or tissue trauma and dysfunction. 2. BUT also covers non kinetic injuries where damage is caused by non mechanical force, such as thermal, chemical and electrical energy 2. Skin and its Role o Skin is the first anatomical barrier from the harsh environment and pathogens o Quick and effective protective mechanism and regeneration o Types of damage (scarring, infection) 3. Classification of Injuries o Kinetic vs Non-Kinetic injuries 1. Kinetic Injuries 1. Blunt force injuries – 1. Bruises / contusions – 2. Abrasions – 3. Lacerations 2. Sharp force injuries – 1. Incised wounds – 2. Cut or slash – 3. Stab wounds 2. Non- Kinetic Injuries 1. Thermal; Heat or cold – 2. Chemical 3. Electrical; High or low voltage 4. Electromagnetic radiation; Radio wave, microwave, infrared, light, ultraviolet, xrays, gamma rays o Depending on the severity→ simple or grievous o Depending on the time of infliction→ Antemortem, Perimortem, and Post- mortem o Depending upon the manner of infliction→ Suicidal, Homicidal, Accidental, Defence wounds, Self-inflicted, Fabricated fictitious injuries 4. Types of Wounds o Blunt force injuries (bruises, contusions, lacerations) 1. Bruises/contusions 1. Occurs Due to Blunt Injury: Caused by impact or force. 2. Blood Leakage: Blood escapes from capillaries into tissues (subcutaneous or submucosal). 3. Skin Remains Intact: The outer layer of the skin isn’t broken. 1  4. They change colour over time; fresh(red, blue), old(yellow/brown). 5. may be external or internal 6. occurs in lax (loose) tissues 7. may be superficial or deep 8. may indicate the nature of the weapon used; discoid(fingertip), tramline bruise(rod/cane) 9. Common in 1. infants 2. elderly 3. alcoholics 4. clotting problem 10. site 1. specific type of injury – neck 2. bruises v hypostasis 3. post-mortem bruises 11. Petecchiae 1. capillary rupture 12. Periorbital Haematoma(black eyes) 1. local trauma – punch to eye (unilateral) 2. wounds to forehead, blood will track down 3. fracture base of skull often bilateral 2. Abrasions; 1. scratches/grazes; involve the outer layer of the skin. 2. Are important for forensics 3. body surface / intradermal bleed 4. brush/crush on imprint. 5. When linear→ they are produced by a pointed object; thorn, pin, fingernail 6. Direction→ identified by the skintags→ where the instrument separates from the body 7. Pattern indicates the object used; muzzle marks, whip marks, grill mark(cars), tyre or rope 8. Site→ fingernails on neck, seatbelt, and road rash 1. Fingernails on neck can belong both to the assailant and the victim 9. abrasions also occur post-mortem 1. Usually over exposed bony prominences 2. Oozing, scab formation and colour changes are absent 3. brown, leathery, parchmentisation 10. Timing 1. Fresh: oozing of lymph and blood 2. 12-24 hours: dries up to form a scab 3. 2-3 days: reddish brown scab 4. 4-7 days: epithelium covers the defect under the scab 5. After 7 days: scab dries, shrinks and falls off 6. Normally heal without the formation of permanent scar. 2  3. Bite marks 1. may be present though a bruise and abrasion and may be accompanied by a laceration. 4. Lacerations 1. blows/RTAs/falls/assault 2. Splitting the full thickness of the skin 3. +/- deeper 4. tissue bridges in depth 5. irregular margins 1. except on bone 2. may be slightly inverted. 6. + bruises /abrasions 7. contain trace evidence 8. shape 1. could indicate the weapon. 2. Circular object tend to cause a crescent-shaped laceration 3. Square or rectangular object tend to cause a laceration with a Y-shaped split at its corners 9. Internally may cause damage to the → through indirect violence. 1. Speen 2. Liver o Sharp force injuries (incised wounds, stab wounds) 1. Sharp weapon 1. Incised/cuts. 2. Stab/penetrating/ puncture injury. 2. Incised wounds; 1. Sharp trauma 2. Sharp object = clean cut edge 3. May be knives / scissors / glass 4. CUT / SLASH - longer skin mark than depth 1. Linear; surgical wounds 2. Suicide; 1. Tentative 2. May be numerous 3. Hesitant 4. parallel/close 5. depth varies but similar 6. Common in the wrists/ neck, elbows/ groins, chest/abdomen, 7. They are repetitive 3. Homicide 1. Not tentative 2. Forceful 3. Found in vital spots 4. mutilation – face 5. not repetitive 3  6. defence wounds; found mostly on the arms 5. STAB - deeper than they are wide 1. cutting instrument with a point 1. sharp /blunt 2. may be with a 1. knife 2. scissors 3. iron bar 4. screwdriver 5. pen / pencil 3. Slit shape 1. two points (double edged) unusual 2. triangle (single edge) 4. Slit size shorter - recoil of skin 1. longer - knife at an angle 2. curved – rocking 5. depending on the track length the length of the blade can be determined. 6. hilt mark 7. force : sharpness of tip 8. determining the age of the stab; 1. 48 hours: pus may be present if sepsis occurs 2. 10 – 15 days: complete healing by primary intention if no sepsis occurs 3. 3 weeks: red scar 4. 3 months: scar becomes coppery 5. 6 months: scan is thin and pale 6. CHOP - combined sharp and blunt, severe and deep, caused by cleavers, swords, axes o Non-kinetic injuries (thermal, chemical, electrical) 5. Medico-Legal Importance o Site and direction of force o Certain features are suspicious for serious internal injury o Patterns may be helpful in connecting the crime with the object which produces them o The age of the injury can be estimated o In open wounds, dirt, dust, etc. are usually present which may connect the injuries to the scene of crime o Manner of injury many be known from its distribution 1. Abrasions on the face or body of the assailant indicate a struggle 2. In smothering, abrasions may be seen around the mouth and nose 3. In sexual assault, abrasions may be found on the breasts, genitals, etcs 4 Wounds II - Gunshot Wounds 1. Ballistics o The Study of motion and effects of projectiles. 2. Key Factors: o Velocity and mass determine kinetic energy. o High velocity leads to greater tissue damage. o The caliber + shape influence the “drag effect” and thus the loss of KE. o The structure of the bullet influences the bullet deformation and break-up. High velocity projectiles are more likely to break up than low velocity projectiles. o The longer the wound track = greater loss of stability + greater deformation of the projectile. o The denser the tissue through which the projectile passes, the greater the retardation of the projectile and thus the greater the loss of KE. o The extent of the injury depend on the Mechanical shredding and crushing of the tissue (“drilling effect”) Shearing, compression and stretching injuries to the tissue due to temporary cavity formation Secondary injuries due to breakup of the bullet 3. Gunshot Wounds (GSW) o Types: Penetrating (no exit wound). Perforating (entry and exit wounds). 4. Weapons and Ammunition 5. Smooth Bore Weapons: o Shotguns with multiple pellets(lead shots) o Gauge(size) depends on the bore diameter Gauge; the number of solid lead balls, with diameter equal to bore diameter o Patterns vary by range (tattooing, soot deposition). 6. Rifled Weapons: o Spin imparted for accuracy. o Types: Rifles: High velocity. Pistols/Revolvers: Shorter range. o Leave rifling marks on the bullet. Raised lands/ grooves o The calibre is determined by measuring the diameter of barrel measured between opposite lands 7. Ammunition o metal cartridge case - shell o primer in the base centrefire rimfire o then propellant o bullet at distal end 5  metal, usually lead covered by metal jacket 1. copper / cupronickel cartridge case may carry manufacturer's marks 8. Range of Fire o Contact: hard and loose contact muzzle is applied to skin hard contact wounds, all the materials will be driven into the wound in loose contact, the skin is not indented by the muzzle. Soot carried by the gas is deposited in a band around the entrance Gas, soot, and metallic particles driven into tissue. o Near contact: There is no contact with the skin Soot deposition with blackened skin. The soot can be wiped away o Intermediate: Powder tattooing + cannot be wiped away. o Distant: No soot or tattooing, clean entry wound. Irregular, cruciform or stellate entrance wounds can occur 9. Wound Characteristics 10. Entry Wounds: o The leadshot emerges as a solid mass o diverges progressively in a cone shape o cone varies in shape for same weapon with different ammunition o generally no exit wound exception with a shotgun injury to head o shot or pellets disperse inside body o range has effect on severity of injury o Smaller, inverted margins, soot/tattooing based on range. o The internal damage may be examined via X-ray; would show the spread of pellets 11. Exit Wounds: o Larger, everted margins; irregular in shape. 12. Special Cases: o Stellate wounds over bony areas. 13. Special Investigations 14. Gunshot Residue (GSR): o Chemical analysis of primer/bullet residue. o Found on shooter or victim. 15. Bullet Marks: o Unique rifling marks used for weapon identification. 16. Gunshot suicide; o Found on site o Discharged at arm’s length o GSR should be identified on firing hand, clothing, hair 6 Wounds III - Thermal injuries 1. Body Temperature o Normal Body Temperature Average: 36.8°C (98.2°F) Normal Range: 36.4°C - 37.3°C (97.5°F – 99.1°F) Diurnal variations o Temperature Regulation: Controlled by hypothalamus via autonomic nervous system Mechanisms: Skin radiation, perspiration evaporation 2. Heat Injury – Hyperthermia o Definition: Core temperature ≥ 40.6ºC (105ºF) o Factors: Environmental heat, exertion, obesity, substance use 1. Ecstasy→ causes chemical in the brain to be released leading to the heat production in the body. Prevention: 1. Adequate hydration, moderated activity Conditions: 1. Heat exhaustion: Normal temperature, sweating, dizziness 2. Heat stroke: ≥ 40.5ºC, dry skin, confusion, potentially fatal children, elderly, obese more susceptible 3. Types of Thermal Injuries o Moist Heat (Scalds) o Dry Heat (Burns) o Cold Injuries o Chemical Corrosives o Electric Contact o Radiation Burns 4. Moist Thermal Damage – Scalds o Causes: Hot liquids/gases o Characteristics: Redness, blistering, clothing entrapment o Common Victims: Children, elderly o Types: Accidental, Child abuse (specific patterns) 5. Burns o Causes: Dry heat, temperature > 50ºC o Severity: 1st Degree: Superficial, no dermis loss 2nd Degree: Full epidermis destruction, dermis exposure 3rd Degree: Full skin thickness destruction, possible muscle/bone exposure 6. Extent: o Rule of Nine→ in calculating the area burned, apply to adults not infants. 7  o Used for prognosis reasons. o patterns suggestive of position of victim o clothing protects from severity of injury o poor prognosis ▪ 1/3 or more of body burnt ▪ elderly - may not survive 10-20% burns ▪ site - face, hand more serious than legs ▪ children can withstand more extensive burns o recovery depends on severity & extent of burns ▪ complications include ▪ infection ▪ loss of fluid / electrolytes, renal failure ▪ damage to airways/ lungs ▪ blood coagulation problems ▪ death may be unexpected weeks after burns sustained, presumably from electrolyte imbalance 7. Fires o Pathologist's Role→ Identify cause of death, establish fire conditions, victim’s status during fire o Causes: Accidents (e.g., electrical, careless handling) 1. common manner of death 2. young / elderly / influence of alcohol/drugs 3. usually carelessness in starting a fire e.g. clothes brush against a fire throwing lighted matches or cigarettes faulty electrical appliances 4. inability to escape/combat fire 5. may collapse against fire/heater during a fit/infarct/stroke Suicide→ rare West/Europe, more likely in Eastern cultures or homicide→ rare/ conceal homicide o Examination of Fire Victims: Burn types, soot in airways(if below the vocal chords indicates that the victim was alive during the fire and was inhaling smoke), CO poisoning, pugilistic attitude(- muscles stiffen, flexors) Accelerants may be found on the body Body of adult cannot be destroyed without trace in a house fire (temperatures may reach up to 780°C) Body of a child can be totally burnt in an oven skin - brittle, splits in long / wide cracks 1. cherry pink colour due to CO indicates victim was alive in the fire Always obtain full body X-ray 1. fractures due to heat or trauma 2. bone / joint disease 3. metal fragments from clothing, trace evidence 4. bullets 8  exclude natural death o Cause of Death: Hypoxia from smoke inhalation, 1. Hypoxia→ most common cause of death in death by fire → smoke inhalation Low oxygen high carbon monoxide. cardiac arrest from heat effects Co2 poisoning Smoke poisoning→ noxious gases, apart from CO, produced by degradation of natural and man-made fibres 8. Carbon Monoxide Poisoning o Sources: Fires, engines, tobacco smoke o Effects: High affinity for hemoglobin, impairs oxygen transport Symptoms: Cherry pink coloration of blood/skin(indicates the victim was alive in the fire) Low levels may be indicative of a rapid death. 9. Cold Injuries: o Hypothermia: Core temperature < 35°C, fatal below 28°C Risk groups: Elderly, alcoholics, children, outdoor sportsmen, in cold sea Indications; 1. pink skin, patchy, over joints 2. internal body damage o Frostbite: prolonged hypothermia affecting only extremities Localized cold injury causing tissue infarction Common in extremities Risk groups; elderly/babies at a cold homes Seen mostly in cold countries 10. Explosives o Causes: Military,terrorist, industrial, and accidental events o Injury Mechanisms: Blast effects, projectiles from explosive materials, burns from hot gases and objects on fire, structural collapses o Blast Injury Types: Primary (pressure effects)→ at interface of tissue with atmosphere – ear, lung, bowel rupture Secondary (trauma)→ penetrating/blunt trauma to soft tissues, fractures Tertiary (fractures)→ head injuries, multiple fractures 11. Electrical Injuries o Mechanisms: Arrhythmias→ current interferes with conduction system of heart 9  can be reversed if current ceases→ therefore resuscitation should always be prolonged respiratory paralysis→ diaphragm and intercostal muscles go into spasm respiratory failure→ due to brain stem paralysis if current enters head o Amount of current producing death depends not only on value but also on exposure time o Wet skin = less resistance = more susceptible to electrocution o Sweating also lowers resistance of body o Insulation - rubber soled footwear o Identification of injury; entry point 1. fingers, hand or forearm small burn, blister 2. no contact - spark - nodule of fused skin 3. wet skin - no sign as entry is over a diffuse area exit wounds 1. feet, maybe hand 2. often absent 12. Lightning Injuries o High electrical force causing burns and explosive compression effects Changes After Death 1. Can be used to determine Time of death Manner of Death Disposal of the dead 2. Body Temperature Cooling Process: 1. Sigmoid curve: Initial plateau (about 3 hours after death), linear cooling, then flattening. 2. Temperature falls faster in water and snow. 10  3. Rectal temperature is considered to be the core temperature 4. Rectum is swabbed if looking for sperm & follows serial readings 5. liver / ear / nose temperature ◦ serial readings of environmental temperature Modifying Factors: 1. Body temperature at time of death 1. lower if moribund(approaching death) hours after injury 2. raised in a fever, after heavy exercise, and possibly in deaths following a violent struggle or in asphyxia or with intracerebral (brain) haemorrhage 2. Body factors: 1. Cool faster→ slim build, children, cachectic person (Eat. Dis) 2. Cool slower→ if obese, woman, children, clothing, or illness (e.g., fever or asphyxia). Thick clothing, naked bodies 3. oedema (swelling) retards cooling / persons with congestive cardiac failure retain heat ; electric blankets 4. dehydration causes increased cooling 3. Environment: Faster cooling in breezes, snow, and cold water. Slower cooling in warm, enclosed spaces. A body will not cool after death if ambient temperature 3. Post-Mortem Hypostasis (Lividity) Timing and Process: 1. Onset about 3 hours after death, fixed after 6-12 hours. 2. Distribution in dependent areas, with pressure areas appearing blanched. Colour: Cherry pink (carbon monoxide poisoning), bluish-red in normal cases. 4. Rigor Mortis Timing: 1. Onset at about 3 hours after death, fully developed by 6-12 hours, disappears with decomposition (around 36 hours). 2. The body becomes stiff, there is the irreversible fusion of the actin and myosin, chemical reaction→continuous contraction+ eventually tissues break down, with decomposition 3. Distribution 1. all muscles - skeletal / smooth / heart 2. small muscles ‘felt’ first 3. disappears’ from the small muscles first 4. Other forms of stiffening 1. frozen bodies 2. pugilistic attitude - fire 3. cadaveric spasm Temperature Estimation: 1. Flaccid warm ( air Injuries 1. Ante-mortem / post-mortem / recovery 4. Factors which influence the condition of the body; o Salt water vs fresh water o Water source tidal vs non-tidal o Presence of possible predators o Water temperature o Clothing o Type of surface at the base of the water 5. Mechanisms of Death o Freshwater Drowning: Hypotonic water absorbed into circulation → heart failure and cardiac arrest. Denaturation of surfactant → alveolar collapse. o Saltwater Drowning: Hypertonic water draws fluids from circulation → dehydration and cardiac dysfunction. 6. Post-Mortem Findings and Investigations o External froth, pleural fluid accumulation, and water in the stomach. 19  o Use of diatoms to confirm drowning and differentiate fresh vs. saltwater drowning. o Post-mortem blood chloride and specific gravity analyses – to differentiate fresh and sea water drowning o Role of alcohol: Hastens hypothermia, impairs response, and contributes to drowning risk. Alcohol levels in blood→ may be decreased, in fresh water drowning. Must be corroborated with urine levels o ‘rule of thumb’ - decomposition in water in temperate climates occurs at roughly half the rate of a body left in air o Decomposition slower in sea then fresh water o Post-mortem injuries: contact against with sea/river bed 1. Especially shallow water Propeller blades → deep ‘chop’ wounds / lacerations Marine creatures 1. Circular skin defects 2. caused by crustaceans, fish etc. Fragments / limbs may become detached and lost Ante-mortem vs post-mortem injuries→ assault o Other signs; Foreign material in airways / stomach 1. sand, silt, weeds in lower airways, alveoli 2. large volume of water (+/- debris) in stomach suggests immersion during life 3. absence of water in stomach suggests either rapid death by drowning, or death prior to submersion Cadaveric spasm: 1. E.g. seaweed clutched in hand indicates benign alive in water o Microscopy: Alveolar distention Alveolar rupture and haemorrhage Narrowed capillaries 7. Drowning vs. immersion o In certain circumstances, death may be extremely rapid after falling into water, there being insufficient time for drowning to occur. o Mechanism: a reflex cardiac arrest, of a type similar to ‘vasovagal inhibition’ o Stimulation → over activity of the parasympathetic system → bradycardia → cardiac arrest Sudden immersion in cold water 8. Scuba diving: o Uses a self-contained underwater breathing apparatus (scuba) o Longer underwater endurance than breath-hold divers o Pressure far higher than at surface of sea o Dysbarism – medical conditions resulting from changes in ambient pressure o Effect of nitrogen 20  1. Narcosis → resembles drunkenness 2. Decompression sickness as diver rises, nitrogen comes out of solution more at risk if underlying disease this is indicative of when a diver rises to quickly nitrogen gas embolises (travels in blood vessels) 1. infarction (death from lack of oxygen) of brain, spinal cord gas in skin - surgical emphysema Barotrauma 1. Mechanical damage from gas released into tissue 1. Introduction o Quotes from Paracelsus: "All substances are poisons..." "There are no harmless substances..." o Ways to enter biological organisms: Ingestion Inhalation Injection Dermal absorption 2. Poison and General Principles o Poison - any substance, which, through its chemical action on tissues, can cause ill-health or death o Toxin - a naturally-derived (biological) poison o Issues with determining lethal doses o Concepts like LD50 and variability in toxicological data 3. Toxicology Sample Collection o Importance of correct sampling methods o Types of samples Blood→ femoral vein or other veins Urine→ direct aspirate from urinary bladder or catheter. Bile→direct aspirate from gallbladder Vitreous Humour→ direct aspirate from eye Other samples include gastrointestinal contents, vomit, hair, nails, bone and organ tissue (eg: liver). May submit puncture site for analysis (compared to background skin) o Specific considerations for decomposed bodies (e.g., maggots) 4. Post-Mortem Toxicology o Changes in substance levels after death o Post-mortem decomposition Bacteria can produce alcohol post-mortem. o Post- mortem redistribution 21  Substances in the stomach may diffuse to the heart and lungs post- mortem resulting in an artificially high level if cardiac blood is used for analysis (important in alcohol). 5. Alcohol o Commonly abused substance o Metabolism (absorption, breakdown, and elimination) Absorption: 1. Orally 2. Rapidly from the stomach and upper GI tract. 3. Absorption is delayed by food and at extremes of alcohol conentration Metabolism: 1. Occurs primarily in the liver Elimination: 1. Around 5% eliminated unchanged (breath, sweat, saliva, urine) 2. Acetic acid is elminated via urine. 3. Rate of elimination is higher in chronic alcoholics o Blood Alcohol Concentration (BAC) levels and effects: Ranges from mild relaxation to coma and death o Acute alcohol poisoning and chronic alcoholism Acute alcohol poisoning 1. BAC in excess of 300mg/100mL. 2. Seen in chronic alcoholics 3. Cause of death may be due to the depressant effects of alcohol on brainstem functions together with aspiration of vomit. 4. Drunk person may be involved in motor vehicle accident (as driver and pedestrian), fatal falls, burns (eg: cigarette smoking in bed) and drowning (particularly of immersion type). Chronic Alcoholism 1. External: Unkempt, generally malnourished, cachectic. 2. Liver: Fatty change (greasy liver), nodular cirrhosis. 3. Gastrointestinal Tract: Gastrointestinal haemorrhage due to bleeding varices. 4. Heart: Alcoholic dilated cardiomyopathy 5. Bones: Osteoporosis, traumatic fractures 6. Brain: Cerebellar atrophy, atrophy of the mammillary bodies, traumatic bleeds 7. Psychiatric: Alcohol dependence and alcohol withdrawal syndrome (tremors, sweats, nausea, vomiting), psychosocial consequences. o Delirium Tremens: symptoms and treatment Refers to a rapid onset of symptoms secondary to withdrawal from alcohol. Occurs classically in heavy alcoholics. Usually occurs around 2 days following withdrawal from alcohol, with symptoms lasting for 2 – 3 days from onset. 22  Symptoms include auditory and visual hallucinations, confusion, disorientation, tremors, sweating, formication, tachycardia and hypertension, characteristically worse at night. Treated with benzodiazepines (lorazepam) and thiamine (Pabrinex). o Methyl alcohol (methanol) poisoning: sources, effects, and risks Common industrial solvent and synthetic precursor (winshield washing fluid, deicing fluids, antifreeze, paint removers). May be added to cleaning (industrial) alcohol to deter drinking. Methanol is rapidly absorbed from GI tract and is metabolised to formaldehyde and formic acid (highly toxic!). Effects include blindness (optic nerve and retinal damage) and damage to the basal ganglia 6. Drugs of Abuse o Cocaine: Origins, methods of administration, and effects 1. Extracted from the coca plant 2. Administered: orally or sublingual, nasal (snorting), intravenous, intramuscular, subcutaneous, or intravaginal routes. 3. may be boiled crack cocaine precipitated; may be smoked (cigarettes or pipes). 4. Interferes with reuptake of dopamine. Potent stimulant (euphoric) effect and improves intellectual and motor activities. Subsequent ‘crash’ as levels decline. 5. May be adulterated with heroin (snowball). 6. Highly addictive. Health risks (e.g., nasal septum perforation, vasculitis, cardiomyopathy) o Cannabis (Marijuana): Active ingredients and their effects 1. Psychoactive drug from the Cannabis plant (weed), with numerous active ingredients (THC, cannabidiol). 2. Synthetic cannabinoids often sprayed onto cannabis to enhance potency 3. causing euphoria, altered state of mind and increased appetite, impairing short term memory and balance. 4. Administration via smoking (joint) or ingestion. Also dietery, oils, cannabis tea, alcohol additive 5. Increased prevalence due to medicinal, spiritual and recreational use. Long-term risks like cognitive decline and psychosis o Hallucinogens: Induce dissociative hallucinations, often at low doses. Psychological symptoms include altered perceptions of colour/smell/taste, hallucinations, blurred vision euphoria and loss of ego boundaries. Physical symptoms often non-specific but may include hyperthermia, tachycardia and hyperautonomic effects. 23  Common types (PCP, LSD, Mescaline, Psilocybin, Flakka) Psychological and physical effects o Amphetamines and Ecstasy: Amphetamines (including methamphetamine) refer to a class of medicinals used to treat ADHD, narcolepsy and obesity. Often abused as a performance enhancer by athletes. Ecstasy (MDMA) and its derivatives (MDA, MDM) is an amphetamine derivative that is a potent pscyhoactive stimulant. Common ‘rave party’ drug. Effects broadly range from physical (tachycardia, sweating, hyperthermia, teeth grinding, dehydration) and psychological (euphoria). Overdose (commoner with MDMA) typically due to intracranial haemorrhage, hypertension, DIC, siezures and rhabdomyolysis. o Opioids: Refers to morphine (derived from opium – Papaver somniferum poppy seeds) and its derivatives (principally heroin). Heroin usually injected but may be smoked, snorted or inhaled. Used as a recreational drug for its potent euphoric effects. Rapidly metabolised to morphine and 6-MAM. Main side effect is respiratory depression (may be rapid and fatal – syringe may still be inserted, copious oral froth common). Treated with naloxone. Common injection complications (abscesses, endocarditis, pneumonia, septic dactylitis, impurity granulomas in lung) and blood- borne infections (HIV, Hep B, Hep C). Effects, risks (e.g., respiratory depression), and treatments (naloxone) Opioid addiction and withdrawal symptoms 1. Addiction risk present with most drugs but especially opioids. 2. Symptoms start after the first doses. 3. Effects include; Craving: Psychologial compulsion to achieve the same ‘high’ Opioid Withdrawal Tollerance: Requiring higher doses. 4. Treated by opioid replacement therapy (eg: methadone, buprenorphine, naltrexone) taken under medical supervision. Needs psychiatric / social support. o Solvent Abuse: Deliberate inhalation of fumes or gasses found in common household products (eg: glue, aerosols, cigarette lighter fluid, thinner, petrol, acetone). Results in a relaxed, heightened state but may be sedative, anaesthetic and hallucinogenic at high doses. May cause dependency, especially in young abusers. Fatal doses leave no specific autopsy signs (non specific cardiorespiratory failure). 24 7. Pharmaceuticals o General principles of pharmaceutical poisoning Common, especially in nations with a developed health care system (especially if state-funded). Undesirable effects often be dose related and predictable but may be unpredictable (eg: anaphylaxis). Most are accidental but may be suicidal. Homicide is distinctly rare. Autopsy often leaves no specific findings (except in certain drugs) and may be negative. Rendered more difficult if substance is unknown, delay between ingestion and death (as substance is metabolised and elminated) or if substance is very rapidly metabolised leaving little trace.Toxic levels may not be known, especially for modern drugs. May be missed if adequate history is not provided. 8. Poisons o Cyanide: Sources includes: 1. Fires: Cyanide fumes form through combustion of plastics. 2. Ingestion of Cyanide Salts: Homicidal, suicidal or accidental. Ingestion of potassium cyanide most common. 3. Fruit Seeds: Ingestion of apricot, peach and plum stones and bitter almonds contain amygdalin (reacts with gastric acid). 25  Impedes haemoglobin from carrying oxygen through methaemoglobin synthesis and blocks cell utilisation of oxygen. Often brick-red hypostasis. Internally, tissues are bright pink (tissues cannot use oxyhaemoglobin). Stomach and lower oesophagus may be badly corroded. Characteristic ‘smell of almonds’ on the body. Not everyone can smell (genetic). o Ethylene Glycol: Widely used in antifreeze and solvents (easily available). Often abused as a source of intoxication when alcohol is not available. May be ingested with suicidal intent. First effects resemble drunkenness but progresses into coma and death rapidly. Death occurs as metabolised into oxalic acid. At autopsy, no specific gross findings however, on histology, reflactile oxalate crystals may be seen with plarised light. o Pesticides: In developing countries, access to highly toxic compounds poorly regulated. Commonest agents include; 1. Paraquat: Herbicide. Toxic when ingested, causing irritation of lips, mouth and digestive tract. Also severely hepatotoxic and pneumotoxic (leading to ARDS; may be mistaken as pneumonia). 2. Organophosphates: Insecticides (eg: malathion, parathion). Potent inhibitors of acetylcholinesterase resulting in hyperexcitability. Often greenish oily substance in stomach when ingested. Toxic effects and challenges in diagnosis 26  o Forensic Medicine→ examination of traumas to the deceased. This is done post-mortem to determine cause of death. o Forensic Psychiatry→ branch of psychiatry related to criminology o Forensic Odontology→ – application of dental science (bite marks on the victim, identification based on dental records) Relation to Forensic Science (e.g., toxicology, ballistics, DNA analysis). o Fingerprints - obtaining and comparing prints o Toxicology – study of blood/body fluids to detect drugs/chemicals (poisons) o Serology – study of blood/body fluids/stains on materials to characterise the samples and identify the individual o Molecular Biology/DNA – study of blood/body fluids/stains to isolate DNA. o Trace Evidence – study of biological/chemical in minute amounts ▪ hair (human, nonhuman), natural fibres, pollen, soil ▪ glass, paint, drugs, firearm powder residues ▪ Ballistics – study of weapons and ammunition ▪ Fire & Explosions – study of accelerants / explosive residues o Marks & Scratches - tools and their impressions o Forgeries - paintings, documents, cassettes, videos o Computer /Electronic Crime (Cybercrime) - machines using electronic technology o Photography - stills, videos, special techniques o Forensic Anthropology - skeletal remains Medico-Legal Death Investigation 1. Principles of Investigation: Scene examination.  Body examination. Circumstances leading to death. 2. Aims: This is for proper and accurate certification of death/bodily harm full and accurate statistics Legally 1. criminal justice: discovery / prosecution of crime and protection of innocent from scientific evidence 2. civil justice: info for settling estates / resolution of disputes (e.g. insurance conflicts) Public safety: info to relevant bodies (e.g. car safety) Education: related to preventable deaths and dangers to health and safety Information to public, particularly next of kin: explaining the cause and circumstances of death 3. Medico-Legal Systems: Since here the deaths are considered not natural and therefore no doctor can complete a death certificate, there is a need for a death investigation system. Death investigation systems are arranged to identify and investigate deaths that are (or might be): unnatural, overtly criminal, suspicious, traumatic, caused by poisoning, unexpected, unexplained. Coroner system (e.g., UK, Australia). Medical Examiner system (e.g., US, Canada). Magistrate system (e.g., Malta). 4. Magisterial Inquiry in Malta→the in genere This is done after a request by the police, or from a private citizen Role of magistrates: o To collect ad preserve evidence, in order to determine whether a person should be charged. o Appointed evidence collection and death inquiries. o Collaboration with experts (e.g., SOCOs, pathologists) Reporting deaths under specific circumstances (e.g., custody, violent deaths). 5. Court Experts Article 551(1)→ if the death is sudden, violent, suspicious or the cause is unknown, a report is to be made by the EP to the magistrate on duty. Following such there is to be an inquest on the body to ascertain the cause of death. In orderto ascertain such fact the magistrate can collect as much evidence as is possible. Following this a procès-verbal is to be drawn up and signed. The finsings are to includes the cause of death. Doctor to examine the scene of death (clinical forensic physician or the pathologist) SOCOs (Scene of Crime Officers, members of the Malta Police Force with specific training) A photographer  an architect to document the scene  an expert to hear evidence on oath from witnesses on site (can be the medical expert) others as required (ballistics, toxicologist, DNA, etc.)  independent and funded by judicial system appointed by the court o following continental inquisitorial system (independent establishment of the truth appointed in uneven number their report is submitted only to the Magistrate, is confirmed on oath, and becomes part of the procès-verbal o include photographs, articles, documents relevant to their investigation can see each other's reports, once presented to the Magistrate the only persons entitled to information derived from the results of the investigation are the Magistrate, the AG and the investigating police officers 6. Medical Experts clinical forensic physician attends scene of death/ interviews witnesses/ advises court pathologists (often 2) carry out autopsy, identification (and occasionally attend scene) toxicologist, if necessary  specialist medical experts police call a doctor from health centre to certify death – not an expert witness 7. Which deaths are reported to the Duty Magistrate?(Guidelines) *All death which aren’t cosidered natural* Death in custody as contemplated in the Prisons Act or whilst in Police Custody Mount Carmel Hospital whilst being hospitalised following a court order to is being detained for examination by experts appointed by the court to report on the plea of insanity uncertified (no medical history, foreigner) due to violent, suspicious, or unexplained cause death in legal custody in mental hospital if under custody accident - use of vehicle, car, ship, aircraft accident in public, including hospital, institution, home by drowning in fire or explosion unexplained death in a child possible suicide at work, including industrial disease due to poisoning due to fault of another or to neglect following an abortion death under medical care possible negligence by medical carers therapeutic/ diagnostic hazard under anaesthetic 8. Manner of death  Manner (or Mode) refers to the circumstantial events (legal categorization), during the investigation of a crime, the Magistrate needs to establish the Manner (or Mode) of Death There are 5 manners of death: 1. Natural 2. Unnatural 1. Accident 2. Suicide 3. Homicide 3. Unascertained or undetermined Manner→ how the person died. Cause of Death→ what medical condition caused the death, this is listed on the death certificate. Mechanism of Death → Physiological derangement that results in death. 9. Key Concepts Manner, cause, and mechanism of death. Legal categorization and medical factors. Identification (PAT5753) 1. Identification procedures General Specific Special 2. Identification Scenarios Visual identification possible but there is no ready clue Usually: visual identification not possible but there is a match to a missing person Rarely: visual identification not possible and there is no indication as to name Why is it necessary to identify the victim? 1. Ethical and humanitarian reasons; to know who died 2. Legal reasons; criminal investigations, civil→ inheritance, remarriage(death in absentia), legal claims and obligations & death certificates. 3. Social → religious reasons in order to be buried a death certificate is needed. 4. Statistical and legal purposes. 5. What information should be collected from the scene? The position of the body 1. collect all human remains, clothing, personal effects 2. fingers, teeth may fall off 3. any personal effects→ 4. these are not specifc 5. direct line of enquiry 6. identification by weight of evidence  7. degree of association with body as in mass disasters in confined spaces 8. keys, papers, personalised effects (ID, letters, credit cards), clothing, jewellery What features should you look for on external examination? 1. General characteristics. Height, Weight, Build, Age, Sex Race 1. Height→ may be erroneous because; 1. Loss of water = shrinkage 2. First stage of flaccidity = body lengthens 3. Rigor mortis = body shortens 2. Weight → may be erroneous 1. Early decomposition = increase in weight 2. Late decomposition = decrease in weight 3. Age 1. Babies→ the examination of the fontanelles, the posterior(back) fontanelles is fully fused by 3 months and the anterior fontanelle closes fully between the 18 th and the 24th month. 2. Children→ the examination of the ossification centres & the epiphyses till the 20-25th yrs and also an examination of teeth. 1. Ossifications centres are developed within the 5th year of life. 2. Following this the fusions of the epiphyses begins, and can last until the 25th year of life. 3. The medial clavicular epiphysis (shoulder bone) is usually the last evidence of such fusion 4. The accuracy possible is within 1-2 yrs in foetus and infant. 5. The fusion of epiphyses earlier in females and in tropics. 6. Teeth eruption till 20-25 yrs but earlier in girls and in tropics. After 25 yrs, there are no dramatic events such as tooth eruption or the appearance of ossification centres 3. Adults→ obliteration of cranial sutures (wide range of ages). Thee is also the full ossification of the thin connective tissue ligaments separating the bones at the suture lines begins in the late 20s, and is normally completed in the 5th decade of life 4. Elderly → degenerative bone diseases (especially pubic symphysis, 4th rib, ilium – equally stressed in all individuals regardless of activity, proportional to age only). Edentulous (loss of teeth), wear and tear of teeth 4. Sex 1. obvious in all but severely burnt bodies. 2. elderly may have ambiguous facial features. 3. uterus, prostate resist decomposition  4. teeth - see below* teeth are the hardest and most resistant tissues in the body, can survive total decomposition and even severe fire* 5. combination of morphological (what it looks like (qualitative) and morphometric(measurable details (quantitative)). 5. Race→ some differences in facial skeleton and teeth, but this is usually not possible except for colour of skin. 6. Hair 1. distinguish from animal hair & fibres (microscopy) 2. distribution 3. colour: grey changes to brassy blonde at 120°C brown changes to slightly reddish at 200°C black does not change 4. hair peels in water 7. Eyes 1. colour difficult after a few days 2. with decomposition: tend to darken to brown 3. pupil size and shape (this can be effected by things like an operation) 2. How can you establish if the victim was alive when the fire started? 1. Victim was alive when fire started: 2. Carboxyhaemoglobin saturation 3. Carbon monoxide (CO) toxicity → cherry pink discolouration of skin / internal tissues 4. Carboxyhaemoglobin (HbCO) is the complex formed when haemoglobin is exposed to carbon monoxide. 5. Soot below the level of the vocal cords indicates the victim was alive and breathing. Bone Discovery: 1. Determining human identity, age, sex, and cause of death from bones.What information can be obtained from bone(s)? 1. Height, Weight, Build 1. tables for heights from long bones 2. Age 1. exclude archaeological remains 1. carbon dating 2. aspartic amino acid racemization dating 2. ossification centres, closure of epiphyses*same as above* 3. Sex; 1. Skulls 1. Males→ the skull is larger, there are square orbits, large mastoid process, marked supraorbital ridges and their glabella is marked.  2. Females→ smaller skull, the orbits are round, the mastoid process is smaller, they have a less prominent glabella finally palate is smaller. 2. Pelvis 1. Males→ the infrapubic bone is 90 degrees, there have wider hips, the broad sciatic notch and the sacrum is titled backwards. 2. What investigations are necessary / can be done? 1. anatomical examination with measurements 2. examination of teeth/ dental evidence 1. Sex→ 1. Males→ teeth are larger, the mandible is large with a square chin. The angle of body with ramus is straighter, less than 125. 2. Females → the chin is more rounded with a point in the midline. The differences is jaw are less marked in Indians. 3. measurements compared to published tables for populations. 4. DNA from tooth pulp 2. Race→ cannot really be determined from teeth though there are certain racial characteristics 1. Whites have canines with long pointed roots 2. Negroid races have large teeth and more cusps on molars 3. Mongoloid races (Chinese, Mongols, Eskimos, Japanese) have shovel shaped upper central incisors – not exclusive. 3. Age→ 1. Criteria for age 1. Biochemical test 2. special morphological dental and skeletal methods to assess development and/or deterioration 2. Children 1. easiest up to second decade 2. sequence of deciduous teeth well known 1. modified by sex (earlier in females), race and climate 3. after third molars erupt, age determination more difficult 4. third molar may be congenitally absent 3. Adults 1. wear and colour deteriorate with age  2. marked occlusal attrition indicates age 3. unless rough diet has accelerated process 4. edentulous jaws indicate age 1. beware of skeletons where conservative dentistry not available 2. alveolar margins (mandible) atrophy when teeth are lost 5. different diagrammatic methods to record teeth 6. main examination problem is access due to rigor 1. necessary to cut masseters to release jaw 2. in decomposed bodies or in fires, can remove mandible or skull itself 4. Charting → when it comes to charting the following should be noted; 1. dentures - pressure marks on gums or palate 2. dental prosthesis - bridgework, braces 3. extractions - recent or old 4. fillings - number, position, composition  artificial teeth - composition 5. crowned teeth  broken teeth. 6. pathology of teeth, gums, jaw 7. congenital defects - pearls, ectopic teeth 8. malpositioned teeth – rotated or tilted. 9. hygiene - caries, plaque, tobacco staining, gingivitis 10. racial pointers *Neither a living individual nor a body can be identified simply by taking a dental chart – that chart has to be compared with, and found to match, a chart whose origins are known* 5. X-ray (e.g. ossification centres) 1. These are done before the removal of the skull. 2. For superimposition, frontal sinuses, broken roots, dental work, congenital anomalies, and other foreign bodies. 3. Bite marks→ an image of a bote mark on the victims skin can be correlated with the surface image of the dentition of the suspected offender. 6. DNA 7. Archaeological remains – carbon dating, protein studies  Decomposed Body: 1. What information should be available to the pathologists? 1. tattoos - dermal pigment, scarred skin, skin lesions 2. amputations - not unique 3. healed fractures - unique plates and pins 4. prostheses - glass eyes, contact lenses, artificial joints. 5. surgical scars and sutures 6. occupational scars 7. normal variance - frontal sinuses, sacroiliac joints 8. skeletal disease - degenerative disorders 9. congenital abnormalities - cervical ribs, extra digits 10. pregnancy 11. dental records 2. Investigations which can be done to confirm or exclude identity 1. Document features & general characteristics (full body autopsy) 2. Dental examination of teeth and jaws (forensic odontology) 3. Comparative methods for identification 1. Medical Records 2. Photography 3. Charting 4. Fingerprints 5. Radiography (full body x-ray) 6. DNA 7. Blood grouping 8. Facial Reconstruction 3. Specific features 1. Fingerprints→ 1. they are unique to every individual. 2. for them to change they need to be scarred. 3. They are useful as long as a record of the prints exist. 4. identification based on the classification of the finger ridge pattern.  5. the overall appearance of the ridges can be described as arches, loops and whorls. 2. Full body X-Rays 1. fractures, deformities, degenerative diseases  prostheses, metal sutures 2. dental fillings 3. metallic objects (clothing, jewellery) 3. Blood grouping 1. ABO, Rhesus grouping from blood 2. ABO secretors: people who secrete blood group antigens in their body fluids (e.g. saliva, sweat, tears, semen…) 4. DNA fingerprinting 1. any sample with nucleated cells 1. in forensic practice: 1. saliva, hair 2. bone marrow 3. tooth pulp 4. tissue at the scene of the crime 2. An individual's DNA pattern is unique. 3. Match based on a number of tests. 5. Specific features: special techniques 1. Photo superimposition → alignment of photo with radiograph of the skull with optical precision + superimposed bony facial features, frontal sinuses 2. Facial recognition → Scan features on photo or acquire from vide + Compared with a database of facial images. 3. Computer-enhanced; Aging images of missing children Photograph family members 2. 3D methods→ 1. 3D printing of skull from a CT scan 2. 3D Sculpture 3. Facial reconstruction → from CT scans + facial reconstruction software Outline: Legal Implications of Wounding & Head Injuries 1. Introduction Importance of understanding the intersection of medical and legal fields. Learning objectives: 1. Criminal law on bodily harm (grievous vs. slight). 2. Forensic evidence collection techniques. 3. Specific implications of head injuries. 1. Scalp 2. Skull 3. Brain damage 4. Intracranial haemorrhage 2. Bodily Harm Criminal Law 1. Sub-divisions of crimes against the person (Criminal Code Title VIII): 1. Wilful and involuntary homicide. 2. Wilful and slight bodily harm. 3. Justifiable harm scenarios 2. Definitions and thresholds for Grievous Bodily Harm (GBH): 1. Article 216 1. Loss of life 2. Permanent debility or defect. 3. Disfigurement or deformity 4. Permanent mental infirmity  5. Deformity or disfigurement in the face, neck, or hands 6. Harm to the body cavities without producing permanent debility or defect. 1. Cranial cavity, thoracic, and abdominal cavity. 7. Physical infirmity lasting 30+ days. 8. Impact on pregnant women such that it hastens delivery 2. Article 218, GBH 1. Permanent debility to any organ of the body or permanent defect or permanent mental infirmity 2. Serious and permanent disfigurement in face, neck, or hands. 3. Committed on a woman with child and it cause a miscarriage. 3. Article 217; 1. Punishable with 2-10 years If arms, cutting or pointed instruments explosives, burning or corrosive substance were used 2. Imprisonment for a minimum of 4 years if the offence is committed by means of explosives (& no probation) 4. Criminal Code, Article 220: after grievous bodily harm 1. If death ensures as a result of the nature or natural consequences of the harm and not of a supervening accidental cause: 1. within 40 days → 6-20 years prison 2. >40 days but 60yr)  3. disability (amended in 2021, before it was physical or mental infirmity) 3. Slight Bodily Harm: 1. Harm not causing permanent or extended effects. Punishable with a maximum of 2 years imprisonment or a fine. 2. If bodily harm is of small consequence to the injured, the punishment is reduced, but still more severe with use of arms etc. Evidence Collection, Article 357: the establishing and preservation of the evidence is the same as a drawing up of a “repertus” 1. Preservation and documentation of physical traces. 2. Examination of the suspect (fingerprints, photographs). 3. Legal procedures for obtaining intimate vs. non-intimate samples. Article 554(2)→ suspects may be photographed/measured, have their fingerprints taken or any part of their body/clothing to be examined by experts. 1. When they are no longer required that are to be destroyed or that they are handed over to whom they refer. Intimate/ non-intimate samples 1. Intimate sample→ 1. a sample of blood 2. semen 3. other tissue fluid 4. pubic hair 5. swab from a person’s body orifice other than the mouth 2. Non-intimate sample means 1. sample of hair (other than pubic hair) 2. sample from a nail or from under a nail 3. swab from any part of a person’s body (including mouth, no other orifices) 4. urine 5. saliva 6. footprint or similar impression of any part of a person’s body (not hand) 3. Fingerprints have their own regulations 4. Samples of an arrested person: 1. 355BA→ the investigating officer + consent of the person arrested → take the following samples 1. Fingerprints 2. Non-intimate photographs 3. Non-intimate samples 2. If they refuse(A.355AV)→ the magistrate can authorise these samples to be taken under A.554(2). The magistrate can order the following samples. 1. intimate samples 2. photos of intimate body parts  3. fingerprints, non-intimate samples, non-intimate photos if person had refused consent. 3. Article 355AX→ the magistrate decide if an intimate sample is justified. If this is justified they visit the person and request their consent and before explain the nature of the request and the reasons thereof. The arrested person may still consult their lawyers. 4. Article 355AZ→ refusal without good cause can be interpreted in a manner support the evidence against the person arrested. The refusal can be considered to be corroboration for the evidence related to the refusal. 5. Article 355BA→ the person arrested may ask 1. For non-intimate samples to be taken 2. For intimate samples to be taken but this must be approved by the magistrate. 5. Samples of a non-arrested person: 1. Article 355BB: They may only be taken with the person’s consent in writing, additionally a non-intimate sample requires the Magistrate’s authorisation. 2. Article 355BC: they may also request samples to be taken if they suspect that otherwise they may be arrested, again requiring the Magistrate’s authorisation for intimate samples. Intimate search – arrested person 1. The physical examination of person’s body orifices other than the mouth 2. Article 355AP; if the arresting officer has reasonable suspicion that the person arrested may have concealed on their person any drug, which the possession of constitutes a criminal offence. They may request a Magistrate to order an intimate search of the person arrested. 3. Article 355AQ→ intimate searches are to be carried out by no one else other than a medical practitioner and there needs to be the consent of the arrested person, in writing. Fingerprints→ 1. Article 397(3); fingerprints may be taken and they are to be destroyed or handed over to the person once acquitted 2. Article 355BA(1)→ the investigating officer needs to obtain consent in writing of the person arrested to take fingerprints. 1. If they object authorisation may be required from the magistrate. 3. Fingerprints, Photographs and Measurements of the Accused Persons Regulations (SL 9.04) 1. Fingerprint may be taken by a member of the police force 2. They can be taken in court or wherever the court deems fit. 3. Head Injuries Types of Head Injuries 1. Scalp injuries (abrasions, lacerations). 2. Skull fractures (linear, depressed, base fractures). 1. Linear→ straight line fractures of the vault 1. Skull collided with an object, due to blunt trauma over a wide surface area of the skull. 2. The point of impact and the fracture may occur away from each other. 3. Skull bend inwards on impact 4. This can be caused by both minor and major trauma. 5. It is not considered serious unless there is other brain injury/haemorrhage. 6. They heal with minimal intervention. 2. Depressed→ fractures of the vault 1. They occur at a focussed point of impact with a heavy but small object ex. Hammer or rock. 2. A piece of the skull is pushed inwards by a couple of millimetres. 3. There is the possibility of brain injury and may require surgery. 3. Base fractures. 1. This involves the base of the skull. 2. Occurs due to sever blunt force. 3. It would generally involve sinuses with risk of infection. 4. They are seen in acceleration-deceleration fractures. 1. Ex. Hinge fracture 1. Transverse crack across the base of the skull; motorcyclist’s fracture. 2. Indicates an acceleration- deceleration injury. 3. Evidence of these fractures would be an indication of speeding injuries. 4. Skull fractures: they are a result as a direct injury to the face. There are three types: 1. Type 1→ A horizontal fracture through the upper jaw, the lower part of the nasal septum, and the bones at the back of the upper jaw. 2. Type 2→ A slanted fracture involving the cheekbone, lower eye socket edge, and the nasal bridge.  3. Type 3 → A fracture above the cheekbone, passing through the sides of the eye socket and the joint between the nose and forehead. 3. Brain damage (concussion, contusion, edema)(TBI → traumatic brain injury). 1. Concussion → form of a traumatic brain injury. 1. This is caused by an injury that causes the brain to move back and forth. 2. Temporary disruption of brain functions, without structural damage 2. Coup vs. contrecoup; 1. Coup; where the head is struck 2. Contrecoup; is the diametrically opposite the impact point (classical contrecoup injury 3. Contusion→ bruising to the brain. 1. There could be coup and contrecoup injuries 4. Brain oedema 1. Swelling of the brain. 2. Sign of oedema could be 24-48 hrs after the injury 5. Diffuse axonal injury (DAI) 1. occurs when the brain rapidly shifts inside the skull as a result of a severe head injury. 2. This rapid movement leads to the stretching, shearing, or tearing of axons, which are the long, thread-like parts of nerve cells (neurons) that transmit signals in the brain. 6. Intracranial hemorrhages: 1. Extradural/Epidural: Lucid interval followed by rapid deterioration. Occur typically when there is a fracture of the temporal bone. 2. Subdural: Results from bleeding due to rupture of the bridging veins in the subdural space 1. Often seen in older adults or infants 2. Acceleration force on the brain.  3. There are two types; 1. Subacute subdural haematoma; Gradual pooling of blood in the subdural space 2. Chronic subdural haematoma; A slow ooze of blood starts to organise at the edges after 2 weeks → this displaces the brain → may take months to produce clinical effects → eventually severe compression occurs 3. Subarachnoid: Most common type & any damage to cortex, is accompanied by some degree of subarachnoid haemorrhage; may arise from; all penetrating injuries & blunt injuries 4. Intracerebral: Risk factors include anticoagulant use. Can be due to head injury (may be delayed for 2 weeks or more). Can be due to hypertension, AV malformations or aneurysm rupture Open vs. Closed Injuries: 1. Penetrating injuries vs. intact skull injuries. Forensic Considerations: 1. Coup-contrecoup injuries. 2. Plaques jaunes in contusions. 4. Torture A forensic doctor can investigate allegation of torture/abuse of human rights: Person claiming refugee status due to torture. 1. examination not very fruitful, especially if considerable time has elapsed from the time of torture. 2. less likely to see fresh injuries. 3. all type of mechanisms is used, preferably those that do not scar Prisoners in custody 1. properly treated during detention and interrogation 2. actual physical abuse less frequently seen 3. more subtle use of threats and intimidations 1. hooding, prolonged standing, continuous high-pitched sounds 2. disorientation - food at erratic times, frequently waking person after short intervals of sleep, light in cell all day long. Police Act, chapter 164; Third Schedule: Code of Practice for Interrogation of Arrested Persons 1. Article 16; Any inhuman or degrading treatment, or any form of physical or mental torture is prohibited and an offence under article 139A, Criminal Code → max 9 years imprisonment 1. Guidelines regarding interrogation: 1. person being interrogated should all times be seated 2. no foul language, threats, deprecatory laughter, menacing gestures 3. firearms, weapons not to be exhibited unless part of investigation.  4. person questioned must not be bound by rope, chain, shackle, but may be handcuffed for safety or to prevent escape. 2. Article 17; intellectual disability: interviewed only in presence of parent/ tutor/ carer/ social worker of same sex as interviewee 1. documents signed by the person with disability and by parent / accompanying person at interview 2. persons under influence of drugs, alcohol, medicine, or in shock, should only give statements when able to appreciate significance of questions and their answers 3. certification by doctor of any sick person before interrogation Pregnancy, Abortion, Assisted Reproduction 1. Introduction o Relevance of reproductive health laws in criminal, civil, and ethical contexts. o Learning objectives: 1. Proving pregnancy in legal scenarios. 2. Criminal and legal frameworks surrounding abortion. 3. Assisted reproductive technologies (ART). 4. Deaths in infancy and their medico-legal implications. 2. Pregnancy o Legal Scenarios: 1. Allegations of abortion. 2. Infanticide investigations. 3. Inheritance disputes. 4. Witness exemptions or sentencing deferments. o Diagnostic Techniques: 1. Early pregnancy: Hormonal markers (hCG) and ultrasound. 2. Late pregnancy: Physical examination and palpation.  3. Recent pregnancy: Uterine changes, lactation evidence, uterus remains palpable up to 2 weeks after delivery 3. Abortion o Types of Abortion: 1. Spontaneous (therapeutic or criminal). 1. Spontaneous → miscarriage, foetal chromosomal abnormalities incompatible with life (50%) Maternal or paternal problems 2. Induced → terminating of a pregnancy through a medical procedure, typically within the 2nd trimester. 1. Therapeutic abortion seeks to save the mother’s life. 2. doctors with strong religious/moral objections can refuse. 3. Legal abortion conditions (life-threatening cases under Maltese law). 4. Criminal abortion 1. The deliberate termination of a pregnancy outside the legal provisions of the state. 2. against ethics of medical profession, disciplinary action by Medical Council 3. it can be done by anyone, the mother herself, a health worker, or a lay person. When the mother herself performs an abortion; doctor - patient confidentiality remains in effect ad they are to treat the patient as usual. The doctor needs to report the incident if the woman passes away. If by a professional abortionist; the name, if known, could be disclosed without any breach of confidentiality. o Methods: 1. Drugs 1. Home remedies; like vegetables compounds/chemical. 2. Medical abortion; mifepristone [block progesterone thus halting the growth of the foetus], misoprostol[makes the uterus contract.] 2. Instrumentation: 1. Dangerous because it can lead to tears in the vagina/cervix or perforate uterus/intestines. 3. General violence: self-inflicted or not 1. deaths of woman from trauma, often no foetal death 4. local interference: 1. chemicals to cervix/uterus cause burns/irritation 2. maternal death from toxic absorption or embolism 5. Surgical procedures (vacuum aspiration, dilation and evacuation). 6. Complications: Hemorrhage, sepsis, air embolism. o Legal Framework: 1. Articles 241-243: Penalties for induced and negligent abortions. 2. Recent amendments permitting life-saving terminations.  1. Article 243B → if the maternal life is at an immediate risk or the health of the mother is in grave jeopardy which may lead to death. All other treatments have been exhausted. Decision is taken by 3 specialists 1. obstetrician/gynaecologist who carries out the intervention. 2. another obs/gynae; 3. a specialist in the condition she is suffering (except in emergency cases: only the first) the foetus is not viable. The intervention is to be carried out in a hospital. o Complications. 1. Perforation of vagina, uterus, adjacent organs 2. Haemorrhage (due to local genital trauma) 3. Sepsis (due to non-sterile instruments and lack of antibiotic prophylaxis) 4. Air embolism (due to injection of fluid into the uterus) 5. Shock 6. Cardiac arrest 7. Deep pelvic vein thromboses (late) 8. Sterility 4. Assisted Reproduction o This arises from infertility; the inability to conceive after at least one year of engaging in sexual intercourse without contraception. o Techniques: 1. Medically assisted procreation 1. IUI→ Artificial or intrauterine insemination 2. In vitro fertilization (IVF) + embryo transfer (ET) 3. Intracytoplasmic sperm injection (ICSI) + embryo transfer (ET) 4. Egg / sperm / embryo donation 2. The ART clinic→ (assisted-reproductive-technology-clinic) at MDH offers two types of services: 1. Medically assisted reproduction services to prospective parents facing infertility issues. 2. Fertility preservation to patients undergoing chemotherapy. o Embryo Protection Act; Chapter 524: 1. Provides for the protection of human embryos. 2. Restrictions on embryo use and fertilization limits. 3. Age limits for procedures.  1. Permissible age for implantation is up 48 years(women) 4. Prohibition on sex selection and cloning. 5. Donor: A third party who donates germ line cells to be used in medically assisted procreation. 6. Donations are not permissible in the following cases: 1. Between an ascendant and a descendant. 2. Between a descendant and an ascendant. 3. Between siblings. 7. Embryo: The human organism that results from the fertilization of a human egg cell by a human sperm cell, which is capable of developing. 8. Medically Assisted Procreation: Includes the in vitro handling of human oocytes, spermatozoa, or embryos to establish a pregnancy. 9. Examples of procedures: 1. Intra-uterine insemination 2. In vitro fertilization (IVF) 3. Intracytoplasmic sperm injection (ICSI) 4. Embryo transfer 5. Cryopreservation of gametes, germinal tissue, or embryos 6. Oocyte or embryo donation 10. Article 4(3) 1. Adoption of embryos if the death of the women ensues before implantation. Or any other reason where the prospective parent refuses the implantation or the maximum age permissible has been reached. 2. The adoption of an embryo may only take place if approved by the Authority. Requirements for Prospective Parents: 1. Must be declared physically fit for embryo transfer by a medical practitioner. 2. Must receive a favorable recommendation from the Adoption Board, in accordance with the Adoption Administration Act, determining their eligibility and suitability. Anonymity: The identity of the adopter(s) and the persons from whom the germ line cells originated shall remain anonymous in all cases. Prohibition:Simultaneous implantation of embryos originating from different persons in a prospective parent during the same cycle is prohibited. 11. Article 6; Unlawful procedures; 1. (a) Artificially fertilizing any egg cell for purposes other than bringing about the pregnancy of the prospective parent is prohibited. 2. (b) Intentionally fertilizing more than 5 egg cells from one woman in a single treatment cycle is prohibited.  Exception: If the prospective parents do not give explicit consent for the cryopreservation of embryos and the donation of fertilized eggs, it is unlawful to fertilize more than 2 eggs per treatment cycle. 3. (c) Transferring more than 2 embryos into the prospective parent within a single treatment cycle is prohibited. 4. (d) Removing an embryo from a woman before the completion of implantation in the womb to transfer it to another woman is prohibited. 5. (e) Selecting or discarding an embryo for eugenic purposes is prohibited. 6. (f) Performing artificial fertilization or transferring a human embryo into a woman who intends to give up her child after birth (surrogate mother) is prohibited. 7. Penalties: Offenders shall be guilty of an offence and subject to: A fine (multa) ranging from €5,000 to €15,000. Imprisonment of up to 3 years. Or both penalties. 12. Article 7; Cryo-preservation of Germ Line Cells and Embryos 1. Sperm Cells: May be cryo-preserved up to the lifetime of the donor. 2. Oocytes: May be cryo-preserved up to the maximum permissible age for fertilization. 3. Embryos: Embryos that cannot be transferred into the prospective parent within a treatment cycle must be cryo-preserved. Cryo-preservation must take place in licensed tissue establishments for future use by that prospective parent. 13. Article 9: Donation and Use of Germ Line Cells 1. (2) A donor must: Be over 18 years of age. Have the legal capacity to contract. Be in good mental and physical health. 2. (3) A donor must not have attained the age of 36 years. 3. (4) Donor identity: Except in cases of direct donation, prospective parents can only obtain generic information about the donor, whose identity shall remain confidential. Medical records that could affect the child's health and the donor's identity (or that of the person from whom an adopted embryo originated) shall: 1. Be accessible to the child upon reaching 18 years of age.  2. Be accessible earlier, with the Authority's consent, in exceptional circumstances where the child's life or health is at risk. 4. (5) Donation limitations: The donation of germ line cells is limited to one donation per donor. Such donation shall be used for one prospective parent only. 14. Article 9(8): No person shall pay consideration to a donor or any other person for arranging the services of a donor or offer to pay such consideration. 1. Exception: Oocyte donors may be compensated for the costs and expenses of the stimulation treatments. 15. Article 10: Prohibition of the selection of sex in sperm cells, except in cases of sex-linked genetic illness. 16. Article 11: Prohibition of cloning, defined as any intervention attempting to create a human being genetically identical to another embryo, fetus, or human being. 17. Article 13: Prohibition of the artificial alteration of human germ line cells. 18. Article 15: Prohibition of experimentation on human embryos. 19. SL 452.114 1. Article 3(1): Prospective parents undergoing the process of medically assisted procreation, whether in or outside Malta, are entitled to 100 hours of leave with full pay. 2. Article 3(2): Leave for medically assisted procreation can be utilized at any time during the process. 3. The distribution of leave: The prospective parent acting as the receiving person is entitled to 60 hours of leave. The other prospective parent is entitled to 40 hours of leave. Leave can be used in a non-continuous manner. A maximum of 3 processes of medically assisted procreation can be covered by this leave. o Ethical Considerations: 1. Anonymous donations. 2. Single-use donor restrictions 5. Infant Deaths o Terminology: 1. Foetal death: prior to the complete expulsion or extraction from its mother (irrespective of the duration of the pregnancy) 2. Perinatal death: Fetal death after 22 weeks and up to 7 days after birth, this includes stillbirths and foetal death. 3. Neonatal death: Within 28 days of birth. 1. Early: within the first 7 days of life 2. Late: after the 7th but before the 28th day of life  4. Infant: death after 1 year. 5. SIDS: Sudden and unexplained death of an infant. o Stillbirth v. Miscarriage: 1. Stillbirth→ foetal death at/after 22 completed weeks of gestation. 2. Miscarriage→ loss of pregnancy before the 22nd week o Stillbirth 1. “Signs of life” include: 1. Respiration 2. Heartbeat 3. Movement 4. Crying 5. Pulsation of the umbilical cord 2. Most stillbirths have an autopsy 3. Often no ascertainable cause of death, even after autopsy 1. If death occurs within a couple of days before birth→ maceration is present[early decomposition combined with exposure to fluid] 4. To bury a stillbirth, a death certificate is required. 5. Possible causes of stillbirth are varied and include: 1. Intrauterine infection (viral, bacterial, fungal) 2. Maternal medical conditions 3. Congenital defects (especially in the cardiovascular or nervous system) 4. Placental insufficiency 5. Problems during labour or delivery (intrapartum stillbirth) 6. Malta has a high infant mortality rate because of anti-abortion laws. o Causes and Investigations: 1. Causes; 1. Malformations