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.

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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).

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• .

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• .

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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