QUESTIONS AND SOME

ANSWERS IN FORENSIC
MEDICINE &CLINICAL
TOXICOLOGY
Dr. Mona EL-Gohary
 A child aged 3 years was found dead at home , The
servant witnessed that he was playing with a small
rod of metal while she was talking to somebody
who knocked the door then in less than 2 minutes
she heard a loud cry and found the child collapsed
to the floor. At autopsy, there were 2 wounds one
on the palm of the right hand and the other on the
sole of the left foot.
How to verify the age of the child?
Mention the cause of death in this case and its
mechanism.
Describe the external lesions and postmortem
investigations that should be done in this case
 1- To verify the age of 3 :
a- The child has 20 milk teeth in his mouth 4 incisors, 2 canines
and 4 molars in each jaw.
b- The first molar not erupted (they erupt at 6 years).

2- the cause of death is electrocution where the body of the child

was included in a complete circuit the entry was in the palm of the
right hand and the exit was in the sole of the left foot which was
earthed.
Mechanism of death:
Since death occurred immediately as witnessed by the servant the
mechanism of death would be
1) Ventricular fibrillation:
As it is Common with alternating current
2) Respiratory Failure:
Most probably peripheral because electric current usually
passes in the shortest path: It occurs when the current passes
through the thorax that will lead to tetanic contractions of the
intercostal muscles & diaphragm peripheral asphyxia.
3) Neurogenic shock:
Most commonly parasympathetic due to fear.

 The external lesions are electric burns they are

1-direct contact burns: due to electrothermal
heating.
a-The lesion in the palm of the right hand is an Entry
mark: (The point where the current enters the body).
It is a thermal burn results from heating epidermis and
dermis raised blister.
When the current ceases the blister cools and
collapses.
The collapsed blister is annular, raised, grey or white
with an umbilicated center.
b-The lesion in the sole of the left foot is an Exit
mark (Earthling lesion):
It is similar to entry mark but less severe.
 Investigations:
Tissue samples should be taken from the entry lesion and
the following investigations should be done:
- Chemical, histochemical & spectrographic techniques.
- Scanning electron microscope.
- Neutron activation analysis to look for Metallisation that
may be invisible by naked eye :
(Metallisation occurs due to transfer of metals from
metallic conductor to the skin and subcutaneous tissues.
- Histological examination will also reveal:
Compression of stratum corneum with superficial
carbonization
Separation of the epidermis by blister formation
Cells are separated in the form of slits (electric channels)
Coagulation of the dermis.
 There was a quarrel between 2 friends at home one of them
threw the other and fell on a carpet on the left side of his
head , ata that time the assailant took a heavy stick and
stricked his friend on the right side of his head . There was
no bleeding from the scalp. The assailant said sorry to his
friend who cooled down but he felt drowsy for a while then
he was well and talked to his friend and walked to his home
then after about one and half an hour the victim fell in
coma . At hospital The CT showed collection of blood in
extra-dural space. The victim was 25 years and the
assailant was 32years.
a-How to verify the ages of both victim and assailant.
b-What are the expected wounds in the victims head?
c- Mention the causes and mechanisms of drowsiness and
loss of consciousness in the victim?
d- What are the factors governing skull fracture?
 To verify age of 25:
a- X ray will show:
Lower end of femur united with shaft,
Upper end of tibia and fibula united with shaft,
Epiphysis of ischial tuberosity united with ischium.
b- Saggital suture doesnt close yet (It closes at
30 years)
To Verify age of 32:
a) Saggital suture is closed
b) The medullary cavity of humerus reaches the
surgical neck
a) Union of xiphoid process with the body of sternum
doesnt occur. (it occures at 40)
b) Union of greater wing of hyoid with body doesnt
occur (it occures at 40)
c) Coronal suture doesnt close yet (it occures at
40)
 The expected lesions in the victims head:
a- Contusion in the scalp because absence
of scalp bleeding means there is no open
wound.
b- Fissure fracture (polar fracture) in the
middle of the skull midway between point of
support and strike,
C- Extradural hge due to injury of of middle
meningeal artery or one of its branches
because loss of consiousness occurs rapidly
after head injury so the source of bleeding
should be arterial not venous.

 The cause of drowsiness in this case is

concussion
Its mechanism: It is due to the vibrations
affecting the reticular formation, of the brain
stem which is responsible for the normal
conscious state of the individual.
The cause of loss of consciousness in this
case is compression, its mechanism is:
 1- Stage of irritation:
I.C.T closure of veins first congestion
& edema cerebral irritation of the higher
centers on the side of the lesion manifested
by irritative signs: miosis, exaggerated
reflexes, twitches, high B.P. and slow pulse.
2- Stage of paralysis:
More I.C.T. closure of the thick walled
cerebral arteries ischemia & paralysis of
the higher centers on the side of the lesion
(Mydriasis, loss of reflexes, muscle
paralysis and fever).
 A man aged 67 years was found dead in the
back yard on 22th of August by the police
on morturary, External exam. Revealed
hypostasis in the back, greenish
discolouration of the skin of right lower
anterior abdominal wall.No external wounds
were found.
a- How to verify the age.
b- What is the time passed since death
c- Mention mechanism of rigor and its state
in this dead body.

 The time passed since death in this case is

nearly 24 hours because the problem stated
that the dead body was found on 22th of
August (summer month) so the greenish
discolouration of skin of the anterior
abdominal wall that starts opposite to the
right iliac fossa,is considered as a first sign
of putrifaction due to the presence of
caecum in this place which contains fluid
full of bacteria .
 Rigor disappear and the muscles are in a state of
secondary flaccidity ,when rigor is taken as a key
to know the post moertem interval it is done as
follows:
- 2 hours after death: Rigor mortis starts to appear
in small muscles of the face (eye lids & lower jaw).
- Then progress gradually to muscles of the neck,
trunk and limbs (small joints are affected before
large joints).
- About 12 hours: It is usually completed all over
the body.
- It disappears in the same order and the body
again becomes flaccid (secondary flaccidity).
- About 24 hours in the summer and about 36
hours in the winter: It disappears completely.
 2-Mention four factors affecting:
A- Hypostasis
B- Burn gravity
C- Severity of electric injury
D- Shape of firearm wound inlet.
3- Mention mechanism of :
A- Death in hanging
B- Countercoup brain injuries
C- Brain compression
 Enumerate medicolegal importance of:
A- Abrasion
B-Adipocer
C- Sex chromatin
D- Hyoid bone
 How to prove that:
A- The wound is stab wound
B- The distance of firing is contact
firing
C- The wound is an inlet of electric
current
D- The tear in hymen is recent
E- The woman delivered recently.
 Toxicology
A young female ingested a large number of tablets
prescribed for her pregnant mother as a tonic. After few
hours she suffered from repeated vomiting and diarrhea
with hematemesis and bloody stool. Some hours later she
became very ill.
On exam. Blood pressure was 80/50 pulse rate was 100/min
respiratory rate was 28/min.
Laboratory investigations revealed severe metabolic
acidosis.
What is your provisional diagnosis
What are the investigations necessary to confirm the
diagnosis and manage the case
How to treat this case?
 The provisional diagnosis is Acute severe iron
toxicity based on c/p mentioned in the case, the
child came in the first stage (within 6 hours) as
she was shocked (bp 70/50 and pulse was
100/min) with metabolic acidosis in addition to the
history given of repeated vomiting and diarrhea
with hematemesis and bloody stool.
Investigations required are:
(1) Laboratory findings:
Serum iron level: normal 50-175 ug/dL & may reach to
350 ug/dL. 500 ug/dL is definitely toxic. > 1000 ug/dL
is fatal.
Liver function tests.
(2) Radiography: of GIT reveal tablets or diffuse
densities.
 Treatment:-
(B) Emergency & supportive treatment:
Treat shock, coma, metabolic acidosis. (general
toxicology)
(C) Specific antidote (chelators): Deferoxamine
(desferal)
For serious toxicity or serum iron 500 ug/dL give 10-
15 mg/kg/ 4-6hr IV infusion up to 6 g/day.
Continue treatment until clinical resolution or serum
iron 100 ug/dL.
(D) Decontamination:
Gastric lavage.
Whole bowel irrigation: if any concretions appeared
on X-ray.
(E) Enhanced elimination:
To remove deferoxamine-iron complex in patients with
renal failure.
 A young child ingested a whitish solution
prepared by his mother for washing
purposes. He cried immediately and
vomited. On examination in the hospital
there was excessive salivation, repeated
vomiting (soapy vomitus) and erythema and
edema in the oropharynx with growing
respiratory distress and rapid weak pulse.
A- What is your provosional diagnosis?
B- Mention the possible complications of
this ingestion?
C- How would you manage the case?
 Diagnosis is acute ingestion of alkali
corrosive (coustic potassh) based on
mentioned clinical picture that appears
immediately after taking the drink together
with appearance of repeated vomiting,
erythema and edema in the oropharynx with
growing respiratory distress and rapid weak
pulse
The excessive salivation and the soapy
vomitus highly suggest alkaline corrosive.
 Management of the case:
I- Investigations:
1)Laboratory investigations
- Electrolytes and renal profile.
- Arterial blood gases (ABG).
2) Radiography:
- Chest X-ray to rule out early pneumonia, pleurisy or mediastinitis.
- Abdominal X-ray (upright position) to detect any free air in case of perforation.
3)Endoscopy:
It should not be passed beyond the first circumfrential burn, contraindicated if respiratory
distress is present.
4) ECG (serial) will detect early appearance of pericarditis and mediastinitis
II- Treatment:
(A) Prevent further exposure.
(B) Emergency & supportive treatment:-
Pain killers.
Stabilization of vital signs of the patient including ABC
(C) Decontamination:
Dilution therapy: One or two glasses of cold milk or water are given to the adult within 30
minutes ( given in multiple small amounts for fear of inducing vomiting).
(D) Other measures:-
- Steroids: to prevent fibrosis, in stridor, bronchospasm or acute pulmonary edema.
- Antibiotics to guard against infection.
- H2 blockers (rantidine) to minimize HCL secretion.
- Total parentral nutrition for at least 3 weeks.
- Surgical interference according to the severity of the case.
-Surgical and ophthalmic consultation is indicated.
 Comment on the following:
Differential diagnosis of toxic bite.
Mechanism of (toxicity)actions of:
Ethanol
Methanol
Digitalis
Botulinum toxin
Elapedea poison
Vipredea poison
 GOOD LUCK AND HAVE A NICE
SUMMER