Penatalaksanaan Cedera Kepala Setelah Resusitasi dari Henti Jantung

Morphologic Determinants of Asphyxia in LungsA Semiquantitative Study in Forensic AutopsiesDisusun Oleh :Cut Lamia IsnainiElda MaharaniRidha MawaddahPembimbing:Dr.dr.H.Taufik Suryadi,Sp.F

BAGIAN/SMF FORENSIKFAKULTAS KEDOKTERAN UNIVERSITAS SYIAH KUALA BLUD RSUD Dr. ZAINOEL ABIDINBANDA ACEHJOURNAL READINGCarlos Delmonte, M.D., Ph.D., and Vera Luiza Capelozzi, M.D., Ph.D.From the Forensic Institute of Medicine (C.D.) and Departmentof Pathology (V.L.C.), University of So Paulo School ofMedicine, So Paulo, Brazil.Asphyxia is a name given to different kinds of lesions that can produce similar histologic findings. Thus, because of the varied nature of the different kinds of lesions, as well as the incidence of similar qualitative histologic findings with different causes, the aim of this work was to study special kinds of injuries with particular subsequent impairment. These include some diagnostic problems of sudden death of natural causes, including aspiration, suffocation, drowning, and strangulation.Lung autopsies with congestion, septal hemorrhage, and foreign body showed a specificity of 100% for victims of aspiration, where as ductal overinsufflation, interstitial edema, and bronchiolar constriction showed a specificity of 81.8% in victims of suffocation. Intraalveolar edema and dilatation of the alveolar spaces with secondary compression of the septal capillaries characterized drowning. Victims of strangulation showed a strong alveolar hemorrhage, with alveolar collapse and overinsufflation, associated with bronchiolar dilatation. It is concluded that semiquantitative analysis of lung autopsies might be a useful supplementary histologic criterion to support the diagnosis of asphyxia.

ABSTRACTIn biologic systems, the extent and type of pathologic and toxicologic findings can often be correlated with the specific circumstances of the fatal event.it is important to document the pathologic changes in such cases to exclude other forms of trauma or other modes of death that may denote murder made to appear as suicide or natural death.INTRODUCTIONit appears to us that subtle differences n the particular constellation of histopathologicchanges within the asphyxia death category may reflect how death occurred, through a gradation and quantitation of pathophysiologic alterations based on both the rapidity of compromise of the respiratory tract and its degree of completeness.the aim of this work was to determine semiquantitative morphologic parameters inprevious demographic and circumstantial data in 167 consecutive asphyxia deaths by aspiration, suffocation, drowning, and strangulation investigated by the Forensic Institute of Medicine in So Paulo.METHODSDemographic and Situational DataThe deaths included in this study consisted of 200 cases consecutively investigated from 1996 to 1998 by the Forensic Institute of Medicine (Table 1)Technical Procedures to Obtain the LungsThe thoracotomy was done in the anterior medial line by sternopubic incision.Multi-agent Regimen

METHODSMorphologic Study

Qualitative Analysis (Figure 1,2,3,4)Quantitative Analysis

Statistical AnalysisAll statistical procedures were done by use of the SPPS (version 6.0) statistical package (9), and the level of significance was 0.5%.FIG.1Lung parenchyma in asphyxia by suffocation. (AD) Alternating zones of ductaloverinsufflation (ov) and alveolar collapse (col) of the lung parenchyma in suffocation cases. (B,D) Characteristicinterstitial edema (ed).

FIG. 2. Lung parenchyma in strangulation(suicidal hanging and homicidal ligaturestrangulation). (A,B) Intraalveolar hemorrhage (hem). (CF) Alternating areas of alveolar collapse (col) and overinsufflation (ov). (G,H) Zones of bronchiolar constriction (brc) and dilatation (brd), a characteristic morphologic picture in this group.

FIG. 3. Lung parenchyma indrowning cases. (A) Panoramic view of intraalveolar deposition of proteic and amorphous material (am).(B) High-magnification view showing acute dilatation of the alveoli with extension, elongation, and thinning of the septa and compression of the alveolar capillaries by a prominent intraalveolar reddish liquid similar to edema (am).

FIG. 4. Lung parenchyma inaspiration cases.(AD) Characteristichistologic appearanceof congestion areas(cong) and engorged capillaries protruding into the alveolar lumen (arrows), as well as the foreign body occupyingthe bronchiolar and alveolar lumen (arrowheads).(E,F) Septal hemorrhage(double arrows), a typical morphologic reactionfinding in this.

METHODSQuantitative AnalysisThese parameters were semiquantified by a histopathologic score according to the extent and severity of the histopathologic lesions present in total tissue, examined as follows:0: Absence of lesion1: Presence of lesions in 1% to 25%2: Presence of lesions in 26% to 50%3: Presence of lesions in 51% to 75%4: Presence of lesions in 76% to 100%RESULTAspirationCongestion and hemorrhage allowed a distinctive histologic pattern to be highly associated with a diagnosis of aspiration, in which a septal hemorrhage was the typical morphologic reaction In addition to this picture of hemorrhage, there was considerable foreign body occupation of the lumen of the bronchioles and alveoli . Thirty aspiration victims (100%) were properly classified as having aspirationSuffocationIn the second pattern of asphyxia, the extension of the area occupied by ductal overinsufflation. and interstitial edema, were statistically more frequent in suffocation than in drowning or strangulation. However, ductal overinsufflation in the form of acute substantial emphysema was characteristically present in most cases of death by suffocation.StrangulationThe extension of the area occupied by alveolar hemorrhage, was significantly higher in lungs associated with strangulation. Equally significant was the association of alveolar collapse, alveolar overinsufflation, and alternating zones of bronchiolar constriction and bronchiolar dilatationDrowningIn the third pattern of asphyxia, extension of the area occupied by intraalveolar deposition of proteic and amorphous material, was the semiquantitative parameter statistically associated with drowning. The other parameters, although still present, were not as statistically significant in drowning as the edema was.DISCUSSIONAsphyxia can be defined as the injuries caused by oxygen deficiency (hypoxia) that involve all conditions and sequelae caused by impairment or interruption of the oxygen supply or utilization in the tissues.suffocation in forensic medical usage is restricted, for practical purposes, to cases in which environmental suffocation (inadequate oxygen in the atmosphere due to environmental conditions), smothering (due to mechanical obstruction of the nose and mouth), choking (due to blockage of the internal airways), and mechanical (due to pressure on the chest)In addition, the known macroscopic and histologic signs of general damage through hypoxia, e.g., edema, hemorrhage, pulmonary emphysema, passive congestion, and degenerative cellular changes, are usually diverse and are not conclusive as individual findings . Similar findings can also arise through injuries leading to impairment of the circulation, or ischemia, thereby reducing or interrupting the tissue oxygen supplies.In this work, qualitative study revealed common morphologic parameters for the four groups of asphyxia. In all cases histologically analyzed, the pulmonary architecture showed variables in the degree of alveolar tissue collapse, overinsufflation, bronchiolar constriction, and dilatation.DISCUSSIONAs aspiration lung was characterized by gastric content or amniotic fluid, partially or totally filling the bronchiolar lumen and the alveolar spaces, thus characterizing the foreign material aspirated. As a consequence, occlusion of the small airways, mainly the membranous and respiratory bronchioles, was atypical morphologic finding.In the fourth group of asphyxia, strangulation, alternating areas of bronchiolar constriction and dilatation leading to alveolar collapse and overinsufflation, associated with a picture of alveolar hemorrhage, were the morphologic characteristics of lung involvement. The Hamburg working group around Brinkmann has systematically studied the pathophysiologic processes that occur in the pulmonary vascular system and pulmonary tissue during strangulation. The object of these animal experiments and comparative pathologic studies in humans was the compilation of findings utilizing histopathologic staining methods and forensic-medical assessments. Further investigations concerning these problems involve the frequency of pulmonary hemorrhage in death by strangulationfresh-water drowned lung was characterized by acute dilatation of the alveoli with extension, elongation, and thinning of by a prominent intraalveolar intense rose-colored liquid similar to edema. Reidbord and Spitz and Spitz et al, described similar findings in victims drowning in fresh water, and unlike the findings of Knight, these positive signs of drowning were not scanty and nonspecific. The histopathologic picture of intraalveolar deposition of proteic and amorphous material (near-edema) found in fresh-water drowned lung has strong support in experimental studies on rats involving active aspiration of watery liquids of various osmolarities.TERIMA KASIH