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Nguyen Le Cat 2013, Signs and injuries of drowning in forensic identification, Journal of Practical Medicine, 876 7:... In order to do so, the forensic examiner has to fully collect thep

Specialized : Pathology and Forensic Medicine

ABSTRACT OF THE THESIS FOR MEDICAL DOCTOR

HA NOI - 2020

IN HA NOI MEDICAL UNIVERSITY

Scientific Supervisor:

1 PhD Luu Sy Hung

2 Associate Professor Dinh Gia Duc

The first Reviewer: Associate Professor Nguyen Phuc Cuong

The second Reviewer: PhD Nguyen Duc Nhu

The third Reviewer: PhD Tran Ngoc Dung

The Thesis approved by Council of scientist in Ha Noi Medical University

At: Date: 2020

References theThesis in:

1 Vietnam National Library

LIST OF PUBLICATIONS

This Thesis is based on the following papers:

1 Nguyen Le Cat (2013), Signs and injuries of drowning in

forensic identification, Journal of Practical Medicine, 876 (7):

Drowning is being asphyxiated caused by submersion of noses ormouth The mechanism is complicated and varied depending on thesituation, not only the asphyxia in submersion It is believed as the firstproblem of public health, and early studied because of social valuation

In evaluation of WHO, the proportion of drowning is 5.6/100.000population, two third is accidental, 1/3 suicidal drowning, rarelyhomicidal drowning Most of victims are children or young people.Vietnam is a tropical country, there are a large number of lakes andrivers, long beach which are potential for drowning, especially inhurricane season As others countries, the most common cause isoccupational or daily activity Others are homicidal or suicidal cause

In Military Institute of Forensic Medicine, the proportion ofdrowning is high However, there is no research of epidemiology,pathology and victims identification

In forensic examination, there are some problems for solving:

- Who is the victim? The cause of death? The cause of death isdrowning or not? Which examination or test to confirm the drowning cause?

- Could the patient be identified ? Which test for identification?

In order to do so, the forensic examiner has to fully collect theprimary evidences, analysis the scene, and forensic results, incombination with proper identification method

Therefore, the study “Assessment the forensically pathologic characteristics and identification method of drowning victims” aims to:

1 Description of the pathologic signs and characteristics of drowning victims.

2 Application of DNA analysis in identification of drowning victims.

1 The need of the thesis

The thesis is an answer for debating question regarding ofpathologic characteristics of drowning and proposes the DNA analysisfor identification method The description study concluded the valuablepathologic signs and characteristics for diagnosis In this study, the DNAanalysis was applied for victims identification

2 The contribution of the thesis

Statistical description of general characteristics of drowning such as:conjunctivitis (100%), lividity pattern (74.6%), rigor mortis (89.4%),froth (66.4%), wrinkle skin (58.1%), exophthalmos (100%), flared mouth(78.8%), peeling skin (72%), fluid and foam in the airway (54.8%),pulmonary edema (88.5%), the foreign body in airway (35.5%), water instomach (30.8%), the laceration of aveoli (88.5%), rupture RBC invessels and organs (50%) Diatom test plays an important role indiagnosis confirmation and location of drowning

The application of DNA analysis is an appropriate method tovictims identification: there was 18.02% victims need to DNA analysisfor identification, successful identification was 100% (31/31); from 1-4postmortem days, most of victims were identified by the normal method(83.3%-84.2%); 85% victims was required the DNA analysis foridentification from 5-9 days postmortem From 1-4 days postmortem, thenucleus analysis was used for every victim From 5-15 postmortem, themitochondrial analysis was more preferred, After 15 days postmortem,most victims was identified by mitochondrial analysis

3 The structure of the thesis

The thesis includes 108 pages General description (02 pages),Conclusion (02 pages), and proposal (01 page) Four chapters : Chapter

1 : General description (31 pages), Chapter 2 : Objects and Methodology(13 pages), Chapter 3: Results (22 pages), Chapter 4: Discussion (37

pages) It also includes 26 tables, 04 images, 09 charts, 73 referencematerials, study form and victims list, the image illustrates.

Chapter 1 BACKGROUND

1.1 Definition and classification of drowning

1.1.1 Definition

In 2002, the International Congress of Drowning defined drowning

as : “The asphyxiated process caused by submersion in liquid”

1.1.2 Classification

It is classified into two categories: intention and un-intention.Intention: homicidal or suicidal, Un-intention: accident, or undefinedcause

1.2 Statistical evidence of drowning

1.2.1 General statistics of drowning

According to WHO, there are 372000 death caused by drowningeach year; 42 death caused by drowning in average each hour Drowning

is the top cause of death for 1-24 years old population

1.2.2 The co-factor of drowning

1.2.2.1 Age

The most common is in 1-4 years old children, then 5-9 years old It

is one of the most 5 cause of death for 1-14 years old population in 48/85countries

1.2.2.4 Time

It depends on the victims and seasons

1.2.2.5 The causes

In the international congress, the causes was classified as:Accidental (56.2%), suicidal (23.8%), homicidal (0.28%), unidentified(16.5%).

1.2.2.6 Others risk factors

Alcohol, smoking, poorness, shortage of safety facility, climate, thetreatment approach, rehealibitation are the others risk factors

1.3 The pathologic mechanism

1.3.1 The history of drowning knowledge

It was firstly introduced in Greek 2 AC by Galen At that time, itwas supposed that the water filling in stomach and intestine causes thedeath The later studies showed that the water fills in the airway and lungcausing death

1.3.2 The mechanism of drowning

There are four main mechanisms: water inhalation, the filtration ofwater in blood stream, alveolus rupture and nervous reflex

c, Stage 3 (1-1.5 minutes): Epilepsy, coma, low BP, arrythmias,ventricular fibrillation, cardiac arrest

1.3.2.2 The water filtration in blood stream

There are two situations:

a) Drowning in fresh water: The dilution of blood causing thehypoosmolar natrium and chlorium causing the blood cells ruptures b) Drowning in salt water: Condensed blood No rupture of blood cells,the electrolyte equilibration is unchange

1.3.2.3 The alveolus rupture

Water enter the alveolus causing dilation and rupture Hemorrhage

in the lung parenchyma, other alveolus without water would be stressedcausing emphysema

1.3.2.4 The nervous reflexion.

Beside the alveolus rupture, water in the airway causing inhibition

of respiratory and cardiovascular centers located in the medullar leading

to death

1.4 The forensic pathology of drowning

1.4.1. The external signs

1.4.1.1. The foam

It is typical sign of drowning It is different with foam caused bypulmonary edema, this foam is more diluted and fragile

1.4.1.2. The rapid death in drowning

Cold cadaver, the temperature is equal with enviroment in primary8-24 hours, pale and wrinkle skin, eyes swelling

1.4.1.3. Signs of body soaked in water

Skin spikes, cold corpses, body temperature decreased by theambient temperature of the autopsy detected in 8-24h, skin of palms andfeet pale, wrinkled, eye mucus bulging due to water absorption

1.4.1.4. The traumas and evidences before and post mortem.

a, Traumas and evidences before mortem: water jumping, epilepsy,trauma injuries

b, Trauma and evidences post mortem: Caused by floating cadavers

1.4.1.5. The decomposition signs

In the water, it is pale cadavers In the early of air exposure, the skincolor change from green to black The cadavers will be decomposedrapidly, especially in summer

1.4.2. The internal signs

Water infiltrates in the sinus of head and face Hemorrhage in themiddle ear and mastoid bone Emphysema Soil, grass in the palm.Parasites.

1.4.2.2. Decomposed cadavers

The importants signs are disappeared: deflated lungs, foam andwater in trachea Water is in the shallow of chest The foreign body couldappear in the airway

1.4.3. The signs of untypical drowning

Inhibition reflexion (cardiac arrest, larynx spasm, dry drowning,death because of drowning complication)

1.4.4. The evolution of signs

In general: Self water absorption, decomposition and self movementFloating time: depends on the water temperature and characteristics

of alveolus The gold diagnosis is the appearance of water foreign body

in small bronchi and alveolus

1.4.5.2. Liver

The dilation hepatic and portal veins are filled with blood andwater The portal areas are dilated, swelling vessel wall, the parenchyma

is filled with water and blood Congestion of organs

1.4.6. The change of biochemistry

Imbalance serum electrolyte caused by water filtration

1.4.7. The biologic agents.

Diatoms test: In 1941, Incze proposed the diatoms test to definelocation of drowning

1.5 Some new studies of drowning

In 2015, Hosahally J.S et al conclued that: in fresh water drowningvictims, the intima of aorta root was darker In 2005, J.Blanco Pamoin et

al showed that 21.58% victims had the rupture of gastric mucosa Milone

A et al also showed that CT scanner could help to define the death before

1.6.2 DNA forensic examination

The DNA identification of drowning is exact and efficient.Especially in case of decomposed cadavers

1.6.3 DNA structure

DNA is double chains created by two single nucleotids chain InDNA, there are a lots of genes in particular order The location of gene inchromosome is called locus In nuclear DNA, each locus has two allens,one from dad, the other from mom Mitochondrial DNA is completelymaternally generated

1.6.4 The DNA analysis

1.6.4.1 The nuclear DNA

Nuclear DNA analysis is based on the structure and geneticcharacteristics With this method, the individual could be well identifiedonly by small sample

1.6.4.2 The mitochondrial DNA

Beside nuclear, the DNA also exists inside the mitochondrial in thecircle form, and maternal heredity Therefore the mitochondrial DNAanalysis gave lots of success

1.6.4.3 The comparison in DNA analysis

- Direct comparison: Between the victims DNA and the storedvictims DNA

- Indirect comparison: Between the victims DNA and the DNA ofvictims familial members

1.6.4.4 The comparison of nuclear and mitochondrial DNA

- Nuclear DNA analysis: It is unstable in the nature enviroment It iseasy, cheap and rapid analysis

- Mitochondrial DNA analysis: Circle form, stable in natureenviroment It is more difficle, poorly exact, long time for analysis

Chapter 2 OBJECTS AND METHODOLOGY

- Fulfilled forensic profile

- According to examination protocol

- Identification by DNA analysis

2.1.2 Exclusion criteria

- Unfulfilled profile

- Unrespect the protocol

- During investigation period

2.2. Study design

- Retrospective, perspective, cross sectional study

- Time: From Jun 2014 to Jun 2018

- Location: The Military Institute of Forensic Medicine, ForensicDepartement of Hanoi Medical University, Forensic center of Vinh Phuc,Forensic center of Phu Tho

2.3. The objects of study

2.3.1 General characteristics of objects.

Age, gender, time of death, time of examination, location, situation

2.3.2 External signs

Statistical, assessing and evaluating common signs

2.3.3 Internal signs

Statistical, assessing and evaluating common signs

2.3.4 The test

2.3.4.1 Pathology

Evaluation of histopathologic results

2.3.4.2 Diatoms test

To identify the location of drowning

2.3.4.3 Other complimentary tests

For Alcohol, drug, toxic in organs

2.3.5 Statistic of untypical drowning

2.3.6 Victims identification by DNA analysis

2.3.6.1 Nuclear DNA analysis

2.3.6.2 Mitochondrial DNA analysis

2.4 Ethic consideration

2.5 Biostatistic method

- Excel 2016 and SPSS 16.0

- Biostatistic analysis with significance in p<0,05

2.6 Bias and confounder

Chapter 3 RESULTS

3.1 General characteristics

3.1.1 Age and gender

Table 3.1. The distribution of age and gender

3.1.3 Time of forensic examination

Table 3.3. Post mortem forensic examination

Day 5-9

Day 10- 15

>15 days

Well-Sea wate r

Tan k Floo

d Total

n 69 53 9 24 8 1 5 3 172

% 40.1 30.8 5.2 14.0 4.7 0.6 2.9 1.7 100

 Educational level of the victim

Table 3.7 Educational level of the victim

Education

al level

Non educate

d

Primar y school

Seconda

ry school

High scho ol

Graduati

on of high school

defin e

Un-Tota l

% 4.1 17.4 50.6 11.6 6.4 9.9 100

 Ethnic

Table 3.8. Ethnic distribution

Ethnic minority Ethnic Ethnic major Undefine Total

3.2 The external signs

Table 3.9 Statistical of external signs

>15 Days Undefine

Scale off 1 24 20 4 3 0 52 30.23

Total 108 36 20 4 3 1 172 100

3.2.6 Flaring mouth

Table 3.15. The flaring mouth post mortem

Day 5-9

Day 10-15

>15 days

define

Day 2-4

Day 5-9

Day 10-15

>15 Days

define

Un-Total

p

n % Less change 105 16 3 0 0 1 125 72.67

3.2.8 Decomposition post mortem

Table 3.17. Decomposition post mortem

3.2.9 Foreign bodies in palms

Table 3.18. Foreign bodies in palms

Day 5-9

Day 10-15

>15 Days

define

Table 3.19 Injuries caused by floating and animal

Injuries Front of body Back of body Total p

3.3.1 Signs and lesions in the trachea and bronchi

Table 3.20 List of signs and lesions in the trachea and

bronchi

Characteristic

s

Fluid, air bubble s

Foreign object in airway, bronchi

Decompositio n

Unknow n

Tota l

3.3.2 Signs in the organ

Table 3.21 Statistics of signs in the organ

Signs Yes No Unknown

Water in stomach 85 81.7 16 15.4 3 2.9 104

Water in sphenoid sinus 9 8.6 1 0.9 94 90.5 104

Table 3.22 Characteristics of pulmonary lesions

Pulmonary lesions Yes n %

Lung stretch and slice with more blood 92 104 88.5Lung bland and slices with little blood 8 104 7.7

3.3.2.2 Congestive of organs

Table 3.23 Characteristics of congestive in organs

Congestive of organs Yes n %

Hanging trauma 1 0.96 103 99.04 0 0 104Cutting wist 1 0.96 103 99.04 0 0 104Hematoma around shoulder

Table 3.27 Signs and lessions of histopathology

Signs and lessions Yes No

Alveolus rupture and oedema 92 88.

5 2 1.9 10 9.6 104Breaking red blood cells 52 50 52 50 0 0 104Congestive in liver 79 76.

0 4 3.8 6 5.8 104Congestive and bleeding in heart 81 77.

9 5 4.8 18 17.3 104Congestive and oedema in brain 56 53.

8 3 2.9 45 43.3 104Congestive and oedema in kidney 71 68.

3 3 2.9 30 28.8 104

3.5.2 Diatom test

Table 3.28 Results of diatom test

Categories of diatom Yes No Total p