From Big Medical Encyclopedia

ASPHYXIA (asphyxia; grech, and - otritsa. + sphyxis pulse) — suffocation; life-threatening pathological the state caused sharply or subacutely arising lack of oxygen of blood and accumulation of carbonic acid in an organism and which is shown a heavy symptom complex of disorders of the vital functions of an organism, hl. obr. activity of a nervous system, breath and blood circulation.

Vida Asfiksiya

Asphyxia as a result of disturbances of external respiration meets most often. Reason And. there can be mechanical obstacles to access of air to respiratory tracts at their prelum from the outside (e.g., a suffocation) or their considerable narrowing. The last can be caused by inflammatory process (e.g., diphtheria), hypostasis of a throat, retraction of language (at wounds of a mandible; during an anesthesia and at other unconsciousnesses), a tumor, a laryngospasm or small bronchial tubes (e.g., at bronchial asthma). Frequent reason And. there can be a closing of a gleam of respiratory tracts as a result of aspiration of food and emetic masses, blood, waters (during the drowning), hits of various foreign bodys, etc. At a fruit And. of this sort can arise in cases of premature emergence of spontaneous respiratory movements and intake of amniotic liquid in respiratory tracts, and also at the full or partial obstruction of respiratory tracts caused by accumulation of slime. Wounds and the closed injuries of a thorax breaking it respiratory excursions, and also a pulmonary collapse at hit of significant amounts of air in pleural cavities (pheumothorax) or accumulation of liquid in them (exudative pleurisy, a hemothorax) can also bring to And.

Asphyxia from a lack of oxygen of inhaled air it can be observed at hypobaropathy (see), in the specific working conditions connected with breath in loop systems with forced feed of gas mixture when supply of oxygen and absorption of carbon dioxide gas is broken; And. arises at stay in the isolated closed space when there is a gradual fall of the oxygen content in air and the progressing increase of concentration of carbon dioxide gas. Characteristic for And. disorders of life activity develop in such cases against the background of normal or even the increased lung ventilation in the beginning. Further activity of a respiratory center is broken, the volume of ventilation falls, and And. gets a usual current.

Asphyxia as a result of defeat of a nervous system it is also caused by disorders of ventilation. Here cases of the paralyzes of respiratory muscles resulting from disturbances of conductivity of neuromuscular synapses (poisoning with kurarepodobny means, effect of bacterial toxins, toxic agents), paralyzes of respiratory nerves (multiple neuritis) or widespread defeat of motor-neurons of a spinal cord in cervical and chest segments at injuries, poliomyelitis and other infectious and noninfectious diseases belong.

And. can arise also at long spastic states, napr, at tetanus, poisoning with strychnine and other poisons causing spasms.

One of the frequent reasons And. the rough disorders of activity of a respiratory center resulting from its organic lesions of various character are and also at intoxications, overdose of hypnotic drugs and drugs and at the hypoxia of bulbar structures which is followed by power exhaustion of neurons of a respiratory center and easing or complete cessation of their function.

The disturbances of external respiration bringing to And., can have the reflex nature. It is observed at irritation of receptors of a trachea and bronchial tubes by various gas-and vaporous chemical compounds, smoke, particles of dust, the pathological process (an inflammation, a tumor) localized in pulmonary fabric or respiratory tracts. The reflex influences on a respiratory center arising at the same time will disorganize the act of breath.

And. arises and when respiratory excursions cause strong sensation of pain (at fractures of edges, pathological processes in a pleural cavity, intercostal neuralgia).

Asphyxia as a result of disturbance of transport of oxygen arises at acute blood losses and other cases of an acute circulatory unefficiency, at difficulty of outflow of a venous blood from a head cavity (congestive And.), at poisoning with «blood poisons» (carbon monoxide, methemoglobin formers). In an experiment this form A. arises during the bandaging of both carotid and vertebral arteries (so-called acute ischemic And.).

Asphyxia as a result of disorder of interstitial breath it is characterized by disturbance of utilization of oxygen fabrics. These frustration can be various; e.g., cyanic connections, hydrogen sulfide will paralyze cytochrome oxydase, interfering with oxidation of the reduced cytochrome and by that cause a fabric hypoxia in a brain and other fabrics, gives edges to fabric And. Some bacteritic toxins and viruses also cause And., blocking various links of oxidizing processes in fabrics. For fabric And. the normal oxygen content in blood is characteristic.

Asphyxia of a fruit holds a specific place; it can be a consequence And. mother who is followed by reduction of the oxygen content and increase in content of carbonic acid in the blood supplying a fruit and also a consequence of disturbances of uteroplacental or funic blood circulation. K A. give also gross violations of function of a respiratory center of the newborn. In one cases their action can be mediated through an organism of mother (a hypoxia, drug overdose, infectious intoxication, etc.), in others is directed directly to a fruit (a birth trauma of a head, disturbance of blood supply). In certain cases in the absence of the visible reasons And. connect with the lowered excitability of a respiratory center of the newborn in relation to carbonic acid (see. Asphyxia of a fruit and newborn ).

Thus, it is obvious that And. can arise at a certain stage of any form of a hypoxia if the last leads to heavy disorders of gas exchange and accumulation of carbon dioxide gas in an organism.

Biophysical mechanisms of asphyxia

as a result of air hunger of fabrics in blood a large number of intermediate products of a metabolism collects, the metabolic acidosis progresses. The products of partial oxidation circulating in blood, influencing biochemical processes in cells, cause sharp oppression of their function; there is a fabric hypoxia. Cells of an organism lose ability to absorb oxygen, in them there occurs a number of the irreversible chemical, physical and chemical and other changes which are, apparently, a direct or indirect consequence of disturbance of membrane structures of a cell and intracellular organellas. The most vulnerable elements of a cell are phospholipidic components of membranes. At decrease in concentration of oxygen in cells decreases or ATP disappears completely, function of oxidation-reduction enzymes is broken, the quantity of acid products of metabolism, in particular lactic acid increases, the indicator of pH decreases. Membranes react to these changed conditions falling of membrane potential and sharp increase in permeability (owing to lack of ATP) or a complete separation (because of reduction of pH) that leads of cells to death. Temporary decrease in the oxygen content creates premises for peroxide oxidation of lipids, mainly unsaturated fatty acids that further, already at sufficient access of oxygen, leads to chain radical oxidation of lipids and the related sharp increase in permeability of cellular membranes and an inactivation of the vital enzymes and processes (Yu. A. Vladimirov, 1972). One of causes of infringement of membrane structures is effect of hydrolases of lysosomes. As a result of increase in permeability of cellular membranes or their gap there is an exit of lysosomic hydrolases: cathepsines, phospholipases and others, Sa activated by ions 2+ , fatty acids and low pH. Effect of lysosomic hydrolases on cellular components conducts to an autolysis and death of a cell. Labilization of lysosomes and an exit of hydrolases occurs not at once, and only after earlier in comparison with changes of lysosomes the diffusion changes of ultrastructure of a cellular membrane, cytoplasmic reticulum and mitochondrions developing within the first hour of ischemia.

Disturbance of all types of exchange and development of proteolytic processes at And. most quickly occurs in cells of a brain. At localization of these irreversible processes in the respiratory and vasomotor centers there comes death. In heart at And. muscle fibers and intersticial fabric are surprised. In muscle fibers dystrophic changes, hypostasis, vacuolation and quite often a necrosis of separate groups of fibers come to light; in an interstitium — hypostasis, hemorrhage and the strengthened development of connecting fabric. In walls of blood vessels of heart and in an aorta hypostasis, a razvolokneniye of collagenic and elastic fibers, accumulation of acid mucopolysaccharides are observed. Deep disturbances of exchange processes in cells of fabrics and bodies are the cornerstone of these phenomena.

The pathophysiological changes characteristic of asphyxia are defined by the air hunger of fabrics, specific action of excess of carbonic acid and acidosis arising as owing to a hypercapnia, and accumulation of nedookislenny products of exchange. Each of these factors plays an essential role in development And., however crucial importance belongs to a hypoxia. In initial stages And. the specified factors act as irritants of the corresponding receptor educations (chemoceptors of sinocarotid and kardiaortalny zones, receptor structures of a reticular formation of a myelencephalon) and cause a number of the reactions having zashchitnoprisposobitelny character by the nature in an organism. In process of deepening And. manifestations of the various frustration caused accrue hypoxia (see), hypercapnia (see) and acidosis (see).

Pathological anatomy of asphyxia

Fig. 1. Spotty hemorrhages in a visceral pleura (Tardye's spot).

Morphological changes at And. depend on the reasons which caused it. There is, however, a number of the general signs which subdivide on outside and internal. Carry to outside: 1) cyanosis of the person which develops the first minutes And. during lifetime also remains on a corpse; 2) bystry emergence of diffuse bluish-lilac livors mortis that depends on the liquid state of blood inherent And.; against the background of livors mortis multiple ecchymomas can be observed; 3) dot hemorrhages in connecting covers a century; 4) traces of an involuntary urination, defecation, eruption of sperm; 5) expansion, is more rare narrowing of pupils. Internal signs have bigger value: 1) the liquid state of blood caused by a hypercapnia; 2) overflow by blood of the right heart at a zapustevaniye of its left half as a result of stagnation and hypertensia in a small circle of blood circulation and a cadaveric spasm of a cardiac muscle; 3) plethora of internals; 4) melkopyatnisty hemorrhages in serous covers (is more often in a pericardium and a pleura — Tardye's spots, fig. 1); 5) acute (alveolar, is more rare interstitial) the emphysema of lungs arising in the period of an asthma; 6) fluid lungs.

Fig. 2. A small blood vessel with perivascular hypostasis in a brain. In the middle of the drawing the otsloyenny vascular wall is visible; x 200.

The most vulnerable at And. the c is. N of page. In all its departments circulatory disturbances [dystonia of vessels, perivascular hypostasis (fig. 2) and hemorrhages] are observed, more they are expressed in a brain trunk. In nervous cells there is gidropichesky dystrophy, pericellular, perinuclear hypostasis, «serious illness» of nervous cells (a large number of vacuoles, spraying of basphilic substance, a karyopyknosis, an acidophilia), lipoid dystrophy. In an astrocytic glia swelling of bodies, and also shoots of astrocytes, fragmentation of the last, coagulation of protoplasm, disappearance of a contour of bodies of astrocytes is noted. In a microglia dystrophic changes happen less expressed. In an oligodendrogliya emergence of a large number of edematous (drainage) forms of cells is observed. More changes are expressed in phylogenetic younger departments of a brain; an oblong and spinal cord change to a lesser extent.

All listed morphological features are not specific and constant. In a different combination they meet also in other cases of quickly come death.

A clinical picture

It is accepted to distinguish several phases A. The first phase is characterized by the strengthened activity of a respiratory center in the form of increase and increase in power of its rhythmic cycles of excitement, increase in arterial pressure, increase and strengthening of serdtsebiyeniye, mobilization of the deposited blood is observed. Often in the first phase the breath in this connection this stage is extended and strengthened And. call a phase of an inspiratory asthma. In general the picture of the strengthened excitement of the respiratory and vasomotor centers and dominance in the field of vegetative regulation of sympathetic effects is characteristic of it. The second phase is characterized by the urezheniye of breath which is quite often followed by the strengthened exhalation (an expiratory asthma) and considerable delay serdtsebiyeny (vagus-pulse); arterial pressure at the beginning of the second phase usually is still increased, but further gradually decreases. At this stage And. effects of excitement of a parasympathetic nervous system in which emergence the great value is given to direct effect of carbonic acid on kernels of vagus nerves prevail.

Sharp excitement of the parasympathetic kernels responsible is normal for implementation of brake influences on a respiratory center, is the cornerstone of following — the third stage of asphyxia. The termination of rhythmic activity of a respiratory center — a so-called preterminal pause is characteristic of it temporary (from several seconds to several minutes). At this time usually arterial pressure considerably decreases, spinal, eye and other reflexes die away, there comes the loss of consciousness.

The fourth phase is shown by rare deep convulsive «sighs» — so-called terminal, or agonal, the breath which is usually continuing several minutes, but sometimes much longer. At this time severe spasms develop, quite often there is an involuntary eruption a calla and urine, release of sperm that depends on sharp excitement of centrum anospinale and centrum vesicospinale. At acute And. pregnant women can have a misbirth.

Death from And. occurs owing to paralysis of breath; cordial reductions, as a rule, a nek-swarm time continue also after the termination of breath.

Electrocardiographic researches show, in addition to the tachycardia which is replaced by bradycardia, various disturbances of a cordial rhythm, disturbance of conductivity, change of teeth of R and T; at an apnoea there are monocomplex changes.

In an initial stage And. desynchronization of electric activity of bark of big hemispheres is usually observed; in process of an urezheniye of breath the main rhythm is oppressed, begin to prevail slow a theta - and delta waves. Biocurrents usually completely disappear at emergence of terminal breath or slightly earlier.

From biochemical composition of blood for And. decrease in pH, increase in indicators of an alkaline reserve, decrease in content of chlorine in plasma and its increase in erythrocytes is characteristic. Level of sugar increases that is connected by hl. obr. with effect of carbon dioxide gas on the vegetative centers and disintegration of a glycogen of a liver. Coagulability of blood is, as a rule, lowered.

Clinical picture A. and rate of its development significantly depend on features of the etiological factor which caused an asphyxial state. So, if reason And. primary oppression of a respiratory center was, the phase of excitement is absent. At And. from drowning the first phase is breath holding at water immersion and lack of increase of respiratory movements at stay under water; the breath which was resumed after primary apnoea at once is urezhenny in comparison with initial and remains such up to a terminal pause. During the hanging and strangulation character and the sequence of changes of breath depend on the level of strangulation (above or below a throat) etc.

General duration And. (from its beginning before death) can also fluctuate in quite wide limits. At sudden complete cessation of lung ventilation duration And. makes no more than 5 — 7 min. In cases gradually developing And. (e.g., at breath in the closed space or at neurologic diseases) duration And. it can be considerable bigger.

There are essential age distinctions of sensitivity to A. Chem more young an animal, that it transfers easier And. So, the infant rat at the age of 12 — 15 hours lives without access of air up to 30 min., six-day — apprx. 15 min., twenty-day — apprx. 2 min.; the adult — 3 — 6 min. whereas the newborn — 10 — 15 min.

Features of resuscitation

Resuscitation at asphyxia consists in elimination of the reasons which caused it, maintenance of function of vitals in fight against effects of a hypoxia and a hypercapnia. A basis of resuscitation directly on site of incident is recovery of passability of pneumatic ways (removal of foreign bodys, liquids, slime, emetic masses, introduction of an air duct at retraction of language, release of a neck from the squeezing loop etc.), artificial respiration (see) and at clinical death outside cardiac massage (see). These measures shall be carried out immediately after the victim is evacuated from a dangerous zone (the rooms filled with natural gas, captured by the fire from water or a zone of moving transport etc.), and not only the medic, but also any adult who appeared on site incidents.

The most effective method of artificial ventilation in the absence of any devices or devices is breath of companies in a mouth or a mouth in a nose. Unconscious patients for the prevention of aspiration are transported with the head turned to the right and put on the right forearm in situation on the right side. At danger of regurgitation introduction of a gastric tube is shown. In cases of an acute disorder of passability of a throat, trachea or bronchial tubes (foreign bodys, aspiration of blood or food masses, an injury, a stenosis or a tumor) the intubation of a trachea is necessary (see. Intubation ), tracheotomy (see) or bronkhoskopiya (see). In an extra hospital situation tracheotomy can be replaced kriko-or a konikotomiya (see. Laryngotomy ). At a laryngospasm introduction of muscular relaxants, an intubation of a trachea and artificial ventilation of the lungs is shown.

Certain features are represented by resuscitation at bronchospasm (see).

The first actions at And., arisen owing to bilateral pheumothorax, include a puncture of pleural cavities thick needles and suction of air from pleural cavities. After elimination of acute disorders the main attention shall be paid to maintenance of adequate breath and blood circulation, and also correction of disturbances of an acid-base state and water and electrolytic balance. It is wrong to compensate aspiration inefficiency of ventilation by strengthening of oxygen in the inhaled gas mixture: it does not warn a hypercapnia and insufficiency of breath. Therefore at inefficiency of independent breath, and also at spasms and sharp motive excitement it is necessary to carry out after an intubation of a trachea or tracheotomy long artificial ventilation of the lungs by means of a respirator to a complete recovery of independent breath and consciousness. These measures do not eliminate completely danger of disturbance of passability of pneumatic ways owing to a bronchospasm, accidental endobronchial obturation, a prelum, an excess or obstruction of an endotracheal tube etc. Therefore constant control behind efficiency of artificial ventilation of the lungs is necessary. Importance in system of resuscitation actions at And. prevention of a fluid lungs and a brain (the rational mode of artificial ventilation, hormonal and dehydrational therapy, a hypothermia etc.) has. Due to the increase in venous pressure at And. bloodletting from a vein is reasonable. At toxic And. along with other measures of resuscitation full or partial blood substitution is shown. At And. as a result of defeat toxic agents (see) an important role use of antidotes plays. During the drowning in sweet water, and also under the influence of some toxicants, medicines, a hypoxia and a hypercapnia, after a sharp hyperventilation there can occur fibrillation of ventricles, to-ruyu it is necessary to eliminate immediately electric defibrillation (see).

Mental disorders

Sharply arising asphyxia (e.g., at self-hanging) is followed by almost instant switching off of consciousness. After removal from this state it is observed anterograde, the retroecmnesia, amnesia on current events, is more often than passing character. Disturbances of intelligence, up to full dementia, are defined by weight and duration of asphyxia, can be irreversible (mnestiko-intellectual weak-mindedness).

At And., arising from a lack of oxygen («hypobaropathy» of pilots), the alarm, decrease in sharpness of feelings and perceptions, assessment of time and the space relations, euphoria, obnubilation are observed (see. Devocalization ). Loss of consciousness comes without harbingers. Cases when there are no disturbances of health take place or at their existence the critical relation to them sharply decreases. In some cases slackness, a hypobulia, changes of an emotional state are observed: indifference or irascibility. Distinctions in manifestations are connected with specific features: inborn resistance to air hunger, fitness, etc. Are more sensitive to a hypoxia of the person vegetative and labile (after a craniocereberal injury, neuropaths). Euphoria, disturbance of consciousness — a subjective factor of accidents and accidents where fulfillment of duties is connected with possible developing of a hypoxia.

At And. from an acute poisoning with carbon monoxide elementary visual and acoustical deception at the kept consciousness is noted. Further there comes the coma. And after assistance to the victim it is in the deafened, disoriented state, actions of its nekoordinirovanna, remind an ebrietas. Retrograde amnesia, a dysmnesia of fixing are observed. At hron, a poisoning with carbon monoxide — dizzinesses, as at intoxication, an adynamy, concern, indecision, crazy episodes; in hard cases — a picture of a pseudoparalysis.

The forecast

With the timely resuscitation help at victims with And. recovery of the vital functions is possible. However at the persons who transferred And., mental and neurologic disorders, in particular retrograde amnesia, paresis of phonatory bands are quite often observed; the fluid lungs and pneumonia are the most frequent cause of death at the persons brought from a state And.

Asphyxia in the medicolegal relation

Due to the development of the doctrine about a hypoxia definition And. in the medicolegal relation lost the former value and is conditional in a crust, time. Before under the term «asphyxia» in forensic medicine different types of death from the acute air hunger resulting from various external influences, generally from disturbances of external respiration combined. However at the same time And. not always takes place and it can be not always proved. Therefore there are all bases to define such types of death as death from a hypoxia.

In a thanatogenesis of death from disturbances of external respiration by the leader there can be not only air hunger, and a reflex cardiac standstill owing to irritation of the terminations of a vagus nerve, napr, during the closing of respiratory tracts with a foreign body, during the drowning and death in water, during the hanging, strangulation by a loop or hands.

The concept «hypoxia» includes and And. Therefore under And. in forensic medicine understand in the broadest sense strangulation owing to air hunger. Distinguish And., arisen from mechanical obstacles for breath (mechanical And.), and And., caused by the damaging effect of various substances on the physiological mechanisms providing gas exchange (toxic And.).

Most often in medicolegal practice the following types mechanical meet And.: hanging, strangulation by a loop, hands; closing of openings of a nose and mouth with soft objects; closing of a gleam of respiratory tracts with various foreign bodys, food masses, etc.; a prelum of a breast and stomach any objects, napr, car, the earth at collapses; drowning. Each of these types of death as a result of mechanical And. has the pathophysiological and morphological features that allows to establish these types on a dissecting table.

And. toxic arises at action of the damaging agent directly on a respiratory center (morphine), on respiratory muscles (strychnine, a curare), on blood (carbon monoxide, aniline, nitrites), on respiratory enzymes of protoplasm of cells (cyanides); to the same types And. belongs And. from the fluid lungs coming from influence of suffocating OB, etc. Cases toxic And. diagnose on the basis of features of a clinical current (poisoning with morphine, strychnine) or a morphological picture (poisoning with carbon monoxide — a carboxyhaemoglobinaemia, aniline, nitrites — a methemoglobinemia), and also a judicial and chemical research of internals, a spectral analysis of liquids of a body.

The cadaveric phenomena at And. are presented by a complex of the non-constant changes which are observed in general at quickly come death of various origin. Treat these signs: well-marked livors mortis, cyanosis of integuments of the person, ecchymomas in conjunctivas, face skin, dark liquid blood in heart, vessels, sine of a firm meninx, a plethora of internals, subpleural and subepicardial ecchymomas, etc. Earlier a complex of these signs considered pathognomonic for And. Actually each of these signs separately and all in total do not give the grounds to make the diagnosis And., as are observed also at other types of death and can arise even after death. E.g., at a low arrangement of the head of a corpse there can posthumously be both cyanosis of integuments of the person and ecchymomas in skin, in conjunctivas. At bystry death from acute cardiovascular insufficiency, an electric trauma, etc. blood always liquid and dark. There can be also ecchymomas in conjunctivas, under a pleura and an epicardium. On the other hand, at subjects with a cachexia, secondary anemia at undoubted death from And. all these signs can be absent. The signs characterizing separate types of mechanical disturbance of external respiration have the major diagnostic importance: a strangulyatsionny furrow, damages to area of a neck (see. Hanging , Strangulation ), diatomic plankton in internals (see. Drowning ).

Traumatic asphyxia

Traumatic asphyxia — the peculiar symptom complex caused by a temporary cessation of breathing at a sharp prelum of a thorax, stomach or all trunk wheels of cars, fragments of the destroyed buildings, soil at collapses in mines, heavy objects etc. The name of a symptom complex comes from similarity of coloring of the face of the victim to coloring of integuments at heavy And.

Symptoms traumatic And. are described by Ollivier in 1837. G. Perthes and Braun in 1899 gave more complete description of her clinic and a pathogeny.

Traumatic And. during the Great Patriotic War it was observed in 0,2% of the closed injuries of a breast. In peace time traumatic And. occurs at 0,2% of all patients with injuries, and at the closed injuries of a thorax and trunk from 1,1 to 11,6% of cases.

Etiology and pathogeny

Traumatic And. arises at a sharp prelum of a thorax in the front-back direction. Traumatic And. at children it is observed very seldom, but proceeds extremely hard. At young people the skeleton of a thorax is rather elastic and can be compressed with a force up to 1,2 — 1,7 kg/cm 2 without fracture of edges. Persons of mature and advanced age have a prelum of a breast with a force exceeding 0,3 — 0,6 kg/cm 2 , is followed by a fracture of edges (G. S. Bachu). The strong prelum of lungs, with their extensive vascular system, is followed by a delay and sharp restriction of breath, a prelum of an upper vena cava and disturbance of outflow of blood from it. It causes sharp build-up of pressure in system of an upper vena cava and a reversed current of blood in veins. P. Milner considers that at the same time convulsive short circuit of a glottis and sharp tension of a prelum abdominale is of great importance. Due to the lack of valves in brachiocephalic veins (vv. brachiocephalica dextra et sinistra) and sharply arising insufficiency of valves in the venous trunks falling into these veins that is connected with increase in a gleam of veins under the influence of sharp, sudden build-up of pressure in them blood directs on the periphery to sites of an upper half of a body, free from a prelum; at the same time there is sharp restretching of venous walls, small veins, paresis of capillaries and venous staz blood in them. In hard cases, besides, the rupture of capillaries and venules and as a result — dot hemorrhages is observed.

The scourge and Kobb (Beach, Cobb) at microscopic examination of skin of victims did not find hemorrhages around vessels while L. Aschoff observed them. It is explained, apparently, by varying severity of the patients observed by authors with And. traumatic. G. S. Bachu observed emergence of dot hemorrhages in skin of an upper part of a trunk at a prelum of all surface of a breast even on fresh corpses (to 6 hours).

Violet-blue or crimson-blue coloring of skin of an upper half of a trunk is caused by hl. obr. a resistant capillary venous staz since in the course of recovery transition of coloring of skin to greenish, brown and yellow colors as it happens at a rassasyvaniye of hypodermic hemorrhages is seldom observed.

The clinical picture

the Face of the victim bloated, skin is painted in crimson, purple-red, dark-violet, and in hard cases in almost black color (masque ecchymotique). This coloring sharply breaks on an upper half of a breast. It does not disappear, and only slightly decreases during the pressing by the glass pallet. On this background small hemorrhages are quite often visible. On site a dense prileganiye to skin of parts of clothes (a collar, braces, straps of a bra, etc.) there are strips of normally painted skin. Often subconjunctival hemorrhages, an exophthalmos, and in hard cases a vision disorder owing to hemorrhage in retrobulbar cellulose and a vitreous of an eye are found.

Visual acuity can be weakened, sometimes there is no perception of color, especially red. In hard cases the total blindness owing to injury of an optic nerve is possible. Pupils are expanded, inertly react to light. Sometimes there is a loss of consciousness.

Hemorrhages are noted also on a mucous membrane of a nose, language, a mouth, a throat and are followed sometimes by hoarseness of a voice, a nasal shade of the speech, more rare a full aphonia. Hearing is often reduced owing to paresis of n. vestibulocochlearis caused by stagnation of a venous blood in capillaries of a snail and a kortiyev of body.

The pains in inguinal and axillary areas complicating the movements are often observed. Pains are caused by restretching, perhaps, disturbance of an integrity of valves of veins the reversed current of blood arising at the time of compression of a breast. Veins of upper extremities are expanded, crowded with blood, clearly eminate through skin.

Though outward of the patient reminds heavy And., the condition of patients, in the absence of the heavy accompanying damages (fractures, an internal injury), remains satisfactory. Shock, a loss of consciousness usually demonstrate existence of the heavy accompanying damages or long crush of muscles of a breast. Standard temperature or is lowered. The diuresis is usually lowered, in urine find protein, cylinders, erythrocytes. In hard cases the acute renal failure, uterine bleeding, a sluggish lower paraplegia owing to disturbance of blood circulation in a spinal cord develops.

The accompanying damages and complications are diverse: multiple fractures of edges, damage of pulmonary fabric and bronchial tubes, a hemopneumothorax, disturbance of an integrity of abdominal organs, the extensive crush of muscles which is followed by a peculiar syndrome of long crush (crush syndrome), or so-called traumatic toxicosis (see) for to-rogo the acute renal failure is characteristic (see). Injury of a backbone, spinal cord and other bodies is sometimes observed.

Forecast at uncomplicated pure forms traumatic And. favorable. Tsianotichesky coloring of skin with 3 — begins to decrease the 8th day and through 2 — 3 weeks passes. Hemorrhages on mucous membranes and scleras resolve in 4 — 6 weeks. The heavy current and death are possible only in the presence of the accompanying damages.

Treatment symptomatic: a semi-sitting position in beds, oxygen, cardiacs and analgetics; holding special events for treatment of the accompanying damages and their complications — see. Hemothorax , Bleeding , Traumatic toxicosis , Shock .

Bibliography: Armstrong G. An air medicine, the lane with English, page 232, M., 1954; Vladimirov Yu. A. and Archakov A. I. Peroxide oxidation of lipids in biological membranes, M., 1972, bibliogr.; D r and h at to P. S. Traumatic asphyxia, Orthopedics, traumatology and protezir., No. 6, page 47, 1963; Kessler G., etc. Resuscitation, the lane from Czeches., Prague, 1968, bibliogr.; L e-bedeva JI. B. The main patterns of fading and recovery of cordial activity and breath during the drowning and the subsequent revival of dogs, Works konf., posvyashch. probl. patofi-ziol. c of therapy of terminal states in a wedge, and prakt. acute management, under the editorship of V. A. Negovsky, page 70, M., 1954; Markovaye.A. Influence of acute asphyxia on change of excitability and lability of the respiratory and vasomotor centers in the course of dying and recovery of functions of an organism, in book: Fiziol, and patol. breath, a hypoxia and an oxygenotherapy, under the editorship of. A. F. Marchenko, etc., page 450, Kiev, 1958; Petrov I. R. Air hunger of a brain, L., 1949, bibliogr.; With about at 1 1 os P. N. Mechanical resuscitation in advanced forms of asphyxia, Surg. Gynec. Obstet., v. 66, p. 698, 1938, bibliogr.; P about about t A. Manuel alpha-bätique de psychiatrie, P., 1965.

A. in the medicolegal relation — Avdeev M. I. Course of forensic medicine, page 269, M., 1959, bibliogr.; A. P thunders. A course of lectures on forensic medicine, page 180, M., 1970; N. V. Priests. Forensic medicine, M., 1950; Fedorov M. I. Medicolegal and clinical value of post-asphyxial states, Kazan, 1967, bibliogr.; D i-е t z G. Gerichtliche Medizin, Lpz.» 1970, Bibliogr.; Prokop O. Forensische Medizin, S. 674, B., 1966, Bibliogr.

H. H. Sirotinin; M. I. Avdeev (court. medical), Yu. V. Gulkevich, G.F. Puchkov (stalemate. annate.); M. I. Kuzin (hir.), M. I. Perelman, A. I. Smaylis (rean.); A. N. Rossels (biophysical.), H. N. Timofeev (psychiatrist.).