RU2444284C1 - Method of postmortem determination of intracranial pressure in premortal period of life - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to forensic medical examination and pathologic anatomy. In order to carry out postmortem determination of intracranial pressure in premortal period of life, in condition of integrity of examined object, measurement of pressure of corpse's scull cavity content is performed. Pressure of corpse's scull cavity content is determined by installation of puncture needle of injectometer irrigation system into scull cavity. Obtained value is multiplied by coefficient of intracranial pressure drop, conditioned by coming of biological death, whose value is taken equal 2.

EFFECT: method makes it possible to determine intracranial pressure in premortal period.

2 cl, 1 dwg, 3 ex

Description

The invention relates to medicine, namely to forensic medical examination and pathological anatomy, and can be used to establish the cause of death.

Intracranial pressure (ICP) is the difference between the pressure in the cranial cavity and atmospheric pressure. Measurement of intracranial pressure allows you to identify intracranial hypertension or hypotension of the premortal period of life and evaluate their severity in various critical and terminal conditions that occur with various diseases, craniocerebral injuries, poisoning, etc.

Normally, ICP has its own physiological limits. With an increase in ICP (hypertension), a hydrodynamic conflict arises in the intracranial box, since the cranial box, represented by bone tissue, is a rigid closed cavity and is not able to expand if necessary. In an adult, in the supine position, normal ICP values are 7-15 mm Hg (on average 11 mm Hg), in children 3-7 mm Hg, in newborns 1.5-6 mm Hg .art. A critical level of increasing ICP in adults is its persistent increase above 20-25 mm Hg.

The objective of the invention was the creation of a method that allows you to determine the ICP of the pre-mortal period of life by recording the value of the total pressure of the contents of the cranial cavity in corpses (HRSP), with a sufficiently short duration of the study (less than 2 minutes).

It is known that the cranial cavity is filled with three main "liquid" substances (components): brain tissue, cerebrospinal fluid and blood located in the lumen of the arterial and venous vascular network of the membranes, brain tissue and sinuses of the dura mater. In some cases, for example, with tumors, traumatic brain injuries, the fourth component in the form of a neoplasm — tumor tissue, hematoma or hemorrhage — can form in the cranial cavity. It is these components of the contents of the cranial cavity, as well as the features of their close hydraulic relationship (contact) with each other that determine the ICP level and the pressure value of the contents of the corpse cranial cavity of the corpse (RHCR) at the time of their registration and evaluation.

From a biomechanical point of view, the ICP level at the time of its study is considered as the result of the interaction: 1 - active (life-supporting) hydrodynamic blood pressure and 2 - passive or volumetric (formative) hydrostatic pressure of the three main "liquid" components of the contents of the cranial cavity (HFC): brain, cerebrospinal fluid and blood.

It is known that when biological death occurs in humans, cardiac arrest, respiration and a drop in the life-supporting average blood pressure, including the hydrodynamic pressure of the blood located in the lumen of the arterial vessels of the membranes and brain tissue, occur.

According to reports [Soloviev G.M., Radzivil G.G. Blood loss and regulation of blood circulation, M .: Medicine, 1973, p. 27] in cases of "sudden" nature of the onset of biological death in relatively healthy adults, the drop in life-supporting average blood pressure ends with the establishment in the cardiovascular system of the so-called "average system pressure of the filled system", equal to 5, 6 mm Hg, provided that it is preserved (integrity) in all areas. A similar level of blood pressure is established in the vascular system of the cranial cavity. Therefore, taking into account the existing close hydraulic contact (ratio) between the components of the HFC, it can be assumed that when biological death occurs, the ICP also drops with the formation of the total hydrostatic pressure of the “liquid” HFC components (rHF) in these corpses, which is also equal to 5.6 mmHg .art. Consequently, it can be considered that in all cases of violent and non-violent death, ICP decreases, which decreases by about 2 times (11 / 5,6≈2) with the formation of corpuscles of a certain magnitude of the HRSP corresponding to ICP of the premortal period of life. Thus, the foregoing may indicate the presence of an ICP drop coefficient universal for all age groups, which is caused by the onset of biological death (k ↓ ICP), approximately equal to 2.

Thus, in order to solve the problem, in particular, to posthumously diagnose ICP of the pre-mortal period of life, it is necessary to measure the magnitude of the RHP of a corpse and multiply it by 2 (14 ICP). The registration and assessment of the magnitude of the rHCR in a corpse should be carried out subject to the integrity of the object of study (skull).

There are many direct (invasive) and indirect methods for intravital diagnosis of ICP changes:

1. The most accurate of them is intracranial ICP dynamometry. The method is carried out by invasive (intracranial) placement of the ICP sensor to the patient. This is a relatively new method used in the last few years in intensive care practice.

2. The oldest is echoencephalography (EchoEG). This is an indirect method for determining ICP from the corresponding changes in the signals that occur during cerebral edema. There are still no ways of posthumous diagnosis of ICP of the premortal period of life.

In the claimed method, the pressure of the contents of the corpse’s cranial cavity (HRCT) may include introducing into the cranial cavity of the corpse through a trepanation hole of a puncture needle with a lateral outlet connected to the injection meter irrigation system, which is filled with liquid (water) in the device under a pressure of 0 mm Hg. Art. Then, the volume of liquid in the system of the device rises to a set minimum level (V ¹ ) and pressure (P ¹ ). The value of the total pressure of the “liquid” components of the corpse’s cranial cavity (HRPC) is determined by the volume (level) of the remaining fluid in the irrigation system of the device after its spontaneous injection into the cranial cavity as a result of pressure equalization of the liquids in the device and the cranial cavity, according to the well-known formula:

rHCR = V ² × P ¹ / V (in mmHg)

where RSPCH - pressure of the contents of the cavity of the skull of the corpse; V ² is the level of the liquid remaining in the injectometer system; P ¹ - set fluid pressure in the chamber of the injector; V ¹ - the additional volume of fluid required to create pressure P ¹ .

A study of the HRC is carried out in a morgue, with the corpse horizontal on a section table. This method is invasive and is carried out by piercing the dura mater and inserting the puncture needle of the injectometer into the cranial cavity through a trepanation hole in the frontal region after scalping of the scalp in corpses over the age of 1 year. In corpses under the age of 1 year, the puncture needle of the injectometer is inserted into the cranial cavity by puncture of the scalp and dura mater in the area of the unshackled fontanel of the frontal and parietal bones of the skull. The method is performed after examining the corpse, before its autopsy - opening the skull, chest and abdominal cavities, allocation of internal organs.

As a device for implementing the method, an injectometer "A device for measuring biophysical parameters" (copyright certificate for utility model No. 16870 of 02/20/2001) can be used.

The design of the known injectometer shown in the drawing (Figure 1). The device comprises: a membrane pressure gauge 1, an irrigation system (route), consisting of a measuring glass tube 2, connected to the pressure gauge by a flexible hose having a "pressure" relief valve 5, coupled to the inlet control valve 3 to replenish the volume of liquid and increase the pressure in the device system and an outlet valve 4 connected by an elastic tube 6 to a puncture needle at the working end.

The hydrodynamic and hydraulic laws laid down in his work, established by J.L. Poiseuille and O. Frank (1899), should be considered a design feature of the irrigation system of the injectometer. These patterns allow the injection (hydrodynamic) method to record the degree of hydraulic resistance (elasticity) or the total pressure of the "liquid" components of the contents of the corpse cranium (corpus).

The principle of operation of the injectometer is similar to the hydrodynamic model of O. Frank, which he considered as an “elastic (elastic) reservoir” of the arterial part of the cardiovascular system of a living person’s body, designed to study the hydraulic resistance of the peripheral vascular system of blood circulation.

A method for determining ICP of the premortal period of life may include the following steps:

1. Preparation of the device for operation includes the following manipulations.

A syringe filled with distilled water is tightly connected to the inlet of the injection meter irrigation system (inlet valve 3), and the elastic tube 6 with a puncture needle at the working end is tightly connected to the exhaust valve 4.

Using a syringe, with the inlet and outlet valves 3 and 4 open and the pressure release valve 5 closed, the device’s irrigation system is filled with distilled water to the “0” mark of the device’s microburette. In this case, using the pressure relief valve 5, the liquid pressure level in the system is also set at the “0” mark on the gauge 1 scale.

2. After the end of the external examination of the corpse and scalping of the scalp, through the performed trepanation hole in the frontal bones of the skull along the midline, the puncture needle of the working end of the elastic tube of the device’s irrigation system is inserted into the cavity of the skull of the corpse by puncture of the dura mater.

In the corpses of infants, newborns and miscarriages (fetuses), the puncture needle is inserted by piercing the scalp in the area of the unclosed “large fontanel” of the bones of the skull.

3. Using a syringe, with the valves 4 and 5 closed and the inlet (closing) valve 3 open, an additional volume (V ¹ ) of liquid is introduced into the irrigation system within 1.5 ml, which corresponds to the set pressure level P ^{1 of} the device pressure gauge scale of 20 , 40, 60, 80, or 100 mmHg After that, the inlet valve 3 of the device is closed.

Thus, the additional volume of liquid V ¹ located in the irrigation system of the device corresponds to a pressure (P ¹ ), which exceeds the estimated total hydrostatic pressure of the existing "liquid" components of the HF in the corpse.

For example, to set the pressure in the device’s system to 20 mmHg, an additional 0.35 ml of liquid must be added to the irrigation system, and to create a pressure of 60 mmHg. - 1.0 ml of liquid.

4. Next, with the valves 3 and 5 closed, it is necessary to open the exhaust valve 4. This creates a message between the liquid of the irrigation system of the device and the “liquid” components of the HFC. If the skull cavity has a lower pressure than the fluid pressure in the device’s irrigation system, the fluid from the latter will be spontaneously injected into the cranial cavity until the rhfp and the fluid pressure in the device system are equal. As a result of this, the pressure P ¹ and the volume of liquid in the device V ¹ decrease almost to the value of the available RSPC in the corpse. This is visually recorded by the "drop" of the liquid in the microburette to the level of V ² and the corresponding division of the gauge scale of the device.

In cases where there is no effect of liquid injection at a given minimum pressure of 20 mm Hg the exhaust valve 4 is closed, the volume of fluid in the irrigation system of the device rises to the next pressure level of 40 mm Hg and the exhaust valve 4 opens again. Thus, the studies are repeated until the injection effect occurs and the corpus is found (registered).

5. In cases of registration of the RFHR at a corpse close to the “0” mark of the device’s pressure gauge (less than 20 mmHg) or negative pressure, the value of the RFHR is calculated according to the formula above:

HRCT = V ² · P ¹ / V ¹

For example: when an additional volume of liquid of 0.65 ml (V ¹ ), which is in the irrigation system of the device under a pressure of 40 mm Hg, is injected into the cavity of the skull of the corpse. (P ¹ ), the liquid level in the microburette stopped at 0.15 ml (V ² ). To determine the RHR of a corpse, 0.15 is multiplied by 40, and the resulting figure is divided by 0.65. As a result of these simple calculations, we obtain a pressure value of 9.2 mm Hg, which corresponds to the magnitude of the HRC of a corpse.

6. The ICP of the pre-mortal period of life is determined by multiplying the obtained value of the rhp by 2 - the universal coefficient of incidence of ICP due to the onset of biological death (k ↓ ICP), according to the formula

ICP = rHF × k ↓ ICP (in mmHg)

where ICP is the intracranial pressure of the premortal period of life; RSPCH - pressure of the contents of the cavity of the skull of the corpse; k ↓ ICP - ICP drop coefficient due to the onset of biological death.

For example, the resulting magnitude of the rhpc of the corpse is 9.2 mmHg. multiply by 2 and get the ICP level of the premortal period of life at 18.4 mm Hg.

The technical result of the proposed method is to diagnose the severity of intracranial hypertension or hypotension of the premortal period of life arising from critical and terminal conditions in patients and victims in cases of violent or non-violent death. The technical result is achieved by registering the magnitude of the rHCR in a corpse, followed by multiplying it by the universal drop coefficient of ICP due to the onset of biological death (k ↓ ICP), the average value of which is 2.

This method of post-mortem diagnosis of ICP is carried out at any time of the day, in a morgue. The registration of the magnitude of the rHCR in a corpse, followed by an assessment of the ICP of the pre-mortal period of life, can be performed by doctors with different levels of training (experience, category) in the process of pathological anatomical or forensic medical examination (examination) of the corpse at different times after the onset of biological death; does not take much time and does not require large material costs.

Examples of the use of the presented method in the practical work of the regional bureau of forensic medical examination of N. Novgorod

Example 1. The corpse of infant S., 4 months old, was taken to the morgue from a children's hospital with a diagnosis of closed blunt traumatic brain injury, severe brain contusion, depression of consciousness to a terminal coma, swelling and brain swelling. From the direction of the investigator of the prosecutor's office, it was established that approximately 10 days before admission to the hospital, he received a head injury, having hit his head on the floor. According to medical records, the child was admitted to the hospital in serious condition, the level of consciousness is a moderate coma, floating eyeballs, muscle hypotension, and a two-way symptom of Babinsky. With CT of the brain, signs of edema and swelling of the brain, a high level of intracranial pressure, a crack of the parietal bone on the right were found. Against the background of mechanical ventilation and appropriate infusion therapy, depression of consciousness to a terminal coma was noted. During a forensic medical examination (examination), a corpse of an infant was found to have: extensive bruising in the soft tissues of the head in the right behind the ear region, a bulging large fontanel in the area of "non-closure" of the bones of the skull. The injection method of the corpse was measured by rhpc, which turned out to be equal to 28.4 mmHg. By multiplying this value by 2 (k ↓ ICP), an ICP of the premortal period of life was obtained at the level of 56.8 mm Hg, which is approximately 8 times higher than the intravital ICP “norm” for this age group (6-7 mm Hg). Art.). Such a high level of ICP confirms the clinical diagnosis, the presence of a critical condition in the form of a terminal coma in the infant in the premortal period of life.

Example 2. The corpse of a man B., 57 years old, heightened fatness entered the morgue from the scene (from home). According to relatives, during his life he suffered from hypertension, which manifested itself as a frequent increase in blood pressure, headaches (crises). An external examination revealed no damage. Represented by injection method, the corpse was measured at the corpse, which turned out to be equal to 18.5 mm Hg. By multiplying this value by 2 (k ↓ ICP), an ICP of the premortal period of life was obtained at the level of 37 mm Hg, which is more than 2 times the upper limit of the intravital age-related norm of ICP at 15 mm Hg. An internal investigation of the corpse revealed: an increase in the weight and size of the heart, a fine tuberous surface of the kidneys, atherosclerotic changes in large vessels, which did not exclude the possibility of hypertension, atherosclerosis in life in Mr. B. A posthumously high ICP level of 37 mmHg was established. suggests that the death of Mr. B. occurred, most likely, from acute cardiovascular failure, the clinical manifestation of which was intracranial hypertension of the premortal period of life.

Example 3. The corpse of a man S., 34 years old, of normal physique and fatness, entered the morgue from the scene of an accident (accident) with severe injuries (fractures) of the chest, spine and lower extremities, bruises of vital organs of the chest cavity (heart and lungs), rupture of the liver, spleen. The injection method of the corpse was measured by the RHR, which turned out to be 6.3 mm. Hg By multiplying this value by 2 (k ↓ ICP), the ICP of the premortal period of life was obtained at the level of 12.6 mm Hg, which is within the intravital age norm. The post-mortem ICP level established within the intravital age "norm" may indicate that Mr. S. died suddenly from incompatible damage to vital organs (heart and lungs), against the background of intracranial normotension of the premortal period of life.

It should be borne in mind that multiplying the obtained value of hRPF by the coefficient of incidence of intracranial pressure (k ↓ ICP), equal to 2, gives the most probable value of ICP of the premortal period of life, while deviations k ↓ of ICP within 10-12% can be considered acceptable.

In the study of patent and medical literature (forensic and pathoanatomical), no methods for posthumous diagnosis of ICP level of the premortal period of life were revealed.

Claims (2)

1. The method of posthumous determination of intracranial pressure of the premortal period of life, carried out under the condition of the integrity of the studied object, which consists in measuring the pressure of the contents of the corpse cranial cavity and multiplying the obtained value by the coefficient of incidence of intracranial pressure due to the onset of biological death, the value of which is assumed to be 2. 2. The method according to claim 1, in which the pressure of the contents of the cavity of the skull of the corpse is determined by installing in the skull cavity of the puncture needle of the irrigation system of the injectometer, which is a device for forming a sealed chamber connected to the skull cavity, creating a pressure in the chamber of the injectometer that exceeds the pressure of the contents of the skull cavity , by introducing an additional volume of liquid and performing the calculation after spontaneous injection of a liquid resulting from equalization of the liquid pressure children in the system of the device and the cavity of the skull of the corpse, according to the formula
p HR = V ² · P ¹ / V ¹ ,
where RSPCH - pressure of the contents of the cavity of the skull of the corpse;
V ² is the level of the liquid remaining in the injectometer system;
P ¹ - set fluid pressure in the chamber of the injector;
V ¹ - the additional volume of fluid required to create pressure P ¹ .

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