sign in sign up
<<
Home , Commotio cordis

Rev Mex Med Forense, 2019, 4(3):1-15 ISSN: 2448-8011

Forensic medical aspects of sudden cardiac death caused by commotio cordis due to the impact of a tear gas bomb during manifestations in Venezuela in 2017 Original Article

Araujo-Cuauro, Juan Carlos 1

Received: March 8, 2019, Accepted: May 18, 2019, Published: September 15, 2019

1 Professor of Legal Medicine. Faculty of Legal and Political Sciences. University of Zulia (LUZ). Av. 16 (Guajira). University City "Dr. Antonio Borjas Romero". Humanistic Nucleus Maracaibo Venezuela Corresponding author: Juan Carlos Araujo Cuauro, [email protected]

SUMMARY gas bomb direct to the precordial area of a protester's , fired by law Purpose: The objective of the study was to enforcement officers, in street protest visualize the sudden cardiac death manifestations for economic political and generated by the Commotio Cordis social claims in Venezuela in 2017. phenomenon, due to the impact of a tear- Likewise, it seeks to know the legal Araujo JC. Rev Mex Med Forense, 2019, 4(3):1-15 regulations and the forensic approach that Scientific and Criminal Investigation Body derives from this, as well as the legal (CICPC), who performed a forensic consequences that face the public order autopsy; the following postmortem agents; we analyzed the legal medical diagnosis was concluded: closed thoracic responsibility of the forensic pathologist in trauma in the left chest region that caused the autopsy report necessary to exercise cardiogenic shock and cardiac contusion. the criminal legal actions that are Discussion: It is necessary to know the perceived under the charges of homicide physiopathological mechanism that with treachery or for futile or ignoble causes the sudden cardiac death product motives. of the commotio cordis and the revision of Materials and methods: We report the the current regulations of security and case of a young adult who died due to the control of the manifestations by the impact of a tear gas bomb in the thoracic national and international public order precordial area, triggered by law agents; we analyzed the problems of legal enforcement officers during the social medical forensic significance due to the political manifestations that took place in diverse implications related mainly to the city of Caracas-Venezuela in the year criminal and / or civil law, in which the 2017. He underwent forensic evaluations figures of homicide (fraudulent or (autopsy) by the National Service of negligent) and professional responsibility Medicine and Forensic Sciences arise. (SENAMECF). Conclusions: Sudden cardiac death by Case description. A 20-year-old young commotio cordis due to the impact of a adult impacted by a tear gas bomb that tear gas bomb on the precordial area is an was fired directly by law enforcement uncommon but very devastating event, officers on the thorax at the level of the which is why it must be distinguished as a precordial area, which caused sudden crime against humanity due to the cardiac death also known as commotio violation of human rights of the victims, cordis. which is typified in the Rome Statute in Results: We analyzed the result international criminal law. transcribed in the death certificate issued Key words: Sudden cardiac death, by the forensic pathologist of the commotio cordis, , prosecution and the National Service of tear gas, impact, thorax, precordial, Medicine and Forensic Sciences medical, forensic, manifestation. (SENAMECF) attached to the Criminal

INTRODUCTION low energy and apparently trivial, producing a ventricular fibrillation (VF) Thoracic trauma as an extra- and a cardiorespiratory arrest (CRP) [1]. cardiac event that usually causes a lethal arrhythmia and sudden cardiac death is The victims are usually very called "commotio cordis" or "blow of young; it usually occurs in the context of death"; this refers to an event triggered practices, although its appearance after an impact in the precordial region, of has also been described during daily Araujo JC. Rev Mex Med Forense, 2019, 4(3):1-15 activities. The pathogenesis seems to be impact and not to the totality of related to a phenomenon of "R on T" at a mechanically induced arrhythmias [4]. In particularly vulnerable moment of cardiac the 1990s the term commotio cordis was repolarization, which triggers a accepted outside the forensic field as an cardiorespiratory arrest (CRP) due to eminent cause of sudden cardiac death in ventricular fibrillation. the absence of findings of thoracic injury If we go back in history, the term and a structurally normal in the commotio cordis appears for the first time finding of the necropsy, with the known in medical literature in the 19th century, antecedent of a non-harmful impact; the although the essence of commotio cordis episodes of sudden cardiac death by (cardiac concussion) was already commotio cordis were appearing in the described in the millenary writings of the form of isolated clinical cases in the Chinese martial arts such as Dim Mak or clinical medical literature [5]. "touch of death"; in Western society of the eighteenth century, written accounts are Since then, in the medical recorded that show episodes of sudden community, the relevance of commotio cardiac death (MSC) after minimal cordis as a cause of sudden cardiac death thoracic impacts, mostly by accident has been observed in healthy individuals during the workday [2]. who are usually children, adolescents or young adults, and who mostly practice Schlomka was the first author who some kind of sports. for competitive or described the conduction alterations and distraction purposes, although its arrhythmias caused by the impact on the appearance has also been described during chest wall, causing ST segment alterations, routine activities (Table 1). ventricular extrasystoles, ventricular branch and atrial blocks, ventricular So far the death of individuals in (VT) and ventricular street demonstrations for social, economic fibrillation (VF); he identified three factors and even political changes has not been that influence the appearance of reported, cases when the security forces arrhythmias: the type of projectile, the repress the masses firing tear-fire force and the location of the impact; it projectiles directly on the corporal surface, must be differentiated from another term, specifically at the level of the rib cage over Contusio cordis, which is observed in the the precordial area. absence or presence of structural lesions; the absence of macroscopic lesion due to It is likely that commotio cordis as impact differentiates the commotio cordis a cause of sudden death in the protesters from cardiac contusion, in which a high who were hit by tear gas bombs, has been energy collision (for example in the underestimated by the forensic doctors polytraumatized thorax over the precordial who carried out the autopsy protocol. region) produces myocardial lesions and overlying the thoracic cage [3]. Approximately 50% of the cases of sudden cardiac death by commotio cordis Commotio cordis as a pathology occur in the development of competitive receives little attention in medical organized sports, in relation to the impact scientific literature and there are few cases of a projectile (, , , reported. Currently, this term restricts its ) or the physical impact against meaning to sudden cardiac death after an other players (rugby, , Araujo JC. Rev Mex Med Forense, 2019, 4(3):1-15 soccer, karate, among others). 25% of the related to sports practices of any kind, but cases of commotio cordis occur in may be triggered by everyday activities. apparently dangerous activities such as recreational sports at home, in family The use of rubber balls by riot gatherings, in children's games, among police has also been described as a cause others. The majority of the commotio of death by commotio cordis after a cordis in children under 10 years of age thoracic impact. But in this investigation occurred under these circumstances. And we describe the impact of a tear gas bomb finally, the other 25% of cases are not on the thorax region as a cause of sudden cardiac death by commotio cordis [5].

Baseball, softball, , lacrosse

Batter hit by a ball thrown by the pitcher. Pitcher hit by a ball thrown by hand or batted. Player hit by batted ball. Catcher, referee or spectator hit by ball failed. Catcher hit by a bat. Body collisions in the bases. Player fallen on a softball after collecting it

American Football

Players hit by helmet, shoulder pads, knees or elbows of opponents. Collisions during melee or interceptions. Collisions against posts. Impacts of the ball against the thorax when trying to block a point.

Football

Impact of a kick in the chest. Balonazo in the chest of the goalkeeper. Player hit against the post.

Hockey

Goalkeepers or other defensive players hit by a goal shot. Multiple collisions between players. Players hit by sticks.

Fights and aggressions

Psychiatric guardian beaten by a patient. Professor beaten after mediating a fight between teenagers. Diverse impacts during games. Impact by fist of boxer (with glove) doing sparring. Children beaten by parents or kangaroos (physical punishment). Child hit by snowballs. Adolescents and young people involved in fist fights. Demonstrators scattered with rubber balls. Baby beaten during a diaper change. Adult beaten in a prison ritual. Araujo JC. Rev Mex Med Forense, 2019, 4(3):1-15

Kick kick on child's chest.

Other circumstances

Child hit by a horse kick. Young man hit by the recoil of a rifle during big game. Young man hit against the steering wheel of his vehicle in low energy accident. Child hit by a swing. Child fallen frontally from a slide or more height. Young man hit by a tennis ball filled with coins. Child hit by the head of a dog of 20 kg. Child hit by a frisbee (frisbee). Teen who received a slap on the chest to cut the hiccups. Boy hit by the handlebar when falling off the bicycle. Tabla 1. U.S. National Commotio Cordis Registry. Some situations that have triggered a sudden cardiac death by commotio cordis

The biomechanics of the impact the impact object. The objects launched at and the pathophysiological mechanism of different speeds have demonstrated the sudden cardiac death by commotio cordis, existence of two determining factors in the unleashed after a confrontation or violent appearance of the commotio cordis. The situation with a blunt object (tear bomb), first circumstance has to do with the are arrhythmic events unleashed when the location of the impact, this has to occur kinetic energy as a result of the impact of directly on the center of the cardiac a blow abruptly affects the thorax region in silhouette at the level of the left parasternal the precordial area and profoundly alters line (precordial area) [7]. The second the stability of the electrical conduction of determining circumstance is realated to the the myocardium, leading to a ventricular exact moment after the impact on the chest fibrillation that can cause sudden death. wall, which must occur with a narrow margin of 10 to 20 milliseconds; the rapid This event occurs when victims are rise in left ventricular pressure after impact hit by projectiles considered as standard is likely to cause the activation of ion implements or game objects (balls, balls, channels through mechanoelectric chips, among others) or by common coupling, in which there is a scattering of implements (blunt objects) or by a direct repolarization, an increase of this and, as a blow to the precordial area; nevertheless consequence, an electrical heterogeneity; the object product of the investigation is the generation of inward current through unusual since it is the impact of a tear gas ion channels sensitive to mechanics bomb fired by a firearm [6]. probably causes an increase in repolarization and non-uniform In the biomechanics of the impact myocardial activation, and is the cause of that triggers the pathophysiological premature ventricular depolarizations that mechanism, crucial variables have been are triggers of "direct" ventricular identified that include the speed of the fibrillation, without being preceded by impact, the location of the impact, the premature ventricular contractions or intensity of the impact and the hardness of Araujo JC. Rev Mex Med Forense, 2019, 4(3):1-15 ventricular tachycardia (configuring a "R on T phenomenon") [8]. Figure 1.

Figure 1. Exact location of the impact and the time it occurs are the determinants of ventricular fibrillation caused by commotio cordis. Ventricular Fibrillation is triggered immediately after the impact when it occurs in the vulnerable area of repolarization (10-20 msec before the peak of the T wave). Scheme of the subcellular physiopathological sequence responsible for the phenomenon of the commotio cordis

Although the cardiovascular gas bombs fired by a driving firearm, have collapse in the commotio cordis is really a probability of triggering ventricular instantaneous, up to 20% of the victims fibrillation (commotio cordis) when they remain physically active and with a level progressively increase to an impact speed of consciousness preserved after the of 64 km per hour. At speeds greater than impact (being able to walk, returning the 80 km per hour, the risk of structural object that has impacted them, even damage to the chest and heart, such as speaking, among others), which is hematoma and rupture of the myocardium, attributed to the individual tolerability of which are characteristic of concussion adolescents or healthy young adults or rather than concussion, increases. sustained ventricular tachycardia, before it degenerates into ventricular fibrillation. The importance of the hardness, location of the impact, internal structure of The kinetic energy supplied in the the projectile and speed at the time of impact varies enormously by virtue of the inducing a ventricular fibrillation is in type, speed, mass, shape, size, weight, relation to the intracavitary pressure hardness and orientation of the projectile induced in the left ventricle after the trajectory, biological plausibility, as well impact, which would generate the as the morphology and deformability of activation of ion channels, which it would the thoracic cage. Projectiles, such as tear in turn lead to a dispersion of the Araujo JC. Rev Mex Med Forense, 2019, 4(3):1-15 repolarization and an electrical CASE REPORT heterogeneity of the myocardium capable of generating a ventricular fibrillation; this It was a 20-year-old male is currently the most accepted hypothesis, economics student from the Metropolitan due to the selective activation of potassium University of Caracas, who was in a channels mediated by adenosine peaceful collective protest for socio- triphosphate (ATP), which contribute to economic and political demands in the the establishment of ventricular fibrillation Chacao municipality of the city of in myocardial ; it is currently Caracas; he received the direct impact of a considered the most likely pathogenic tear gas bomb on the thoracic region at the substrate in the appearance of the precordial area, fired by the shotgun of a commotio cordis [9, 10]. member of the internal order body of the Bolivarian National Guard; after the METHODS impact, the young man remained active, with a preserved level of consciousness, The case of a young adult, who but then he collapsed on the pavement and died due to the impact of a tear gas bomb was helped by his partner; he was in the thoracic precordial area, is reported; transferred to a medical center but he had the most plausible hypothesis is that it was no vital signs; to the physical examination fired directly on the victim's humanity by is appreciated in the precordial region, at law enforcement officers of the security the level of the fifth space, a concussion forces in charge of maintaining internal tattoo product of the object that impacted order, such as the Bolivarian National him; the public ministry states that it is Guard (GNB) and the Bolivarian National about the impression of a blunt object, like Police ( PNB), during the demonstrations a tear gas bomb. of peaceful protests for economic, political and social demands that emerged in the The young man was hit by a three-phase city of Caracas-Venezuela in the year tear gas bomb fired 2 to 3 meters away; the 2017; the individual was subjected to tear gas bombs, when detonated correctly forensic evaluations (autopsy) by the with a shotgun, reach a distance of 56 to 70 National Service of Medicine and Forensic meters; when they are fired directly and Sciences (SENAMECF). horizontally they become a lethal projectile. The impact received by the victim is similar to being hit by a blunt 80 kg object at a speed of approximately 270 km / h (Figure 2)

Figure 2 Infographics. A Contusion halo is seen in the area of impact of a blunt object on the body of the victim (red arrows). B. Tear-off cartridge 37 to 40 mm three-phase CAVIM.

RESULTS 8,610; In January 2015, the Ministry of the Popular Power for Defense authorized the Evaluating the results of the use of force by means of firearms and autopsy protocol performed by the chemical agents by the military agent for forensic pathologist attached to the Office functions of control of public order in of the Prosecutor and the National Service order to disperse peaceful protests. of Medicine and Forensic Sciences (SENAMECF) of the Criminal Scientific This resolution gives a nuance of and Criminal Investigation Body legality to the performance of military (CICPC), the following causes of death personnel in peaceful demonstrations diagnosis were established: Closed according to the principle of thoracic trauma in the left chest region that proportionality; This principle is caused a Cardiogenic Shock and Cardiac controversial since it contradicts a Contusion. constitutional precept contained in Article 68 of the constitutional text which it The investigation established that wields. "Citizens have the right to the violence executed by law enforcement demonstrate, peacefully and without agents of the Venezuelan State security weapons, without other requirements than forces, with the use of firearms and those established by law." Based on this, it chemical agents during the demonstrations is speculated that the military personnel or peaceful protest of the Venezuelan violate the Human Rights of the population, has its origin in resolution N demonstrators by shooting them directly at Araujo JC. Rev Mex Med Forense, 2019, 4(3):1-15 the body with a firearm (shotgun), even in firearm in the region of the thorax at the the case of a tear gas bomb; This can be level of the precordial area and that can lethal if it impacts on the thorax region in cause sudden cardiac death [12]. the precordial area, which can trigger a sudden cardiac death by the commotio The biomechanical knowledge for cordis. The national and international the forensic pathologist at the time of regulations according to the Venezuelan performing the autopsy is very useful, Public Ministry prohibits tear gas bombs since they can explain the mechanism of from being thrown or fired at point-blank production of the injury. It distinguishes range (<10 cms) or short distance (10 to between injuries that are the result of direct 70) centimeters directly on people. trauma, those that are the result of inertial damage or those that may occur as When the analysis of the case consequences of both mechanisms due to presented from the forensic medical legal the impact of a tear gas bomb [13]. point of view is made, the type of projectile, the force and the location of the After a thoracic trauma, an impact, as well as the kinematics or individual presents a sudden cardiac death; biomechanics of the impact, it is necessary in the assessment, it must be determined if to differentiate a contusio cordis from the it is a single trauma or if it has been due to commotio cordis; in contusio cordis there a direct trauma on the precordial area to is presence or absence of structural justify this injury or damage. Therefore, injuries; The absence of macroscopic from the perspective of biological injury due to impact is what differentiates plausibility, it can be argued that it is commotio cordis from cardiac contusion, possible that after an isolated thoracic given that a high-energy collision, such as trauma the commotio cordis occurs thoracic trauma over the precordial region, leading to this fatal outcome, as happened produces myocardial and overlying in the case presented [1-3]. damage to the thoracic cage. DISCUSSION It is necessary to study the biomechanics of the impact or The sudden death of cardiac origin biomechanics of the injuries. The damage by the commotio cordis, is in general, can be a solution of continuity in the although not invariably fatal; it has been material, as in this case a considered in the legal medical field due to (rib, sternum), muscle rupture, or a its rapid presentation, its character and its functional lesion in this case heart [11]. violent origin. Impact biomechanics is not a science with accuracy and scientific rigor, so many Sudden violent death is defined, times it is necessary to address many of the with medical legal criteria, as due to an problems from the probabilistic level. In accidental, suicidal or homicidal spite of this, legal and forensic medicine mechanism. It usually obeys to traumatic needs the application of this mechanisms or to strange forces that erupt biomechanical knowledge, fundamentally violently in the organism. There is the those where the purpose is the valuation of existence of an exogenous mechanism that the corporal damages by the traumatic has set in motion the process of death and, injuries to the people; an example of this is the impact of a tear-gas canister fired by a Araujo JC. Rev Mex Med Forense, 2019, 4(3):1-15 as a result, may be the responsibility of the attention in the medical scientific field; at person or persons who originated it [4,5]. present it is a pathological term that is restricted to sudden cardiac death after an Deaths that occur during or impact and not to the totality of immediately after a violent confrontation mechanically induced arrhythmias. It is associated with social, economic or probable that in the cases recorded, in cultural claims are especially complex and which the triggering mechanism was the controversial cases within the forensic impact of a blunt object, commotio cordis pathology. is not ruled out as a cause of sudden cardiac death. It is well known in forensic practice that many individuals who suffer Article 3 number 2 of the Law for sudden cardiac death from the impact on the disarmament and control of weapons the thorax of a blunt object (tear gas), if and ammunition defines Firearm as "the they are standing at the time of suffering mechanical instrument that uses an the fatal arrhythmia, may fall unconscious, explosive material that propels one or unable to protect themselves, hitting the multiple projectiles by means of gas ground or surrounding objects, even on the pressure, which are thrown at great speed, face. Bruised wounds sometimes suggest a product of the deflagration of gunpowder, traumatic death. Therefore, in these cases which give off high pressure gas after a should try to distinguish between the chemical reaction of combustion”. injuries suffered and those produced by the However, in numeral 22 of the commented impact mechanism. article, it exposes the concept of non-lethal weapons, which "include those weapons or Commotio cordis is rare, but it has technologies that have been specifically a high mortality. Documenting and designed to incapacitate or immobilize one recording it in countries such as the United or more persons, minimizing the States of America (USA), requires that the possibility of causing death or permanent trauma, well documented, be followed by injuries, as well as damage to property and immediate cardiovascular collapse, as well the environment”. Taking this definition as the absence of thoracic fractures and / or into account, tear gas bombs fall into this cardiac contusion [3] . category; However, when a tear gas bomb is used as a projectile that impacts the The Code of Forensic Medical precordial region, it can trigger a Instruction in its Article 77 states: "When commotio cordis resulting in sudden individuals who have suffered violence die cardiac death. from consequences of them, the Judge will decree the autopsy...". It is for all this that Although it is an unusual the autopsy is the only procedure that will occurrence, it gives rise to a series of determine the cause of death and grants the problems and medical and legal forensic death certificate. All autopsies in cases of consequences that tend to have a sudden cardiac death by commotio cordis considerable transcendence; Outstanding should follow an orderly sequential those related to Criminal Law, in the figure examination. of intentional or intentional homicide typified in Article 407 of the Venezuelan As deaths by commotio cordis are criminal code in force. "Whoever has infrequent, they have generated scant intentionally killed any person will be Araujo JC. Rev Mex Med Forense, 2019, 4(3):1-15 punished with imprisonment from twelve crimes of concern to the to eighteen years." In the cases listed international community as a below, the following penalties shall be whole. The Court shall have applied: "1. Fifteen to twenty-five years of jurisdiction, in accordance with imprisonment for the person who commits this Statute, with respect to the the homicide by means of poison or fire, following crimes: a) The crime of submersion or another of the offenses genocide; b) Crimes against provided for in title VII of this book, with humanity; c) War crimes; d) The treachery or for futile or ignoble reasons”. crime of aggression. 2. The Court shall exercise This code defines other crimes jurisdiction over the crime of against public order, such as illegal aggression once a provision is association or criminal association, that is, approved in accordance with the union of two or more people to carry articles 121 and 123 in which the out an illegal activity; This is stated in crime is defined and the conditions article 287: "When two or more persons under which it will be established. are associated with the purpose of That provision will be compatible committing crimes, each of them shall be with the relevant provisions of the punished, by the mere fact of the Charter of the United Nations. association, with imprisonment of two to five years." Article 288 establishes that "if The International Criminal Court, in its the conscripts cross the fields or roads and article 7, defines crimes against humanity if two of them, at least, carry weapons or as "any of the following acts when have them in a certain place, the penalty committed as part of a generalized or shall be imprisonment for a period of systematic attack against a civilian eighteen months to five years." Finally, population and with knowledge of said article 289 states that "the promoters or attack: a) Murder ... "Also in part III of this heads of the sheaf shall incur the penalty Statute are established the general of imprisonment from eighteen months to principles of criminal law in Article 22 five years, in the case of article 287 and states the following:" Nullum crimen sine from thirty months to six years, in the case lege: No one shall be criminally liable in of Article 288." accordance with this Statute unless the conduct of which it is, at the moment in Article 255 defines the crime of which it takes place, constitutes a crime concealment. Establishing that "those within the jurisdiction of the Court " who, after committing an offense punishable by imprisonment or The element of intentionality of these imprisonment, without prior agreement to crimes is reflected when: the crime itself and without contributing to carry it to further effects, will nevertheless 1. Except as otherwise provided, a help to ensure their benefit, to avoid the person shall be criminally liable inquiries of the authority”. The Rome and may be punished for a crime Statute of the International Criminal Court within the jurisdiction of the Court states: only if the material elements of the crime are carried out with intent 1. The jurisdiction of the Court shall and knowledge of the material be limited to the most serious elements of the crime. Araujo JC. Rev Mex Med Forense, 2019, 4(3):1-15

2. For the purposes of this article, it is Court, since they are part of the core understood that acts intentionally crimes of international criminal law. who: Crimes against humanity are defined as a) In relation to a conduct, it is certain behaviors that are committed in the proposed to incur in it; context of an attack with certain b) In relation to a characteristics: it must be generalized or consequence, it is proposed systematic and must be directed against to cause it or is aware that the civilian population. The basic criteria it will occur in the normal for determining when one is in the course of events. presence of a crime against humanity are 3. For the purposes of this article, already established in international "knowledge" means the awareness criminal law in the Rome Statute. For the that there is a circumstance or a Venezuelan criminal law, in its domestic consequence will occur in the law this type of crime remains a novum, normal course of events. The because although the criminal code is not words "knowingly" and "with classified as such, however, by this knowledge" shall be understood in immersed the Venezuelan State in the same sense, as stipulated in international conventions, treaties or article 30. treaties, it has to take advantage of said statute of international criminal law, as Finally, when the crime against established in article 23 of the Venezuelan humanity is committed in compliance with constitutional text, which refers to: superior orders and legal provisions article 33 states: "The treaties, pacts and conventions related to human rights, subscribed and 1. Anyone who has committed a ratified by Venezuela, have a crime within the jurisdiction of the constitutional hierarchy and prevail in the Court in compliance with an order internal order, to the extent that they issued by a government or a contain rules on their enjoyment and superior, be it military or civil, exercise more favorable to those shall not be exempt from criminal established in this Constitution and in the liability unless: laws of the Republic, and are of immediate a) He was obliged by law to and direct application by the courts and obey orders issued by the other organs of the Public Power”. government or the superior in question; Article 29 of the Rome Statute refers to b) I did not know that the the non-applicability of statutory order was illegal; Y limitations to crimes within the c) The order was not jurisdiction of the Court. manifestly unlawful. 2. For the purposes of this article, it CONCLUSION will be understood that orders to commit genocide or crimes against The impact of a tear gas bomb over humanity are manifestly unlawful. the precordial area as a trigger of the commotio cordis, brings about the Crimes against humanity are conducts alteration in the stability of the electrical typified by the International Criminal Araujo JC. Rev Mex Med Forense, 2019, 4(3):1-15 conduction of the myocardium, leading to opic.do?topicKey=ad_traum/9443&view a ventricular fibrillation that can cause =print. sudden death cardiac This event can occur [6]. Maron BJ, Mark Estes NA. Commotio when the victim was hit by a tear gas bomb cordis N Engl J Med. 2010; 362:917-27. 2 fired by the security forces of the internal [7]. Nesbitt AD, Cooper PJ, Kohl P. public order. Rediscovering commotio cordis. Lancet. 2001; 357:1195-7. Two situations must be [8]. Geddes LA, Roeder RA. Evolution of distinguished: the first is that sudden our knowledge of sudden death due to cardiac death by the commotio cordis is a commotio cordis. Am J Emerg Med. 2005; rare event, but at the same time very 23:67-75. devastating. And the second is that there is a crime against humanity due to the [9]. Kohl P, Nesbitt AD, Cooper PJ, Lei M. violation of the human rights of the Sudden cardiac death by commotio cordis: victims, which is typified in the Rome role of mechano-electric feedback. Statute in international criminal law, so it Cardiovasc Res. 2001; 50:280-9. must be prosecuted and penalized. [10]. Castellá J, Borondo JC, Betomeu A, Tortosa JM. Aspectos médico-forenses de REFERENCES la muerte súbita del adulto. Med Clin (Barc). 2006; 126:311-6. [11]. C.A. Bir,D.C. Viano. Biomechanical predictor of commotio cordis in high- [1]. Maron BJ, Poliac LC, Kaplan J A, speed chest impact. J Trauma, 47 (1999): Mueller FO. Blunt impact to the chest 468-473. leading to sudden death from [12]. Arregui-Dalmases, R. Teijeira, J. during sports activities. N Engl J Med. Forman Injury biomechanics as a 1995; 333:337-42. necessary tool in the field of forensic [2]. Legome E, in science: a pedestrian run-over case study adult Trauma. Uptodate, 2010. Forensic Sci Int, 198 (2010): e5-e9. (Consultado 3 ago 2017). Disponible en: Disponible en: http://www.uptodate.com/online/content/t http://dx.doi.org/10.1016/j.forsciint.2010. opic.do?topicKey=ad_traum/9443&view 01.008. =print. [13]. Lucena, A. Rico, M. Salguero, M. [3]. Madias C, Maron, BJ, Winstock, J, Blanco, R. Vázquez. Commotio cordis as Mark Estes A, Link MS. Commotion a result of a fight: report of a case cordis sudden cardiac death with chest considered to be imprudent homicide wall impact. J Cardiovasc Electrophysiol Forensic Sci Int, 177 (2008): e1-e4. 2007; 18:115-25. Disponible en [4]. Alonso Blas C, Malagón Caussade F. http://dx.doi.org/10.1016/j.forsciint.2007. Muerte súbita cardiaca causada por 09.008 Medline. commotio cordis. Emergencias 2011; 23: [14]. Asamblea Nacional Constituyente 471-478. (1999). Constitución de la República [5]. Legome E, Blunt Cardiac Injury in Bolivariana de Venezuela. Gaceta Oficial adult Trauma. Uptodate, 2010. de la República Bolivariana de Venezuela (Consultado 3 ago 2017). Disponible en: Nº 5.453 Extraordinario, de fecha 24 de http://www.uptodate.com/online/content/t marzo de 2000. Caracas-Venezuela. Araujo JC. Rev Mex Med Forense, 2019, 4(3):1-15

[15]. Asamblea Nacional. Código Penal de Gaceta Oficial Nº 40.190 fecha 17de junio Venezuela (2005). Gaceta Oficial Nº de 2013. 5.768, Editorial Hermanos Vadell. [18]. Congreso de la República de [16]. Asamblea Nacional. Decreto con Venezuela. Ley aprobatoria del Estatuto Rango, Valor y Fuerza de Ley del Código de Roma de la Corte Penal Internacional. Orgánico Procesal Penal Decreto N° 9.042 Gaceta Oficial Nº 5.507 de diciembre de Gaceta Oficial Nº 6.078. Extraordinario, 2000. p.56-85. [19]. Ministerio del Poder Popular para la [17]. Asamblea Nacional. Ley para el Defensa. Resolución No. 8610 publicada desarme y control de armas y municiones. en la Gaceta Oficial Nº 40.589 de enero de 2015.

Revista Mexicana de Medicina Forense y Ciencias de la Salud