Determination of the severity of harm to health forensic medicine. Criteria for determining the severity of harm to health. What does the expert determine?

Questionnaires to the EMS in cases of personal injury are as follows.

Are there any injuries on the victim's body? What is their character?

What object (tool, weapon) caused the damage?

How long ago did the damage occur?

What is the mechanism of injury (number, sequence, direction of impacts)?

What is the severity of the harm caused to the victim’s health?

Criteria for harm caused to health

The legal classification of the severity of harm to health includes infliction of serious, moderate and light harm to health (Articles 111, 112, 115 of the Criminal Code of the Russian Federation, respectively).

Since all the criteria for determining the severity of harm to health are medical, doctors are responsible for determining the actual severity of harm. In addition to these articles of the Criminal Code, the “Rules for forensic medical examination of the severity of harm to health” are in force, approved on December 10, 1996 by the Ministry of Health of the Russian Federation by Order No. 407 and agreed with Prosecutor General's Office, Supreme Court and the Ministry of Internal Affairs of the Russian Federation, which set out the criteria for assessing harm caused to health of different degrees of severity.

I. Criteria for minor harm to health.

Minor harm to health is harm that caused a short-term health disorder or a minor permanent loss of general ability to work.

A health disorder lasting less than three weeks (less than 21 days) is considered short-term.

A minor permanent loss of general ability to work is a loss of ability to work in the amount of 5%.

II. Criteria for moderate severity of harm to health.

Moderate harm to health - harm that is not dangerous to human life and does not entail the consequences specified in Art. 111 of this Code, but which caused a long-term health disorder or a significant permanent loss of general ability to work by less than one third.

Long-term health disorder refers to consequences directly related to the injury that last for more than three weeks (more than 21 days).

The duration of a health disorder should not be confused with the duration of temporary disability and the duration of treatment. The expert takes these terms into account, but the duration of the health disorder is decisive in determining the severity of the injury.

Significant permanent loss of ability to work of less than one third includes loss of ability to work from 10 to 30% inclusive.

III. Criteria for serious harm caused to health.

1. Life-threatening is harm to health that causes a life-threatening condition that may result in death. Preventing death as a result of medical care does not change the assessment of health harm as life-threatening. Life-threatening harm to health can include both physical injuries and diseases and pathological conditions.

Life-threatening injuries are:

1) injuries that, by their nature, pose a threat to the life of the victim and can lead to his death;

2) damage that caused the development of a life-threatening condition, the occurrence of which is not accidental.

2. Non-life-threatening harm to health, which is grave in consequences:

1) harm to health leading to loss of vision. Loss of vision in one eye represents a loss of organ functions and is considered serious harm to health. The loss of one eyeball represents the loss of an organ. The loss of a blind eye is classified by the duration of the health disorder;

2) harm to health leading to loss of speech, which is understood as loss of the ability to express one’s thoughts in articulate sounds that are understandable to others, or as a result of loss of voice;

3) harm to health leading to hearing loss. Hearing loss in one ear, as a loss of organ functions, is a serious health hazard.

When determining the severity of harm to health based on loss of vision or hearing, the possibility of improving vision or hearing with the help of medical and technical means (corrective glasses, hearing aids, etc.) is not taken into account.

3. Loss of any organ or loss of an organ’s functions.

Loss of an arm, leg, i.e. their separation from the body or loss of their functions (paralysis or other condition that precludes their activity). The loss of the most functionally important part of a limb (hand, foot) is equated to the loss of an arm or leg. In addition, the loss of a hand or foot entails a permanent loss of working capacity of more than one third and, on this basis, also refers to serious harm to health;

4. Mental disorder.

An assessment of the severity of harm to health resulting in mental disorder, drug addiction, substance abuse is carried out after conducting a forensic psychiatric, forensic drug addiction and forensic toxicological examination.

5. Injuries, diseases, pathological conditions resulting in a permanent loss of general ability to work by at least one third.

From a forensic medical point of view, loss of ability to work should be considered permanent, either with a determined outcome, or with a duration of health disorder of more than 120 days.

6. Termination of pregnancy, regardless of its duration, is a serious harm to health if it is in a direct causal relationship with external influences, and is not caused by the individual characteristics of the body or diseases of the person being examined.

7. Permanent facial disfigurement.

In case of facial injuries, the expert determines their severity in accordance with the signs contained in these Rules. In addition, he must determine whether the damage is permanent.

The erasability of damage should be understood as the possibility of disappearance of the visible consequences of damage or a significant decrease in their severity (i.e., the severity of scars, deformations, disturbances in facial expression, etc.) over time or under the influence of non-surgical means. If cosmetic surgery is required to eliminate these consequences, then the damage is considered permanent.

According to Russian criminal legislation, namely Articles No. 111, and, which represent a complete and exhaustive list of signs of damage for each degree, harm to health is a violation of both the physiological functions of the entire body or individual organs, and the anatomical integrity of tissues obtained under the influence of environmental factors.

By their nature, these factors are divided into psychological, physical, biological and chemical.

Medical specialists assign injuries that cause a person a certain group, which depends on their severity. That is, harm to health can be caused in both mild and severe form.

How is the severity of injuries classified?

Each degree of damage has its own characteristic rules and criteria., by which the assessment is made. If the applicant’s injuries are characterized by these signs, for example, of mild severity, then this is what the specialists will indicate after analysis in the papers.

The punishment of the one who caused them will depend on the recorded injuries: for severe and moderate injuries you can receive up to 8 years in prison (up to 15 in the event of the death of the victim), about 1000 hours of correctional labor or a fine of thousands.

Average

To put it simply, moderate severity includes everything that crosses the legal boundaries of mild severity, but does not reach severe severity.

As it becomes clear from the paragraph of the article about the classification of injuries, moderate severity has 4 factors, the first of which (the consequences specified in Article No. 111 of the Criminal Code of the Russian Federation were not revealed) is largely legal. The remaining 3 have the following medical criteria:

There is no danger to the life of the victim. If he is in a hospital or other medical institution where he is provided with professional assistance, and the patient’s condition is under the control of doctors, then there is no danger.
Long-term health disorder. For injuries for which the expert has determined treatment for a period exceeding 21 days (3 weeks), the disorder is called divisive. Examples of such injuries include:
- (or the 1st, but with additional injuries - severe hematomas or bruises on the body);
- deep dissection of limb tissue with damage to nerves and tendons;
- severe inflammation of the eyeball under the influence of household chemicals.
Significant, persistent loss of general ability to self-care by no more than a third (up to 30%). Typically, such injuries include severe closed or open fractures of the joints or phalanges of the fingers. Such damage causes serious problems in everyday life, and can last from 120 days to complete impossibility of restoring the previous level of performance.

In we talked about moderate health damage.

Heavy

The most extensive list of criteria and factors is for severe injuries, since this is the direct danger for the victim.

Here it is necessary to distinguish when the damage is severe, but does not pose a direct danger, - it has especially serious consequences.

In addition, danger to life is divided into two types: those that pose an immediate threat, and those that develop a life-threatening condition (defined above):

The first type is characterized by the following frequent injuries:
- Destruction of the spinal column, including damage to other nearby organs (for example, the spinal cord).
- Severe dislocations and popping out of any cervical vertebrae and fractures of the cervical cartilages.
- Head wounds with holes in it (there may also be through ones, for example, gunshot wounds or penetrations from a bladed weapon).
- Any, with the exception of mild degrees of his concussion: 1st and 2nd.
- Openings penetrating into the neck (pharynx, larynx) and trachea with the cervical part of the esophagus.
- Fractures or chips of the bones of the cranial vault (with the exception of fractures of the bones of the victim’s face: palate, and cheekbones).
- Any injury to the spinal cord that results in disruption of its functions.
- Tears, tears and other closed damage internal organs.
- Multiple injuries to the victim’s ribs; violation of the integrity of their frame.
- A hole in the abdominal region (possibly without affecting the internal organs).
- Injuries leading to a fracture of the sacral spine.
- Severe fractures of the pelvic region.
- Deep wounds and injuries to the chest cavity, including those affecting the lungs or ribs.
- Receiving heavy doses of radiation leading to the development of radiation sickness.
- Severe thermal, electrical and chemical burns (4th degree - at least 10%, 3rd - 15%, 2nd - 20% of the entire body surface, respectively).
- Frostbite of areas of the body with a distribution similar to burns in the percentage of damage to the total surface area of the body.
Severe injuries, which belong to the second type of threat, are the initiator of the development of a life-threatening condition. They are somewhat less common and their list is naturally smaller:
- Copious loss of blood fluid.
- Shock varying degrees(grades 3 and 4 are especially dangerous).
- Falling into a stable state of coma.
- Heart or vascular failure.
- Respiratory failure.
- Rushing diseases: sepsis, phlegmon, peritonitis.
- Interruption of the circulatory process in a certain limb or organ, leading to its infarction or embolism of the lungs or brain.
- Severe poisoning (also with narcotic substances).
- Overheating, frostbite, decompression sickness, dehydration, exhaustion and asphyxia of the body.

There is also severe harm to health, which does not pose a direct threat, but has serious consequences:

The last point includes injuries that directly or through their consequences pose significant difficulties for the patient’s daily tasks, that is, for his own self-care.

These include, regardless of medical recovery actions and further consequences, the following damages and injuries, which clearly lead to a decrease in performance by at least a third (30%) of the victim’s entire body:

Any type of humerus fracture.
Fracture of the elbow joint.
Damage to the bones of the forearm area: both simple fractures and additionally with dislocation.
Almost any fractures of the pelvic and femur.
Severe damage to both ankles and tibia bones.

How is the degree determination procedure performed?

Obtaining data on a patient’s injuries occurs only in a specially designated room under certain conditions and only by a specialist. For example, according to Article 62 of the Federal Law of the Russian Federation, examination and research can only take place during the day.

Article 62 Federal Law dated November 21, 2011 N323-FZ “On the basics of protecting the health of citizens in Russian Federation" Forensic medical and forensic psychiatric examinations

Forensic medical and forensic psychiatric examinations are carried out in order to establish the circumstances to be proven in a specific case in medical organizations by experts in accordance with the legislation of the Russian Federation on state forensic activity.
The procedure for conducting forensic medical and forensic psychiatric examinations and the procedure for determining the severity of harm caused to human health are established by the authorized federal body executive power.

The healthcare professional must determine the appropriate methods and techniques for diagnosing the patient, as well as draw up a detailed conclusion after the examination, which will indicate the severity of the harm to health.

Usually, one specialist is required to assess the damage and prescribe the appropriate treatment (this is called a sole examination), but in some cases, for example, in case of eye damage or the termination of pregnancy, medical consultants are required.

They, together with the forensic expert, form a panel, which makes the final decision on assessing the degree of severity. The panel's specialists must explain to the victim that collaborating with doctors is only more beneficial for him if he does not want to give permission to examine damaged areas of the body.

The doctor is given specific task to carry out the examination, and its purpose is also explained. The forensic specialist begins the examination by asking the patient questions about:

Who, where and how injured him.
What a weapon was the perfect crime.
His general feelings at the time of determining the severity of harm to health.

Important! The identity of the victim is determined either by passport or by confirmation of the relevant representative of the authorities. In the latter case, the medical expert notes this fact as a result of the examination, so that responsibility for this decision rests only with that representative.

The selected methods are used to analyze and collect missing information. The results of the examination are recorded in a medical report for the authorities that are investigating the patient’s case.

Who does the examination?

The most important and obligatory specialist in examining and determining the severity of injuries is a forensic expert. He may be either a public servant or a private one, but in any case he bears the full criminal liability for their activities and their results.

The specialist must have a license (this should be checked with private individuals, since state ones undergo strict control)

The procedure itself must be carried out carefully, with respect for human dignity and honor.. The patient is not obliged to provide damaged areas for analysis, but in this case it will not be possible to conduct an examination: there will be no results for further legal processes, as well as treatment.

But a forced version of the examination can also be carried out on criminals if it is required for the crime investigation process.

The acquired results can be used both for personal purposes (for example, receiving insurance payments) and for legal (court) processes. The main thing is to tell the forensic expert everything thoroughly and in detail so that he can accurately determine the severity of the damage caused.

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Order of the Ministry of Health and Social Development of the Russian Federation of April 24, 2008 N 194n
"On approval of Medical criteria for determining the severity of harm caused to human health"

With changes and additions from:

Registration N 12118

The severity of harm caused to human health during a forensic medical examination in civil, administrative and criminal proceedings is determined on the basis of qualifying signs and medical criteria. Medical criteria are used to assess injuries found during a forensic medical examination of a living person, examination of a corpse and its parts, as well as during forensic medical examinations of case materials and medical documents.

Medical criteria for qualifying features in relation to serious harm to health are, for example, harm to health that is dangerous to human life (significant damage to important organs, their loss), complete loss of professional ability to work; in relation to harm to health of moderate severity - temporary disability, long-term health disorder; in relation to minor harm to health - short-term health disorder. Superficial injuries, including abrasions, bruises, soft tissue bruises and other injuries that do not entail short-term health problems or minor permanent loss of general ability to work, are regarded as injuries that do not cause harm to human health.

To determine the severity of harm caused to human health, the presence of one medical criterion is sufficient, but if, for example, multiple injuries mutually aggravate each other, the determination of the severity of harm caused to human health is made based on their totality. If the nature of the harm to health cannot be determined, the outcome of the harm caused is unclear, the necessary medical documents are missing, the person did not appear for a forensic medical examination, the severity of the harm caused to the person is not determined.

A table of percentages of permanent loss of general ability to work as a result of various injuries, poisonings and other consequences of external causes is provided, which is also used in the forensic medical determination of the severity of harm caused to human health, according to the qualifying criteria and medical criterion of permanent loss of general ability to work.

Order of the Ministry of Health and Social Development of the Russian Federation dated April 24, 2008 N 194n “On approval of Medical criteria for determining the severity of harm caused to human health”

Registration N 12118

This order comes into force 10 days after the day of its official publication

harm to health

6. Medical criteria for qualifying features in relation to grievous bodily harm are:

6.1. Harm to health that is dangerous to human life, which by its nature directly poses a threat to life, as well as harm to health that has caused the development of a life-threatening condition (hereinafter referred to as harm to health that is dangerous to human life).

Harm to health, dangerous to human life, creating a direct threat to life:

6.1.1. wound of the head (scalp, eyelid and periorbital region, nose, ear, cheek and temporomandibular region, other areas of the head), penetrating into the cranial cavity, including without damage to the brain;

6.1.2. fracture of the vault (frontal, parietal bones) and (or) the base of the skull: the cranial fossa (anterior, middle or posterior) or the occipital bone, or the upper wall of the orbit, or the ethmoid bone, or the sphenoid bone, or the temporal bone, with the exception of an isolated external crack bone plate of the cranial vault and fractures of the facial bones: nose, lower wall of the orbit, lacrimal ossicle, zygomatic bone, upper jaw, alveolar process, palatine bone, lower jaw;

6.1.3. intracranial injury: crushing of the brain substance; diffuse axonal brain damage; severe brain contusion; traumatic intracerebral or intraventricular hemorrhage; moderate cerebral contusion or traumatic epidural, or subdural, or subarachnoid hemorrhage in the presence of cerebral, focal and brain stem symptoms;

6.1.4. a neck wound penetrating into the lumen of the pharynx or larynx, or the cervical trachea, or the cervical esophagus; injury to the thyroid gland;

6.1.5. fracture of the cartilages of the larynx: thyroid or cricoid, or arytenoid, or epiglottis, or corniculate, or tracheal cartilages;

6.1.6. fracture of the cervical spine: fracture of the body or bilateral fracture of the arch of the cervical vertebra, or fracture of the tooth of the II cervical vertebra, or unilateral fracture of the arch of the I or II cervical vertebrae, or multiple fractures of the cervical vertebrae, including without dysfunction of the spinal cord;

6.1.7. dislocation of one or more cervical vertebrae; traumatic rupture of the intervertebral disc at the level of the cervical spine with compression of the spinal cord;

6.1.8. contusion of the cervical spinal cord with impairment of its function;

6.1.9. a chest wound penetrating into the pleural cavity or into the pericardial cavity, or into the mediastinal tissue, including without damage to internal organs;

6.1.10. closed damage (crushing, avulsion, rupture) of the organs of the thoracic cavity: the heart or lung, or the bronchi, or the thoracic trachea; traumatic hemopericardium or pneumothorax, or hemothorax, or hemopneumothorax; diaphragm or lymphatic thoracic duct, or thymus gland;

6.1.11. multiple bilateral fractures of the ribs with disruption of the anatomical integrity of the chest frame or multiple unilateral fractures of the ribs along two or more anatomical lines with the formation of a movable section of the chest wall like a “rib valve”;

6.1.12. fracture of the thoracic spine: fracture of the body or arch of one thoracic vertebra with dysfunction of the spinal cord, or several thoracic vertebrae;

6.1.13. dislocation of the thoracic vertebra; traumatic rupture of the intervertebral disc in the thoracic region with compression of the spinal cord;

6.1.14. contusion of the thoracic spinal cord with impairment of its function;

6.1.15. abdominal wound penetrating into the abdominal cavity, including without damage to internal organs;

6.1.16. closed injury (crushing, avulsion, rupture): abdominal organs - spleen or liver, and/or gall bladder, or pancreas, or stomach, or small intestine, or colon, or rectum, or greater omentum, or mesentery colon and (or) small intestine; retroperitoneal organs - kidney, adrenal gland, ureter;

6.1.17. a wound of the lower back and (or) pelvis penetrating into the retroperitoneal space, with damage to the organs of the retroperitoneum: kidney or adrenal gland, or ureter, or pancreas, or the descending and horizontal part duodenum, or ascending and descending colon;

6.1.18. fracture of the lumbosacral spine: the body or arch of one or more lumbar and (or) sacral vertebrae with cauda equina syndrome;

6.1.19. dislocation of the lumbar vertebra; traumatic rupture of the intervertebral disc in the lumbar, lumbosacral region with cauda equina syndrome;

6.1.20. contusion of the lumbar spinal cord with cauda equina syndrome;

6.1.21. damage (crushing, avulsion, rupture) of the pelvic organs: open and (or) closed damage to the bladder or membranous part urethra, or ovary, or fallopian tube, or uterus, or other pelvic organs (prostate, seminal vesicles, vas deferens);

6.1.22. a wound to the wall of the vagina or rectum, or perineum, penetrating into the cavity and (or) pelvic tissue;

6.1.23. bilateral fractures of the anterior pelvic semi-ring with disruption of continuity: “butterfly”-type fractures of both pubis and both ischiums; fractures of the pelvic bones with disruption of the continuity of the pelvic ring in the posterior section: vertical fractures of the sacrum, ilium, isolated ruptures of the sacroiliac joint; fractures of the pelvic bones with disruption of the continuity of the pelvic ring in the anterior and posterior sections: unilateral and bilateral vertical fractures of the anterior and posterior sections of the pelvis on one side (Malgenya fracture); diagonal fractures - vertical fractures in the anterior and posterior parts of the pelvis on opposite sides (Vollumier fracture); various combinations of bone fractures and ruptures of the pelvic joints in the anterior and posterior sections;

6.1.24. a wound penetrating the spinal canal of the cervical or thoracic, or lumbar, or sacral spine, including without damage to the spinal cord and cauda equina;

6.1.25. open or closed spinal cord injury: complete or incomplete break of the spinal cord; spinal cord crush;

6.1.26. damage (rupture, separation, dissection, traumatic aneurysm) of large blood vessels: aorta or carotid artery (common, external, internal), or subclavian, or axillary, or brachial, or iliac (common, external, internal), or femoral, or popliteal arteries and (or) accompanying main veins;

6.1.27. blunt trauma of reflexogenic zones: the larynx area, the carotid sinus area, the solar plexus area, the external genital area in the presence of clinical and morphological data;

6.1.28. thermal or chemical, or electrical, or radiation burns of III - IV degree, exceeding 10% of the body surface; burns III degree exceeding 15% of the body surface; second degree burns exceeding 20% of the body surface; burns of a smaller area, accompanied by the development of burn disease; burns respiratory tract with symptoms of edema and narrowing of the glottis;

6.1.29. frostbite of III - IV degree with an affected area exceeding 10% of the body surface; frostbite of the third degree with an affected area exceeding 15% of the body surface; frostbite of the second degree with an affected area exceeding 20% of the body surface;

6.1.30. radiation injuries, manifested by acute radiation sickness of severe and extremely severe degrees.

6.2. Harm to health that is dangerous to human life, causing a disorder of the vital functions of the human body, which cannot be compensated by the body on its own and usually ends in death (hereinafter referred to as a life-threatening condition):

6.2.1. shock of severe (III - IV) degree;

6.2.2. coma II - III degree of various etiologies;

6.2.3. acute, profuse or massive blood loss;

6.2.4. acute cardiac and (or) severe vascular failure, or severe cerebrovascular accident;

6.2.5. acute renal or acute liver, or severe acute adrenal insufficiency, or acute pancreatic necrosis;

6.2.6. severe acute respiratory failure;

6.2.7. purulent-septic condition: sepsis or peritonitis, or purulent pleurisy, or phlegmon;

6.2.8. disorder of regional and (or) organ circulation, leading to infarction of an internal organ or gangrene of a limb; embolism (gas, fat, tissue, or thromboembolism) of blood vessels in the brain or lungs;

6.2.9. acute poisoning with chemical and biological substances of medical and non-medical use, including drugs or psychotropic drugs, or hypnotics, or drugs acting primarily on the cardiovascular system, or alcohol and its surrogates, or technical fluids, or toxic metals, or toxic gases, or food poisoning causing a life-threatening condition listed in paragraphs 6.2.1 - 6.2.8 of the Medical Criteria;

6.2.10. various types mechanical asphyxia; consequences of general exposure to high or low temperature (heatstroke, sunstroke, general overheating, hypothermia); consequences of exposure to high or low atmospheric pressure (barotrauma, decompression sickness); consequences of exposure to technical or atmospheric electricity (electrical injury); consequences of other forms of adverse effects (dehydration, exhaustion, overexertion of the body), causing a life-threatening condition given in paragraphs 6.2.1 - 6.2.8 of the Medical Criteria.

6.3. Loss of vision - complete permanent blindness in both eyes or such an irreversible condition when, as a result of injury, poisoning or other external influence, a person has a deterioration in vision, which corresponds to a visual acuity of 0.04 or lower.

Loss of vision in one eye is assessed based on permanent loss of general ability to work.

Post-traumatic removal of one eyeball, which had vision before the injury, is also assessed on the basis of persistent loss of general ability to work.

Determination of the severity of harm caused to a person’s health as a result of the loss of a blind eye is carried out based on the duration of the health disorder.

6.4. Loss of speech is the irreversible loss of the ability to express thoughts in articulate sounds that are understandable to others.

6.5. Hearing loss is complete permanent deafness in both ears or such an irreversible condition when a person cannot hear spoken speech at a distance of 3 - 5 cm from the auricle.

Hearing loss in one ear is assessed based on permanent loss of general ability to work.

6.6. Loss of any organ or loss of an organ’s functions:

6.6.1. loss of an arm or leg, i.e. their separation from the body or permanent loss of their functions (paralysis or other condition that excludes their functions); the loss of a hand or foot is equivalent to the loss of an arm or leg;

6.6.2. loss of productive capacity, expressed in men in the ability to copulate or fertilize, in women - in the ability to copulate or conceive, or bear children, or bear children;

6.6.3. loss of one testicle.

6.7. Termination of pregnancy is the termination of pregnancy, regardless of duration, caused by harm to health, with the development of miscarriage, intrauterine fetal death, premature birth, or necessitating the need for medical intervention.

If external reasons determined the need to terminate the pregnancy through medical intervention (uterine curettage, cesarean section, etc.), then these injuries and the resulting consequences are equated to termination of pregnancy and are assessed as serious harm to health.

6.8. A mental disorder, the occurrence of which must be in a cause-and-effect relationship with the harm caused to health, i.e. be its consequence.

6.9. Drug addiction or substance abuse.

6.10. Permanent facial disfigurement.

The severity of the harm caused to a person’s health, expressed in permanent disfigurement of his face, is determined by the court.

The forensic medical examination is limited only to establishing the indelibility of this damage, as well as its medical consequences in accordance with Medical criteria.

Indelible changes should be understood as those damage to the face that do not disappear on their own over time (without surgical removal of scars, deformities, facial expression disorders, etc., or under the influence of non-surgical methods) and their elimination requires surgical intervention (for example, cosmetic surgery).

6.11. Significant persistent loss of general ability to work by at least one third (persistent loss of total ability to work over 30 percent).

The following injuries are considered to be serious harm to health, causing a significant permanent loss of general ability to work by at least one third, regardless of the outcome and the provision (failure) of medical care:

6.11.1. open or closed fracture of the humerus: intra-articular (humeral head) or periarticular (anatomical neck, sub- and transtubercular), or surgical neck or diaphysis of the humerus;

Russian Center for SME: Commentary dated 00.00.2008

RULES
DETERMINING THE SEVERITY OF HARM,
CAUSED BY HUMAN HEALTH

1. These Rules establish the procedure for determining, during a forensic medical examination, the severity of harm caused to human health.

The procedure for determining the severity of harm caused to human health within the framework of a forensic medical examination is based on the human and civil rights enshrined in the Constitution of the Russian Federation (1993) and protected by law, the rights of the citizen and the patient, set out in the Fundamentals of the Legislation of the Russian Federation on the protection of the health of citizens (1993 ), the provisions of the Criminal Code of the Russian Federation (1996) in terms of causing harm to human health, the provisions of the Code of Criminal Procedure (2002) and the Federal Law on Economic Activity (2001) in relation to the requirements for examination, examination and examination, as well as these Rules, departmental regulations on the organization of judicial medical activities in the Russian Federation, fundamental theoretical and applied, clinical and forensic knowledge.

2. Harm caused to human health is understood as a violation of the anatomical integrity and physiological function of human organs and tissues as a result of exposure to physical, chemical, biological and mental environmental factors.

Within the meaning of clause 2, we are talking about causing harm to health, i.e. causing harm to a living person, since health (or ill health) is an exclusive characteristic of a living being. However, this provision does not exclude the possibility of establishing the severity of harm to a person’s health when examining his corpse. In this case, it is established what the severity of harm to a person’s health was before his death occurred, i.e., ultimately, we are talking about assessing intravital trauma.

Harm to health is understood as a consequence, the result of external influence, therefore the definition of the concept of “harm to health” almost completely coincides with such concepts as “injury” or “damage” (naturally, we are talking about intravital injury or intravital damage).

Violation of anatomical integrity (structure) and physiological function is considered in duality, since there cannot be a violation of the anatomical structure of a living organism without the function being impaired. In the same way, there cannot be a dysfunction of the body in the absence of some morphological substrate that caused the identified functional changes. Moreover, the morphological equivalent of the impaired function can be identified not only at the organ or tissue level, but also at the cellular and subcellular levels. That is, we mean harm that is caused to the health of the body as a whole, and not just individual organs or fabrics.

The definition of the concept of “harm to health” provides an exhaustive list of causes (damaging factors) of injury: physical, chemical, biological, mental. Moreover, these factors can cause harm to health, either individually or in various combinations (in the latter case we are talking about the occurrence and, therefore, the need for an expert assessment of a combined injury). What these factors have in common is that they are all external (in relation to the human body) damaging factors, or environmental factors.

3. Harm caused to human health is determined depending on the degree of its severity (serious harm, moderate harm and light harm) on the basis of the qualifying criteria provided for in paragraph 4 of these Rules, and in accordance with the Medical criteria for determining the severity of harm caused to health person, approved by the Ministry of Health and Social Development of the Russian Federation.

The Criminal Code of the Russian Federation defines only three degrees of severity of harm caused to human health: severe, moderate and light. This is the result of external traumatic influence, the result of the action of one or more external damaging factors.

Qualifying criteria are also established by the Criminal Code of the Russian Federation. It provides an exhaustive list of qualifying features (results of external influences): danger to life; loss of vision, speech, hearing or any organ function or loss of function; miscarriage, mental disorder, drug addiction or substance abuse; permanent facial disfigurement; complete loss of professional ability to work; persistent loss of general ability to work; health disorder. The last two signs have gradations:

- persistent loss of general ability to work:
- a) “not less than one third”,
- b) “significant... less than one third”,
- c) “insignificant”;
- health disorder, according to the Rules, can be long-term or short-term.

The vast majority of qualifying features are an unambiguous characteristic of the result of an illegal action: danger to life, loss of vision, speech, hearing or some organ, loss of organ function, permanent loss of general ability to work, complete loss of professional ability to work, health disorder, termination of pregnancy, mental disorder , drug addiction or substance abuse.

One of the signs contains a two-pronged characteristic - indelible facial disfigurement. In this sign, the first component is established by medical specialists and is the result of the action of some damaging factor (mechanical, thermal, chemical, etc.) on a person’s face. The second component characterizes the action - disfigurement, therefore, like any action, it is ultimately established and assessed by the court.

Some qualifying features represent a fact that receives its qualifying certainty at the time of harm to health, regardless of the actual outcome of the damage (for example, danger to life and some types of permanent disability). To establish other qualifying criteria, it is necessary to determine the actual outcome, i.e., the temporary or irreversible damage to anatomical structures and physiological functions that was caused by the primary (initial) exposure (for example, a health disorder of varying duration).

4. Qualifying signs of the severity of harm caused to human health are:

a) in relation to grave harm:
harm dangerous to human life;
loss of vision, speech, hearing or any organ or loss of organ functions;
termination of pregnancy;
mental disorder;
drug addiction or substance abuse;
permanent facial disfigurement;
significant permanent loss of general ability to work by at least one third;
complete loss of professional ability to work;
b) in relation to average severity of harm:
long-term health disorder;
significant persistent loss of total working capacity of less than one third;
c) in relation to minor harm:
short-term health disorder;
minor persistent loss of general ability to work.

The qualifying characteristics listed in clause 4 of the Rules fully comply with Art. 111, 112, 115 of the Criminal Code of the Russian Federation.

5. To determine the severity of harm caused to human health, the presence of one of the qualifying signs is sufficient. If there are several qualifying criteria, the severity of the harm caused to human health is determined by the criterion that corresponds to the greater severity of the harm.

The first part of clause 5 is stated clearly and unambiguously - one qualifying feature is enough to establish the degree of severity of harm to health. However, this only applies to the case where the qualifying feature is the only qualifying characteristic of the damage.

If there are several qualifying criteria, the severity of the harm caused to human health is established according to the criterion corresponding to the greatest degree of severity of the harm to health.

Meanwhile, having identified several qualifying signs and established the degree of severity of harm on the basis of the greatest severity, the expert, in addition, is obliged to indicate in his conclusion other signs he has identified, since this circumstance will contribute to a more complete and objective determination by the court of the degree of guilt of the guilty person. For example, the degree of guilt may be determined by the court differently if:

a) serious harm to health was limited to danger to life, and the victim recovered from the injury in a short time, for example, after a week he began performing normal work duties;
b) serious harm to health (based on the same sign of danger to life) was accompanied by a long-term health disorder and resulted in a significant permanent, i.e. irreversible, loss of general ability to work.

6. The severity of harm caused to human health is determined in medical institutions of the state health care system by a doctor - a forensic medical expert (hereinafter referred to as the expert).

The rules do not limit the possibility of establishing the severity of harm caused to human health only in forensic medical institutions. These may be, within the meaning of clause 6, other medical institutions, for example, medical universities included in state system health care, licensed to practice specific type forensic medical activities, in particular the examination of living persons.

The defining requirements are: a) state status of the medical institution; b) performance of an examination by a forensic medical expert. This may be a state forensic expert who has the appropriate forensic certificate, a certified doctor of a state medical institution (for example, a teacher in the department of forensic medicine of a state medical university licensed to engage in forensic medical examination of living persons).

Forensic doctors of non-state medical institutions in the status of limited liability companies, joint-stock companies, public associations, etc., who have a license to engage in forensic medical examination of living persons or forensic medical examination of case materials, as well as private forensic doctors, do not Those who are employees of the mentioned institutions can conduct a forensic medical examination to determine the severity of harm to health in accordance with Art. 41 Federal Law GSED in compliance with other requirements of this Law (Articles 2.4, 6-8, 16, 17, 24, 25, Part II of Article 18).

7. The object of a forensic medical examination is a living person or a corpse (parts thereof), as well as case materials and medical documents provided to the expert in the prescribed manner.

Ultimately, the only object of the forensic expert when determining the severity of harm caused to human health is a living person (“living person”). At forensic research corpse, the same problem is solved: what was (or what would be) the severity of the harm caused to a person’s health during his death.

Specific violations of the structure and function of the body can be established during a direct forensic medical examination of the victim.

If the victim was examined or treated for the injury in outpatient or inpatient medical institutions, then the nature of the primary (initial) violation of the anatomical integrity and physiological function is judged indirectly, according to the records in medical documents(card of an outpatient or inpatient stay of a patient, accompanying sheet of emergency medical care, registration journals of trauma centers, forms of special laboratory tests, etc.) or displays on photographs, radiographs, computer images, electrocardiograms, electroencephalograms, etc.

If the victim has died by the time of the examination, then only the anatomical (structural) component of the damage can be established on the corpse. The ability to judge the nature of intravital impaired function is limited by assumptions based on the nature and severity of anatomical injuries, as well as on records in medical documents documenting the state of health of the victim after injury.

Undoubtedly, the forensic medical expert must request the provision of original medical documents with comprehensive information about the nature and clinical course of the injuries. Original documents seized in accordance with the established procedure from a medical institution may contain records, the different time and method of execution of which can be judged by direct inspection of this document (writing a single text with different dyes or different writing instruments, erasures, additions, crossed out or filled in fragments of text and etc.). This gives grounds to draw the attention of the person who appointed the examination to the identified factual data. In some cases, this may be the basis for a preliminary forensic examination of documents, during which destroyed, crossed out, filled in or partially lost text is restored. In other words, the forensic expert must be provided with authentic documents with genuine initial primary information.

In cases where all or part of the handwritten text of a submitted medical document is illegible, the forensic medical examiner has the right to request an official transcript of the text. The use of illegible text during an examination either deprives the expert of the opportunity to obtain complete information about the subject of the study, or creates the danger of a distorted perception of the content of illegible records.

If for some reason the expert cannot be provided with original medical documents, copies certified by a notary or the body that appointed the examination may be officially provided. In such cases, the expert is obliged to note in his Conclusion the fact of providing certified copies. The body that appointed the examination and submitted the copies is responsible for ensuring that the copies correspond to the original.

In addition to textual medical documents, to answer the questions posed, the expert may need original radiographs, electrocardiograms, etc. If they are not presented along with the decision to order a forensic medical examination, they must be requested in the expert’s written request.

If it is impossible to resolve the issues raised without the requested documents, then in the petition the expert is obliged to indicate this circumstance and notify the investigator (or other person who appointed the examination) about the suspension of the examination until the petition is executed.

8. If there is a need for a special medical examination of a living person, medical specialists from organizations that have the conditions necessary to conduct such examinations are involved in conducting a forensic medical examination.

If a special examination (outpatient or inpatient, single or dynamic) is necessary to answer the questions posed, which are within the competence of the forensic medical expert, the forensic medical expert, in accordance with paragraph 8 of the Rules, has the right to demand from medical specialists of organizations (both medical, and non-medical) to provide the technical capabilities to conduct the necessary expert research. If an organization (or doctors of this organization) refuses to provide the conditions available to them, the person who appointed the examination is notified about this in order to take measures provided by law to ensure the technical capabilities of using the organization’s conditions necessary for the examination.

Clause 8 of the Rules does not apply to the production of commission examinations, for the appointment and production of which a different procedure is established.

9. When conducting a forensic medical examination of a living person who has any disease or damage to a part of the body that was previously lost completely or partially before an injury, only harm caused to the person’s health caused by the injury and causally related to it is taken into account.

To determine the severity of harm caused to the health of a person with a previously lost function due to a previous injury or illness, the expert is obliged, by directly examining the victim and studying medical documentation about his previous health (or ill health), to establish:

a) the fact, nature and extent of the previously lost function;
b) the fact, nature and extent of function lost due to the injury being assessed;
c) the influence of previously lost function and individual characteristics of the victim’s body (for example, exhaustion, asthenia, impaired immune status, etc.) on the clinical course of the assessed injury and the degree of impaired additional functions.

When establishing a causal relationship between the degree of harm caused to health and the assessed injury, the expert is obliged not only to formally limit himself to stating the scope of the function additionally impaired by the assessed injury, but also to determine the nature of the influence of the previously impaired function and individual characteristics of the body on the nature and degree of the impairment caused by the assessed injury.

10. The severity of harm caused to human health, in the presence of damage resulting from repeated traumatic impacts (including during the provision of medical care), is determined separately for each such impact.

The problem is solved by a forensic expert in the presence of several isolated injuries or several injuries that coincide in localization, but arise from the action of different damaging factors.

The degree of severity of harm caused to human health by each of several isolated injuries is established depending on the nature of the specific injury, for example, with multiple stab wounds of the abdomen, some of them can penetrate into the peritoneal cavity (this is serious harm to health due to the danger to life), injuries that do not penetrate the peritoneal cavity will be assessed depending on the actual outcome, which may be expressed in a different duration of health disorder.

When there are several injuries that coincide in location, the severity of the harm can be established if these injuries were caused by external damaging factors that are different in nature. For example, a combined injury of the right hypochondrium, expressed in a closed blunt trauma to the abdomen with rupture of the tissue of the right lobe of the liver and thermal burns of the skin in the same area. The first component is assessed as serious harm to health based on danger to life, the second - depending on the actual outcome.

As a result of a single impact, several injuries can occur, for example, a closed chest injury in the form of a rupture of the left lung, fractures of the V-VI left ribs and extensive bruising. These damages resulting from a single exposure are assessed collectively.

Trauma can be caused by multiple impacts to a single anatomical area, such as closed blunt head trauma with severe brain contusion and multiple contusions and facial bruises. In this case, the brain contusion was caused by a combination of several external influences. The cumulative damaging effect is that each subsequent impact aggravates the effect of the previous one, as a result, new sources of intracranial bleeding may appear, stopped bleeding resumes, then intensifies, etc. Therefore, such a head injury should be assessed as a single multicomponent injury, representing serious harm to health on grounds of danger to life. If several injuries are of different duration, the severity of harm to health is established in relation to each injury. In this case, the recommendations provided for in paragraph 9 of these Rules are taken into account.

11. When determining the severity of harm caused to a person’s health, resulting in a mental disorder and (or) drug addiction or substance abuse, a forensic medical examination is carried out by a commission of experts with the participation of a psychiatrist and (or) a narcologist or a toxicologist.

12. When determining the severity of harm caused to a person’s health, resulting in termination of pregnancy, a forensic medical examination is carried out by a commission of experts with the participation of an obstetrician-gynecologist.

Clauses 11 and 12 establish a commission procedure for determining the severity of harm to health resulting in a mental disorder, or drug addiction or substance abuse (clause 11), or termination of pregnancy (clause 12). The methodology for conducting these types of forensic medical examinations is provided for by special Medical criteria approved by the Ministry of Health and Social Development of Russia.

13. The degree of severity of harm caused to a person’s health, expressed in indelible disfigurement of his face, is determined by the court. The forensic medical examination is limited only to establishing the indelibility of the specified damage.

Forensic medical examination establishes and evaluates the anatomical and functional consequences of certain actions. Such a consequence of the action on a person’s face is indelibility. The fact of the action - disfigurement of the face - is established by the court.

MEDICAL CRITERIA
DETERMINATIONS OF THE SEVERITY OF HARM
CAUSED BY HUMAN HEALTH

I. General provisions

1. These medical criteria for determining the severity of harm caused to human health (hereinafter referred to as medical criteria) were developed in accordance with Decree of the Government of the Russian Federation dated August 17, 2007 No. 522 “On approval of the Rules for determining the severity of harm caused to human health” ( further - Rules).

Medical criteria were developed in pursuance of the Decree of the Government of the Russian Federation of August 17, 2007 No. 522 and represent the medical content of the concepts, signs, norms and provisions of the “Rules for determining the severity of harm caused to human health”, put into effect by the mentioned Decree of the Government of the Russian Federation.

2. Medical criteria are a medical characteristic of qualifying characteristics that are used to determine the severity of harm caused to human health during a forensic medical examination in civil, administrative and criminal proceedings on the basis of a court ruling, a decision of a judge, the person conducting the inquiry, or an investigator.

Medical criteria are the medical content (medical characteristics, medical component, medical component) of qualifying signs of the severity of harm caused to human health, provided for by the current criminal legislation of the Russian Federation.

3. Medical criteria are used to assess injuries discovered during a forensic medical examination of a living person, examination of a corpse and its parts, as well as during forensic medical examinations based on case materials and medical documents.

In addition to the forensic medical examination of living persons, the assessment of the severity of harm caused to human health is carried out during a forensic medical examination of the corpse and an examination of the case materials. When starting an examination of the case materials, you should submit a request to present the victim for examination. A direct examination of the victim may reveal injuries (or traces thereof) that do not correspond to the records in medical documents in terms of location, number and nature of injuries. If the victim cannot be presented, the investigator (prosecutor, judge, person conducting the inquiry) must, in response to the expert’s request, indicate the reason for the impossibility of presenting the victim for a forensic medical examination. For an examination to determine the severity of harm caused to human health, original medical documents must be provided. In exceptional cases, copies certified by a notary or by the body that appointed the forensic medical examination are provided.

The severity of harm caused to human health can be established based on the results of a direct examination of a living person or an examination of a dead body. If by the time of the examination the damage caused has healed or changed significantly, then objective information about the damage caused can be obtained by studying medical documents that describe the primary state of the damage and the dynamics of the clinical development of the damage.

If a living victim or a dead body cannot be presented for expert examination, medical documents become the only source of information about the damage in relation to the task of establishing the severity of the harm caused to human health.

4. The degree of severity of harm caused to human health is determined in medical institutions of the state health care system by a doctor - a forensic expert, and in his absence - by a doctor of another specialty (hereinafter referred to as an expert) brought in to carry out the examination, in the manner established by the legislation of the Russian Federation , and in accordance with the Rules and Medical Criteria.

Medical criteria emphasize the important provision of paragraph 6 of the Rules that the severity of harm caused to human health is determined in medical institutions of the state health care system by a doctor - forensic expert in accordance with the Medical Criteria and Rules. The provision on conducting forensic examinations in state forensic examination institutions by state experts corresponds to Art. 1 Federal Law GSED.

At the same time, clause 6 of the Rules and clause 4 of the Medical Criteria do not contradict Art. 41 Federal Law GSED, which allows for forensic examination outside state forensic institutions by persons with relevant special knowledge: “In accordance with the norms of procedural legislation of the Russian Federation forensic examination may be carried out outside state forensic institutions by persons with special knowledge in the field of science, technology, art or craft, but who are not state forensic experts.”

Article 13 of the GSED Federal Law defines the professional and qualification requirements for an expert. In state forensic institutions, the position of expert can be held by a citizen of the Russian Federation who has a higher professional education (in this case, a doctor) and has undergone further training in a specific expert specialty (in this case, a forensic expert).

Confirmation of completion of such training is a certificate of a forensic medical expert. The level of professional training of experts is determined by expert qualification commissions (federal, regional, interregional).

The right to engage in expert activities must be confirmed every 5 years by retraining at postgraduate universities.

Therefore, Part II, Clause 4 of the Medical Criteria also allows for a forensic medical examination by a doctor of a different specialty (non-state forensic expert) in the manner established by current legislation.

Thus, the right of a doctor to carry out an examination to determine the severity of harm caused to human health, outside a state expert institution, is also confirmed by a certificate of a specialist in the field of forensic medical examination of either living persons or corpses, or based on case materials. Consequently, an examination to determine the severity of harm caused to human health can be carried out both in a medical institution of the state health care system by state and non-state forensic experts, and outside such institutions, but by specialists certified to engage in such activities.

5. Harm caused to human health is understood as a violation of the anatomical integrity and physiological function of human organs and tissues as a result of exposure to physical, chemical, biological and psychogenic environmental factors.

The definition of harm caused to human health by an external influence repeats the fundamental forensic medical concept of “damage (trauma)”, i.e. harm to health in the context of clause 5 of the Medical Criteria is synonymous with the concept of damage as a material consequence of some external traumatic influence. It is this understanding of harm to health that determines the essence of a forensic medical examination to determine the severity of harm to health, which consists in the need to initially establish the fact and degree of violation of anatomical structures and physiological functions.

The severity of harm caused to human health is always established in relation to a living person: during the examination of a living person, a corpse, and based on the case materials. Therefore, when determining the severity of harm caused to human health, the expert solves a single problem, establishing both the nature of the violation of anatomical structures and the essence and degree of violation of the physiological functions of the body.

II. Medical criteria for qualifying signs of severity of harm to health

6. Medical criteria for qualifying features in relation to grievous bodily harm are:

Medical criteria establish two types of harm dangerous to human life: a) harm to health that directly poses a threat to life; b) harm to health, causing the development of a life-threatening condition.

Harm to health that directly poses a threat to human life is understood as such damage (disturbances of anatomical structures and physiological functions), which in the normal clinical course can naturally end fatal, i.e. there is a direct cause-and-effect relationship between the damage and the subsequent death.

A life-threatening condition (in relation to assessing the severity of harm to health) is a disorder directly caused by damage to the vital functions of the human body, which cannot be compensated by the body on its own and without the use of special medical care measures naturally ends in death.

The usual clinical course of injury is understood as one of the typical variants of the development of a traumatic disease, not associated with the individual characteristics of the victim’s body (the presence of severe concomitant somatic or infectious diseases, immune deficiency, asthenia, etc.).

An immediate threat to life is understood as the presence of a direct causal relationship between the damage caused and death. A direct causal connection can only be judged if death could not have occurred without causing damage (under the conditions of the specific situation under consideration).

A danger to life is created at the moment of injury or the development of a life-threatening condition, i.e., preventing death in a particular case by medical means does not affect the determination of the fact of danger to life.

Medical criteria contain an exhaustive list of injuries and life-threatening conditions in the form of specific nosological units. Therefore, if, after a special diagnostic forensic medical examination, an expert establishes a nosological unit included in the list of harm to health that poses an immediate threat to life or causes a life-threatening condition, he thereby determines the qualifying feature - danger to life.

Harm to health, dangerous to human life, creating a direct threat to life:

The decisive sign is damage to the dura mater, which limits the cranial cavity. Damage to the dura mater can be detected directly during wound revision, surgery, during special instrumental studies (for example, magnetic resonance imaging - MPT) and indirectly in the presence of specific symptoms (cerebrospinal fluid leakage, loss of cerebral detritus into the wound, etc. ).

The wound can be located in any area of the head: on the scalp and on the face. The wound can result in disruption of the integrity of the skin, skull and dura mater. The wound can penetrate into the cranial cavity through natural external openings with damage to the bones and dura mater (oral cavity, nasal passages, external auditory canals) or the orbit. The wound can penetrate into the cranial cavity without damaging the bones of the skull: through the skin and an anatomical hole at the base of the skull (torn, oval, round, etc.).

6.1.2. fracture of the vault (frontal, parietal bones) and (or) base of the skull: cranial fossa (anterior, middle or posterior), or occipital bone, or upper wall of the orbit, or ethmoid bone, or sphenoid bone, or temporal bone, with the exception of an isolated crack external bone plate of the cranial vault and fractures of the facial bones: nose, lower wall of the orbit, lacrimal ossicle, zygomatic bone, upper jaw, alveolar process, palatine bone, lowerjaws;

In addition to the frontal and parietal vault of the skull, the occipital, temporal and sphenoid bones form - their fractures should also be assessed as life-threatening.

Both open and closed fractures of the vault or base of the skull are included. The fact of a fracture is proven when it is detected during a wound inspection or surgery, or based on the results of an x-ray examination. This group includes any fractures of the internal bone plate, complete fractures with damage to both bone plates, linear, comminuted, depressed, terrace-shaped, perforated, and combined fractures. Exceptions: a single isolated crack in the external bony plate of the cranial vault, fractures of the facial bones (nasal ossicles, nasal turbinates, lower wall of the orbit, lacrimal ossicle, zygomatic bone, upper jaw, alveolar process of both jaws, palatine bone, lower jaw).

Life-threatening fractures include fractures of the perforated plate and crest of the ethmoid bone, which are involved in the formation of the base of the skull. Fractures of the remaining elements of the ethmoid bone are not assessed as life-threatening.

Fractures of the lateral wall of the orbit in the upper part, formed by the orbital surface of the greater wing of the main (sphenoid) bone, are assessed as life-threatening. A fracture of the lower part of the lateral wall of the orbit, formed by the orbital surface of the zygomatic bone, is not life-threatening.

A fracture of the posterior portions of the medial surface of the orbit, formed by the frontal plate of the ethmoid bone and the lateral surface of the sphenoid bone, is life-threatening. An isolated fracture of the lacrimal ossicle is not life-threatening.

Fractures of the upper palate, formed by the maxillary and palatine bones, are not life-threatening.

6.1.3. intracranial injury: crushing of the brain substance; diffuse axonal brain damage; severe brain contusion; traumatic intracerebral or intraventricular hemorrhage; moderate cerebral contusion or traumatic epidural, or subdural, or subarachnodal hemorrhage in the presence of general cerebral, focal and brain stem symptoms;

Traumatic crush injury of the brain substance manifests itself in superficial (sometimes deeper) destruction of the cerebral cortex, which is diagnosed by direct examination of the brain during surgery or autopsy, by studying computed tomograms (CT) or MRI, focal avascular areas of the cortex on cerebral angiograms .

Diffuse axonal damage to the brain is proven by a special histological study (for example, if it is necessary to determine the severity of harm to health when examining a corpse), on computer tomograms when small focal hemorrhages are detected in the semioval nuclei on both sides, in the brainstem and periventricular zones, in the corpus callosum against the background of general diffuse swelling.

A brain contusion is diagnosed clinically: in the acute period, a severe or very severe condition rapidly develops; prolonged loss of consciousness is observed - from several hours to days and weeks; symptoms of primary damage to the brain stem with disruption of vital body functions; a set of neurological symptoms - floating movements of the eyeballs, gaze paresis, spontaneous tonic multiple nystagmus, mydriasis or miosis, changes in the shape of the pupil, loss of pupillary response to light, corneal and bulbar reflexes, divergence of the eyes along the vertical or horizontal axis, changing muscle tone, depression or excitation of tendon reflexes, pathological reflexes; swallowing disorders, absence of abdominal reflexes, paralysis, aphasia, meningeal symptoms; convulsive seizures are possible; the reverse development of neurological symptoms occurs slowly, with the persistence of gross changes in the mental and motor spheres; foci of atrophy and accumulation of cysts in the cortex are detected instrumentally.

After the return of consciousness, disorientation, stupor, pathological drowsiness, followed by motor or speech excitation, retro- and (or) anterograde amnesia, disturbances of cardiac activity, breathing, thermoregulation and metabolism persist.

Instrumental confirmation of severe brain contusion: on the EEG - disturbances in the regularity of the a-rhythm, a combination of this disturbance with 8- and 0-activity in the form of “barrel flashes”; REG - atony of cerebral blood vessels; on EchoEG - persistent displacement of the middle structures and additional impulses; on AH - focal avascular zones; CT scan shows focal increase in cortical density.

In addition to compression, dislocation and swelling of the brain, the symptoms of intracerebral (in the white matter) hematomas depend on the localization of the space-occupying process. As a rule, traumatic intracerebral hematomas are combined with contusional lesions of the cortex and intraventricular hemorrhages. In this case, classification of injuries as life-threatening is based on the fact of detection of focal bruises of the cortex and hemorrhages in the ventricles of the brain.

Hemorrhage into the ventricles of the brain leads to dysfunction of the diencephalic and mesencephalic structures of the brain stem: deep depression of consciousness, tachypnea, increased blood pressure, increased body temperature, hyperhidrosis, oculomotor disorders, meningeal syndrome. Direct evidence of intraventricular hemorrhage is possible by obtaining blood during ventricular puncture, computed tomography and nuclear magnetic resonance imaging.

The decisive argument in classifying moderate brain contusions, epi-, subdural and subarachnoid hemorrhages as life-threatening is the presence of cerebral, focal and brainstem symptoms. Thus, initially it must be clinically, operationally or instrumentally proven that the victim has (at least one of the listed) intracranial hemorrhages, and then its combination with a set of general cerebral, focal and brain stem symptoms. General cerebral symptoms: depression or loss of consciousness, increasing headache, repeated vomiting, psychomotor agitation, etc. Focal symptoms: the appearance of mono- or hemiparesis, unilateral mydriasis, sensory impairment, anisocoria, contralateral hemiparesis, etc. Brainstem symptoms: increasing bradycardia, increased blood pressure pressure, limitation of upward gaze, tonic spontaneous nystagmus, bilateral pathological reflexes, etc.

Diagnosis of the type and degree of brain damage should be carried out by a commission with the participation of a neurosurgeon or neurologist.

6.1.4. a neck wound penetrating into the lumen of the pharynx, or larynx, or cervical trachea, or cervical esophagus; injury to the thyroid gland;

In the vast majority of cases, neck wounds penetrating into the lumen of the pharynx, or larynx, or trachea, or esophagus, or with damage to the thyroid gland, arise as a result of the action of piercing, cutting, piercing-cutting, chopping objects, fragmentation, bullet and other projectile injuries. Such injuries must be surgical treatment, therefore, proof of the fact of one of the listed options for a neck injury is achieved during surgery by detecting through damage to the wall of the larynx, or pharynx, or trachea, or esophagus, or damage to the thyroid gland.

6.1.5. fracture of the cartilages of the larynx: thyroid or cricoid, or arytenoid, or epiglottis, or corniculate, or tracheal cartilages;

A fracture of the thyroid, or cricoid, or arytenoid, or epiglottis, or corniculate cartilage, or tracheal cartilages is diagnosed x-ray. To classify such fractures as life-threatening, it is sufficient to establish a single fracture of any of the listed cartilages, regardless of whether the fracture is open or closed.

6.1.6. fracture of the cervical spine: fracture of the body or bilateral fracture of the arch of the cervical vertebra, or fracture of the tooth of the II cervical vertebra, or unilateral fracture of the archI orII cervical vertebrae, or multiple fractures of the cervical vertebrae, including without dysfunction of the spinal cord;

A fracture of the body or a bilateral fracture of the arch of any cervical vertebra is dangerous as it poses an immediate threat to life. The first cervical vertebra is an irregular ring formed by the anterior and posterior arches. Therefore, any, even unilateral, fracture of the anterior or posterior arch of the first cervical vertebra should be regarded as life-threatening. Fractures of the costotransverse, costal and transverse processes of the first cervical vertebra are not considered life-threatening.

A fracture of a tooth or arch of the second cervical vertebra also poses an immediate threat to life. Moreover, a single fracture of the arch of the second cervical vertebra is sufficient.

Life-threatening include bilateral fractures of the arch of any cervical vertebra or multiple (two or more) fractures of the cervical vertebrae, regardless of the location of the fractures.

A single fracture (fractures) of the spinous and (or) transverse processes of one cervical vertebra is not considered life-threatening.

The presence of a fracture of the cervical vertebrae is proven by x-ray or during surgery.

6.1.7. dislocation of one or more cervical vertebrae; traumatic rupture of the intervertebral disc at the level of the cervical spine with compression of the spinal cord;

To classify it as life-threatening, it is sufficient to establish a dislocation of one of the cervical vertebrae, regardless of the presence or absence of symptoms of spinal cord injury.

Vertebral subluxation should be considered as a variant of vertebral dislocation.

A traumatic rupture of one of the intervertebral discs at the level of the cervical spine is regarded as life-threatening only in combination with compression of the cervical spinal cord. Intervertebral disc rupture is proven by traditional radiography, CT and MRI. Compression of the spinal cord is determined by a set of neurological symptoms: a disorder of the spinal circulation, a conduction disorder that occurs after an injury below the level of compression, flaccid paresis or paralysis of muscles with areflexia and segmental disorders below the level of the lesion, disturbances in cardiac activity, respiration and pelvic organ function. The diagnosis of compression is made after a detailed neurological examination, lumbar puncture, spondylography, myelography. Establishing the fact of spinal cord compression and assessing the severity of harm to health are carried out with the mandatory participation of a neurologist or neurosurgeon.

6.1.8. contusion of the cervical spinal cord with impairment of its function;

Contusion of the cervical spinal cord is morphologically manifested by intracerebral hemorrhage or crushing of its tissue. Symptoms are determined by neurological disorders below the level of the lesion: loss of sensitivity, paresis or paralysis of muscles, areflexia below the level of the lesion, dysfunction of breathing, cardiac activity and pelvic organ function. Diagnosis is aided by studies of cerebrospinal fluid, spondylography, and myelography.

An examination of the severity of harm to health is carried out with the mandatory participation of a neurologist or neurosurgeon.

6.1.9. a chest wound penetrating into the pleural cavity, or into the pericardial cavity, or into the mediastinal tissue, including without damage to internal organs;

Chest wounds penetrating into the pleural cavity, or into the pericardial cavity, or into the mediastinal tissue are subject to mandatory surgical treatment. During primary surgical treatment, the wound canal is revised, the direction of the wound canal is established, the presence or absence of damage to the parietal pleura or cardiac membrane, and the depth of penetration of the wound canal into the mediastinum. If the wound penetrates the pleural cavity or the pericardial cavity, then such damage is assessed as life-threatening even if the integrity of the lungs and (or) heart is preserved. The fact of penetration of the wound into the pleural cavity is confirmed by the presence of signs of subcutaneous emphysema, as well as pneumothorax or hemopneumothorax, detected x-ray or by puncture of the pleural cavity.

6.1.10. closed damage (crushing, avulsion, rupture) of the organs of the thoracic cavity: the heart or lung, or the bronchi, or the thoracic trachea; traumatic hemopericardium, or pneumothorax, or hemothorax, or hemopneumothorax; diaphragm, or lymphatic thoracic duct, or thymus gland;

Traumatic avulsions of the heart, lung or trachea, as a rule, result in death and are not encountered during examination of living persons. Heart bruises and concussions are assessed depending on the presence or absence of a life-threatening condition.

Isolated traumatic avulsions of the bronchi practically do not form. They are usually combined with rupture of the lung tissue and extensive hemorrhages into the lung tissue, which are diagnosed by pulmonary hemorrhage, hemopneumothorax, endobronchial bleeding and blood aspiration.

Characteristic signs of a closed rupture of the trachea or bronchus: respiratory distress, pneumothorax, mediastinal emphysema, subcutaneous emphysema, hemothorax and hemoptysis. Instrumental diagnostics - fluoroscopy, bronchoscopy, bronchography, radiography. As a rule, surgical intervention is required, during which the nature of the injury to the trachea or bronchus is clarified.

Traumatic hemopericardium, or pneumothorax, or hemopneumothorax, is established clinically, radiologically, as well as by obtaining air and blood during puncture of the pleural cavity or only blood during puncture of the pericardial cavity. Objective diagnosis is also facilitated by thoracoscopy, ultrasound, CT and MRI.

Heart ruptures are judged by the condition of the victim: confused appearance, pallor, cold sweat, glassy eyes, faint or semi-fainting consciousness, signs of cardiac temponade (decrease in systolic pressure during inspiration by 15 mm Hg, weakening pulse during inspiration, rapid and significant increase central venous pressure, a sharp weakening of heart sounds, “absence” of pulsations of the heart shadow during fluoroscopy, the presence of a strip of air and a horizontal fluid level between the shadow of the heart and the pericardium (hemopneumopericardium), ECG changes). Direct confirmation of hemopericardium is obtaining blood during puncture of the pericardial cavity.

Diaphragm rupture is diagnosed by a combination of clinical and radiological symptoms.

The thoracic lymphatic duct begins at the level of the second lumbar vertebra, runs along the spine on the anterior surface of the vertebral bodies behind the aorta to the seventh cervical vertebra, turns forward and to the left and flows into the left venous angle formed by the confluence of the internal jugular and left subclavian veins. Damage to the lymphatic thoracic duct in the area of the chest, i.e., from the entrance of the aorta into the chest cavity through the diaphragm to its entry into the venous angle, is life-threatening. Damage to the thoracic duct can be in the form of a complete rupture of the wall and its complete interruption. Closed damage to the lymphatic thoracic duct is usually combined with fractures of the thoracic vertebral bodies, therefore, if a rupture (or interruption) of the thoracic duct is suspected, the thoracic spine should be examined in detail by x-ray.

Damage to the thymus gland can only be detected in adolescents, until the reverse development of this gland has occurred.

6.1.11. multiple bilateral fractures of the ribs with disruption of the anatomical integrity of the chest frame or multiple unilateral fractures of the ribs along two or more anatomical lines with the formation of a mobile section of the chest wall like a “rib valve”;

Multiple bilateral rib fractures require the presence of fractures of at least two left and at least two right ribs. Anatomically, the integrity of the chest frame is expressed by its intactness. Therefore, to classify rib fractures as life-threatening, it is enough to establish the presence of at least two injured ribs on each side, while the violation of the anatomical integrity of the chest frame undoubtedly occurs.

The second option involves multiple (two or more) unilateral rib fractures along two or more anatomical lines in combination With the formation of a movable section of the chest wall like a “costal valve”. A distinctive feature of this option is that a “rib valve” is formed if two or more adjacent ribs are damaged, and each of them is damaged along at least two anatomical lines. In this case, when you inhale, the damaged part of the chest retracts, and when you exhale, it bulges. This leads to increasing respiratory failure and poses a threat to human life.

6.1.12. fracture of the thoracic spine: fracture of the body or arch of one or more thoracic vertebrae with impaired spinal cord function;

The sign is a combination of a fracture of the body or arch of the thoracic vertebra with dysfunction of the spinal cord (with the exception of fractures of the transverse and spinous processes of the vertebra). According to this sign, only a fracture of one thoracic vertebra is sufficient. All other fractures of two or more thoracic vertebrae are assessed as severe when combined with dysfunction of the spinal cord.

The sign does not indicate the degree of dysfunction of the spinal cord: “spinal shock” or “symptoms of irritation” of the spinal cord. “Spinal shock” is characterized by tetra- or paraplegia, areflexia, conduction-type anesthesia, priapism, dysfunction of the pelvic organs and autonomic function (sweating, hemodynamics, skin temperature, pilomotor reflexes, etc.).

“Symptoms of irritation” of the spinal cord: “bone aches”, paroxysmal pain (short-term or multi-day painful attacks), hypoesthesia or anesthesia, tactile paresthesia (numbness, stiffness, “crawling of goosebumps”, “flow of electric current”), spastic syndrome, protective reflexes in the form of motor synergy, urination disorders, etc.

6.1.13. dislocation of the thoracic vertebra; traumatic rupture of the intervertebral disc in the thoracic region with compression of the spinal cord;

The damage is life-threatening if there is only a dislocation of the thoracic vertebra or only a rupture of the intervertebral disc in combination with compression of the thoracic spinal cord. The symptoms of spinal cord compression coincide with the neurological signs of “spinal shock,” which reaches its greatest severity at the time of injury due to a change in the configuration of the spinal canal when a vertebra is displaced (dislocated) or when an injured intervertebral disc prolapses into the spinal canal. One can distinguish anterior, posterior and lateral compression of the spinal cord and their combinations.

In addition to neurological symptoms, a sharp change in the configuration of the spinal canal is proven by X-ray, CT or MRI.

6.1.14. contusion of the thoracic spinal cord with impairment of its function;

Spinal cord contusion (hematomyelia) is diagnosed by the combination of the following symptoms indicating a violation of its function: paralysis and paresis with muscle hypotonia, areflexia, sensitivity disorder (pain, deep and temperature while maintaining tactile), dysfunction of the pelvic organs, blood in the cerebrospinal fluid. Morphologically, spinal cord contusion can manifest as intrathecal and intracerebral hemorrhages, the volume and frequency of which determine the severity of the victim’s condition.

6.1.15. abdominal wound penetrating into the abdominal cavity, including without damage to internal organs;

Wounds penetrating into the peritoneal cavity arise from the action of sharp objects (most often piercing and piercing-cutting), firearms (bullets, shot, buckshot, etc.), fragments of explosive devices, etc. Abdominal wounds penetrating into the peritoneal cavity are a direct indication to surgical intervention, during which the fact of violation of the integrity of the parietal peritoneum is revealed, which is evidence of the penetrating nature of the wound. If the diagnosis of a wound penetrating into the peritoneal cavity was not made in a timely manner, then in the early period an indirect sign of a wound penetrating into the abdominal cavity may be limited or diffuse peritonitis.

To prove the penetrating nature of the wound, a special technique is used - vulnerography - contrasting the wound channel. Water-soluble contrast (10 ml) is injected directly into the wound canal and radiography is performed in two projections: the entry of contrast into the peritoneal cavity indicates the penetrating nature of the wound, and the presence of contrast only in the subcutaneous fatty tissue and muscle tissue indicates the preservation of the integrity of the parietal peritoneum.

6.1.16. closed injury (crushing, avulsion, rupture) of the abdominal organs: spleen or liver, and/or gall bladder, or pancreas, or stomach, or small intestine, or colon, or rectum, or greater omentum, or colonic mesentery and (or) small intestine, retroperitoneal organs (kidney, adrenal gland, ureter);

This paragraph provides for three types of damage: crushing, tearing and rupture of tissue of a hollow or parenchymal organ of the abdomen or retroperitoneal space. Each of these injuries is accompanied by hemorrhage into the surrounding tissue damage. In itself, hemorrhage into the tissue of an organ can only be a manifestation of one of the three above types of damage, but in itself formally does not constitute damage provided for in clause 6.1.16. Therefore, the detection of hemorrhage is a circumstance that dictates the need to determine its origin: crushing, avulsion, rupture.

Tear of the tissue of a parenchymal organ - the degree of rupture of its tissue - should be considered as serious harm to health. A rupture of the wall of a hollow organ is a complete violation of the integrity of all the layers that form its wall.

Syndromes of internal bleeding or peritonitis or a combination of both allow one to suspect damage to the internal organ of the abdomen.

General symptoms: severe pain throughout the abdomen with the greatest severity in the area of the damaged organ, nausea, vomiting, protective muscle tension of the anterior abdominal wall, symptoms of peritoneal irritation, upon percussion, “disappearance” of hepatic dullness, the appearance of dullness in sloping areas of the abdomen, subcutaneous emphysema, with blood loss - pallor of the skin and mucous membranes, increased heart rate, drop in blood pressure, forced position (when the position changes, the victim again takes the original position that causes him the least suffering, for example, the knee-elbow position in case of damage to the pancreas or squatting in case of intraperitoneal rupture of the rectum ). If the stomach or duodenum is damaged, blood is observed in the vomit, if the rectum is damaged, blood is observed in the stool, blood in the urine may indicate kidney damage, and cessation of urination indicates a ruptured bladder.

These and other signs only allow one to suspect damage to an internal organ. Proof is achieved by using instrumental methods: abdominal radiography, ultrasound, laparoscopy, laparocentesis using a search catheter or peritoneoscopy.

6.1.17. a wound of the lower back and (or) pelvis penetrating into the retroperitoneal space with damage to the organs of the retroperitoneum: kidney, or adrenal gland, or ureter, or pancreas, or descending and (or) horizontal part of the duodenum, or ascending and descending colon;

The main qualifying feature is damage to one or more organs listed in clause 4.6.1.17.

Wounds of the lower back and (or) pelvis, provided for in clause 6.1.17, are a wound channel penetrating into the retroperitoneal space with mandatory damage to any organ: kidney, or adrenal gland, or ureter, or pancreas, or descending or horizontal parts of the duodenum, or descending colon. Such damage occurs mainly from the action of sharp objects, fragments and gunshots. The wounds indicated in clause 6.1.17 are a direct indication for surgical intervention, during which the actual volume and nature of the injury, the volume and nature of damage to each organ are revealed.

6.1.18. fracture of the lumbosacral spine: the body or arch of one or more lumbar and (or) sacral vertebrae with cauda equina syndrome;

6.1.19. dislocation of the lumbar vertebra; traumatic rupture of the intervertebral disc in the lumbar, lumbosacral region with cauda equina syndrome;

6.1.20. contusion of the lumbar spinal cord with cauda equina syndrome;

Dislocation of the lumbar vertebra is life-threatening.

The leading sign for classifying other injuries listed in clauses 6.1.18, 6.1.19 and 6.1.20 as life-threatening is the presence of cauda equina syndrome, which is manifested by paraplegia, sensitivity disorder from the inguinal fold, dysfunction of the pelvic organs ( in the acute period - urinary retention), impaired motor function in the lower extremities with subsequent hypo- and muscle atrophy.

Fractures of the body or arch of a lumbar vertebra, its dislocation, traumatic rupture of the intervertebral disc and their consequences are diagnosed using direct and lateral spondylograms, CT and MRI, using peridurography or discography, liquorodynamic tests, myelography, injection of air into the subarachoid space, angiography, endoscopy, lumbar puncture.

6.1.21. damage (crushing, tearing, rupture) of the pelvic organs: open and (or) closed damage to the bladder, or the membranous part of the urethra, or the ovary, or the uterine (fallopian) tube, or the uterus, or other pelvic organs (prostate, seminal vesicles) , vas deferens);

General symptoms of trauma to the pelvic organs: widespread pain throughout the abdomen, most severe in its lower parts, signs of internal bleeding, symptoms of peritonitis, shock, collapse, nausea, vomiting, etc.

Signs of damage to the bladder: pain in the suprapubic region, radiating to the perineum, penis, rectum; muscle tension in the supra-groin area, blood in the urine; urinary retention with frequent urge to urinate; false “bloody” anuria; pain when palpating the groin and perineum. The leakage of urine into the peritoneal cavity from a ruptured bladder leads to the development of peritonitis. With extraperitoneal ruptures of the bladder wall, urine leaks into the peri-vesical tissue with the formation of urinary streaks and the development of purulent inflammation of the tissue. The diagnosis is confirmed by cystoscopy, ascending cystography, laparocentesis and laparoscopy, ultrasound, CT.

The main symptoms of urethral damage: impaired urination, blood in the urine, hematoma of the scrotum and (or) perineum, pain when urinating, ineffective urge to urinate, soaking the surrounding tissue with urine with the formation of urinary ducts, and subsequently purulent inflammation of the tissue. The diagnosis is confirmed by urethroscopy, contrast urethrography using a Foley catheter, CT.

The main signs of uterine rupture: abdominal pain, sharp pain when palpating the uterus, symptoms of peritoneal irritation, symptoms of internal bleeding (general weakness, pallor of the skin and mucous membranes, cold sweat, anxiety, tachycardia, weakened heart sounds, decreased blood pressure, etc. ). Ruptures of the pregnant uterus can lead to miscarriage or fetal death. Damage to the ovaries and fallopian tubes is accompanied by the above symptoms, although expressed to a slightly lesser extent. The final diagnosis is made after a special gynecological examination, laparoscopy, ultrasound and CT.

6.1.22. a wound to the wall of the vagina, or rectum, or perineum, penetrating into the cavity and (or) pelvic tissue;

Decisive for classifying damage as clause 6.1.22 is a violation of the integrity of the entire wall of the vagina or rectum, or perineum in combination with a violation of the integrity of the parietal peritoneum of the pelvic cavity and (or) penetration of the wound into the pelvic tissue (while maintaining the integrity of the peritoneum).

Wounds to the vaginal wall are accompanied by vaginal and internal bleeding. The hematoma can spread to the external genitalia and into the pelvic tissue. A growing hematoma causes bursting pain. Definitive diagnosis is achieved by a special vaginal or rectovaginal examination.

Wounds of the rectum are manifested by rectal bleeding, rapidly developing paraproctitis and peritonitis.

Wounds of the vagina, rectum and perineum penetrating into the pelvic cavity are a direct indication for revision of the wound canal and surgical intervention, during which damage to the parietal peritoneum is established and penetration of the wound into the lower floor of the peritoneal cavity - into the pelvic cavity, which ultimately As a result, it creates an immediate threat to life, being a health hazard that is dangerous to human life.

6.1.23. bilateral fractures of the anterior pelvic semi-ring with a violation of its continuity: fractures of both pubic and both ischial bones of the “butterfly” type; fractures of the pelvic bones with disruption of the continuity of the pelvic ring in the posterior section: vertical fractures of the sacrum, ilium, isolated ruptures of the sacroiliac joint; fractures of the pelvic bones with disruption of the continuity of the pelvic ring in the anterior and posterior sections: unilateral and bilateral vertical fractures of the anterior and posterior sections of the pelvis on one side (Malgenya fracture); diagonal fractures - vertical fractures in the anterior and posterior sections on opposite sides (Vollumier fracture); various combinations of bone fractures and ruptures of the pelvic joints in the anterior and posterior sections.

Life-threatening injuries that pose an immediate threat to life include any fractures that disrupt the continuity of the pelvic ring. Clause 6.1.23 does not include isolated horizontal, oblique-horizontal fractures of the iliac bones, isolated fractures of one of the branches of the pubic or ischial bones.

General clinical symptoms of pelvic ring fractures: passive position of the victim, sharp pain in the pelvic ring when trying to move the legs, asymmetry of the pelvis, abnormal mobility and crepitus of fragments in the area of fractures, “shortening” of the legs, asymmetry of the gluteal folds, Volkovich’s symptom (increased pain in the pelvic area when trying to rotate the legs bent at the knees), Marx's symptom (increased pain in the fracture sites with loads on the pelvic ring in the sagittal and frontal directions, vertical direction from the tubercle of the ischium to the iliac crest). Pelvic fractures are detected by radiography and CT.

6.1.24. a wound penetrating the spinal canal of the cervical, or thoracic, or lumbar, or sacral spine, including without damage to the spinal cord and cauda equina;

Penetration of a stab, stab, bullet, shrapnel, etc. wound into the spinal canal occurs only if the damaging object breaks the integrity of the dura mater. An immediate threat to life is created by the very penetration of the wound into the spinal canal, regardless of direct injury to the spinal cord. Evidence of a wound penetrating the spinal canal can be the results of instrumental studies (radiography, CT, MRI and myelography), as well as the fact of damage to the dura mater, revealed during surgical revision of the wound canal.

6.1.25. open or closed spinal cord injury: complete or incomplete break of the spinal cord; spinal cord crush;

When the spinal cord is damaged, its interruption syndrome develops: tetra- or paraplegia with low tone, areflexia, conduction-type anesthesia, priapism, dysfunction of the pelvic organs and autonomic functions (“spinal shock”). These changes may be reversible within a few weeks or months. If the changes are irreversible, they speak of a complete break of the spinal cord. Morphologically, the manifestation of a break in the spinal cord is its crushing, hematomyelia, and local transverse necrosis. Evidence of spinal cord interruption is obtained from neurological examination, radiography, CT, MRI, myelography, lumbar puncture.

6.1.26. damage (rupture, avulsion, dissection, traumatic aneurysm, arteriovenous fistula) of large blood vessels: aorta or carotid artery (common, external, internal), or subclavian, or axillary, or brachial, or iliac (common, external, internal), or femoral or popliteal arteries and (or) accompanying main veins;

General clinical diagnosis of damage to large blood vessels is based on the fact of severe bleeding immediately after injury, signs of general significant blood loss (thirst, pallor of the skin and mucous membranes, weakening of the pulse, drop in blood pressure, shortness of breath, tachycardia, sometimes loss of consciousness), location of the wound canal in the projection of the topography of large blood vessels, “case” hematoma along the blood vessel, ischemic pain in the wounded limb, ischemic contracture. The nature of the damage to the blood vessel (rupture, avulsion, dissection) is established during surgical revision of the damaged area.

To prove the traumatic origin of an aneurysm, the fact of damage to at least one of the layers of the vascular wall (for example, the intima) must be proven and pathological changes in the area of damage to the blood vessel must be excluded. Damage to the intema can lead to traumatic occlusion of the vessel and cessation of blood circulation in its basin; such damage is assessed as life-threatening.

6.1.27. blunt trauma to the reflexogenic zone: the larynx area; carotid sinus areas; solar plexus area; the area of the external genitalia in the presence of clinical and morphological data;

To classify the damage as life-threatening according to clause 6.1.27, injury to at least one of the reflexogenic zones is sufficient.

Evidence of blunt trauma to the reflexogenic zone is based on a cumulative assessment of: a) events preceding the injury; b) the presence of external damage in the projection of reflexogenic zones; c) the clinical picture recorded immediately after the injury.

Traumatic exposure is usually preceded by a long or short-term conflict, during which the victim experiences emotional overexcitation.

The fact of such an impact on the reflexogenic zone is judged by the presence in the projection of at least one of these zones (larynx area, sinocarotid zone, solar plexus, scrotum) of external damage - abrasions, bruises, subcutaneous hematomas. However, features of the anatomical structure (for example, compliance of the anterior abdominal wall) and long time from the moment of injury to the forensic medical examination of the victim may be the reason for the failure to detect external injuries. Although “hidden” subcutaneous hemorrhages can be detected by thermal imaging methods.

A clinically detectable health disorder occurs immediately after the injury: the victim stops (“stunning”), his arms drop, his legs bend at the knee joints, his body “goes limp,” and he may fall flat or backward. Sometimes short-term (5-10 seconds) coordinated movements are observed (several steps, sluggish resistance to the attacker, etc.), almost simultaneously with this, collapse syndrome develops: extreme muscle weakness, feeling of cold and thirst, pallor of the skin and mucous membranes, alternating various cyanosis of the whole body, veins sink, heart sounds like “clock ticking” or embryocardia, tachycardia (rarely bradycardia), thread-like pulse, drop in arterial and venous pressure, breathing is frequent and shallow, sometimes with wheezing or “gurgling”, respiratory movements are frequent (tachypnea), uneven in rhythm and different in depth, foaming from the mouth, consciousness is lost, pupils dilate, motor excitation and tonic convulsions, involuntary physiological acts. This condition, without the provision of resuscitation benefits, often ends in death.

6.1.28. thermal or chemical or electrical or radiation burnsIII-JV degrees exceeding 10% of the body surface; burnsIII degree, exceeding 15% of the body surface; burnsII degree, exceeding 20% of the body surface; burns of a smaller area, accompanied by the development of burn disease; burns of the respiratory tract with symptoms of edema and narrowing of the glottis;

Day To classify burns as directly life-threatening, it is necessary to establish: a) the depth of the burns and b) their area. A complete diagnosis also requires determining the origin of the burns: thermal, chemical, electrical, radiation.

The following degrees of burns are distinguished by depth:

I degree - damage only to the epidermis, redness and swelling of the skin, burning pain;

II degree - deep skin damage with preservation of the papillary layer; the epidermis is exfoliated with the formation of blisters filled with clear liquid, skin hyperemia, areas of hyperemia turn pale when pressed, which indicates the preservation of blood circulation;

III degree - partial necrosis of the skin with damage to the tops of the papillary layer with preservation of hair follicles, sweat and sebaceous glands; some of the blisters are filled with a cloudy hemorrhagic fluid, the other part of the blisters is opened, the bottom is dryish yellowish-brown, the remaining hair is pulled out painlessly;

III-b degree - complete necrosis of the epidermis, dermis and partially subcutaneous tissue; the burn surface is brown or dark brown, dry; the burn surface is deepened in relation to unaffected skin or burn surfaces of I-II degrees;

IV degree - necrosis of the skin, subcutaneous tissue, muscles, tendons, joints, bones; the burn surface is black-brown, muscles, tendons, and bones are exposed.

Third- and fourth-degree burns are considered deep.

The area of the burn surface is determined by the “palm area”, conditionally equal to 1% of the body surface, and by the “rule of nines”: the surface of the head and neck - 9%, the front surface of the body - 9x2=18%, the back surface of the body - 2x9=18%, thigh surface - 2x9 = 18%, lower leg with foot - 9%, perineum - 1%.

Burn disease is a set of dysfunctions of various organs and systems caused by burns and characterized by the development of four successive periods: burn shock, burn toxemia, burn septic-toxemia and convalescence. Burn shock of the III-IV degree and burn sepsis should be classified as life-threatening conditions. The course of a burn disease is characterized by the natural development of complications such as pneumonia, sepsis, bacterial shock, burn exhaustion, acute (stress) ulcers of the gastrointestinal tract with bleeding or perforation of the wall of the stomach or intestine, acute acalculous cholecystitis, thrombosis of the mesenteric vessels, nephrolithiasis.

Burns of the respiratory tract are diagnosed by clinical manifestations (swelling of the vocal cords and mucous membrane of the larynx and trachea, difficulty in external breathing, cough, sputum production mixed with black soot particles, etc.) and instrumentally - by ENT examination of the larynx, tracheoscopy.

6.1.29. frostbiteIII-IV degree with a lesion area exceeding 10% of the body surface; frostbiteIII degree more than 15% of the body surface; frostbiteII degree over 20% of the body surface;

The following degrees of frostbite differ in depth:

I degree - disorder of intradermal circulation and innervation without skin necrosis: the skin is purplish-red or blue, swollen, “marbled” in appearance; these phenomena disappear after 3-7 days;

II degree - necrosis of the epidermis to the basal layer; blisters with transparent contents on purplish-bluish skin, the bottom of the blisters is pink, painful; complete healing in 2-3 weeks;

III degree - necrosis of the entire skin and partially subcutaneous tissue; blisters with dark hemorrhagic contents, their bottom is blue-purple, insensitive; scar healing;

IV degree - necrosis of the skin, subcutaneous tissue, muscles, bones, wet gangrene develops with purulent complications, dry gangrene with pathological amputation of the affected parts (most often peripheral formations: phalanges, fingers, feet, etc.).

The area of frostbite is measured in the same way as the area of burn surfaces.

6.1.30. radiation injuries, manifested by acute radiation sickness of severe or extremely severe severity.

In the clinical course of acute radiation sickness, a primary reaction, a latent phase and a period of pronounced clinical symptoms are distinguished.

Primary reaction (from a few minutes to 3-4 days): nausea, vomiting, heaviness in the head, severe muscle weakness, drowsiness,

moderate changes in the cellular composition and biochemical properties of blood.

Latent stage (up to 2-4 weeks): hair loss, general neurological disorders, decrease in blood cellular elements, inhibition of hematopoiesis.

The period of pronounced clinical symptoms: a sharp deterioration in general condition, multiple intradermal and submucosal hemorrhages, anemia, massive internal hemorrhage, infectious complications.

A severe degree of radiation injury is the transition of radiation sickness to the latent stage or the period of pronounced clinical symptoms.

6.2. Harm to health that is dangerous to human life, causing a disorder in the vital functions of the human body, which cannot be compensated by the body on its own and usually ends in death (hereinafter- life-threatening condition):

Harm to health that is dangerous to human life, causing the development of a life-threatening condition, contains an exhaustive list.

6.2.1. shock severe (III-IV) degree;

Criteria for stage III shock: systolic pressure 50-70 mm Hg. Art., Algover index (ratio of pulse rate to systolic pressure) more than 1.2; deficit of BCC (circulating blood volume) 30% or more; the victim is in a soporous state.

Criteria for stage IV shock: blood pressure less than 50 mm Hg. Art. or not determined, breathing is shallow or convulsive, consciousness is lost. The outcome is clinical death.

6.2.2. comaII-III degree of various etiologies;

Coma is a state of deep depression of central nervous system functions with complete loss of consciousness and disruption of vital functions.

Coma II degree (deep): complete absence reactions to painful stimuli, diffuse muscle hypotonia, suppression of reflexes, severe disturbances in external respiration and cardiovascular activity. Coma III degree (terminal, atonic): areflexia, atony, bilateral mydriasis, severe vital disturbances (pathological breathing, apnea, collaptoid state).

Nosologically we are talking about post-traumatic coma.

6.2.3. acute, profuse, or massive blood loss;

A rapid loss of 30% of circulating blood volume leads to acute anemia, cerebral hypoxia and can naturally lead to death.

Subjective signs of acute heavy blood loss: general weakness, dizziness, darkening of the eyes, dry mouth, thirst, shortness of breath, nausea, vomiting, anxiety, euphoria, a feeling of fear, flashing “spots” before the eyes.

Objective signs: pallor of the skin and mucous membranes, cyanosis, cold sticky sweat, tachypnea, tachycardia, decreased arterial and venous pressure (BP below 50-70 mm Hg), impaired consciousness, Algover index 1.3-1.4.

Massive blood loss, including chronic, is diagnosed when there is a loss of more than 2-2.5 liters of blood.

6.2.4. acute cardiac and (or) severe vascular failure, or severe cerebrovascular accident;

Factors that form acute post-traumatic heart failure (cardiogenic shock): direct symptomatic nervous effects on the heart muscle with increased release of norepinephrine from nerve endings; decreased ratio of blood flow in the endocardium and epicardium, inconsistency in oxygen delivery to the heart; excessive tachycardia with impaired blood flow through the coronary arteries; hypercatecholaminemia with a predominant increase in the concentration of adrenaline in the blood; hypoxemia and respiratory acidosis. Clinical manifestations in severe acute heart failure: hard breathing, moist rales in the lungs, congestion in the pulmonary circulation, dull heart sounds, tachycardia, high central venous pressure, decreased ECG voltage, depression of the ST segment in the precordial leads, low minute volume of blood circulation, decreased blood pressure , decrease in diastolic pressure, increase in myocardial depression.

Collapse is an acutely developing vascular insufficiency, characterized by a drop in vascular tone, a decrease in circulating blood mass, a sharp decrease in arterial and venous pressure, brain hypoxia, and inhibition of vital body functions. When trauma occurs, hemorrhagic collapse occurs, caused by massive blood loss.

A severe degree of cerebrovascular accident is expressed by the formation of an intracerebral hematoma, edema and dislocation of the brain due to intrathecal (subdural, subarachnoid), suprathecal (epidural) hematoma, intraventricular or intrastem hemorrhage.

6.2.5. acute renal or acute liver, or severe acute adrenal insufficiency, or acute pancreatic necrosis;

Acute liver failure can develop as a consequence of purulent-septic complications of a traumatic disease or severe traumatic shock. Clinical manifestations of acute liver failure: yellowness of the skin and mucous membranes, subcutaneous and submucosal hemorrhages, bleeding into the lumen of the digestive tract, an increase (sometimes a decrease) in liver size, pain on palpation of the liver, ascites, splenomethalia. The diagnosis is supported by the results of biochemical studies: hypoproteinemia, a violation of the ratio of protein fractions with a predominance of globulins, hyperbilirubinemia, a decrease in the level of fibrinogen, prothombin, cholesterol, an increase in transaminases, a decrease in the level of potassium and sodium, an increase in the thymol test and a decrease in the mercuric test.

Acute renal failure in traumatic illness is associated with the development of traumatic shock and toxic complications. Clinical manifestations of acute renal failure: a decrease (less often, an increase) in the daily volume of urine; with oliguria, the daily volume can decrease to 50-100 ml; with polyuria, the daily volume can reach 2.5-5 liters or more; tubular necrosis leads to inhibition of the concentrating ability of the kidneys, azotemia, uremia (accumulation of waste), an increase in urea and creatinine, intravascular hemolysis, and myoglobinuria.

Acute adrenal insufficiency is manifested by a sharp decrease in the products of hormones of the adrenal cortex, expressed by nervous tension, diffuse abdominal pain, vomiting, hyperthermia, hemorrhagic syndrome, and ends in collapse and coma. These changes are observed with primary (traumatic) or secondary hemorrhages in the adrenal cortex.

Acute pancreatic necrosis is expressed in necrosis of pancreatic tissue in combination with hemorrhagic impregnation of its tissue and severe metabolic changes, hypotension, sequestration, necrotization of areas, multiple organ failure leading to death. Clinically, from the very beginning, sharp, constant pain occurs in the epigastric region, radiating to the back and becoming encircling in nature, followed by nausea and vomiting. The abdomen is swollen, there are yellowish-bluish spots on the left lateral surface of the abdomen, high tympanitis over the entire surface of the abdomen, when exudate appears in the abdominal cavity in sloping measures, dullness appears on percussion, later the skin becomes jaundiced. Instrumental diagnostics are provided by ultrasound and CT.

6.2.6. severe acute respiratory failure;

Respiratory failure in trauma is defined as the inability of the external respiratory system to provide the required level of gas exchange.

Causes of acute respiratory failure in trauma: open and tension pneumothorax, forced compression of the chest, spinal injuries with spinal cord damage, severe traumatic brain injuries, aspiration of blood and vomit, airway obstruction, hemorrhages into the lung parenchyma, interstitial edema, etc.

Severe degree of acute respiratory failure in trauma (“shock lung”) is characterized by a progressive increase in tachypnea and hyperpnea, severe tachycardia, the presence of moist rales against the background of a minimal amount of sputum, a decrease in the elasticity of the lung tissue, an increase in arterial hypoxemia, etc.

6.2.7. purulent-septic condition: sepsis or peritonitis, or purulent pleurisy, or phlegmon;

Purulent-septic conditions are one of the naturally developing stages of a traumatic disease. They manifest themselves as sepsis, or peritonitis, or purulent pleurisy, or phlegmon.

Sepsis is a generalized infection that is characterized by significant clinical polymorphism. The leading ones in the clinical picture are dysfunctions of the central nervous system(encephalopathy), hemodynamic disorders, signs of infectious-toxic shock with the development of liver and kidney failure, progressively increasing decompensation of water-electrolyte metabolism and acid-base status. In victims with sepsis, hectic temperature with rises to 39-40 ° C, chills, heavy sweating, tachycardia, arterial hypotension, arrhythmia of cardiac function, decreased cardiac output and volumetric blood flow, weak and rapid pulse, and “marbling” of the skin are noted. Death can occur within 1-3 days.

Peritonitis is inflammation of the peritoneum. This is a secondary disease, which, in particular, is one of the complications of severe trauma. Clinical manifestations of peritonitis: abdominal pain, lack of abdominal breathing, weakness, thirst, shortness of breath, pain when palpating the abdomen, muscle tension in the anterior abdominal wall, peritoneal irritation syndrome, dullness in sloping areas of the abdomen upon percussion. Instrumental diagnostic methods: radiography, ultrasonography, laparoscopy, abdominal puncture. During the examination, the fact of injury, the presence of complications (peritonitis) and the causal relationship between them must be proven.

Purulent pleurisy is a post-traumatic inflammation of the pleura with accumulation of pus in the pleural cavity, resulting from injury. Clinical manifestations of purulent pleurisy: general weakness, pain in the side, impaired external respiration, dry cough, increased body temperature, pleural friction noise on auscultation, pain when breathing can radiate to the shoulder or abdomen, dullness of percussion sound over the lungs and weakening of breathing in the area accumulation of fluid in the pleural cavity. Instrumental confirmation: X-ray, X-ray, CT, puncture of the pleural cavity to obtain pus. During the examination, the fact of injury, the presence of purulent pleurisy and the causal relationship between them must be proven.

Cellulitis (post-traumatic) is an acute diffuse inflammation of fatty tissue. There are superficial phlegmons (subcutaneous, epifascial), deep (intermuscular) and phlegmons of cellular spaces. Phlegmons can be serous, purulent, putrefactive (the last two are the most dangerous). Common symptoms include: weakness, headache, increased body temperature up to 40 °C with chills, leukocytosis, neutrophilia, increased ESR, shortness of breath, tachycardia. Local signs: inflammatory infiltrate, which later softens with the appearance of fluctuations. The skin above the site of fluctuation is bluish. Lymphadenitis, lymphangitis, and thrombophlebitis are noted. The greatest danger is posed by phlegmon of the retroperitoneal space (purulent paranephritis), perineum (purulent paraproctitis), and mediastinum (purulent mediastinitis). Instrumental diagnostics: ultrasound examination, puncture of phlegmon, radiography. During the examination, it is necessary to prove the fact of injury, the presence of phlegmon of a certain localization and the causal relationship of phlegmon with the previous injury. Life-threatening conditions include phlegmon, accompanied by the development of a general purulent-septic state of the body.

To establish a life-threatening condition according to clause 6.2.8, it is initially necessary to prove that the victim has a gas or tissue embolism, or thromboembolism. Embolism refers to the blockage of a blood vessel by gas bubbles, drops of fat, pieces of tissue from various (injured) organs and tissues, and broken blood clots. All of the listed types of embolism can be reliably diagnosed morphologically, for example, during a forensic medical examination of a corpse.

During life, gas embolism is reliably recognized by X-ray, CT or MRI detection of air bubbles in the blood vessels or cavities of the heart.

Intravital evidence of fat embolism is based on a set of clinical signs that appear in the immediate period after injury: unmotivated tachycardia, acute respiratory failure, changes in the psyche, consciousness, possible hypoxic coma, transient neurological symptoms, widespread petechial hemorrhages and gastro-duodenal bleeding, a characteristic picture of the eye fundus (whitish-silver cloud-like spots around the retinal vessels, multiple hemorrhages, etc.), constant hyperthermia. An X-ray of the lungs shows bilateral lesions in the form of a so-called “blizzard”; CT and MRI show ischemic areas in the brain.

The clinical presentation of tissue embolism depends on the size of the tissue embolus, the caliber of the affected blood vessel, and the affected target organ. The consequences of tissue embolism are expressed in the formation of more or less extensive ischemic infarctions of internal organs (primarily the lungs and brain).

Clinical picture of thromboembolism: sudden feeling of lack of air (tachypnea, dyspnea), cough, tachycardia, chest pain, swelling of the neck veins, cyanosis of the face and upper half of the body, moist rales, hemoptysis, sharp increase in body temperature, collapse. Massive thromboembolism ends in death within a few hours, and fulminant thromboembolism ends within 10-15 minutes from right ventricular failure or anorexia of the brain.

Paragraph 6.2.9 assumes either chemical or biological effects with the corresponding consequences provided for in this paragraph.

To classify a chemical injury, the varieties of which are listed in clause 6.2.9, as a health hazard dangerous to human life, it is necessary: a) to first prove the fact of poisoning (drugs or psychotropic drugs, or sleeping pills, or drugs acting primarily on the cardiovascular system, or alcohol, or its surrogates, or technical liquids, or heavy metals, or toxic gases, or food products); b) prove that the victim has a life-threatening condition provided for in clauses 6.2.1-6.2.8 of these Medical Criteria; c) establish a causal relationship between the identified poisoning and a proven life-threatening condition. The method for classifying a biological injury as life-threatening is not fundamentally different from the method given above for a chemical injury.

It is advisable to establish the severity of harm caused to human health according to clause 6.2.9 with the participation of clinicians of the appropriate profile.

6.2.10 various types of mechanical asphyxia; consequences of general exposure to high or low temperature (heatstroke, sunstroke, general overheating, hypothermia); consequences of exposure to high or low atmospheric pressure (barotrauma, decompression sickness); consequences of exposure to technical or atmospheric electricity (electrical injury); consequences of other forms of adverse effects (dehydration, exhaustion, overexertion of the body), causing a life-threatening condition given in paragraphs. 6.2.1-6.2.8.

To classify one or another type of injury caused by external physical damaging factors as a health hazard dangerous to human life, it is necessary: a) to initially establish that the victim has one of the injuries listed in clause 6.2.10 (mechanical asphyxia, general consequences high or low temperature in the form of heat or sunstroke or general overheating of the body, the consequences of a transition of high or low atmospheric pressure in the form of barotrauma or decompression sickness, the consequences of technical or atmospheric electricity, the consequences of dehydration, or exhaustion, or overstrain of the body); b) prove that the victim has at least one life-threatening condition provided for in clauses 6.2.1-6.2.8 of the Medical Criteria; c) establish a causal relationship between the identified damage and the proven life-threatening condition.

6.3. Loss of vision- complete permanent blindness in both eyes or such an irreversible condition when, as a result of injury, poisoning or other external influence, a person has deteriorated vision, which corresponds to visual acuity equal to 0.04 or low.

Loss of vision in one eye is assessed based on permanent loss of general ability to work.

Cyst-traumatic removal of one eyeball, which had vision before the injury, is also assessed on the basis of persistent loss of general ability to work.

Determination of the severity of harm caused to a person’s health as a result of the loss of a blind eye is carried out based on the duration of the health disorder.

Loss of vision is understood as complete permanent (irreversible) blindness in both eyes or an irreversible decrease in vision in both eyes to an acuity of 0.04 or lower, to light perception (no more than “counting fingers on the face”).

Loss of vision in one eye is assessed on the basis of permanent disability: for example, with initial visual acuity of 1.0-0.8, the size of permanent disability with the loss of such an eye will be more than one third, i.e. serious harm to health; with initial visual acuity of 0.7 or less, the amount of permanent disability will be less than one third, i.e. harm to health of moderate severity.

Post-traumatic removal of one eyeball is assessed as permanent disability depending on the visual acuity of that eye before the injury.

In case of loss of a blind eye, the severity of harm to health is assessed based on long-term health impairment. If there is a need to assess damage to the blind eye on the basis of indelible disfigurement of the face, the expert is limited to establishing the indelibility of the damage.

When determining the severity of harm to a person’s health, the expert should not take into account the possibility of improving vision through surgery or medical technical means (glasses, lenses, etc.).

Determination of complete or partial loss of vision is carried out jointly with an ophthalmologist.

6.4. Loss of speech- irreversible loss of the ability to express thoughts in articulate sounds that are understandable to others.

Speech loss refers to the irreversible loss of the ability to express thoughts in articulate sounds. During the examination, it is necessary to establish the cause of speech loss: loss of language, damage to the vocal cords, damage to the central nervous system, etc. When determining the severity of harm to a person’s health, the expert should not take into account the possibility of full or partial restoration of speech by surgical means.

If necessary, an examination to determine the severity of harm to health is carried out with the participation of one or more clinicians: an otolaryngologist, an oral and maxillofacial surgeon, a speech therapist, a neurologist, and a psychiatrist.

6.5. Hearing loss- complete persistent deafness in both ears or such an irreversible condition when a person cannot hear spoken speech at a distance of 3- 5 cm from the auricle.

Hearing loss in one ear is assessed based on permanent loss of general ability to work.

Hearing loss refers to complete persistent (irreversible) deafness in both ears or such a decrease in hearing when a person cannot hear spoken speech at a distance of 3-5 cm from the auricle.

Complete deafness in one ear is assessed on the basis of permanent disability.

When determining the severity of harm to a person’s health, the expert should not take into account the possibility of improving hearing through surgery or hearing aids.

If necessary, an otolaryngologist should be invited to participate in the examination.

6.6. Loss of any organ or loss of an organ’s functions:

This paragraph provides only two options: 6.6.1 - complete or partial loss of a limb or its function; 6.6.2 - loss of productivity.

The loss of a limb (arm or leg) refers to the anatomical loss of an entire limb or its peripheral segment (hand or foot) or permanent (irreversible) loss of its function, for example in the form of limb paralysis.

If necessary, assessment of the nature and degree of loss of limb function is carried out with the participation of a neurologist and (or) traumatologist.

6.6.2. loss of productive capacity, expressed in men- in the ability to copulate or fertilize; in women- in the ability to copulate or conceive, or bear fruit, or bear children.

6.6.3. loss of one testicle.

The loss of productive ability in men is understood as the loss of the ability to copulate (loss of the penis, complete interruption of the cavernous bodies, cessation of blood circulation in the penis, etc.) or loss of the ability to fertilize (aspermia, break of the spermatic cord, loss of both testicles, etc.).

If, as a result of an injury, one testicle is lost (or surgically removed), then the severity of harm to a person’s health is assessed based on permanent disability. The degree of loss of productivity in men is assessed with the participation of a urologist.

The loss of productive capacity in women means the loss of the ability to copulate (for example, vaginal atresia, significant cicatricial reduction of the vaginal lumen, etc.), or to conceive (obliteration of the fallopian tubes, cessation of ovarian function, etc.), or to bear a fetus (for example, post-traumatic intrauterine synechiae, extirpated uterus), or to delivery (post-traumatic narrowing and deformation of the pelvic ring, cicatricial narrowing of the cervix and perineal muscles, etc.).

Assessment of the severity of harm to health due to loss of productive capacity in women is carried out with the participation of an obstetrician-gynecologist.

6.7. Termination of pregnancy- termination of pregnancy, regardless of duration, caused by harm to health, with the development of miscarriage, intrauterine fetal death, premature birth, or necessitating the need for medical intervention.

Termination of pregnancy as a result of diseases of the mother and fetus must be in a direct cause-and-effect relationship with the harm caused to health and should not be caused by the individual characteristics of the body of the woman and the fetus (diseases, pathological conditions) that existed before the harm to health. If external reasons determined the need to terminate the pregnancy through medical intervention (uterine curettage, cesarean section, etc.), then these injuries and the resulting consequences are equated to termination of pregnancy and are assessed as serious harm to health.

“Termination of pregnancy” as a sign of serious harm to health is understood as post-traumatic termination of pregnancy at any stage. Termination of pregnancy can occur through miscarriage, or as a result of intrauterine fetal death, or premature birth, or as a result of medical intervention (uterine curettage or cesarean section), the indication for which was the consequences of injury or a condition that threatens the life of the mother or fetus.

During the examination, the fact of a former pregnancy and the fact of injury must initially be established, then a direct causal connection between the injury and the subsequent termination of pregnancy. The presence of a direct causal relationship is established if, in the absence of injury, the pregnancy would have proceeded in normal physical conditions. To judge the presence of a direct causal relationship between injury and termination of pregnancy, it is necessary to exclude the negative impact on the natural course of pregnancy of the characteristics of the pregnant woman’s body (diseases, hormonal disorders, etc.), complications of pregnancy, the degree of development and viability of the fetus. Information about this is obtained both by studying medical documents about the course of pregnancy and the woman’s health before and during pregnancy, and by directly examining the victim and examining the born or surgically removed fetus (or its fragments).

An examination of the severity of harm to health based on post-traumatic termination of pregnancy is carried out with the participation of an obstetrician-gynecologist, and, if necessary, a therapist, endocrinologist, etc.

6.8. A mental disorder, the occurrence of which must be in a cause-and-effect relationship with the harm caused to health, i.e., be its consequence.

The list of mental disorders is contained in International classification diseases X revision (ICD-10). To classify harm to a person’s health as grave, it is necessary: a) to establish the fact that the patient has a mental disorder; b) establish the fact of a previous injury that is directly related to the event under investigation; c) exclude possible mental disorders before the injury; d) establish the existence of a direct causal relationship between the mental disorder and the trauma that preceded it.

To classify harm to health as grave under clause 6.8, it is sufficient to establish the fact of a mental disorder and a cause-and-effect relationship with the previous injury. In this case, a mental disorder can be both temporary and irreversible.

The severity of the harm caused by a mental disorder is assessed with the participation of a psychiatrist. To exclude pathological causes of mental disorder, neurologists and neurosurgeons may additionally be involved in the examination.

6.9. Drug addiction or substance abuse.

The disease of drug addiction or substance abuse should be considered as a variant of chemical injury. When proving the fact of drug addiction or substance abuse, this harm to a person’s health should be considered serious. The examination in such cases is carried out with the participation of a psychiatrist and (or) a narcologist, and (or) a toxicologist.

6.10. Permanent facial disfigurement.

The severity of the harm caused to a person’s health, expressed in permanent disfigurement of his face, is determined by the court.

The forensic medical examination is limited only to establishing the indelibility of this damage, as well as its medical consequences in accordance with Medical criteria.

The fact of permanent disfigurement of the face as a qualifying sign of grave harm to human health is established by the court. The responsibilities of a forensic medical expert are limited to determining the indelibility of facial injuries and other medical criteria for the severity of harm to human health. Indelible are post-traumatic scars of the skin, deformations of elements of the facial structure due to fractures of the bones of the facial skeleton, functional lesions leading to impaired facial expressions, etc., which cannot be eliminated with the help of non-surgical means. If correction of the consequences of the damage caused is possible only through surgical intervention, such changes are considered indelible.

When conducting a forensic medical examination, it is necessary to take into account the following anatomical boundaries of the face: upper - the frontal edge of the scalp, lateral - the anterior edge of the base of the auricles and the posterior edge of the branches of the lower jaw (in forensic terms, the boundaries of the face include ears), lower - the lower edge of the angle and the lower edge of the body of the lower jaw.

Facial disfigurement is an action aimed at distorting a person's facial features. The degree of post-traumatic distortion of the static and dynamic characteristics of a person is determined by the court, based on its internal conviction.

If damage to the face leads to long-term or short-term health problems, the expert is obliged to note this qualifying feature in his conclusion.

6.11. Significant persistent loss of general ability to work by at least one third (persistent loss of total ability to work over 30 percent).

6.11.1. open or closed fracture of the humerus: intra-articular (humeral head) or periarticular (anatomical neck, sub- and transtubercular), or surgical neck, or diaphysis of the humerus;

6.11.2. open or closed fracture of the bones that make up the elbow joint;

6.11.3. open or closed fracture-dislocation of the bones of the forearm: fracture of the ulna in the upper or middle third with dislocation of the head of the radius (Montagia fracture-dislocation) or fracture of the radius in the lower third with dislocation of the head of the ulna (Galeazzi fracture-dislocation);

6.11-4. open or closed fracture of the acetabulum with displacement;

6.11.5. open or closed fracture of the proximal femur: intra-articular (fracture of the head and splinter of the femur) or extra-articular (intertrochanteric, pertrochanteric fractures), with the exception of an isolated fracture of the greater and lesser trochanters;

6.11.6. open or closed fracture of the femoral diaphysis;

6.11.7. open or closed fracture of the bones that make up knee joint, with the exception of the patella;

6.11.8. open or closed fracture of the diaphysis of the tibia;

6.11.9. open or closed fracture of the ankles of both tibias in combination with a fracture of the articular surface of the tibia and rupture of the distal tibiofibular syndesmosis with subluxation and dislocation of the foot;

6.11.10. compression fracture of two or more adjacent vertebrae of the thoracic or lumbar spine without dysfunction of the spinal cord and pelvic organs;

6.11.11. open dislocation of the shoulder or forearm, or hand, or thigh, or leg, or foot with rupture of the ligamentous apparatus and joint capsule.

Persistent loss of general ability to work in other cases is determined in percentages divisible by five, in accordance with the Table of percentages of permanent loss of general ability to work as a result of various injuries, poisonings and other consequences of external causes, attached to these Medical criteria.

Work ability is a socio-medical concept that defines the totality of a person’s congenital and acquired abilities to act aimed at obtaining a socially significant result in the form of a certain product, product or service (“Regulations on the procedure for establishing the degree of loss of professional ability by medical labor expert commissions... ", approved by Decree of the Government of the Russian Federation dated April 29, 1994 No. 392).

General working capacity is the totality of a person’s ability to perform unskilled work and provide self-care (hygienic procedures, independent movement in space, eating, putting on clothes, shoes, etc.).

Persistent loss of general ability to work is such an irreversible loss of function (functions) that deprives a person of the ability to fully or partially perform unskilled work and provide self-care.

Depending on the nature of the extent of permanent loss of general ability to work, harm to a person’s health can be assessed as severe, moderate or mild.

Persistent loss of general ability to work is assessed according to clause 6.11, regardless of the actual outcome of the damage caused. Clause 6.11 provides an exhaustive list of such damages. On the day of classifying the injury as one of those provided for in clauses 6.11.1- 6.11.11, an objectively confirmed diagnosis of the corresponding injury is sufficient.

In clauses 6.11.1-6.11.9, the listed fractures are a significant permanent loss of general working capacity of at least one third, regardless of their nature: both open and closed.

In clauses 6.11.2, 6.11.7 we mean fractures of those parts of the bones that form the joint (elbow or knee), regardless of the rupture of the articular capsule.

According to clauses 6.11.2 and 6.11.7, one should keep in mind the intra-articular nature of fractures, i.e. fractures of bone fragments forming the corresponding joints.

The amount of permanent loss of general ability to work for different outcomes of injury is provided for in a special Table, which is an integral Appendix to the Medical Criteria. During the forensic medical examination, a specific outcome of the injury must be established, which is compared with the corresponding data contained in the Table, which shows the amount (in %) of permanent loss of general ability in relation to the established outcome of the damage caused to the victim.

The outcome can be determined during a single or dynamic clinical expert study.

If the final outcome has not been determined within 120 days, then a conditionally permanent (irreversible) loss of general ability to work is considered to be the amount of lost function that has formed in the victim after the specified period of time.

If the victim suffered from some kind of disease before the injury. If he has partially or completely lost the function(s) of some organ, or segment, or part of the body, then only the consequences of the injury are subject to expert assessment. To do this, first, through a direct expert (usually a commission) examination of the victim and the study of medical documents about his previous injury, the degree of permanent loss of general ability to work at the time of injury is established. Then the consequences of the injury are identified, its outcome is determined, and the amount of permanent loss of general ability to work is also determined. In this case, the possible negative impact of the previous pathological background on the clinical treatment and outcome of the injury must be taken into account. Analysis and cumulative assessment of all this information makes it possible to establish the severity of the harm to health caused by the injury. Depending on the concomitant pathology, appropriate clinical experts may be involved in the commission examination.

A significant persistent loss of general working capacity of at least one third is understood as a persistent loss of general working capacity of more than 30%. Since in the special Table (appendix to the Medical Criteria) the gradation of the amount of loss of ability to work is a multiple of 5%, then a significant permanent loss of general ability to work by at least one third will be a loss of 35% or more.

Regardless of the outcome, a number of fractures, an exhaustive list of which is given in clause 14.1: 14.1.1-14.1.11, are classified as serious harm to human health on the basis of a significant permanent loss of general ability to work by at least one third.

A significant permanent loss of general working capacity of less than one third is understood as a loss of such working capacity from 10 to 30% inclusive, and a minor loss is less than 10%, i.e. 5%.

6.12. Complete loss of professional ability to work Professional ability to work is associated with the ability to perform a certain volume and quality of work in a specific profession (specialty) in which the main work activity is carried out.

The degree of loss of professional ability to work is determined in accordance with the Rules for determining the degree of loss of professional ability to work as a result of accidents at work and occupational diseases, approved by Decree of the Government of the Russian Federation of October 16, 2000 No. 789 (Collected Legislation of the Russian Federation, 2000, Zh" 43, Art. 4247).

Complete loss of professional ability to work is established through a commission forensic medical examination with the participation of a specialist in the field of medical and social examination.

7. Medical criteria for qualifying signs in relation to moderate severity of harm to health are:

7.1. Temporary dysfunction of organs and (or) systems (temporary disability) lasting more than three weeks (more than 21 days) (hereinafter referred to as long-term health disorder).

A health disorder is a dysfunction of the body that is directly related to an injury or disease. When determining the severity of harm caused to a person’s health, the health disorder in connection with the injury is taken into account.

A temporary health disorder should not be equated with a temporary loss of ability to work or temporary incapacity for work, the duration of which is determined by the “Temporary Incapacity Sheet”. Work ability is established by law from the age of 14, i.e., if we understand temporary disability as a health disorder, then it will not be possible to determine it in children and adolescents under 14 years of age. If for schoolchildren under 14 years of age temporary disability can be conditionally equated to the inability to attend school, then for preschoolers even such a conditional criterion will not exist. Unemployed people and pensioners may not use the Temporary Disability Certificate at all. In addition to a brief diagnosis, the “Certificate of Temporary Incapacity for Work” does not contain any information about the state of health of the victim, which does not allow one to critically evaluate the validity of the length of stay in hospital or for outpatient observation and treatment (however, often the basis for issuing a “Certificate of Temporary Incapacity for Work” are only subjective complaints patient). On the other hand, the victim may refuse treatment, leave the hospital before recovery and start working prematurely.

Thus, the only basis for judging the duration of a health disorder in connection with an injury will be the duration of post-traumatic dysfunction (functions) of the body, recorded in medical documents (medical record of an outpatient, medical record of an inpatient, results of clinical laboratory, instrumental studies, etc. ) and during direct forensic medical examination of the victim.

Medical criteria establish two gradations of health disorder: long-term health disorder, i.e. temporary post-traumatic impairment of function lasting more than three weeks (more than 21 days), and short-term health disorder, i.e. temporary post-traumatic impairment of function lasting within three weeks (in within 21 days).

The resulting injury can worsen the victim’s existing chronic disease, and a patient admitted to the hospital for injury may remain in a hospital bed for a long time to correct the health status and worsening chronic disease. In such cases, to assess the severity of harm to health, it is necessary to differentiate between dysfunction due to injury and chronic disease, taking into account only the duration of post-traumatic impairment when determining the severity of harm to health.

If a surgical operation was performed to eliminate the consequences of an injury, then when determining the severity of harm to health, the duration of the health disorder, including the postoperative period, should be taken into account.

If a surgical operation is undertaken for diagnostic purposes, then the harm to health caused by the surgical intervention is not taken into account when assessing the severity of the harm to health.

Damage to health caused as a result of a defect in the provision of medical care is assessed independently, regardless of the damage caused and its consequences, in accordance with the qualifying criteria provided for by the Rules and the Criminal Code of the Russian Federation. If, as a result of a surgical operation or some other medical intervention, there is a defect in the provision of medical care and additional suffering is caused to the victim, the latter are not grounds for increasing the severity of the harm to health caused by the previous injury. With a presumptive diagnosis (for example, a concussion), when there are no clear signs of injury (impairment of structure and function), the victim may be admitted to the hospital for clinical observation, since signs of injury may not appear immediately, but after several days. If such signs do not appear, the time spent in hospital is not considered as the duration of the health disorder.

7.2 Significant persistent loss of general ability to work by less than one third - persistent loss of general ability to work from 10 to 30 percent inclusive.

See commentary to paragraph 6.11 of the Medical Criteria.

8. Medical criteria for qualifying signs in relation to minor harm to health are:

8.1. Temporary impairment of the functions of organs and (or) systems (temporary disability) lasting up to three weeks from the moment of injury (up to 21 days inclusive) (hereinafter referred to as short-term health disorder).

See commentary to paragraph 7.1 of the Medical Criteria.

8.2. Minor persistent loss of general ability to work - persistent loss of general ability to work less than 10 percent.

9. Superficial injuries, including: abrasion, bruise, soft tissue contusion, including bruising and hematoma, superficial wound and other injuries that do not entail short-term health problems or minor permanent loss of general ability to work, are regarded as injuries that do not cause harm to health person.

Single superficial injuries do not lead to health problems or permanent loss of general ability to work: abrasions, bruises, limited in area and shallow wounds. They are recorded by the expert as injuries that do not lead to short-term health problems or minor permanent loss of general ability to work. Multiple abrasions, bruises and shallow, usually bruised, wounds can be accompanied by severe swelling of the surrounding tissues and lead to limitation of functions (limitation of visual fields due to swelling of injured eyelids, limitation of movements in joints due to edematous pain in injured soft tissues, etc.) . Such injuries, as those accompanied by dysfunction, are assessed on the basis of a health disorder.

III. Final provisions

10. To determine the severity of harm caused to human health, the presence of one of the qualifying signs is sufficient.

11. If there are several qualifying criteria, the severity of the harm caused to human health is determined by the criterion that corresponds to the greater severity of the harm.

See commentary to clause 5 of the Rules.

12. The severity of harm caused to human health in the presence of several injuries resulting from repeated traumatic impacts (including during the provision of medical care) is determined separately for each such impact.

13. If multiple injuries mutually aggravate each other, the severity of the harm caused to human health is determined based on their totality.

14. In the presence of injuries of different ages, the severity of the harm caused to human health is determined for each of them separately.

See commentary to clause 10 of the Rules.

15. The occurrence of a life-threatening condition must be directly related to the infliction of harm to health that is dangerous to a person’s life, and this connection cannot be accidental.

See commentary to paragraph 6.2 of the Medical Criteria.

16. Prevention of death due to the provision of medical care should not be taken into account when determining the severity of harm caused to human health.

See commentary to paragraph 6.1 of the Medical Criteria.

17. A health disorder consists of a temporary disruption of the functions of organs and (or) organ systems, directly related to damage, disease, or pathological condition that causes temporary disability.

18. The duration of dysfunction of organs and (or) organ systems (temporary disability) is established in days, based on objective medical data, since the duration of treatment may not coincide with the duration of restriction of the functions of organs and (or) human organ systems. The treatment provided does not exclude the presence of post-traumatic limitation of the functions of organs and (or) organ systems in a living person.

See commentary to paragraph 7.1 of the Medical Criteria.

19. The criterion for loss of general ability to work is applied* in case of unfavorable labor and clinical prognosis or with a determined outcome, regardless of the duration of limitation of work ability, or when the duration of a health disorder exceeds 120 days (hereinafter referred to as persistent loss of general ability to work).

See commentary to paragraph 6.11 of the Medical Criteria.

20. Persistent loss of general working capacity consists of irreversible loss of functions in the form of limitation of life activity (loss of a person’s innate and acquired abilities for self-service) and a person’s ability to work, regardless of his qualifications and profession (specialty) (loss of a person’s innate and acquired abilities to act aimed at obtaining socially significant result in the form of a specific product, product or service).

See commentary to paragraph 6.11 of the Medical Criteria.

21. In children, the labor prognosis in terms of the possibility of permanent loss of general (professional) ability to work in the future is determined in the same way as in adults, in accordance with these Medical criteria.

Medical criteria propose to define persistent loss of general ability to work in children in the same way as in adults. Meanwhile, in a particular case, the age and characteristics of the child’s developing body should be taken into account, therefore a forensic medical examination should be carried out on a commission basis with the participation of a pediatrician and (or) a pediatric neurologist, etc.

22. If there is a need for a special medical examination of a living person, medical specialists from organizations that have the conditions necessary to conduct such examinations should be involved in conducting a forensic medical examination.

See commentary to clause 8 of the Rules.

23. When conducting a forensic medical examination of a living person who has any disease or damage to a part of the body that was previously lost in whole or in part before an injury, only harm caused to the person’s health caused by the injury and causally related to it is taken into account.

See commentary to clause 9 of the Rules.

24. Deterioration in a person’s health condition caused by the nature and severity of injury, poisoning, disease, late start of treatment, age, concomitant pathology and other reasons is not considered as harm to health.

If a person with injury (poisoning, “disease”) has experienced a deterioration in their health due to deficiencies in treatment, previous diseases, or individual characteristics of the body, then the dysfunction associated with these factors should not be taken into account when assessing the severity of the harm caused by the injury.

25. Deterioration of a person’s health condition due to a defect in the provision of medical care is considered as causing harm to health.

26. Establishing the severity of harm caused to human health in the cases specified in paragraphs 24 and 25 of the Medical Criteria is also carried out in accordance with the Rules and Medical Criteria.

See commentary to clause 16 of the Rules.

27. The severity of harm caused to human health is not determined if:

in the process of a medical examination of a living person, studying case materials and medical documents, it is not possible to determine the essence of harm to health;

at the time of a medical examination of a living person, the outcome of harm to health that is not life-threatening is unclear;

a living person in respect of whom a forensic medical examination was ordered did not appear and cannot be taken for a forensic medical examination, or the living person refuses a medical examination;

medical documents are missing or they do not contain sufficient information, including the results of instrumental and laboratory research methods, without which it is not possible to judge the nature and severity of harm caused to human health.

The “moment of medical examination” must be understood as the time of the forensic medical examination.

An unclear outcome occurs if, by the time of the examination, the full extent of the violation of the integrity of anatomical structures and (or) the degree of disturbance or loss of physiological functions of the body directly caused by the injury has not been established.

The severity of harm caused to a person’s health cannot be determined in the absence of the victim himself if the submitted medical documents do not contain enough information about the nature of the structural and functional disorders caused by the injury. Responsibility for the accuracy of the information contained in medical documents lies with the person who appointed the examination.

The inability to present a living person for an expert examination and the reasons for such impossibility must be confirmed in writing by the person who appointed the examination. The same applies to the inability to provide the expert with the necessary medical documents and results of medical (instrumental and laboratory) tests.

When determining the severity of harm caused to human health, in the event of his death harm to health is assessed as heavy, If:

the harm caused to human health was in itself the cause of death or led to death as a result of a developed complication that was not accidental;

harm caused to human health led to death due to the development of a life-threatening condition that was not accidental;

harm caused to human health has at least one of the medical criteria for life-threatening harm;

medical documents record a clinical picture of a life-threatening condition resulting from this harm to health;

medical documents contain medical criteria for loss of vision, speech, hearing, any organ or loss of organ functions, or mental disorder, or drug addiction or substance abuse, or permanent disfigurement of the face;

there are anatomical or functional signs indicating a significant permanent loss of general ability to work by at least one third or a complete loss of professional ability to work.

The assessment is carried out based on the results of a complete forensic medical examination of the corpse and the results characterizing the state of health of the deceased before the injury, in connection with the injury and after the injury, recorded in medical documents.

In the absence of qualifying signs and medical criteria listed above, harm to health is assessed as moderate severity, If:

death occurred within a period exceeding 21 days after the injury to health (based on the duration of the health disorder);

there are anatomical signs of a significant permanent loss of general working capacity of less than one third.

In order to assess the severity of harm caused to human health as moderate, it is initially necessary to exclude the presence of the qualifying signs and medical criteria for serious harm listed above in the victim. During a forensic medical examination of a corpse, harm to health is assessed as moderate severity in relation to unhealed injuries, if death occurred 21 days after receiving the injuries and the duration of the assessed injuries is also more than 21 days.

Harm to health of moderate severity during a forensic medical examination of a corpse is considered to be of moderate severity if there are anatomical signs of a significant permanent loss of general ability to work, less than one third - from 10 to 30% inclusive.

If death occurred earlier than 21 days after the injury to health, then if injuries that have healed during this period are detected, they are assessed on the basis of a short-term health disorder as slight harm to health. Harm to health is also assessed in the presence of anatomical signs indicating a slight permanent loss of general ability to work.

If, during the examination of the corpse and the study of medical documents, no objective signs are found to judge the outcome of the harm caused to health, an assessment of the severity of non-life-threatening harm to health is not carried out.