ASPHYXIA
The term asphyxia (from Greek, “a” = without & “sphuxis"= pulse or heartbeat). It
refers to a state in which the body becomes deprived of oxygen while in excess of
carbon dioxide (i.e. hypoxia and hypercapnoea) without a steady supply of oxygen,
the body's vital functions shutdown within four to six minutes.
Hypoxia: means that O2 lack in the tissues.
Anoxia: means that no O2 is present in the tissues. ASPHYXIA
Phases of Asphyxial Death:
1. Dyspneic Phase
- Due to lack of oxygen and the retention of carbon dioxide in the body
tissue. The face, hands and fingernails become bluish, especially in the
case of infants.
2. Convulsive Phase
- Due to the stimulation of the central nervous system by carbon
dioxide. The victim may become unconscious during this stage.
- Tardieu Spots
3. Apneic Phase
- Due to the paralysis of the respiratory center of the brain.
- The recovery at this stage is almost nil
Types of Asphyxial Death:
1) Anoxic Death
- Failure of the arterial blood to become normally saturated with
oxygen
2) Anemic Anoxic Death
- Due to a decreased capacity of the blood to carry oxygen.
3) Stagnant Anoxic Death
- This is brought about by the failure of circulation.
4) Histotoxic Anoxic Death
- Due to the failure of the cellular oxidative process, although the
oxygen is delivered to the tissues, it cannot be utilized properly.
- Cyanide and alcohol
Classifications of Asphyxia:
1. Hanging
2. Strangulations
a. Strangulation by ligature
b. Manual strangulation or throttling
c. Special forms of strangulations
1. Palmar strangulation
2. Garroting
3. Mugging or yoking
4. Compression of the neck with a stick
3. Suffocation
a. Smothering
b. Choking
4. Asphyxia by drowning
5. Traumatic Crush Asphyxia
6. Irrespirable Gases
Hanging
Mechanism of Death
Symptoms:
1. Gradual loss of sensibilities
2. Sensation of constriction of neck
3. Loss of Consciousness and muscular power
4. Numbness of the legs and clonic convulsion
5. Sensation of ringing inside the ear
6. Sensation of flash of light before the eyes
7. Face becomes red, with eyes prominent and feeling of heat in the hand
The Time Required to Produce Death in Hanging is Influenced by The Following
Factors:
Severity of Constricting Force
Point of Application of the Ligature
Physical Condition of the Subject
The Rate of Consumption of Oxygen in the Blood and Tissues
Amount of Tension in the ligature sufficient to occlude the vital structures of the
neck:
Jugular Veins…………………………………………………… 2 kilos
Carotid Artery………………………………………………….. 5 kilos
Trachea…………………………………………………………. 15 kilos
Vertebral Artery ………………………………………………. 30 kilos
Post-mortem Findings in Death by Hanging:
General External Appearance
Neck elongated and stretched with the head inclined on the side opposite the knot
or noose
Eyes closed or partially opened with pupils usually dilated on one side and small on
the other side (facies sympathetic)
Lividity of the face (pallor) with swelling and protrusion of the tongue
Hands are clenched firmly and purple colored fingernails
Lips livid or blue
Saliva Dribbled from the mouth with froth
(for males) State of erection or semi-erection of the penis with seminal fluid in the
urethral meatus
Post-mortem lividity with ecchymosis are mostly marked at the legs
Urination or defecation due to the loss of power of the sphincter muscles
Internal Findings
Engorgement of the lungs
Venous System contains dark-colored fluid blood
Right side of the heart and the big blood vessels connected with it are distended
with blood.
Blood vessels of the brain is generally congested
Kidneys are congested
Sub-pleural, sub-pericardial punctiform hemorrhages (Tardieu Spots)
Findings on the Neck
Neck is flexed opposite the side where the knot is located
Ligature mark
The course of the ligature- inverted V-shaped
The skin at the site of the ligature is hard with red line of congestion and
hemorrhage in some points
Ecchymosis of the neck
Rupture of the underlying blood vessels, muscles and other soft tissues
Lining of the membrane of blood vessels- lacerated
Fracture of the upper cervical vertebrae and the injury of the spinal cord
Fracture of the hyoid bone or the tracheal rings
Contusion of the inner wall of the trachea
Determination whether Hanging is Ante-mortem or Post-mortem:
VITAL REACTION
Antemortem if:
Redness or ecchymosis at the site of ligature
Ecchymosis of the pharynx and epiglottis
Line of redness or rupture of the intima of the carotid artery
Subpleural, subepicardial punctiform hemmorhages
Determination Whether Hanging is Accidental, Homicidal or Suicidal:
1. Homicidal
- Nature of Windows and doors
- Signs of Struggle
- Presence of stains, defense wounds, and bodily injuries in the body of
victim
2. Suicidal
- The dead body is compatible with self-suspensions
- Unusual position of the body
- Absence of signs of struggle
- Signs of vital reaction in the ligature marks around the neck
- Signs of previous ineffective suicide attempt
- Other signs of suicide
3. ACCIDENTAL HANGING IS VERY RARE
ASPHYXIA BY STRANGULATION:
Produced by compression of the neck by means of a ligature which is
tightened by a force other than the weight of the body.
Commonly observed in rape cases
MECHANISM OF DEATH
Hanging Vs. Strangulation with Ligature
Hanging
Hyoid Bone- frequently injured
Direction of the ligature mark- inverted V-shape
Ligature- at the level of hyoid bone
Ligature groove is deepest opposite the site of the knot
Vertebral injury is frequently observed
Strangulation with Ligature
Hyoid bone- frequently spared
Ligature mark- usually horizontal
Ligature- usually below the larynx
Ligature groove is uniform in depth in its whole course
Vertebral injury is not observed
Post –mortem Findings:
External Examination
Face- livid and swollen
Eyes are wide open, prominent, congested and pupils are dilated
Tongue swollen, dark colored and protruded
Bloody froth may escape from the mouth and nostrils
Tardieu Spots
Internal Examination
Intense venous congestion of both lungs with numerous petechial hemorrhage
Blood-stained froth is found in big bronchi
Right side of the heart is filled with dark fluid blood
Congestion of the brain
Congestion of the visceral organs
Examination of the Localized Lesion in the Neck
Mark of violence on the neck is in the form of ligature mark, abrasion, or ecchymosis
Fracture of the larynx or tracheal rings
Laceration of the tunica intima of the carotid and jugular vessels
Accidental, Homicidal or Suicidal Strangulation by Ligature
Homicide- most common of the three forms of strangulation by ligature
Smothering- may be done by placing a handkerchief gag in the mouth
Ligature- may be passed around the neck and then the feet and hands are bound
together
Evidence of struggle or marks of violence
Suicidal
Quite rare
Accidental
Most of the victims are children or epileptics who are helpless and incapable of
extricating themselves
Manual Strangulation or Throttling:
Constricting force applied in the neck is the hand
Manners of Death in Manual Strangulation:
The air passage may be blocked and death is due to asphyxia
The pressure on the neck may cause compression of the blood vessels and disturb
the blood supply of the brain
The nerves of the neck may be traumatized
Post-mortem Findings;
Cyanosis of the face
Subpleural and subpericardial hemorrhage is not so conspicuous
Heart – distented with blood
Overdistention of the lungs with interstitial emphysema is occasionally
observed in children.
Findings on the neck:
There may be no external injury on the skin but there may be contusion with
the form and shape of the fingers
Abrasions may be found in front or at the back of the neck
Interstitial hemorrhages in the muscles of the neck
Fracture of the laryngeal cartilage may occasionally be found
Petechial hemorrhages and congestion of the larynx and pharynx
Bruising of the tongue
Hemorrhages present in the capsule of the thyroid, submaxillary and even in
the parotid glands
Accidental, Homicidal or Suicidal Manual Strangulation
Suicidal Throttling
Not possible
Accidental Throttling
May occur but the victim never died of asphyxia but of some other causes.
Homicidal Manual
The most common
Special Forms of Strangulation:
Palmar Strangulation
The pressure must be sufficient to occlude the lumen of the windpipe
Garroting
A mode of judicial execution during the 19th century and it is still being practiced in
Spain and Turkey
Mugging (Strangle-hold)
May be the cause of death in wrestling
With the assailant standing at the back and the forearm is applied in front of the
neck.
Compression of the Neck with a Stick
Asphyxia by Suffocation
Exclusion of air from the lungs by closure of air openings or obstruction of
the air passageway from the external opening to the air sacs.
Smothering and Choking
Smothering:
Overlaying
Accidental Smothering of Epileptic
Gagging
Plastic bag suffocation
Choking:
Vomitus
Regurgitation of food from the stomach
Bolus of Food
Detached membrane in diphtheria
False set of teeth
Blood in tonsillectomy operation
Respiratory hemorrhage as in tuberculosis
Compression Asphyxia (Traumatic or Crush Asphyxia):
Whereby the free exchange of air in the lungs is prevented by the immobility
of the chest and abdomen due to external pressure or crush injury.
Burking
A form of traumatic asphyxia death invented by Burke and Hare for the purpose of
murdering people to be sold to medical schools for dissection.
Death by Crucifixion
Asphyxia by Breathing Irrespirable Gases:
Carbon Monoxide (Carbon Oxide Gas, “Silent Killer”)
Hydrogen Sulfide (Sulphuretted Hydrogen)
Hydrogen Cyanide
Sulfur Dioxide
War Gases
Carbon Monoxide
Formed from the incomplete combustion of carbon fuel
Accidental and Suicidal death by Carbon Monoxide poisoning is common
Above 80% Saturation level of CO-H – Rapid death from respiratory arrest
Post Mortem Appearance:
Face – Cyanosed
Pupils – Dilated
Lungs – Congested
Small Intestine, pericardium, pleura and galea of scalp – Ecchymotic patches
Blood – increase amount of carbon dioxide
Internal organs – Dark and congested
Hydrogen Sulfide
Formed during a decomposition process of organic substances containing
Sulphur.
In sewer, septic tanks, drainage pipes and deep wells
Colorless, transparent gas, sweetish taste and emitting an odor similar to a
rotten egg.
Post-mortem Findings:
Putrefaction sets rapidly
Offensive odor is noticed on opening the body
Blood (fluid state) – Dark brown in color
Lungs – congested and edematous
Other organs – congested and dark colored
Hydrogen Cyanide
Formed by addition of acid to potassium or sodium salt of cyanide.
Found in leaves of cherry-laurel, in bitter almond, in kernels of common cherry,
plum, peaches, in ordinary bamboo shoots, and in certain oil seed and beans.
Orally, 60-90 mg. of hydrogen cyanide is FATAL.
Post-mortem Findings
Body – livid or violet
Post-mortem lividity – bright red or pink
Fingers – clenched; Fingernails – blue
Jaws – closed
Eyes – bright and glistening; Pupils – dilated
Sulfur Dioxide
A colorless gas, which is heavier than air and with pungent odor.
Disinfectant, bleaching agent, a powerful reducing agent and found usually in
eruption of volcanoes
Post-mortem findings
Cyanosis with signs of Asphyxia
War Gases
Lacrimator or Tear Gas
Vesicant or Blistering Gas
Lung Irritants (Asphyxiant or Choking Gas)
Sternutator
Paralysants (Nerve Gas)
Blood Poisons
CASE OF OYETRI DEY
JANUARY 17, 2018
CASE STORY
2 years and 5 months old Oyetri Dey was admitted to AMRI Hospital
Mukundapur on 15 January 2018 with a normal complaint of fever, cold and cough.
Her parents were told that she has a normal tonsil gland infection due to
which she was getting whooping cough (later on it was discovered that she had an
acute bronchitis). She needed to be nebulized at the hospital (Dr. Joyeeta Sengupta)
with oxygen and it was urgent. The doctor also needed to run some tests on her,
they said.
Her parents were told the examination would take about two days. At the
time that Oyetri was admitted, she didn’t even have fever. She had a normal cough.
She was being nebulized at regular intervals.
A little while later, a nurse did an intravenous (IV) channel on her. She was
not on any kind of saline drip. She was consuming food through her mouth. Only the
medicines were given via IV.
She was recovering and her doctor had said she would be discharged the
same week. At 10 pm, she had dinner, and a little later, started feeling lethargic. The
amount of urine that she was passing, went down.
Nurses measured Oyetri’s diaper and said that this might be a symptom of
something else. They gave her IV Volus and she passed urine in 45 minutes.
Around 5.45am on 17 January 2018, the nurse firmly gave Oyetri two
injections of “Augmentin”. After the injections, the child started feeling restless like
she wanted to vomit but was unable to. She was unable to breathe either.
The doctor asked the nurse to get an oxygen mask. She promptly replied that
it was occupied with some other bed and couldn’t be brought to her. The doctor
then asked for a saturation machine which was also not working.
By that time, Oyetri collapsed and her lips turned blue. Two hours later, they
gave me the verdict that my daughter was no more.
POST MORTEM ANALYSIS OF CASE (by experts)
2 years old and 5 months Oyetri Dey died due to the effects of asphyxia,
according to the postmortem report. Other findings:
• Petechial haemorrhagic spots of variable sizes in the lungs and the left
surface of the heart.
While Oyetri’s family claimed that the report proved medical negligence, some
experts pointed out the child might have choked due to lack of oxygen and not due
to wrong medication.
She had been intravenously given Augmentin — an antibiotic used to treat
bacterial infection — shortly before her death.
It could have been responsible for a sudden cardiac arrest only if the
drug was administered without a skin test to check for allergic reactions, said
Debashish Saha, consultant at AMRI Hospitals.
Those allergic to Augmentin may suffer a swelling in the larynx, choking
the airways and leading to asphyxia.
Petechial hemorrhage, on the other hand, could result from a
disseminated intravascular coagulation, which is triggered by sepsis or an
infection in the bloodstream. It could also occur as an aftermath of asphyxia.
The hospital had cited "cardiac arrest" as the cause of death, saying it
suspected the toddler had an underlying heart ailment.
Forensic medicine experts said asphyxia is caused by an obstruction in
the air pipe. The girl had convulsed moments before she died, suggesting asphyxia.
ANALYSIS OF CASE (group analysis)
Immediate Cause of Death- Asphyxia (Toxicological)-swelling in the
larynx, choking the airways
What lead to the asphyxia?
Antecedent Cause of Death- Allergic Reaction to Augmentin
What Triggered the Event?
Underlying Cause of Death- Acute Bronchitis
Viruses most often cause acute bronchitis.
Antibiotics do not help treat viruses. They can help treat cases caused by
bacterial infections. Some people who have acute bronchitis need medicine that
treats asthma. You might need this if you are wheezing. It can help open your
bronchial tubes and clear out mucus. You usually take it with an inhaler. An inhaler
sprays medicine right into your bronchial tree. Your doctor will decide if this
treatment is right for you.
What lead to the asphyxia?
Antecedent Cause of Death- Allergic Reaction to Augmentin
SIGNS:
• Petechial hemorrhagic spots of variable sizes in the lungs and the left surface
of the heart.
• Signs Vomiting
ADVERSE SIGNS OF AUGMENTIN:
Gastrointestinal Disorders: Tablet/Powder for Suspension:
Adults:
Very Common: Diarrhoea.
Common: Nausea, vomiting.
Children:
Common: Diarrhoea, nausea, vomiting.
Injection:
Common: Diarrhoea.
Uncommon: Nausea, vomiting, indigestion.
Immediate Cause of Death- Asphyxia (Toxicological)-swelling in the
larynx, choking the airways
The Child showed signs of vomiting but was unable to do so and difficulty of
breathing.
She choked on her own vomit due to the swelling of larynx which obstructs
her respiratory tract.
There was negligence on the part of the hospital nurse because she did not
follow the proper procedural testing whether the Child is allergic to the prescribed
drug.
There was also a lack of managing the facilities in the hospital, especially for
emergency purposes.
Health care providers of the hospital were not clearly trained in their
profession.
