Asphyxia
Asphyxia: interference with the process of oxygenation, absence of pulsation
Types:
1. Mechanical: obstruction of air passages from within or outside
2. Pathological: exchange of gases blocked by disease process
3. Toxic: exchange of gases blocked by poisonous gases e.g CO
4. Environmental: insufficient O2 in inspired air e.g. high altitude, deep wells, closed space
5. Iatrogenic: in anesthesia/ surgery
Patho-physiology:
1. Hypercapnia
2. Anoxia/hypoxia
Hypoxic anoxia
Anoxic anoxia
Anemic anoxia
Stagnant anoxia
Histotoxic anoxia
Mechanical asphyxia: mechanical obstruction can be at 5 levels
Mouth/nose >> SUFFOCATION
Glottis>> HANGING
Larynx/upper trachea>> STRANGULATION/ THROTTLING
Trachea/ main bronchus >> CHOKING
Muscles of respiration >> TRAUMATIC ASPHYXIA e.g. stampede, building collapse, RTAs
Trachea blockage > air passage blockage
Carotid arteries blockage> cerebral anoxia, unconsciousness
Jugular vein blockage> congestion and brain hemorrhage
Vagus nerve/ due to carotid sinus> cardiac arrest to vagal inhibition
Signs of asphyxia:
i. Cyanosis
ii. Vascular congestion
iii. Edema of tissues and organs
iv. Petechial hemorrhage (tardieu spots <1mm in
size) in conjunctiva, face, epiglottis etc.
v. Fluidity of blood
vi. Pronounced lividity
o Violent asphyxial deaths:
1. Hanging
2. Ligature strangulation
3. Manual strangulation (throttling)
4. Suffocation
5. Drowning
A. Hanging: violent asphyxia death caused by suspension of body by a ligature around the neck the
constriction of force being the weight of the body
Types of hanging:
i. Complete hanging: when feet don’t touch the ground & weight of whole body
works as constricting force
ii. Incomplete/ partial hanging: when weight of head only works as constricting force
iii. Typical hanging: when ligature is situated in midline above thyroid cartilage & in this
position theres much chance of arterial occlusion
iv. Atypical hanging:
Symptoms of hanging:
i. Flashes of light before eyes
ii. Ringing in the ears
iii. Unconsciousness followed by death
Causes of death in hanging:
i. Coma (due to cerebral anoxia from arterial occlusion)
ii. Cerebral congestion (due to venous occlusion)
iii. Asphyxia (due to blocking of air passages)
iv. Shock (due to vagal inhibition)
v. Spinal column injury (in judicial hanging)
vi. Combination of any above
Fatal period of hanging:
Instantaneously in case of judicial hanging due to drop causing fracture of 2nd&3rd or
3rd&4th cervical vertebra
Death is rapid if cause of death is asphyxia
Less rapid if cause is asphyxia>> 5-8 mins if no spinal injury &
Post-mortem appearance:
Cyanosis
Petechial hemorrhages (tardieu spots)
Neck stretched due to upward pull
Neck tilted on side opposite to the knot
Tongue congested and protruded
Dribbling of saliva from angle of mouth opposite the knot
PML on legs, arms, penis and above ligature
Ligature mark:
Its an imprint of ligature on neck
Appears as yellowish brown, dry hard parchment like groove around the neck
On the side of knot it appears as inverted V >> in case of fixed noose
Appears relatively horizontal >> in case of running noose
Method of cutting noose is away from knot to see if it was fixed or running in the
first place
Internal appearances:
Head, thorax and abdomen to be opened first
Y-incision is preferable
Neck is to be opened in layers
Fibers of platysma and sternocleidomastoid maybe torn
Posterior horn of thyroid cartilage maybe fractured
Hyoid bone is RARELY fractured (before age 40) but outward compression is seen if
it happens
Lymph nodes above and below ligature are congested
Intimal tears of carotid arteries
The under surface of ligature marks reveals a dry and compressed white band of
tissues with few petechial ….
Medico-legal aspects of hanging:
Whether it is ante-mortem or post-mortem hanging?
Whether it is suicidal, homicidal or accidental hanging?
o Ante mortem or post mortem?
External findings are same like petechial hemorrhages on face and conjunctiva, ligature marks,
PML on hands, feet, genitalia. So we go for internal examination. Following changes do not
occur if person is hanged after death:
i. The under surface of ligature mark reveals dry and compressed white band of tissue
with few petechiea
ii. Intimal tears of carotid arteries
iii. Congestion of lymph nodes
iv. Fracture or fracture dislocation of cervical vertebrae
v. Absence of fatal injuries or poisoning
Types of hanging
Suicidal Homicidal Accidental
Usually male Justifiable >> judicial hanging Children who get caught in
Official method of execution of cords of window or in ropes
death sentence under the while playing
orders of court of law, convict w
covered face stands on trap Toddlers by slippage of
doors retaining traps
Hx of previous suicidal attempts 5-7 feet drop, C3 C4 fractured, Rarely hanging can occur
rupture of spinal cord, intima of without ligature e.g. when a
carotid arteries show tranverse person slips down a ladder and
tears, instantaneous death get suspended by one of its
rungs
Hx of depression/ psychiatric Non-justifiable (lynching) group Auto-erotic hanging:
illness of people kill someone for an Sexual asphyxia: partial cerebral
alleged offence without a legal hypoxia may cause sexual
trial, especially by hanging enhancement
Body must be found in position Knot on back, mouth is gagged, Sexual asphyxia findings:
compatible with self suspension signs of struggle and non-self 1. Padded ropes
i.e. knot on front or sides, some inflicted injuries 2. Nakedness/ exposed
material for climbing to height genitalia
3. Pornographic material
around
Direction of ligature mark>> Other methods of execution: *ASTAGHFIRULLAH*
oblique Electric chair
Lethal injections:
1. Thiopental sodium
2. Pavulon (pancuronium
bromide)
3. Potassium chloride
B. Strangulation:
It’s a form of asphyxia death caused by the constriction of neck by ligature or by any means
without suspending the body
Types:
I. Ligature
II. Manual strangulation/ throttling
III. Mugging
IV. Garroting
V. Bansdola
Causes of death in strangulation:
Coma (syncope)
Anoxic hypoxia
Cerebral ischemia / venous congestion
Asphyxia + venous congestion
Vagal inhibition
Shock due to reflex cardiac arrest
Pale face >> rapid death from reflex cardiac arrest
Cyanosed face w petechiae >> delayed death
Classical features of strangulation when cardiac arrest is delayed:
Petechiae
Ear bleed
Nose bleed
Congestion
Bruises, abrasions & fingernail marks (signs of struggle)
Ligature marks
Paler skin below neck
Ligature marks:
Examination of ligature for blood, fragments of epidermis, hair etc.
Signs of struggle
Pseudo strangulation groove: seen in infants, children w short neck, ppl who wear tight
collars
Internal examination findings:
Severe congestion and hemorrhage
Fracture of thyroid cartilage
Laceration of muscles
Injury to laryngeal cartilages, tracheal rings & carotid arteries
Medico-legal aspects:
Homicidal strangulation:
Knot is tied at the back of neck
Hands are tied mouth is gagged
Signs of struggle present
INFANTICIDE>> strangulation by umbilical cord
Throttling:
Asphyxia produced by compression of neck by HANDS.
Bruises produced by tips of fingers
Pressure of nails produce crescentic marks
Hyoid bone fracture and bruising> inward compression
(rmr hyoid bone fracture was RARE in hanging)
Garroting:
Compression of neck by ligature which is quickly tightened
by twisting it with a lever
Results in sudden loss of consciousness and collapse
Mugging:
Strangulation by holding the neck in the bend of the
elbow/knee
Bansadola:
Strangulation practiced in north india using bamboo sticks
A foot or knee maybe placed across the front of throat and pressed while the victim is lying on
the ground
C. Suffocation:
Form of asphyxia caused by mechanical obstruction to air passage due to causes other than
constriction of the neck
Sites:
i. External air passages >> SMOTHERING, OVERLAYNG
ii. Internal air passages – nasopharynx, larynx>> GAGGING, CHOKING
iii. Chest
iv. Combination of 2
Classification:
Traumatic asphyxia>> chest
Burking>> combination
o Traumatic asphyxia:
Respiratory arrest due to mechanical fixation of chest so that the respiratory
movements are prevented
E.g. stampede in crowded gatherings, fall of earth-coal mines, tunneling accidents
Post mortem appearance: intense deep purple red
color of the head, neck and upper part of chest
above the level of constriction
Causes of death: asphyxia, vagal inhibition,
laryngeal spasm
o Burking:
Method of homicidal smothering + Traumatic
asphyxia
o Gagging:
Asphyxia resulting from pushing a gag (cloth or paper balls) into the mouth, deep
enough to block the pharynx
Combines features of smothering + choking
CAFÉ CORONORY: Accidental choking when a bolus of food produces complete
obstruction of the larynx, mimicking a heart attack usually seen in an intoxicated
restaurant person. Laryngeal irritation causes vagal inhibition causing sudden death due
to cardiac arrest
D. Drowning: (immersion)
Death resulting from defective oxygenation of blood in the lungs due to presence of fluid in air
passages after entering through mouth or nose
Depth of water required: not necessarily deep water, submersion or partial drowning can occur
in shallow water with face downwards as seen in bath tub drowning
Classification:
I. Typical: (wet drowning)
(a) Fresh water
(b) Salt water
II. Atypical: (dry downing)
(a) Immersion syndrome
(b) Submersion of unconsciousness
(c) Post immersion syndrome (secondary drowning)
Causes/mode of death:
I. Asphyxia hypoxic hypoxia:
(a) Obstruction by inhalation of fluid
(b) Laryngeal spasm
II. Syncope:
(a) Ventricular fibrillation (in fresh water)
(b) Cardiac standstill (in salt water)
III. Vagal inhibition: (dry drowning)
IV. Hypothermia (chilling by immersion in cold water)
V. Injuries during fall
(a) Concussion
(b) Vital organs
Fatal period
Fresh water: 3-5mins
Salt water 8-12min
READ ASPHYXIA 3 FROM SLIDES >>> time nahi tha mere pass but here are some imp notes to revise:
Crack mbbs notes:
1. Dry drowning> laryngeal spasm
2. Fresh water drowning >Ventricular fibrillation
3. Salt water> cardiac standstill
4. Gettlers test is done for > chloride content
5. Undertaker fracture> aka Clay shoveler fracture> C6-C7
6. Human organ first examined by nuclear med was> thyroid
7. Diagnostic of Antemortem drowning? Cadaveric spasm (weed in clenched hands) and diatoms in bone
marrow, brain and liver
8. Gold standard test for diagnosis of antemortem drowning? Diatom Test
9. Vital phenomenon indicating antemortem drowning> oronasal fine froth
10. Diatoms in antemortem drowning? Distant organs (brain,bone marrow, liver)
11. Hyperkalemia is associated w fresh water drowning
12. Massive pulmonary edema in salt water drowning coz water drawn into lungs from blood stream
13. Fatal period in: Fresh water drowning> 3-5min Salt water drowning> 8-12min
14. burking= smothering + traumatic asphyxia
15. Antemortem hanging? Coronary artery Intimal tears with bleeding
16. Cerebral anoxia most common cause of death in hanging
17. Cafe coronary>>reflex vagal inhibition> cardiac arrest
18. Immersion syndrome>> Vagal inhibition
19. Last structure to be autopsied in asphyxial death is >>neck
20. Fracture of hyoid bone> manual strangulation/throttling
21. Fine froth in air passages> emphysema aquosum (crepitus sound)
22. Strangulation is characterized by extensive burning of neck muscles and ecchymosis of
subcutaneous tissue in the neck
23. Mugging may leave no mark externally
24. 6 penny bruise> throttling
25. Petechial hemorrhage is a typical feature of antemortem hanging
26. Most of the violent asphyxial death> mechanical asphyxia
27. Purtscher's retinopathy>> traumatic asphyxia
