VIOLENT ASPHYXIA

Definition:
• Asphyxia is used as being equal to “lack of oxygen”
or “hypoxia”.
• Asphyxia word is Greek means 'pulsenessness' or
'absence of pulse’).
• Etiological classification:
1. Mechanical/violent: Mechanical interference to the
passage of air into the respiratory tract.
2. Pathological: Entry of oxygen to the lungs is
prevented by disease of the upper respiratory tract
or lungs, e.g. laryngeal edema, spasm, tumors and
abscess.
3. Toxic or chemical: Cessation of the respiratory
movements due to paralysis of the respiratory center
in poisoning with morphine, barbiturates
Gordon’s classification:
• Anoxia is classified into 4 types:
I) Anoxic anoxia:
This means defective oxygenation of blood in the lung and due to:
1- Absence of oxygen .
2- Obstruction to respiratory passage
3- Obstruction to respiratory movements
4- Depression of respiratory centre
 II) Anemic anoxia
 O2 carrying capacity of the blood: hemorrhage and
CO poisoning.

III) Stagnant anoxia:

Inefficient circulation through the tissues, as in: Shock
and heart failure

IV) Histotoxic anoxia:

Inability of the tissues to utilize oxygen delivered to them,
cyanide poison
Types or causes of violent Asphyxia

according to the site and mechanism of occlusion:

1- Hanging
2- Ligature strangulation
3- Manual strangulation (Throttling)
4- Smothering
5- Choking
6- Traumatic asphyxia (Crush asphyxia)
 General signs of asphyxia

• External appearance: due to struggle to breath against

some resistance.
• Cyanosis of face, lips & nails.
• Bulging eyes with subconjunctival hemorrhage.
• Dark blue hypostasis except in red asphyxia.
• Bloody froth at mouth and nose.
• Protruded tongue, which may be bitten except in hanging
with posterior suspension.
• Minute hemorrhages: in the skin above the level of
obstruction, especially in the face, eye lids and
subconjunctival.
Internal signs
• Intense venous congestion of the mucosa of air passages,
lungs (except in drowning) and all internal organs.
• Tardieu spots: It is petechial haemorrhage which may be ,
subpleural subpericardial, subarachnoid, in the brain,
heart & mucous membranes.
• Silvery spots (subpleural).
• Dark fluid blood (excess CO2 & excess fibrinolysin and
disturbed plasma calcium).
• Dilated right auricle and ventricle due to secondary
muscular flaccidity.
Petechial hemorrhages:

They are present everywhere externally as

well as internally.
They are most observed in the serous
membranes, particularly in the pleurae and
they are called Tardieu spots and visceral
pericardium.
They are due to:
1. increased intra-capillary pressure as a result
of mechanical obstruction of venous return .
2. escape of blood into tissue space: due to
increased capillary permeability as a result of
anoxia.
Petichial hge in skin & eyes , especially upper eyelid , conjunctiva ,
sclera , skin of face , lips , behind ears
* appear within 15 – 30 seconds
Peteachial hemorrhage
 Smothering:
• Caused by mechanical occlusion of the external
respiratory orifices from outside (i.e. the mouth and
nostril) by hand or by any object.
• PM picture
• Asphyxial signs will be present except in case of plastic
bag suffocation.
• Abrasions and contusions on the skin of the face
around mouth and nose
(Absent if a soft material, such as a pillow, is used).
Suicidal, homicidal, or accidental:

• Suicide By hand is impossible.

(Tying a plastic bag over the head is rare).

Accident: (most common)

• In children playing with plastic bags.
• An alcoholic adult who rolls over (during sleep) and his face in the
pillow.
 Post mortem examination
1. Non specific general pathological changes.
2. Special pathological changes:
Externally: Abrasions and contusions are found around
nose and mouth related to assailant's hand. Nose may be
distorted from continuous compression. Signs may be
minimal with non resistant victims as infants and
alcoholics.

Internally: Bruises and contused wounds may be found on

the inner aspects of the lips and cheeks and are caused by
pressure upon the jaw and teeth. Some teeth may be
found loose or even broken.
Injuries
to the
inner
cheek in
a
homicid
al
smotheri
ng case
 THINK

• What do you think about the causes of death of a

victim when pressure is applied on the neck.
Effect of pressure on neck:

jugular vein brain congestion

• carotid a. Cerebral anaemia
• carotid sinus cardiac arrest
• air passages Asphyxia
2- Manual strangulation (Throttling)
 caused by constricting the neck by the hand.
Mechanism of death:
 Autopsy appearances:

When death occurs as a result of vagal

inhibition, Asphyxial signs will be absent.
 Suicide, homicide, or accident:

 Suicide: A case was recorded, and it was

due to cadaveric spasm.
 Homicide: (most common)
 Circumstantial evidence.
 Presence of signs of struggle.
 Evidence of drink or drugs, or the victim is
young or weak.
Post mortem signs:
1. Nonspecific general pathological changes
2- General external examination:
• Cyanosis of the face and lips.
• Multiple petechial hemorrhages in the skin of the
face, eyelids, scalp, and ear drums and in conjunctivae
• Bruises and abrasions around the nose and mouth
and are resulted from the attempts of the assailant to
prevent the victim from crying or as signs of resistance
in an attempt of the victim to remove the assailant’s
hands.
3 - Special examination of the neck:
• External examination:
Injuries on the neck:
• Abrasions (caused by finger nails).
• Contusions (caused by finger pads).
• Both are found on the front and sides of the neck
 Internally
• Extensive bruises are usually found in the deeper layers
of skin, fascia, muscles of the neck, as well as in the
substance of the thyroid gland.
• Fractures of the hyoid bone are commonly found in
throttling and are accompanied by hemorrhage at the
site of fracture. Fractured hyoid bone is a diagnostic sign for
throttling even in a putrefied body.
• Fracture of other laryngeal cartilages occurs depending
on the hand's grip and age of the victim.
Hanging
Incomplete hanging
Fixed knot and running noose
 Externally:
•The neck is stretched.
•The face is pale or bluish swollen.
• Eyes : prominent , protruded tongue
•Froth at mouth & nostril
•Hypostasis: is most marked in the legs, hands and
feet.
•Saliva may be seen dripping from the mouth
(It is a vital sign and is present only in hanging but
not in postmortem suspension).
Typical Ligature mark:
• Not running around full circumference of neck
(incomplete.)
• The mark rises to a peak pointing to this junction
(node)
• High: is situated above the thyroid cartilage
• oblique
• The pattern of the ligature:
Is imprinted on the neck as a pressure abrasion.
Internally (Internal signs):

• Petechial hemorrhage and ecchymosis of the

subcutaneous tissue under the ligature, but never in
postmortem suspension. It appear externally as a
thin line of blue color in the front and along the
lower edge of the brown mark.
Is it hanging or PM suspension?
•Under rope mark: echymosis and tissues are
compressed
•Carotid a. : laceration of intima & media
It is a valuable sign pointing to suspension
during life.
•Posterior pharyngeal wall : contusion caused
by the backward displacement of the tongue.
•Hyoid & thyroid : may fracture
 Is it suicidal, homicidal, or accidental
hanging?

Suicidal: (most common):

• Circumstantial evidence (history of failure).
• Absence of signs of struggle.
• Presence of signs of previous suicidal attempts.
• Suicidal note, chair, table.
• How to differentiate between hanging and PM
suspension.
2- Ligature strangulation

• A violent Asphyxial death caused by constricting the

neck by a ligature.

• Mechanism of death:
• Asphyxia: from compression of air passage
• Cerebral congestion or apoplexy:
• Reflex vagal inhibition
• Cerebral anoxia:
Autopsy appearances:

• Externally:
• The face is bluish and congested. The rest of the body is cyanosed.
• The tongue may be protruded, swollen and bitten.
• Bleeding from ears and nose may be seen.
Ligature mark:

• Shape: as in hanging.
• Situation: At the level of thyroid cartilage or below.
• Symmetrical
• Transverse and
• complete (this is the usual).
Ligature mark:

• A postmortem swelling of the neck associated with exaggeration of

• skin folds or any
• clothes worn around the neck
may produce depressed marks. All these look like ligature mark. Neck
dissection can differentiate
Mugging
ng
Ligature marks of strangulation
 Suicide, homicide, or accidental:

• Newborns strangled by the umbilical cord.

• Children playing with ropes
• Adults strangled by the necktie caught in moving machinery.
Methods commonly used for homicidal
strangulation:
• Mugging: by compressing the victim's neck against the forearm.
• Garroting: attacking the victim from behind and grasping his throat or
throwing a ligature over the neck and tightening it quickly.
• Bansdola: compressing the neck between 2 sticks
Garroting: was used as a method of execution.
 Differences between hanging and
strangulation:

 Rope marks:
T. , low, Circumstantial

 Signs of resistance

 No stretched neck
Point Strangulation Hanging

Force From outside on the ligature Weight of the body

itself.
Hypostasis Anywhere In lower limbs

Blood oozing From ear, nose and mouth. Not seen

Neck Not Stretched and elongated

Saliva Not present dribbling from the mouth

Ligature mark Complete Incomplete

T. Oblique
Low high
Hyoid bone not injured May be injured

Thyroid cartilage May be torn Process of thyroid cartilage is

torn
Carotid artery Not torn Intima and media are torn

RetropharyngeaI bruises Absent Present

Spinal column Not common at all May be fractured

Signs of resistance present Absent

Circumstances More homicidal More suicidal

 Post mortem signs:
 1. Non specific general pathological
changes
 2- General external examination:
 Presence of signs of resistance in the form of
finger nails abrasions and contusions.
 Congested face, protruded eyes ,the
conjunctivae are congested with subconjunctival
hemorrhages. The tongue may be protruded.
Fine blood tinged froth sometimes is found at
the mouth and nostrils.
 Blood oozing from ear, nose and mouth is
commonly seen.
3 - Special examination of the neck:
 External examination:
a. The ligature mark:
 Pattern: pressure abrasion
 Course: usually encircles the neck completely
and is directed transversely across the neck.
 Position: usually present at the level of the
thyroid cartilage.
b. Abrasions and bruises are commonly
found in the surrounding skin caused by the
hands of the assailant or the hands of the victim
in an attempt to release the pressure.
 b. Internal examination

 - Bruising and laceration of the neck

muscles are common.

 - Fractures of hyoid bone are unusual,

while fractures of thyroid cartilage at the
level of the ligature may occur unless the
victim is young and the cartilage is elastic.
5- Choking

• Caused by mechanical occlusion of the air passage from inside.

Mechanism of death:
Asphyxia: due to either complete occlusion of air passage, or partial
occlusion that is completed by spasm, edema and mucus secretion.
Accidental: (most common)

May arise from:

• Inhalation of irritant fumes.
• Impaction of foreign material, such as food or
denture.
• Inhalation of dust and sand in falling of houses.
• Inhalation of vomit or blood during operations.
• Falling back of the tongue epileptic fit.
• Café coronary (sudden death after meal ): food
bolus in larynx vagal inhibition
 •
Postmortem Findings
There is severe congestion of face due to struggle to get foreign
body out .

Local examination:
- Bruises and abrasions of the air passage are found
especially if the foreign body is a solid one,
- presence of foreign body is confirmatory evidence.
- In delayed death, pathological changes in the lungs will be
apparent e.g. consolidation, lung abscess etc...
A choking death in an intoxicated individual, with
occlusion of the larynx and upper trachea by a large
fragment of meat
6- Traumatic asphyxia (Crush asphyxia)

• Resulting from trauma to the chest or pressure on

the chest and abdomen which prevent respiratory
movements
• e.g. run-over car accident  fracture of ribs 
restriction of respiratory movements from the
severe pain occurring during respiration.
Pressure on the chest and abdomen
due to:

• Burial in earth following house collapse.

• Crushing by a crowd, as in case of a fire.

7- Drowning (Immersion):
It is a form of violent asphyxia in which death results from
submersion of mouth and nostrils of a living person under water

• Classification (types) of drowning:

1- Typical (wet) drowning:

2- Dry drowning: Water in the larynx 

laryngeal spasm 
asphyxia
3- Secondary drowning (Near-drowning).
Delayed cause of death or secondary drowning or
post-immersion syndrome.

person may survive but subsequently suffer complications or die from

the delayed effects of inhalation of water e.g.
• Inhalation pneumonitis.
• Bronchopneumonia.
• Pulmonary edema.
 Causes of death in drowning
A. Rapid death:
1. Asphyxia of drowning.
2. Electrolyte disturbances. .
3. Hypothermia may develop rapidly in cold water. Sudden
unexpected immersion into cold water can cause death by:
-Cardiac failure due to rises in venous and arterial pressures.
-Ventricular fibrillation.
4. Inhalation of water due to respiratory distress.
5. Laryngeal spasm or dry drowning
6. Fatal head injuries during diving into the water.

• B. Delayed cause of death or secondary drowning or post-

immersion syndrome.
 Postmortem submersion

Bodies may be thrown into water after being killed

by other means. Heavy objects are tied to the body
to keep it under water for a long period. Sure signs
of drowning are absent. Other cause of death is
found e.g. strangulation, head injuries etc....
Physiopathological changes:
 External appearances

1. Signs of immersion:
These are found in any body found dead in water (whatever the cause of
death).
• Coolness of the body.
• Goose-skin the skin is wrinkled.
• Washerwoman-skin: the skin is sodden.
• Peeling of the epidermis in the form of gloves and stockings.
• Hypostasis
 2- Sure external signs:

A-Froth:
(Fine – White – Odorless _ increase)

B-Cadaveric spasm
of the hands on weeds, mud, sand, etc.
 Internal appearances
lungs (emphysema aquosum) are ballooned and overlap
the pericardium. Being loaded with water they pit on
pressure and rib markings are usually present. They are pale
in color.

• Voluminous lungs
• Respiratory passages contain froth (having the same characters of that
found externally at the mouth and nostrils),
• foreign material ( weeds, mud, sand,.).
A normal pink aerated appearance with
,minimal anthracotic pigmentation
Diffuse alveolar damage in which the lung
is diffusely firm and rubbery
Diatom
 Diatoms:
• These are microscopic, unicellular algae, found in fresh as
well as salt water.
• When a live person is drowned in water, they penetrate his
alveolar membrane and pass with the circulation to
distant organs.
• Its importance:
• Sure signs of drowning,
• Could still be identified in putrefied bodies,
• Could give an evidence of the site of drowning (fresh or
salt water species).
The medico-legal (ML) importance of diatoms:

• 1- Sure signs of drowning,

• 2- Could still be identified in putrefied bodies,
• 3- Could give an evidence of the site of drowning (fresh or salt water
species).
CASE1