MEDICO-LEGAL ASPECTS OF

ASPHYXIA
DR.VLADIMIR V.VILLASEÑOR MD., MPA, FPAMS/FIAMS
FORENSIC MEDICAL SPECIALIST
MEDICO-LEGAL CONSULTANT
 ASPHYXIA

• Conditions in which the supply of oxygen to the blood and tissues has
been reduced below the normal working level by any interference with
respiration. Asphyxia is used as being equal to “lack of oxygen” or
“hypoxia”, or “anoxia”.
• Comes from the Greek word, meaning “pulse-less-ness or absence of
pulsation
• Characterized by inadequate oxygenation of tissues
 STAGES OF ASPHYXIA

1. Stage of Dyspnea (Forced Respiration): Cyanosis, rapid deep breathing with acting extraordinary
muscles of respiration. Rapid pulse and high blood pressure. Due to stimulation of respiratory center.

2. Stage of Convulsions: Cyanosis becomes deeper. Breathing becomes difficult and spasmodic, HPN,
constricted pupil. Congestion and edema of lungs and other organs. Petechial hemorrhages in skin, lungs, heart
and brain. Convulsions occur. Due to cerebral irritation.

3. Stage of Apnea (Respiratory Paralysis): Unconsciousness, breathing becomes, shallow, infrequent

and gasping (Cheyne-stokes respiration)then apnea occurs. Pulse becomes weak and BP is reduced,
dilated pupils.

• Death occurs in 3-5 minutes

 POSSIBLE EFFECTS OF PRESSURE ON THE NECK

Explanation for death due to partial hanging- Carotid sinus reflex leading to
cardiac arrest;
• Jugular vein compression leading to cyanosis and petechiae- 2 kg tension
• Carotid artery compression leading to unconsciousness- 3-5 kg tension;
• Airway obstruction leading to hypoxia – 15 kg tension;
• Vertebral artery occlusion leading to unconsciousness- 20 kg tension
 VIOLENT ASPHYXIAL DEATHS

1. Hanging 4.Traumatic Asphyxia(Crush)

2. Strangulation 5. Chemical Asphyxia
A. By Ligature
B. By Manual Strangulation 6. Environmental Asphyxia
C. Mugging
D. Garroting 7. Drowning
E. Bansdola
3. Suffocation
A. Smothering
B. Choking
 1. HANGING

• It is Asphyxial death caused by suspension of the body by a ligature

around the neck, the constricting force being the weight of the body.
Compressing the vessels of the neck.
• Almost all are suicides
A) It may be either complete or partial:
B) It may be either typical or atypical:
TYPES OF HANGING
TYPES OF HANGING
HANGING
 MECHANISM OF DEATH IN HANGING

1. Venous congestion
2. Cerebral Ischemia/anoxia
3. Combined asphyxia and venous congestion
4. Vagal inhibition
5. Fracture dislocation of cervical vertebrae- Long drop seen in
Judicial hanging.
 1. HANGING

• Furrow with inverted V-shaped configuration,

apex of V indicating the point of suspension;
• Gap in furrow at the knot site
• Lies above the pharynx
• Appearance of furrow depends on the
noose
• Pale face
• Tongue protruding and dried out
• Mucus drip from nose
INVERTED V SHAPED MARK
 FINDINGS IN HANGING

• 25% scleral or conjunctival hemorrhage

• 10-15% Fracture of hyoid & thyroid
• 20% hemorrhage of strap muscles
• Fracture of cervical spine is rare
• Pooling of blood in lower extremities and
forearms
• Tardieu spots
 CAROTID ARTERY TEARS & HYOID BONE
FRACTURES

• Transverse tears in intima of both • Fracture of left cornu of hyoid bone with
carotid arteries; inward displacement;
• Common in victims of age above 40 years
• It is the combination of : as the cornu get calcified.
• Radial force- ligature material
• Axial traction- weight of the body
due to suspension.
 AUTOEROTIC HANGING

• Accidental
• Usually male
• Tries to induce cerebral hypoxia
to heighten orgasm during
masturbation
• Erotic literature
• Noose may be padded to prevent
furrow marks
AUTOEROTIC ASPHYXIATIONS?
HANGING VS STRANGULATION
CONT.
 2. STRANGULATION

A. Ligature Strangulation
• A violent Asphyxial death caused by constricting the neck by a
ligature.
• Pressure on the neck is applied by ligature tightened by a force other than body weight.
Occludes both carotid & jugular veins but not vertebral arteries
• Accidental ligature strangulations are rare
• Entangling of tie/scarf in machinery
• Most are homicides
• Women more than men
•
 STRANGULATION

• MECHANISM OF DEATH:
- Asphyxia from compression of air passage Cerebral congestion or apoplexy:
- Reflex vagal inhibition
- Cerebral anoxia:
• 2/3 – ¾ of cerebral blood supply = carotids
• Remainder = vertebral arteries
• Complete occlusion of carotids = loss of consciousness in 10-15 seconds
• Force needed to occlude:
• Carotids – 11 lbs
• Jugular veins – 4.4 lbs
• Result in cyanosis with numerous petechiae of conjuctivae, sclerae and peri-orbital skin
EXTERNAL FINDINGS
 SUICIDE, HOMICIDE, OR
ACCIDENTAL STRANGULATIONS
• Newborns strangled by the umbilical cord.
• Children playing with ropes
• Adults strangled by the neck tie caught in moving machinery.
 METHODS COMMONLY USED FOR HOMICIDAL
STRANGULATION:

2. Manual strangulation (throttling)

• 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 (bamboo
sticks) Practiced in North India
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.
GARROTING
 THROTTLING- CAUSED BY CONSTRICTING THE NECK BY
THE HAND

• Mechanism of death: When death occurs as a result of vagal inhibition ,

asphyxial signs will be absent
• Externally: Injuries on the neck:Semi-circular fingernail marks
Abrasions (caused by finger nails). Contusions (caused by finger pads).
• Both are found on the front and sides of the neck
• Congested face
• Petechiae of the skin and neck and undersurface of jaw
• Hemorrhage in muscles of the neck
• Fractures of hyoid and/or thyroid cartilages
• Usually not present in young individuals
 3. SUFFOCATION

A. Smothering
• Caused by mechanical occlusion of the air passages from outside (i.e. the
mouth and nostril) by hand or by any object.
• Asphyxial signs will be present, except in cases of plastic bag suffocation.
• Abrasions and contusions on the skin of the face around mouth and nose

• (Absent if soft material, such as pillow, is used)

GAGGING AND SMOTHERING
• Gagging
Pinching off nose and clamping hand over the
mouth.

• Overlaying -When parents take an infant

to bed with them and is rolled over during
the night; pressure of beddings and pillows.
PLASTIC BAG SUFFOCATION- PLACING OF THE BAG
OVER THE HEAD CAUSING SUFFOCATION
 B. 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.
 CAUSES OF CHOKING

1. Trying to swallow large pieces of poorly chewed food;

2. Drinking alcohol before or during meals (alcohol dulls the nerves that aid
in swallowing)
3. Wearing dentures- make it difficult to sense whether food is fully chewed
before it is swallowed;
4. Impaction of food in the sensitive larynx causes death due to cardiac
arrest.
CHOKING
 CHOKING

• Homicides are rare

• Most are accidental
• Posterior pharyngeal & laryngeal obstruction due to foreign bodies
• Food Aspiration
• Associated with
• Alcohol intoxication
• Senility
• Mental retardation
• Absent gag reflex
• Acute epiglotitis
• No typical findings at autopsy except obstruction of airway
ACCIDENTAL CHOKING (MOST COMMON)

1. Inhalation of irritant fumes;

2. Inhalation of foreign material, such as food or denture;
3. Inhalation of dust and sand in falling of houses;
4. Inhalation of vomit or blood during operations.
5. Falling back of the tongue epileptic fit.
6. Café coronary:
 CAFÉ CORONARY

• Sudden collapse during or shortly after a meal should always raise the
possibility of café coronary and the autopsy examination should not
only attempt to demonstrate airway occlusion by a bolus of food, but also
to identify or exclude underlying neurological disease.
• Café coronary syndrome-fatal choking on food
 4.TRAUMATIC ASPHYXIA
(COMPRESSION OR CRUSH)

• The free exchanges of air in the lungs is prevented by the immobility of the chest and
abdomen during external pressure or crush;
• Burking- Resulting from trauma to the chest or pressure on the chest and abdomen
which prevent respiratory movements ; the murderer kneels or sat on the chest and
with his hands, closes the nostrils and mouth of the victim.
• Penetrating trauma e.g. stab injury – pneumothorax- lung collapse
• Non- penetrating trauma 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- burial in earth following house collapse, landslide, mudslide;
crushing by the crowd, stampede, as in case of fire.
BURKING- RESULTING FROM TRAUMA TO THE CHEST OR PRESSURE
ON THE CHEST AND ABDOMEN WHICH PREVENT RESPIRATORY
MOVEMENTS
TRAUMATIC ASPHYXIA BY BURYING
TRAUMATIC ASPHYXIA BY CRUCIFIXION- PERSON
MAY DIE DUE TO DIFFICULTY OF CHEST MOVEMENTS
TRAUMATIC ASPHYXIATION THRU PRESSURE
FIXATION OF CHEST WALL AND ABDOMEN BY
LARGE SNAKES LIKE ANACONDAS
Positional Asphyxia-Asphyxia resulting from being trapped in a position such
that they cannot breath or respiration becomes inadequate; Individual suspended upside
down for a prolonged period of time
 5. CHEMICAL ASPHYXIA
( INHALATION/BREATHING OF IRRESPIRABLE
GASES)
• Prevention of utilization of oxygen at the cellular level
• Carbon monoxide
• Usually accidental
• Hydrogen cyanide
• Usually suicidal
• Hydrogen sulfide
• Virtually all accidental
• Working in sewer plants and cess pools
 CHEMICAL ASPHYXIATION
Carbon monoxide inhalation Working in sewerage/septic tanks
 GASES

• Carbon monoxide- Carbonic gas, CO, silent killer; Painless death

• Colorless gas, insoluble in water and alcohol;
• Main action is oxygen deprivation;
• Tests: Kunkel test, Potassium Ferro cyanate test, GC, Spectroscope, Infra red analysis.

• Carbon dioxide- colorless , heavy, has often mixed with carbon monoxide and hydrogen
sulfide; results to LOC, with or w/o convulsion and death;
• Cause of death: asphyxia due to deficiency of oxygen supply to the brain;
• Tests: Barium nitrate – gives white precipitate; Silver nitrate- white precipitate.

• Hydrogen cyanide- most toxic and rapid acting gas( 60-90mh, 2-10 mins death)
• Body livid, fingers clenched, fingernails are blue and jaws firmly closed
• Hydrogen sulfide- sulfureted hydrogen, H2S, colorless, transparent gas, sweetish taste and
emitting an odor similar to rotten odor;
• Tests- offensive odor; Litmus paper moistened with lead acetate will turn black
• Putrefaction sets rapidly, offensive odor dark brown blood, congested and edematous lungs;

• Sulfur dioxide- colorless gas, heavier than air with pungent odor, produces irritation of
respiratory passages;
• Cyanide poisoning- ingestion or inhalation, with bitter almond odor.
 WAR GASES
CLASSIFICATION BASED ON PHYSIOLOGICAL ACTION

Lacrimator or Tear Chloracetophenone(CAP), sour fruit odor

Gas Bromobenzylcyanide(BBC), heavy, oily, dark brown liquid, bittersweet odor
Ethyliodoacetate dark brown oily liquid with pear odor.

Vesicant or blistering Contact with skin may cause bleb or blister formation;
Gas Mustard gas
Lewisite
Lung Irritants When inhaled, they cause dyspnea, tightness of chest and coughing, varying degree of
conjunctival irritation, vomiting, coma and death;
Chlorine, Phosgene, Chloropicrine, Diphosgene
Sternutator Nasal irritants or vomiting gases
Diphenyl chlorasine, Diphenylamine chlorasine
Paralysant Causes inactivation of cholinesterase and consequent increase of acetylcholine
causing paralysis
Blood Poisons Hydrocyanic acid, Hydrogen sulfide, Carbon monoxide
 6. ENVIRONMENTAL ASPHYXIATION

• A type of asphyxia that leads to death as a result of accidental happening

and occurs in relation to closed spaces, deep sea diving or very high
altitude;
• Examples:
• Child trapped inside the trunk of a car or unused refrigerator;
• An adult fell into a deep well.
 7. DROWNING
Drowning is a form of asphyxial death due to aspiration of fluid into the air passages by submersion of
the body in water or fluid medium
• Complete submersion not necessary, submersion of nose and mouth is enough.
• 1-11/2 minutes , considered fatal;
• 2-5 minutes- average time required for death in drowning.
Treatment:
a. Schaefer method- patient in prone position and the operator exerts pressure on the lower ribs at
the rate of 12-15 minutes;
b. Sylvester method- swing the arms of the patient forward and then pressing the chest wall, repeated
every 3-5 seconds
 Phases of Drowning
Brouardel’s Experiment:

1. Respiration de surprise- Occurring at the moment where the mouth and nose
are covered with fluid consisting of one deep inspiration;(5-10 secs)
2. Phase of Resistance- Short period of apnea;( 1 minute)
3. Dyspneic Phase- Forceful respiratory movement; (1 minute)
4. Another Apneic Phase;(1 minute)
5. Terminal Respiration- After which the breathing stops permanently(30 secs)
 CLASSIFICATION OF DROWNING

A.) Typical Drowning- Obstruction of air passages and lungs by inhalation of fluid
and is known as “Wet drowning”. Salt or fresh water drowning.
Typical signs are found at autopsy.
B.) Atypical- Conditions in which there is very little or no inhalation of water or
fluid in the air passages, water may enter URT but not the Lungs. “Dry drowning”
C.) Immersion Syndrome (vagal inhibition)- water striking epigastrium, cold
water entering ear drums, nasal passages larynx , pharynx.
D.) Secondary drowning syndrome/near drowning- delayed death
E.) Submersion of the unconscious
 A. DROWNING

• Occurs when water is inhaled,

filling up the alveolar spaces and
preventing gas exchange
• In warm water, irreversible
hypoxia = 3-10 minutes
• Champignon d’ ocume(whitish
foam that accumulates in mouth
and nostrils)
FRESH WATER DROWNING
SALT WATER DROWNING
DRY DROWNING
 B. IMMERSION SYNDROME
(HYDROCUTION)
Features of Submersion/Immersion Syndrome/Cold Water Drowning
• Wet clothes and body surface; Cutis anserina, with washerwoman’s skin appearance; Soiling with mud,
grass etc.
• Cold water striking the epigastrium, entering the nasal passages, pharynx, larynx, ear drums etc.
• COD: Cardiac arrest due to Vagal inhibition
• Usually found in temperate or cold zones
• Mostly young swimmers
• Features of drowning will be absent
 C. SECONDARY DROWNING

• Immersion in water is the predisposing cause of death

• Submersion victim who arrives at ER and usually survives for 24 hours
• Electrolyte changes-mild
• Hemoglobinemia-mild
• Children
• Elderly
• Sickly victims

• Ultimately die due to:

• Septic pneumonia
• Pulmonary edema
• Chemical pneumonitis
• Metabolic acidosis
• Infection
 D. SUBMERSION OF UNCONSCIOUS

• Epilepsy
• Heart disease
• Alcohol intoxication
• Head injury during fall in water
• No effort to breathe
 SHALLOW WATER DROWNING

• Drowning occurs in a small puddle of water

• Victims: disabled, incapacitated, epileptics, drunkards, comatose, etc.
• Either accidental or homicidal
 POSTMORTEM SIGNS OF DROWNING

Seen in 35% of Drowning cases

• Froth in the nose and mouth( Champignon d’ ocume)
• Pulmonary edema
• Over distention of lungs
• Middle ear hemorrhages
• Chemical test (Unreliable)
• Dry drowning
• Non-specific changes of immersion
 A. POSTMORTEM FINDINGS (SKIN)

• Cutis anserina (Goose skin/Goose flesh)- due to spasm of the erector pilae muscles
and due to exposure to cold water at the time of death. Skin appears granular and
puckered with hair standing on the end.
 B. POST MORTEM FINDINGS (EXTREMITIES)

• Washerwoman’s hands and feet- the skin of the finger, palms and later
the soles of the feet may be, wrinkled, bleached and sodden. Due to
osmotic action of water on thickened epidermis.
 C. POST MORTEM FINDINGS ( LARYNX-TRACHEA
BRONCHIAL TREE)
• Airways filled with froth, sands, mud, dirt, weeds, aquatic vegetation, etc..
• Fine white blood- tinged froth
• Congestion
• Gastric contents regurgitation
• Lower bronchial tree- Mukherjie slide test
 D. POST MORTEM FINDINGS ( LUNGS)

• Lungs are voluminous, edematous,

doughy to firm in consistency, with rib
markings.
• Emphysema Aquosum- oozing out
of blood stained frothy fluid and
ballooning of the lungs, weight up to
2kgs.
• Paltauf’ hemorrhages seen.
 POST MORTEM FINDINGS ( LUNGS)

• Paltauf ’s spots- are petechial

hemorrhages located beneath the
pulmonary pleuras in both lungs, and
appear in wet drowning.  Compared to
Tardieu’s spots, Paltauf’s spots are larger
and not as sharply defined due to
hemolysis. In the literature, they are
also referred to as Rasskazov-Lukomskij
spots.
 E. POST MORTEM FINDINGS (STOMACH AND
INTESTINE)
• Evidence of water swallowing- gravel , dirt, sand , aquatic vegetation shell,
etc.
• Positive sign of ante mortem drowning
• Water cannot enter into stomach and intestine when a dead body is
thrown into water;
• Absent: Death due to Vagal inhibition, shock, syncope, advanced
putrefaction, unconscious before falling into water
 BIOCHEMICAL CHANGES

• Getlers Test- chloride content in chambers of the heart is normally 600mg/100ml, Chloride decreases by 50% in
fresh water and increases by 40% in salt water.
• In Fresh water drowning- Cl content in Left chamber < Right chamber
• In Salt water drowning – Cl content in Left chamber is > Right chamber
• Demonstration of the difference of at least 25mgs proves that death occurred in fresh or salt water pool and drowning is
the cause of death.

• Test is of doubtful value in:

Septal defect
Putrefaction
Death due to vagal inhibition
Chloride in water
 DIATOMS

• Diatoms- microscopic unicellular algae,

present in water (10-80microns), circulation
can transport diatoms from lungs to the brain
or bone marrow.. When a live person is
drowned in water, they penetrate his alveolar
membrane and pass with the circulation to
distant organs. But when a dead body is
thrown into the water, the absence of a
beating heart prevents circulation of diatoms
to distant organs.
 FLOATING OF BODY IN DROWNING:

• Occurs within 24 hours, on account of decomposition, which

causes accumulation of gases;
• Tete de negri- bronze color of the head and neck of a person
who dies in water during the process of decomposition.
Questions ???