PATHOLOGY 425

ASPHYXIA
Dr. J.A.J. Ferris

DEFINITION

The physiological definition of "asphyxia" is complex and often means more than hypoxia. In the field of forensic
pathology, asphyxia is considered to be a consequence of a struggle to breathe against some mechanical interference with
respiration.

General Autopsy Findings in Asphyxial Deaths

The following are general findings in death by asphyxia. Their prominence will vary with individual cases and petechial
hemorrhages, in particular, may be completely absent, or extremely rare. It is also important to note that all of the findings in
asphyxial deaths may be found, on occasion, in other circumstances.

1. Pulmonary edema, with froth in trachea and bronchi.

2. Bulky, crepitant and over-distended lungs.
3. Right ventricular dilatation.
4. Petechial hemorrhages on the conjunctival and facial tissue, usually above the level of the airway obstruction
in strangulation cases.

Suffocation

Suffocation results from the mechanical obstruction to the entry of air into the lungs by obstruction of the external
respiratory orifices. Common agents used are plastic bags, soft pillows, or soft materials used to occlude the mouth and nostrils.

Smothering can be homicidal, suicidal, or accidental. In homicidal suffocation, there is usually considerable physical
disparity between the assailant and victim, or the victim is debilitated by drugs or injury.

Scene investigation may not be helpful. Some cases of Sudden Infant Death Syndrome have been erroneously
attributed to overlying by the mother.

The autopsy findings are subtle and injuries may be completely absent. Examination of a suicidal death by suffocation
with a plastic bag usually reveals moisture on the face and on the inner surface of the bag.

In homicidal suffocations, there may be fingernail scratches, or bruises to the face, or tears to the buccal mucosa.
There may be marks associated with use of a tape or a gag. If neck compression does not occur, petechial hemorrhages may
not be found. The diagnosis of suffocation may be impossible to establish with certainty on the basis of the postmortem
examination alone.
Upper Airway Obstruction (Choking)

The usual mechanisms of asphyxia in choking are mechanical obstruction of the airway, usually involving the pharynx,
larynx and trachea.

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 The most common situation is the so-called "cafe coronary". Victims are usually intoxicated, or have pre-existing
neurological debilitation. Choking occurs suddenly while eating. The obstructing foreign body may be removed prior to autopsy.
Children may choke on small toy objects, nuts or grapes.

The vast majority of choking deaths are accidental. Suicides and homicides occur very rarely.

Inhalation, or aspiration, or gastric contents as a primary event is extremely unusual. When aspiration occurs, drugs,
such as alcohol, a head injury, or serious neurological disease process should be sought. Significant aspiration of gastric
contents during an epileptic seizure is relatively unusual.

The autopsy findings in choking, again, may be subtle, particularly if the occluding object has been removed.
Petechiae may be present if significant retching has occurred. There may be injuries to the buccal mucosa, related to
resuscitation. The right ventricle of the heart is dilated and the lungs hyperinflated and possibly edematous. Inhalation of blood
may play a significant accelerating role in trauma cases, such as those associated with facial fractures. Aspiration is usually the
mechanism of death and not the cause of death and a complete autopsy and toxicological examination are necessary to identify
these modifying factors.

Hanging

As in most asphyxial deaths, hanging can be suicidal, accidental, or homicidal, but suicidal hangings are by far the
most common.

Hanging deaths result from compression of the airway and neck vessels as a result of suspension in such a manner
that the force acting on the ligature is that of all or part of the weight of the body.

Examination of the scene is important. The posture, position and method of hanging and ligature used must all be
examined and injuries, other than those attributable to hanging, require careful assessment and interpretation. It is important to
remember that complete suspension is not necessary. In most hanging deaths, the ligature and ligature mark lie above the
thyroid prominence, with a point of suspension usually behind one ear. Frontal knots are unusual. The appearance of the
ligature mark varies with the type of ligature used and with the physical characteristics of the individual neck. Soft broad
ligatures may not leave any recognizable marks. In most cases, the ligature does not completely encircle the neck.

Successful hanging can be accomplished in a variety of positions, including a semi-reclining sitting or lying position.
The only requirement is for sufficient sustained pressure to be applied to the neck.

The findings at autopsy and hanging include the ligature mark, which is usually abraded and parchmented and may,
depending on the ligature used, show specific patterning. The deepest furrow is opposite the point of suspension and fades as it
approaches the knot. Scratches, in relation to the ligature mark, with the appearance of fingernail scratches, should be
documented and investigated.

Petechial hemorrhages are usually completely absent, when the full weight of the body acts on the ligature, but are
present in varying degrees of prominence, when the victim is only partly suspended. Layered neck dissection usually shows
completely absent, or only minimal, bruising into the soft tissue. Dissection of the carotid arteries may show occasional linear
traction type tears. Fractures of the vertebrae do not occur unless there is a significant drop, such as a judicial hanging.

Accidental hangings are far more common in children, than in adults. They are frequently the result of articles of
clothing caught up in machinery.

Auto-erotic asphyxial deaths usually involve males and occur in isolated or secluded sites. There may be evidence of
transvestitism, bondage, mirrors, cameras, etc.

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Ligature and Manual Strangulation

Strangulation results when the application of a constricting force to the neck is such that the force exerted is other than
that of the weight of the body. The two types of strangulation include manual strangulation and strangulation by ligature. The
victims are usually women, children, or the elderly. Ligature suicides can occur, but the ligatures must be fashioned in such a
manner that the pressure on the neck is maintained after loss of consciousness.

At autopsy, in cases of ligature strangulation, the ligature mark is usually horizontal and crosses the neck in the region
of the lower end of the thyroid cartilage. Particularly with ridges on thin ligatures, a furrowed mark will be evident. Large bulky
ligatures may not leave any surface evidence of injury to the neck. Petechial hemorrhages to the face and conjunctiva are
usually prominent, as are the usual signs of asphyxia in the lungs and heart. A layer by layer dissection of the neck should be
performed, with the neck incision extending up to the level of the mastoid processes. Serial photographs should document the
distribution and pattern of bruising to the soft tissue and muscle.

Pure ligature strangulation is relatively uncommon and there is usually an associated manual component.
Consequently, fractures of the hyoid and thyroid are seen, due to compression of these structures against the cervical vertebrae.
Other associated injuries should be carefully sought for and documented, such as scratches to the face, or neck, or bruising to
the extremities. Evidence of an associated sexual assault should also be sought. Decomposition may render marks difficult, or
impossible, to recognize.

Mechanism of Death in Neck Compression

In hanging, unconsciousness is rapid, due to obstruction of circulation to the brain. Significant obstruction of the
carotid arteries can occur with a tension of approximately ten pounds. Vascular obstruction is the main mechanism, leading to
death with neck compression.

In ligature and manual strangulation, incomplete carotid occlusion is expected to occur and the struggle may continue
for a period of time. This accounts for the injuries and petechial hemorrhages evident at autopsy in strangulation cases. As in all
cases of neck compression, the rapidity of death can be effected by susceptibility of the victim to carotid sinus stimulation. Neck
holds used by the police may be extremely dangerous and there is some evidence that cocaine intoxication increases
susceptibility to sudden cardiac arrest from vagal inhibition.

Crush or Traumatic Asphyxia

These situations occur when external compression of the chest prevents effective respiratory moments. These deaths
are almost always accidental and occur in situations, such as pinning of the victim beneath an overturned car, or in crowds or
mob panics. In this category also falls the procedure, "burking".

At autopsy, there is evidence of severe congestion and cyanosis above the level of compression frequently with a
sharp line of demarcation. Petechial hemorrhages are prominent and may be confluent above the point of compression. There
may be associated sternal, or spinal, fractures and interstitial emphysema.

Positional Asphyxia

Position alone can cause death. Victims suspended upside down in industrial accidents may die as a result of the
effects of the abdominal organs compressing the diaphragmatic movement necessary for respiration. Acute positional flexion of
the neck in a deeply intoxicated individual may result in hypoxia and subsequent death.