Legal Medicine

ASPHYXIA - Petechial hemorrhages under the pleura and

Stages of asphyxia pericardium and in the internal organs
1. Stage of dyspnea (forced respiration) - Congestion and edema of the viscera except the
- Cyanosis, rapid deep breathing with acting spleen
extraordinary muscles of respiration, rapid - The blood is dark in color and more fluidly
pulse, high BP - The right heart and great veins are engorged with
- Due to stimulation of respiratory center blood
2. Stage of convulsion
- Cyanosis becomes deeper, breathing becomes Types of asphyxia
difficult and spasmodic, HPN, constricted pupil, a. Mechanical
congestion and edema of lungs and other - Hanging
organs, petechial hemorrhages in skin, lungs, - Strangulation
heart and brain, convulsions - Throttling
- Due to cerebral irritation - Traumatic asphyxia
3. Stage of apnea (respiratory paralysis) - Smothering
- Unconsciousness, breathing becomes shallow, - Choking
infrequent gasping (Cheyne-stokes respiration) - Drowning
then apnea, weak pulse, reduced BP, dilated b. Pathological
pupils - Bronchitis
Death occurs in 3-5 mins - Acute edema of the glottis
- Laryngeal spasm
Possible effects of pressure on neck - Tumors
 Explanation for death due to partial hanging - Abscesses
 Carotid sinus reflex leading to cardiac arrest c. Toxic
 Jugular vein compression leading to cyanosis and - CO
petechiae (2kg tension) - Cyanides
 Carotid artery compression (3-5 kg tension) leading - Barbiturates
to unconsciousness - Opium
 Airway obstruction leading to hypoxia (15 kg tension) - Strychinine
 Occlusion of vertebral artery (20kg tension) leading - Gelsemium
to unconsciousness
Hanging
External Postmortem (PM) findings: - It is asphyxia death caused by suspension of the body
1. Petechial hemorrhages (sites and mechanism of by a ligature around the neck, the constricting force
formation) being the weight of the body
2. PM hypostasis - Can be either complete or partial; typical or atypical
3. Cyanosis - Weight of the body tightens a noose around the neck
4. Rigor mortis is rapid compressing the vessels of the neck
5. Putrefication is rapid - Almost all are suicides
- Nooses are constructed of accessible material
Internal PM findings - Noose typically a simple slip knot positioned on the
side of the neck
- Mechanism of death:
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o Cerebral anoxia o Ligature mark- oblique, incomplete, located

o Cerebral congestion above thyroid cartilage
o Asphyxia o Fracture of hyoid bone
o Reflex vaginal inhibition o Intimal tears of carotid
- Externally: o Pallor underneath extravasation in surrounding
o Neck is stretched structures
o Rest of body is cyanosed o Dribbling of saliva
o Saliva may be seen dripping from the mouth o Signs of asphyxia
o Face is pale or bluish (it is a vital sign and is Trait Hanging Strangulation
present only in hanging but not in PM Ligature mark Oblique, Transverse,
suspension) incomplete, complete, mid
o Furrow with inverted V-shaped configuration high in the neck level or below
o Apex of V indicating point of suspension thyroid cartilage
o Gap in furrow at the knot site Base Pale, hard, Contused
 Lies above the pharynx parchment like
 Appearance of furrow depends on the noose Abrasion & Less prominent More
o Tongue protruding and dried out contusion, prominent
o Mucus drip from the nose ecchymosis
o 25% scleral or conjunctival hemorrhage Hyoid fracture More common Less common
o 10-15% fracture of hyoid and thyroid Thyroid Less common More common
o 20% hemorrhage of strap muscles cartilage
o Fracture of cervical spine is rare Carotid Internal tear Not seen
o Pooling of blood in lower extremities and Signs of Less marked More marked
forearms asphyxia
o Tardieu spots Dribbling of Often Rare
- Transverse tears in intima of both carotid arteries in saliva
case of hanging due to combination of radial force Bleeding from Rare Often
(ligature material) and axial traction (weight of the nose, mouth
body due to suspension) and ears
- Fracture of left cornu of hyoid bone with inward Involuntary Occasional Frequent
displacement is common in victims of age above 40 discharge
y/o as the cornu gets calcified after that age
Manner Suicidal Homicidal
- Autoerotic hanging
Injuries on other Rare Common
o Accidental
body parts
o Usually male
o Tries to induce cerebral hypoxia to heighten
Strangulation
orgasm during masturbation
- A violent asphyxia death caused by constricting the
o Erotic literature
neck by a ligature
o Noose may be padded to prevent furrow marks
- Mechanism of death:
- Ingredients:
o Asphyxia from compression of air passage of
o Suspension (POS)
cerebral congestion or apoplexy: reflex vagal
o Ligature encircling the neck
inhibition
o Constricting force
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o Cerebral anoxia
o Combination of any of the above
- Pressure on the neck is applied by ligature tightened
by a force other than body weight
- Accidental ligature strangulations are rare
o Entangling of tielscarf in machinery
- Most are homicides
- Women > men
- Externally:
o Face is either pale or bluish and congested
o Rest of the body is cyanosed
o Tongue may be protruded, swollen and bitten
o Bleeding from ears and nose may be seen
- Accident:
o Newborns strangled by umbilical cord
o Children playing with ropes
o Adults strangled by neck tie caught in moving
machinery
- Methods:
o Mugging by compressing the victim’s neck
against the forearm
o Garroting: attacking the victim from the behind
and grasping his throat or throwing a ligature
over the neck and tightening it quickly
o Bansdola: compressing the neck between 2
sticks, practiced in North India
o Throttling by compressing the victim’s neck by
the hand
Manual strangulation (Throttling)
- Caused by constricting the neck by the hand
- Mechanism of death:
o When death occurs as a result of vagal inhibition,
asphyxia signs will be absent
- Externally:
o Abrasions (caused by fingernails)
o Contusions (caused by finger pads)
Both are found on the front and sides of the neck
o Congested face
o Petechiae of the skin and neck and undersurface
of the jaw
o Semicircular fingernail marks
o Hemorrhage in muscles of the neck
o Fractures of hyoid or thyroid cartilage
o Usually not present in young individuals
Smothering
- Caused by mechanical occlusion of the air passages
from the outside by hand or by any object
- Asphyxia signs will be present except in cases of
plastic bag suffocation
- Abrasions and contusions of the skin of the face
around mouth and nose
(absent if soft material such as pillow is used)
- By mechanical obstruction of nose and mouth
- May be homicidal:
o Gagging
o Pinching off nose and clamping hand over the
mouth
o Overlaying when patients take an infant to bed
with them and is rolled over during the night
- Typically no findings at autopsy
o Bruising of the lips and nose
o Scratches
- Infants:
o Bradycardia in 30 sec
o Flat EEG in 90 sec
o Respiration will not return spontaneously
o Positional asphyxia- resulting from being
trapped in a position such that they cannot
breath or respiration becomes inadequate;
individual suspended upside down for prolonged
period of time
- Entrapment
o Local hypoxia in plastic bag
o Seen in suicide (final exit), accidents with
children
Choking
- Caused by mechanical obstruction of the air passage
from inside
- Mechanism of death
o Asphyxia due to either complete occlusion of air
passage, or partial occlusion that is completed by
spasm, edema and mucus secretion
- Causes:
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o Trying to swallow large pieces of poorly chewed
food
o Drinking alcohol before or during meals
 Alcohol dulls the nerved that aid in
swallowing
o Wearing dentures
 Dentures make it difficult to sense whether
food is fully chewed before it is swallowed
- Blockage of the internal airways
- Homicides are rare
- Most are accidental:
o Posterior pharyngeal and laryngeal obstruction
due to foreign bodies
o Food aspiration
o Associated with:
 Alcohol intoxication
 Senility
 Mental retardation
 Absent gag reflex
o Acute epiglottitis
- No typical findings at autopsy except obstruction of
airway
- Accidental choking
o Most common
o Inhalation od irritant fumes
o Inhalation of foreign material such as food or
dentures
o Inhalation of dust and sand in falling of house
o Falling back of the tongue epileptic fit
o Café coronary or fatal choking on food
 Sudden collapse during or shortly after meal
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
 Impaction of food in the sensitive larynx
causes sudden death due to cardiac arrest
 Healthy intoxicated person in hotel while
eating suddenly turns blue, coughs violently,
collapses and dies
 At autopsy, a large food bolus seen in the
larynx obstructing air passage
 Signs of choking are absent because of high
blood alcohol which inhibits the gag reflex
 PM appearance: the foreign body if
embedded in a thick mucus in the trachea
Traumatic asphyxia
- Resulting from trauma to the chest or pressure on
the chest and abdomen which prevent respiratory
movements (burking)
- Penetrating trauma e.g. stab injury- pneumothorax,
lung collapse
- Non penetrating trauma e.g. run over car accident-
fracture of rib, 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, stamped, as in case of fire
Chemical asphyxia
- Prevention of utilization of oxygen at the cellular
level
- Carbon monoxide
o Usually accidental
o Cherry red discoloration
o Headache- 1st symptom at levels of 10-20%
o Dyspnea and dizziness (levels 20-30%)
o Seizures (levels 30-40%)
o Atraumatic rhabdomyosis (myoglobin binds CO
and prevents normal muscle function)
o Delayed neurologic deficits (memory deficits,
apathy)
o Laboratory findings:
 Lactic acidosis (shift to anaerobic glycolysis)
 Increase CO levels in blood
o Treatment:
 Hyperbaric oxygen therapy
 Administer 100% oxygen therapy with
nonrebreather mask or ET tube
- Hydrogen cyanide
o Usually suicidal
- Hydrogen sulfide
o Virtually all accidental
o Working in sewer plants and cess pools
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Environmental asphyxiation
- Hazards of poor or no ventilation:
o Lack of oxygen (headache, fatigue, asphyxiation,
particularly in confined spaces)
o Excessive heat, cold and humidity
o Toxic fumes (e.g lead, cadmium, zinc)
o Toxic vapors (e.g. benzene, toluene, TCE, MEK)
o Toxic gases (e.g. hydrogen sulphide, ammonia
o Dusts (causing poisoning or gradually reduced
lung capacity
o Fire/explosion
- Types 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 (e.g. a
child trapped inside the trunk or unused refrigerator,
an adult fell into a deep well)
- Excavation hazards
o Cave-ins are the greatest risk
o Other hazards include:
 Asphyxiation due to lack of oxygen
 Inhalation of toxic materials
 Fire
 Moving machinery near the edge of
excavation can cause collapse
 Accidental severing of underground utility
lines
- Clean air act of 1970
o Set national ambient air quality standard for six
criteria air pollutants (CO, NO2, SO4, particulates,
ozone, hydrocarbons)
Drowning
- A form of asphyxia death due to aspiration of fluid
into the air passage by submersion of the body in
water or fluid medium
- Complete submersion not necessary, submersion of
nose and mouth is enough
- Bodies retrieved/removed from water may have:
o Died from sudden natural disease before falling
into the water (e.g. a person walking near water
falls in due to IHD/CAD)
o Died from sudden natural disease while already
in the water
o Died from injury before being thrown into the
water
o Died from injuries while in the water
o Died from the effects of immersion other than
drowning (e.g., exhaustion, exposure to cold
waters)
o Died from drowning
- Phases
o Breath holds
o Inhalation of water, coughing, vomiting and loss
of consciousness
o Convulsions, respiratory arrest then cardiac
arrest
- Brouarderl’s experiment
o Stage of surprise (5—10 seconds)
o 1st stage of respiratory failure (1 min)
o Stage of deep respiration (1 min)
o 2nd stage of respiratory arrest (1 min)
o Stage of terminal grasp (30 seconds)
- Classification:
o Typical or wet drowning- obstruction of air
passages and lungs by inhalation of fluid; salt or
freshwater drowning; typical signs are found at
autopsy
o Atypical or dry drowning- conditions in which
there is very little or no inhalation of water of
fluid in the air passages, water may enter URT
but not the lungs
o Immersion syndrome (vagal inhibition)- water
striking epigastrium, cold water entering ear
drums, nasal passages, larynx, pharynx
o Secondary drowning syndrome/ near drowning-
delayed death
o Submersion if the unconscious
- Occurs when eater is inhaled, filling up the alveolar
spaces and preventing gas exchange
- In warm water, irreversible hypoxia = 3-10 minutes
- Diagnosis is by exclusion
- Abundant bloody edema forth throughout airway
- Water may be present in stomach
- Washerwoman’s hands
o Shrivelled and pale skin
o After being submerged for 1-2 hours
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- Saltwater drowning o Due to:

 Cold water stimulate nerve ending on skin
surface
 Cold water enter eardrums, nasal passages,
pharynx, larynx and stimulate nerve endings
 Cold water strike epigastrium and stimulate
o Features:
 Wet clothes and body surface
 Soiling with mud, grass, etc.
 Cutis anserine with washerwoman’s
appearance
 Vagal inhibition is COD
 Rare
- Freshwater drowning  Usually found in temperate or cold zones
 Young swimmers
- Submersion of unconscious
o Epilepsy
o Heart disease
o Alcohol intoxication
o Head injury during fall in water
o No effort to breathe
- Shallow water drowning
o Drowning occurs in small puddle of water
o Victims: disabled, incapacitated, epileptics,
drunkards, comatose, etc.
o Merge of mouth and nostril
o Either accidental or homicidal
- Dry drowning - Secondary drowning
fall into water column o Immersion in water is the predisposing cause of
death
water entering into nasopharynx o Submersion victim who arrives at ER and usually
or larynx survives for 24 hours
o Mild electrolyte changes
intense laryngeal spasm o Mild hemoglobinemia (in children, elderly, sick
victims)
asphyxia o Ultimately die due to:
 Septic pneumonia
death  Pulmonary edema
 Chemical pneumonitis
- Immersion syndrome  Metabolic acidosis
o Syn: cold water drowning, hydrocution  Infection
o Death from cardiac arrest as a result of vagal - Autopsy signs of drowning (seen in 35% of cases)
inhibition o Froth in nose and mouth
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o Pulmonary edema
o Oversitention of lungs
o Dry drowning
o Middle ear hemoorhage
o Chemical tests (unreliable)
o Nonspecific changes of immersion
o Water in stomach and intestine
o Paltauf hemorrhages/ rasskazov lukomskij spots-
petechial hemorrhages located beneath the
pulmonary pleuras in both lungs and appear in
wet drowning, larger and not as sharply defined
(due to hemolysis) than Tardieu’s spots
o Airway filled with froth, sands, weeds, etc, found
in the water
o Lungs are voluminous, edematous, doughy, firm
with rib markings
o Emphysema aquosum- oozing out of blood
stained frothy fluid and ballooning of the lungs,
weight up to 2 kg, more obvious in saltwater
drowning than freshwater where the water is
rapidly absorbed in the body
o Washerwoman’s hands and feet- the skin of the
finger, palms and later the soles may be
wrinkled, bleached and sodden due to osmotic
action of water on thickened epidermis
o Cutis anserine (goose skin)- due to spasm of the
erector pilae muscle and due to exposure to cold
water at the time of death, skin appears granular
and puckered with hair standing on the end, can
be both ante- or post-mortem
- Findings in larynx-trachea and bronchioles
o Presence of sand, mud, dirt, aquatic vegetations,
etc (lower bronchial tree is important)
o Fine white blood tinged froth
o Congestion
o Regurgitation of gastric contents
- Biochemical changes
o Getlers test
 Normal chloride content is equal in the right
and left chambers of the heart (600 mg/100
ml)
 Difference of >25mg/100ml = drowning
- Changes inside stomach and intestine
 chloride decreases by 50% in freshwater and
40% increase in saltwater
 in freshwater, chloride content of L heart < R
 in seawater, chloride content of L heart > R
 Test is doubtful value in septal defect,
putrefaction, death due to vagal inhibition,
chloride in water
o Diatoms
 Microscopic unicellular algae present in all
natural water sources especially in stagnant
water (10-80 microns) with outer siliceous
wall
 Over 1500 species are found
 Heat and acid resistant
 One of the dependable signs of ante mortem
drowning
 Contain chlorophyll and diatominin (brown
pigment)
 Circulation can transport diatoms from lungs
to the brain or bone marrow
 when a love person is drowned in water,
they penetrate the alveolar membrane and
pass with the circulation to distant organs
 but when the body is thrown into the water,
the absence of beating heart prevents
circulation of diatoms to distant organs
 through ruptured alveolar wall, diatoms
enter the pulmonary vein and then to the
left side of the heart with blood circulation
they are transported to bone marrow, brain
and other organs
 technique of demonstration:
 5 gm of marrow is collected from
sternum bone and is subjected to acid
digestion with 5 times volume of nitric
acid for 1-2 days
 Sediment is examined under phase
contrast or dark background
illumination microscope
 Interpretation of results: control
samples of water from site treated with
iodine is compared for type of diatoms
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o Evidence of water swallowing- gravel, dirt, sand,
aquatic vegetations, shells, etc.
o It is a positive sign of antemortem drowning
o Water cannot enter into the stomach & intestine
when a dead body is thrown into water such as
in vagal inhibition, shock or syncope, advanced
putrefaction, unconsciousness before falling into
water
- Features of antemortem drowning:
o Cadaveric spasm with firmly grasped vegetable
materials, etc
o Froth is white, fine (small bubbles), lathery (soft),
tenacious (adherent/sticky), copious (abundant,
constant)
o Haemorrhage in middle ear (water through
Eustachian tube)
o Lungs:
Trait Freshwater Seawater
Size & weight Ballooned but Ballooned and
light heavy
color Pale pink Purplish/ bluish
consistency emphysematous soft
After removal Do not collapse Collapse
On cut section Crepitus heard, Crepitus absent
with froth, no Froth + fluid
fluid
o Specific signs:
 Sign of krushevsky- full of small bubbles
white foam in respiratory tracts
 Spots of rasskazov-lukomsky- reddening and
edema of mucous tunic of respiratory tract,
increasing and emphysema of lungs, pale
dim hemorrhages on their surface
 Sign of moro- presence of water in small
intestine and abdominal cavity
 Sign of sveshnikov- presence of liquid of
drowning environment in the sinus of
sphenoid
 Increasing of liver in size and presence of
plankton in inner organs
Physical Injuries Due to Changes in Atmospheric
Pressure
Barotrauma
- The normal atmospheric pressure at sea level is 760
mmHg
- The person is subjected to an increase of
atmospheric pressure as he goes deeper in a body of
water and a decrease as he ascend higher in the
atmosphere
- Refers to medical problems that arise from the
pressure difference between areas of the body and
the environment and is a particular concern for
scuba divers
- Kinds:
o Hyperbarism
o Hypobarism
- Rupture of alveolus with subsequent entry of air into
the pleural space (pneumothorax) and/or tracking or
air along the vascular bundle to mediastinum
(pneumomedistinum)
- Risk factors:
o Large tidal volume
o Elevated peak inspiratory pressures
Hyperbarism
- Increase atmospheric pressure
- A condition is observed underwater by scuba divers,
pearl divers, salvage divers, treasure hunters,
pleasure swimmers, etc.
- Henry’s law: at constant temperature, the amount of
gas discovered in a liquid is directly proportional to
the pressure
- Nitrogen narcosis- rupture or drunkenness of the
deep (the nitrogen an inert gas comprising 80% of
the air in the lungs is also dissolved in the body fluid),
this condition is preceded by euphoria
- A rapid decent may cause rupture of the blood
vessels and haemorrhage
- The eardrum may bulge inward resulting to
stretching pain, haemorrhage and ultimate
perforation of the lymphatic membrane
- Cerebral anoxia due to prolonged stay underwater
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- Muscular cramp
- Physical injuries in the process of diving and hitting
hard objects
- Injuries caused by aquatic animals like shark or stings
from venomous fish and coelenterates
- Effects of the changes if atmospheric pressure in a
pre-existing disease like hypertension or coronary
affection
- Post-mortem findings:
o Immediate death: subcutaneous emphysema,
generalize visceral congestion and the presence
of gas bubbles, extravascular bubbles and
hemorrhages in adipose tissue like the
mesentery and omentum
o Death occurred after a lapse of several days:
degeneration and softening of the white matter
of the spinal cord, fat necrosis, osteonecrosis
Decompression sickness or the bends
- More related to Henry’s law which states that more
gas will be dissolved in a liquid when the gas is
pressurized
- Because of the water pressure, body tissues absorbs
nitrogen gas faster as diver descends than when
ascending to the surface
- However, if a diver ascend too quickly, nitrogen gas
bubbles will form in the body tissue rather than
being exhaled, it will cause severe pain
External Ear Squeeze
- Occurs when the ear canal is blocked by something
such as earplugs or earwax
- As the water pressure increase while descending the
air packets between the obstruction and the
tympanic membrane shrinks
- Can damage the tissue in the ear canal
Middle Ear Squeeze
- Occurs when you cannot equalize the pressure in
your middle ear
- When there is problem with the Eustachian tube, the
middle ear volume decreases and pulls the eardrum
inward, creating damage and pain
Internal Ear Squeeze
- Occurs from the suction development of pressure
difference between the middle and internal ear
- Can result from overly forceful Valsalva maneuver or
a very rapid descent
- Results are usually, ringing in the ear, dizziness and
deafness
- Less common than middle ear squeeze
Face mask squeeze/ facial barotrauma
- Occurs if you do not exhale thru the nose into the
dive mask while descending
- Failure to equalize mask air space during descent
- Occurrence:
o As shallow as 25 ft
o Typically unexperienced divers
o Not with full face masks
- s/sx:
o inverted sclera
o periorbital edema
o painless
o no effect on vision
- tx:
o approx. 2 weeks
o any pain or vision problems >>> ophtha eval
Hypobarism
- decrease of atmospheric pressure
- at a higher altitude the atmospheric pressure
becomes lower and more gas will be liberated by the
body fluid
- the release of gases will cause:
o Bends- joint and muscular pain due to presence
of air bubbles
o Chokes- substernal distress, non-productive
coughing and repiratory distress, result of
bubble formation in the pulmonary capillaries or
from the effects of extravascular mediastinal
bubbles exerting pressure on the mediastinal
contents and adjacent pulmonary tissue
o Substernal emphysema- accumulation of bubble
underneath the skin
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o Trapped gas- may result in the doubling of the

size of the hollow viscus like the stomach and
intestine at 18, 000 ft level, may cause
diaphragmatic herniation

Anoxia
- At higher altitude the oxygen content of the
atmosphere become lesser and lesser, hypoxia will
be felt between 8, 000-15, 0000 ft level.

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