Suffocation, Asphyxia, and Fatal

Pressure on the Neck

The Nature of Asphyxia
asphyxia - absence of pulsation. The true
meaning of the term is best described as
pressure on the neck associated with
cardiac arrest.
The long and short of it is that a lack of
oxygen leads to cell death.
Anything that leads to lack of oxygen
can be called asphyxia, but terms like
hypoxia or anoxia are more accurate.
The Nature of Asphyxia
The following conditions may be considered to
be defects in the chain or respiration and are
examples of asphyxia:
Absence of oxygen tension in the atmosphere such
as reduced barometric pressure, or replacement by
carbon dioxide.
Obstruction of the external respiratory orifices as in
smothering or gagging.
Blockage of internal respiratory passages.
Restriction of respiratory movements.
Disease of the lungs that reduces gas exchange
Reduction in cardiac function
Reduced ability of the blood to transport oxygen
Inability of the peripheral tissue cells to utilize the
oxygen being delivered to them.
Mechanical Asphyxia
The normal oxygen in the blood
according to the age and health of the
subject.
Young and middle aged adults have
almost complete saturation of their
arterial blood with oxygen.
90 100 mmHg middle age
60 85 mmHg persons over 60
Severe fatal hypoxia occurs when oxygen
tension falls to below 40 mmHg

terms to know
A number of terms apply somehow to
asphyxia, some of which are confusing
and inexact:
Suffocation the general term used to indicated death from
lack of oxygen
Smothering (more specific) indicates blockage of the
external air passages
Gagging fabric or adhesive tape occludes the external
passages
Choking refers to blockage of the upper air way
Throttling refers to strangulation usually by hand
Strangulation is the most specific term indicating the use
of either the hands or ligature as a means of applying
external pressure to the neck
Mechanical Asphyxia
There have been reported cases where a
violent struggle occurs between
arresting officers and a drunken or
drugged offender in which the death
occurs later.
The death is obscure and almost
untraceable at autopsy but has been
described as catecholamine-induced
cardiac arrhythmia from an exaggerated
adrenal response.
Classic Signs of Asphyxia
certain sings have become known as the
classic sins of asphyxia
A pathologist needs to realize that little
reliance can be placed on them in the absence
of other confirmatory evidence.
In many cases of undoubted asphyxia these
signs are absent and, conversely, they are
often present in some degree in deaths that
can be shown to be non-hypoxic in nature.
In other words, each of the signs must be
looked at IN DEPTH during autopsy.
Classic Signs of Asphyxia
Petechial Hemorrhages
Small pin-point collections of blood lying in
the skin, sclera or conjunctivae and under
the thoracic serous membranes.
A common misnomer is that they occur
from the rupture of capillaries, when they
in fact come from rupture of venules.
(ruptured capillaries would be invisible to
the naked eye)
Most commonly seen of the face and eyes.
Also known as Ocular Petechiae

Significance of Petechiae
Remember, the appearance of Petechiae
must be noted but not always as an
indicator to asphyxia.
Position of the body after death as well as
an enumerable amount of other factors can
lead to the appearance of Petechiae.
Typically, Petechiae are used in
conjunction with other evidence to
indicated asphyxia.
Petechial Hemorrhages
Classic Signs of Asphyxia
Congestion and edema:
Even more nonspecific than Petechiae but is
also the result of obstructed venous return.
Congestion of often associated with tissue
swelling, and thus can often times be
associated with trauma.
Conditions such as pneumonia will also
lead to marked pulmonary edema.
Drug overdoses are also common causes of
raised pulmonary edema
Classical Signs of Asphyxia
Cyanosis
Cyanosis is derived from the Greek word
for Dark Blue.
The color of blood depends on the absolute
quantity of oxyhemoglobin and reduced
hemoglobin present in the erythrocytes.
Constriction of the neck traps venous blood
with decreased oxygenated hemoglobin,
which leads to the bluish color.
Cyanosis may be overshadowed by
hypostasis.
Suffocation
Typically the reduction of oxygen in
the atmosphere by physical
replacement by other gases such as
carbon monoxide or dioxide.
In domestic circumstances, death may
be seen where a heating apparatus
has removed oxygen in the absence
of ventilation.
In a different variety of hypoxic deaths,
children may asphyxiate by being
confined in a small air space.
Smothering
This term refers to death from
mechanical occlusion of the mouth and
nose.
Death may occur either by occluding
substance pressing down on the facial
orifices, or by the passive weight of the
head pressing down.
It is extremely hard to prove intent.
Pressure marks are rarely distinguished
from normal post mortem changes.
Overlaying of infants
Condition with a pedigree as ancient as
the old testament.
Mentioned in the book of Kings, in
which two women who claim the same
child, as the other infant was overlain.
The recent decline in SIDS deaths is
attributed to mothers awareness of baby
position as well as the use of cots and
cribs.
Gagging
Variation on smothering where a pad or
gag is fixed over the face.
At first the device admits air, but as gets
soaked with either saliva or mucus
becomes impervious and asphyxia
occurs.
Often times related to robbery and
violent crimes.
Choking
Refers to blockage of internal airways.
Usually occurs between the larynx and
primary bifurcation of the main
bronchus.
Foreign bodies account form most
choking deaths.
False teeth and hemorrhages following
dental or ear surgeries are common
occurrences also.
Blockages

Traumatic Asphyxia
Refers to the mechanical fixation of the
chest.
Important because it shows the most
evident signs of classical asphyxia.
Signs include face and neck grossly
discolored.
Eyes and sclera are engorged with blood
to a point of obliterating the whites of
the eyes.

Visible Signs

Traumatic Asphyxia: Case history
A 58-year-old man who had visited an inmate in prison got into
trouble with the prison officers.
The prison warden ordered him to leave the prison, but the
visitor disobeyed this order and assaulted the warden.
Although the man was immediately arrested for obstructing the
warden in the performance of his duties, he reacted extremely
violently.
Therefore, six prison officers immediately restrained him in the
prone position.
According to the statements of the prison officers, the victim lost
some of his strength in 1-2 min after being restrained and nearly
completely in 7-8 min.
After about 10 min passed, the victim showed no signs of
resistance, yet the prison officers had to keep restraining him
following the order of their superiors, who had inspected the
situation.
After 14-15 min had passed, a policeman arrived at the scene and
the prison officers relaxed their restraint on the victim. The
victim had already undergone cardiopulmonary arrest.
Autopsy Findings: Traumatic
Asphyxia
Petechiae observed in the
left upper conjunctiva.
General appearance of
the victim
showing obvious
congestion of the face.
Autopsy Findings: Traumatic Asphyxia
Intramuscular bleeding
in the back of the
victim,
(a) right scapular
region,
(b) left infrascapular
region.

Autopsy Findings: Traumatic Asphyxia
Multiple fractures
of the ribs
accompanying the
bleeding in the
surrounding soft
tissues;
(a): right first
through fourth ribs
and
(b): left first and
ninth ribs.
Postural Asphyxia
Closely tied to traumatic asphyxia.
When a person remains in a certain
position long enough to stop
respiration.
Such situations included being trapped,
drunken or drugged state, or
mechanical impediment.
Such positions usually entail inversion
of at least the upper part of the body.
Postural Asphyxia
Drunk who
attempted to
climb through a
window above
his door when
he could not
locate his keys.
He passed out
in this position
and died as a
result
Mechanism Death by fatal
pressure on the neck
Pressure on the neck may arise from
manual strangulation, ligature, hanging,
direct blows, arm-locks and a variety of
accidental lesions.
Strangulation classically was thought of as
occlusion of the airway, but now is
thought to encompass many factors.
Airway occlusion
Occurs either from direct compression
of the larynx or trachea or from lifting
the larynx so that the pharynx is closed
by the root of the tongue.
Various experiments have been done to
try to estimate the amount of force
needed to close the airway and blood
vessels, but it is difficult to translate the
varied results.
Occlusion of the neck veins
Factor most commonly associated with
the classical signs of congestion,
cyanosis and edema with obvious
Petechial hemorrhages.
Experiments done have show that as
little as 2kg of force applied to the neck
is enough to destroy the jugular return.
Compression of the carotid arteries
Much less common than venous
occlusion.
Arteries are typically blocked by the
sterno mastoid muscles and thus require
much more force to be occluded.
4 minutes of carotid artery occlusion is
enough to commit brain death.
Cases with severe hypothermia can
extend the time of this occlusion with
regards to recovery.
Nerve effects
Pressure on the baroreceptors situated
in the carotid sinuses can result in a
condition called bradycardia.
Bradycardia = slowing of the heart.
This mechanism works through a reflex
arch.
Because these impulses are a reflex arch,
the brains need for oxygen is bypassed and
the heart slows, significant oxygen
reduction can be noted
Also called reflex cardiac arrest

Photo

Classical features when arrest is
delayed

Manual Strangulation
Common method of homicide
Most often associated with power and
size of assailant.
Most commonly seen in domestic
homicides
Also common in sex related homicides.
Rarely committed by women unless
committed on a child.
Autopsy appearances of MS
Bruising on the neck



Abrasions on the neck
Manual Strangulation
Manual
strangulation with
bruising from the
assailant and
fingernail abrasions
from the victim.
The face is pale as a
result of rapid
vasovagal cardiac
arrest before
congestive signs
could appear.
Internal appearances in MS
Bruising may be visible internally
At autopsy, it is critical to release
venous pressure before dissecting the
neck to avoid artefactual hemorrhages.
This is done by excising the jugular after
opening the neck.
Radiography may be performed before
the neck is opened.
Careful layer by layer dissections can
then be carried out.
MS bruising

Mucosal hemorrhages

Bleeding behind the larynx
Bleeding over the front of the larynx is
usually genuine if venous pressure was
released before dissection.
The best way to release this venous
pressure is incising the jugulars or
removing the brain.
Banding on the esophagus is also a
common finding in normal autopsies
and not to be confused with
strangulation.
Artefactual Post-mortem
hemorrhage

Injury to the larynx
Damage may occur in
many ways
The superior thyroid
horns are often fractured
as a result of bi-lateral
compression of the
larynx.
Fractured hyoid bones
are often observed
although, in younger
subjects, calcification has
not fully set in.
Strangulation by ligature
May consist of a wide variety of objects,
some not obviously suited for the
purpose.
Cords, wires, ropes, and some belts are
strong enough to cause death.
A U-shaped ligature is often times
sufficient to occlude the airway.
In the majority of cases the ligature is
crossed over itself after passing a full
circle around the neck.
Fracture of the left
laryngeal horn
with a
hemorrhage. The
body was
recovered from a
lake based on the
confession of the
assailant.
External Appearances
Appearance of
congestion cyanosed
forehead.
After removal of ligature
(scarf) the typical bruises
are observed.
The ligature Mark
The appearance at autopsy depends on
the nature and texture of the ligature.
When there is a pronounced patter such
as a weave of a chord pattern abrasions
are commonly noted.
Fabric sometimes leaves marks that are
difficult to interpret.
Fabric may also leave a sharp mark
which may be confused for a chord.
Types
Self strangulation by
ligature with three
turns around the
neck and a complex
knot. There was no
doubt from the
circumstances that
the deceased
committed suicide.
Types
Ligature strangulation by
means of a Spanish
windlass. A penknife
has been thrust through
the knot to twist the
ligature tight.
Position of the ligature mark
The geometry of the mark is important
to interpret the fatal events.
In cases of suicide, the ligature typically
does not have a crossover mark.
In cases of homicide, the crossover is
evident.
The cross may be at the side, front of
back depending on the positions of the
victim and assailant.
Hanging
Form of ligature strangulation in which
the force applied to the neck is derived
from the gravitational drag of the
weight of the body or part of the body.
Total suspension is not needed
Judicial hangings often times saw
victims families pulling on the legs of
the victim to shorten the agony.

Suicidal and Accidental
hanging
Today almost all hanging is accidental
or suicidal.
Death is most often cause by reflex
cardiac arrest from pressure on the
carotid structures.
This is evident when victims are found
with pale faces rather than hemorrhagic
congested faces.
Common Methods Used
Most hangings are self suspensions
Typically a thin rope is attached to some
high point.
The lower end is secured to the neck with
some form of slip knot while the victim is
standing on a support.
The support is then removed to suspend
the weight.
Suspension is often times not high enough
to keep the victims feet off of the floor.
The weight of the upper torso leaning into
the noose is often sufficient to cause
reflexive cardiac arrest.
Victim who used two neck
ties to suspend himself from
a hook placed on his door.
The hook gave way and he
was found lying on the floor
dead.
Notice the pale, uncongested
face indicating a rapid
cardiac arrest.

Suspension with a fixed knot in the chord so
that there is a segment of skin free from the
mark where the chord rises toward the knot.
This is a common feature in domestic
homicides.
Inmate who had a torn up sheet
and attached both ends to a water
tap and is leaning into the loop in a
sitting position.
A deep hanging mark showing the high position
under the chin rising to the back of the neck.
The spiral weave of the rope is clearly imprinted
in the skin. The dark tint of the face is racial not
congestive.
The position of the hanging mark on
the neck can vary.
Top - is the usual position with a
fixed noose and high suspension
point
Middle if a slipknot is used the
tightness of the deeply impressed
loop tends to find the smallest
circumference3 on the neck.
Bottom if the suspension point is
low, the subject may lean away and
the mark can be horizontal.
Hanging by
frontal
suspension.
A leather belt
used as a noose.
Compression
has occurred
around the
whole of the
neck
Features of Sexual Asphyxias
The basic mechanism is the production
of cerebral hypoxia.
This hypoxia is achieved by constriction
of the neck by ligature which can be
voluntarily tightened and loosened.
Some procedures use other means for
creating hypoxia such as anesthetic
agents such as huffing

Features of Sexual Asphyxias
The most common feature is a ligature
connected to some compression device
of the hands and feet which releases the
ligature upon relaxing the legs and
hands.
This feature allows for release in cases
where the victim passes out.
Malfunctions in this release are what
lead to accidental ligature deaths.
Often times hypoxia is produced by
position or placing head in a plastic bag.