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 Fractures of hyoid or thyroid cartilage

o Combination of any of the above o Usually not present in young individuals
- Pressure on the neck is applied by ligature tightened
by a force other than body weight Smothering
- Accidental ligature strangulations are rare - Caused by mechanical occlusion of the air passages
o Entangling of tielscarf in machinery from the outside by hand or by any object
- Most are homicides - Asphyxia signs will be present except in cases of
- Women > men plastic bag suffocation
- Externally: - Abrasions and contusions of the skin of the face
o Face is either pale or bluish and congested around mouth and nose
o Rest of the body is cyanosed (absent if soft material such as pillow is used)
o Tongue may be protruded, swollen and bitten - By mechanical obstruction of nose and mouth
o Bleeding from ears and nose may be seen - May be homicidal:
- Accident: o Gagging
o Newborns strangled by umbilical cord o Pinching off nose and clamping hand over the
o Children playing with ropes mouth
o Adults strangled by neck tie caught in moving o Overlaying when patients take an infant to bed
machinery with them and is rolled over during the night
- Methods: - Typically no findings at autopsy
o Mugging by compressing the victim’s neck o Bruising of the lips and nose
against the forearm o Scratches
o Garroting: attacking the victim from the behind - Infants:
and grasping his throat or throwing a ligature o Bradycardia in 30 sec
over the neck and tightening it quickly o Flat EEG in 90 sec
o Bansdola: compressing the neck between 2 o Respiration will not return spontaneously
sticks, practiced in North India o Positional asphyxia- resulting from being
o Throttling by compressing the victim’s neck by trapped in a position such that they cannot
the hand breath or respiration becomes inadequate;
individual suspended upside down for prolonged
Manual strangulation (Throttling) period of time
- Caused by constricting the neck by the hand - Entrapment
- Mechanism of death: o Local hypoxia in plastic bag
o When death occurs as a result of vagal inhibition, o Seen in suicide (final exit), accidents with
asphyxia signs will be absent children
- Externally:
o Abrasions (caused by fingernails) Choking
o Contusions (caused by finger pads) - Caused by mechanical obstruction of the air passage
Both are found on the front and sides of the neck from inside
o Congested face - Mechanism of death
o Petechiae of the skin and neck and undersurface o Asphyxia due to either complete occlusion of air
of the jaw passage, or partial occlusion that is completed by
o Semicircular fingernail marks spasm, edema and mucus secretion
o Hemorrhage in muscles of the neck - Causes:
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o Trying to swallow large pieces of poorly chewed  Signs of choking are absent because of high
food blood alcohol which inhibits the gag reflex
o Drinking alcohol before or during meals  PM appearance: the foreign body if
 Alcohol dulls the nerved that aid in embedded in a thick mucus in the trachea
swallowing
o Wearing dentures Traumatic asphyxia
 Dentures make it difficult to sense whether - Resulting from trauma to the chest or pressure on
food is fully chewed before it is swallowed the chest and abdomen which prevent respiratory
- Blockage of the internal airways movements (burking)
- Homicides are rare - Penetrating trauma e.g. stab injury- pneumothorax,
- Most are accidental: lung collapse
o Posterior pharyngeal and laryngeal obstruction - Non penetrating trauma e.g. run over car accident-
due to foreign bodies fracture of rib, restriction of respiratory movements
o Food aspiration from the severe pain occurring during respiration
o Associated with: - Pressure on the chest and abdomen- burial in earth
 Alcohol intoxication following house collapse, landslide, mudslide,
 Senility crushing by the crowd, stamped, as in case of fire
 Mental retardation
 Absent gag reflex Chemical asphyxia
o Acute epiglottitis - Prevention of utilization of oxygen at the cellular
- No typical findings at autopsy except obstruction of level
airway - Carbon monoxide
- Accidental choking o Usually accidental
o Most common o Cherry red discoloration
o Inhalation od irritant fumes o Headache- 1st symptom at levels of 10-20%
o Inhalation of foreign material such as food or o Dyspnea and dizziness (levels 20-30%)
dentures o Seizures (levels 30-40%)
o Inhalation of dust and sand in falling of house o Atraumatic rhabdomyosis (myoglobin binds CO
o Falling back of the tongue epileptic fit and prevents normal muscle function)
o Café coronary or fatal choking on food o Delayed neurologic deficits (memory deficits,
 Sudden collapse during or shortly after meal apathy)
and the autopsy examination should not o Laboratory findings:
only attempt to demonstrate airway  Lactic acidosis (shift to anaerobic glycolysis)
occlusion by a bolus of food but also to  Increase CO levels in blood
identify or exclude underlying neurological o Treatment:
disease  Hyperbaric oxygen therapy
 Impaction of food in the sensitive larynx  Administer 100% oxygen therapy with
causes sudden death due to cardiac arrest nonrebreather mask or ET tube
 Healthy intoxicated person in hotel while - Hydrogen cyanide
eating suddenly turns blue, coughs violently, o Usually suicidal
collapses and dies - Hydrogen sulfide
 At autopsy, a large food bolus seen in the o Virtually all accidental
larynx obstructing air passage o Working in sewer plants and cess pools
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Environmental asphyxiation o Died from injury before being thrown into the
- Hazards of poor or no ventilation: water
o Lack of oxygen (headache, fatigue, asphyxiation, o Died from injuries while in the water
particularly in confined spaces) o Died from the effects of immersion other than
o Excessive heat, cold and humidity drowning (e.g., exhaustion, exposure to cold
o Toxic fumes (e.g lead, cadmium, zinc) waters)
o Toxic vapors (e.g. benzene, toluene, TCE, MEK) o Died from drowning
o Toxic gases (e.g. hydrogen sulphide, ammonia - Phases
o Dusts (causing poisoning or gradually reduced o Breath holds
lung capacity o Inhalation of water, coughing, vomiting and loss
o Fire/explosion of consciousness
- Types of asphyxia that leads to death as a result of o Convulsions, respiratory arrest then cardiac
accidental happening and occurs in relation to closed arrest
spaces, deep sea diving or very high altitude (e.g. a - Brouarderl’s experiment
child trapped inside the trunk or unused refrigerator, o Stage of surprise (5—10 seconds)
an adult fell into a deep well) o 1st stage of respiratory failure (1 min)
- Excavation hazards o Stage of deep respiration (1 min)
o Cave-ins are the greatest risk o 2nd stage of respiratory arrest (1 min)
o Other hazards include: o Stage of terminal grasp (30 seconds)
 Asphyxiation due to lack of oxygen - Classification:
 Inhalation of toxic materials o Typical or wet drowning- obstruction of air
 Fire passages and lungs by inhalation of fluid; salt or
 Moving machinery near the edge of freshwater drowning; typical signs are found at
excavation can cause collapse autopsy
 Accidental severing of underground utility o Atypical or dry drowning- conditions in which
lines there is very little or no inhalation of water of
- Clean air act of 1970 fluid in the air passages, water may enter URT
o Set national ambient air quality standard for six but not the lungs
criteria air pollutants (CO, NO2, SO4, particulates, o Immersion syndrome (vagal inhibition)- water
ozone, hydrocarbons) striking epigastrium, cold water entering ear
drums, nasal passages, larynx, pharynx
Drowning o Secondary drowning syndrome/ near drowning-
- A form of asphyxia death due to aspiration of fluid delayed death
into the air passage by submersion of the body in o Submersion if the unconscious
water or fluid medium - Occurs when eater is inhaled, filling up the alveolar
- Complete submersion not necessary, submersion of spaces and preventing gas exchange
nose and mouth is enough - In warm water, irreversible hypoxia = 3-10 minutes
- Bodies retrieved/removed from water may have: - Diagnosis is by exclusion
o Died from sudden natural disease before falling - Abundant bloody edema forth throughout airway
into the water (e.g. a person walking near water - Water may be present in stomach
falls in due to IHD/CAD) - Washerwoman’s hands
o Died from sudden natural disease while already o Shrivelled and pale skin
in the water 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  chloride decreases by 50% in freshwater and

o Oversitention of lungs 40% increase in saltwater
o Dry drowning  in freshwater, chloride content of L heart < R
o Middle ear hemoorhage  in seawater, chloride content of L heart > R
o Chemical tests (unreliable)  Test is doubtful value in septal defect,
o Nonspecific changes of immersion putrefaction, death due to vagal inhibition,
o Water in stomach and intestine chloride in water
o Paltauf hemorrhages/ rasskazov lukomskij spots- o Diatoms
petechial hemorrhages located beneath the  Microscopic unicellular algae present in all
pulmonary pleuras in both lungs and appear in natural water sources especially in stagnant
wet drowning, larger and not as sharply defined water (10-80 microns) with outer siliceous
(due to hemolysis) than Tardieu’s spots wall
o Airway filled with froth, sands, weeds, etc, found  Over 1500 species are found
in the water  Heat and acid resistant
o Lungs are voluminous, edematous, doughy, firm  One of the dependable signs of ante mortem
with rib markings drowning
o Emphysema aquosum- oozing out of blood  Contain chlorophyll and diatominin (brown
stained frothy fluid and ballooning of the lungs, pigment)
weight up to 2 kg, more obvious in saltwater  Circulation can transport diatoms from lungs
drowning than freshwater where the water is to the brain or bone marrow
rapidly absorbed in the body  when a love person is drowned in water,
o Washerwoman’s hands and feet- the skin of the they penetrate the alveolar membrane and
finger, palms and later the soles may be pass with the circulation to distant organs
wrinkled, bleached and sodden due to osmotic  but when the body is thrown into the water,
action of water on thickened epidermis the absence of beating heart prevents
o Cutis anserine (goose skin)- due to spasm of the circulation of diatoms to distant organs
erector pilae muscle and due to exposure to cold  through ruptured alveolar wall, diatoms
water at the time of death, skin appears granular enter the pulmonary vein and then to the
and puckered with hair standing on the end, can left side of the heart with blood circulation
be both ante- or post-mortem they are transported to bone marrow, brain
- Findings in larynx-trachea and bronchioles and other organs
o Presence of sand, mud, dirt, aquatic vegetations,  technique of demonstration:
etc (lower bronchial tree is important)  5 gm of marrow is collected from
o Fine white blood tinged froth sternum bone and is subjected to acid
o Congestion digestion with 5 times volume of nitric
o Regurgitation of gastric contents acid for 1-2 days
- Biochemical changes  Sediment is examined under phase
o Getlers test contrast or dark background
 Normal chloride content is equal in the right illumination microscope
and left chambers of the heart (600 mg/100  Interpretation of results: control
ml) samples of water from site treated with
 Difference of >25mg/100ml = drowning iodine is compared for type of diatoms
- Changes inside stomach and intestine
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o Evidence of water swallowing- gravel, dirt, sand, Physical Injuries Due to Changes in Atmospheric
aquatic vegetations, shells, etc. Pressure
o It is a positive sign of antemortem drowning
o Water cannot enter into the stomach & intestine Barotrauma
when a dead body is thrown into water such as - The normal atmospheric pressure at sea level is 760
in vagal inhibition, shock or syncope, advanced mmHg
putrefaction, unconsciousness before falling into - The person is subjected to an increase of
water atmospheric pressure as he goes deeper in a body of
- Features of antemortem drowning: water and a decrease as he ascend higher in the
o Cadaveric spasm with firmly grasped vegetable atmosphere
materials, etc - Refers to medical problems that arise from the
o Froth is white, fine (small bubbles), lathery (soft), pressure difference between areas of the body and
tenacious (adherent/sticky), copious (abundant, the environment and is a particular concern for
constant) scuba divers
o Haemorrhage in middle ear (water through - Kinds:
Eustachian tube) o Hyperbarism
o Lungs: o Hypobarism
Trait Freshwater Seawater - Rupture of alveolus with subsequent entry of air into
Size & weight Ballooned but Ballooned and the pleural space (pneumothorax) and/or tracking or
light heavy air along the vascular bundle to mediastinum
color Pale pink Purplish/ bluish (pneumomedistinum)
consistency emphysematous soft - Risk factors:
After removal Do not collapse Collapse o Large tidal volume
On cut section Crepitus heard, Crepitus absent o Elevated peak inspiratory pressures
with froth, no Froth + fluid
fluid Hyperbarism
o Specific signs: - Increase atmospheric pressure
 Sign of krushevsky- full of small bubbles - A condition is observed underwater by scuba divers,
white foam in respiratory tracts pearl divers, salvage divers, treasure hunters,
 Spots of rasskazov-lukomsky- reddening and pleasure swimmers, etc.
edema of mucous tunic of respiratory tract, - Henry’s law: at constant temperature, the amount of
increasing and emphysema of lungs, pale gas discovered in a liquid is directly proportional to
dim hemorrhages on their surface the pressure
 Sign of moro- presence of water in small - Nitrogen narcosis- rupture or drunkenness of the
intestine and abdominal cavity deep (the nitrogen an inert gas comprising 80% of
 Sign of sveshnikov- presence of liquid of the air in the lungs is also dissolved in the body fluid),
drowning environment in the sinus of this condition is preceded by euphoria
sphenoid - A rapid decent may cause rupture of the blood
 Increasing of liver in size and presence of vessels and haemorrhage
plankton in inner organs - 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 Internal Ear Squeeze

- Physical injuries in the process of diving and hitting - Occurs from the suction development of pressure
hard objects difference between the middle and internal ear
- Injuries caused by aquatic animals like shark or stings - Can result from overly forceful Valsalva maneuver or
from venomous fish and coelenterates a very rapid descent
- Effects of the changes if atmospheric pressure in a - Results are usually, ringing in the ear, dizziness and
pre-existing disease like hypertension or coronary deafness
affection - Less common than middle ear squeeze
- Post-mortem findings:
o Immediate death: subcutaneous emphysema, Face mask squeeze/ facial barotrauma
generalize visceral congestion and the presence - Occurs if you do not exhale thru the nose into the
of gas bubbles, extravascular bubbles and dive mask while descending
hemorrhages in adipose tissue like the - Failure to equalize mask air space during descent
mesentery and omentum - Occurrence:
o Death occurred after a lapse of several days: o As shallow as 25 ft
degeneration and softening of the white matter o Typically unexperienced divers
of the spinal cord, fat necrosis, osteonecrosis o Not with full face masks
- s/sx:
Decompression sickness or the bends o inverted sclera
- More related to Henry’s law which states that more o periorbital edema
gas will be dissolved in a liquid when the gas is o painless
pressurized o no effect on vision
- Because of the water pressure, body tissues absorbs - tx:
nitrogen gas faster as diver descends than when o approx. 2 weeks
ascending to the surface o any pain or vision problems >>> ophtha eval
- However, if a diver ascend too quickly, nitrogen gas
bubbles will form in the body tissue rather than Hypobarism
being exhaled, it will cause severe pain - decrease of atmospheric pressure
- at a higher altitude the atmospheric pressure
External Ear Squeeze becomes lower and more gas will be liberated by the
- Occurs when the ear canal is blocked by something body fluid
such as earplugs or earwax - the release of gases will cause:
- As the water pressure increase while descending the o Bends- joint and muscular pain due to presence
air packets between the obstruction and the of air bubbles
tympanic membrane shrinks o Chokes- substernal distress, non-productive
- Can damage the tissue in the ear canal coughing and repiratory distress, result of
bubble formation in the pulmonary capillaries or
Middle Ear Squeeze from the effects of extravascular mediastinal
- Occurs when you cannot equalize the pressure in bubbles exerting pressure on the mediastinal
your middle ear contents and adjacent pulmonary tissue
- When there is problem with the Eustachian tube, the o Substernal emphysema- accumulation of bubble
middle ear volume decreases and pulls the eardrum underneath the skin
inward, creating damage and pain
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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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