Asphyxia

asphyxia
signs of asphyxia
drowning
throttling
strangulation
hanging
diatoms
burking

1. ASPHYXIAL DEATHS Dr Arun Pinchu Xavier Assistant Professor Dept: Of Forensic Medicine Sree Mookambika Institute Of Medical Sciences

2. ASPHYXIA The physiological and chemical state in a living organism in which there is acute lack of oxygen available for cell metabolism is associated with inability to eliminate excess of carbon dioxide Asphyxia is a misnomer. “ Pulselessness ”

3. Barcroft’s/Gordon’s classification Anoxic anoxia- prevention of o2 reaching lungs- Hanging ,Strangulation, Smothering Anaemic anoxia -inability of blood to carry sufficient o2 due to low hb conc - Haemorrhage ,CO poisoing Stagnent anoxia -impaired blood flow resulting in lack of oxygenated blood flow-CCF Histotoxic anoxia -adequate amount of o2 is available in blood stream but cannot be utilized-Cyanide ,Chloroform poisoning

4. SIGNS OF ASPHYXIA Cyanosis- bluish discoloration Petechial haemorrhage-tardieu’s spots Fluidity of blood-fibrinolysins Congestion of the face- Venous congestion Engorgement of the chambers of the right side of the heart

5. Classification of Asphyxial deaths

6. HANGING

7. HANGING Violent mechanical asphyxia where body is been suspended by a ligature around the neck,the constrictor force being provide by the weight of the body. Classification: Based on degree of suspension: Based on the position of the knot:

8. Classification : 01 .Based on degree of suspension A .Complete hanging – body completely suspended ,Constricting force being weight of the body B .Incomplete / Partial hanging- some part of the body touches the ground ,here weight of the head acts as the constricting force

9. Classification… 02 .Based on the position of the knot: a.Typical hanging- knot at the occiput b & c.Atypical hanging- knot anywhere other than the occiput

10. Causes of death in case of pressure over neck structures : Occulsion of External jugular vein- 2kg Occlusion of Carotid artery -5kg Occlusion of the Airway -15kg Occlusion of the Vertebral artery -25kg Vagal stimulation- caused by pressure over the carotid sheath and carotid body results in bradycardia leading to sudden cardiac arrest

11. Post Mortem findings… Ligature mark Findings above the ligature M Findings below the ligature M

12. P M findings Ligature mark Pressure patterened abrasion Usually above the thyroid prominence Runs obliquely upwards and backwards Reddish brown grooved dry hard parchmentized skin Atimes fingernail scratches by reflex instinct to save life

13. P M findings.. Findings above the ligature mark Dribbling of saliva-seen at the angle of mouth Le facie sympathique -compression of the cervical sympathetic ganglia Other findings- Toungue swollen Petechial haemorrhage Face is congested

14. P M findings… Findings below the ligature mark: Rigor mortis sets in early due to exhaustion of ATP,due to violent struggle Glove and stocking type of PM Lividity Cyanosis is noted over the lips, fingertips ,nail bed and tip of nose.

15. Internal features..Hanging Briusing of soft tissue,damage to thyroid and cricoid cartilage. Fracture of hyoid bone seen in elderly persons after complete ossification, outward compression Fracture .

16. JUDICIAL HANGING Official method of death sentence Face of the person is covered and made to stand over trap door,which opens downward through the mechanism of a lever. A rope is loped around the neck with sufficient length to allow a drop of 5-7 feet according to weight age and built Transaction of spinal cord

17. Hyoid bone fractures Classified into three different types: Inward compression fractures with outside periosteal tears Antero-posterior compression fractures with inside periosteal tears Avulsion fractures

18. STRANGULATION Strangulation is a type of violent mechanical asphyxia where there is constriction around the neck, the constrictor force being other than the weight of the body .

19. Types of strangulation Application of ligature ( ligature strangulation) Application of human hands (manual strangulation) Others : mugging, bansdola , garroting

20. Ligature Strangulation Constriction around the neck ,applied by a constricting band that is tightened by a force other than weight of the body Medicolegal significance Invariably homicidal in nature- Unless proved In children – accidental during play In suicidal- multiple twisted ligature which maintains the pressure on the neck even after loss of consciousness

21. Ligature Strangulation – External features Pressure patterened abrasion – reddish brown , grooved, dry, hard and parchmentized Usually wound transversely around the neck, with several turns, Encircle the neck completely Below the level of thyroid cartilage . Congestion of face, bleeding from nose, mouth and ears Scratches and contusions over the face and arms – marks of struggle

22. Internal findings Contusion - soft tissues of the neck and muscles are more prominent than hanging Thyroid cartilage and cricoid cartilage – may at times get fractured and contused Injury to blood vessels and hyoid bone are rare

23. Throttling / Manual strangulation Violent mechanical asphyxia brought about by constricting of the neck by hands Medicolegal significance Invariably homicidal

24. Throttling external features Neck findings Disc like finger tip bruises Crescentric finger nail scratch mark – struggle marks Internal findings – bloodless dissection of neck Haemorrhage under the skin Bruising of strap muscles Damage to the superior horns of thyroid and greater horns of hyoid (inward compression)

25. Bansdola – where two sticks are placed across the victims neck and the neck is constricted Mugging – It is brought about by squeezing the neck by crook of the elbow ,or bend of the knee. Garroting – An assailant who comes up behind a seated victim throws a ligature around his neck and pulls it tight . What is…?

26. Differences between Hanging and Strangulation HANGING STRANGULATION 1.Ligature mark Oblique, above the level of thyroid cartridge. Not encircling the neck completely Transverse,at or below the level of thyroid cartridge,completely encircling the neck with crossing of the ligature mark 2.Injuries to neck structures Under the ligature, on reflection of skin, tissues look pale.Bruising of neck muscles is less common Bruising of neck muscles is more common 3.Hyoid bone Fracture may occur Fracture is uncommon 4.Thyroid cartilage Fracture is less common Fracture is more common 5.Larynx and trachea Fracture rare Fracture may occur 6.Signs of asphyxia Less prominent More prominent 7.Bleeding From ears,nose,and mouth, is less common From external orifices is more common 8.saliva Dribbling often present absent

27. Autoerotic asphyxia

28. Autoerotic asphyxia Sexual asphyxia is a fatal condition resulting from self induced hypoxia during the course of solitary erotic act Mechanism suffocation – partial cerebral hypoxia – sexual arousal and orgasm

29. Medicolegal significance: Common in Males Accidental in nature Due to failure of safety precaution Failure of slip knot to loosen Plastic bags covering the face may cause suffocation

30. Indicators of death due to autoerotic asphyxia Asphyxia produced by strangulation and presence of padding around the neck Evidence of self-rescue mechanism Coexisting paraphilias Solo sexual activity Ponography Evidence of prior acts- healed injuries over neck

31. SUFFOCATION

32. SUFFOCATION A type of violent mechanical asphyxia caused by Obstruction of the passage of air into the lungs by obstruction of external resp orifices,excluding drowning due to pressure over neck structures. External means – Closure Of Mouth And Nostrils – Smothering Overlying Or By Pressure Over Chest And Abdomen - Traumatic Asphyxia Internal means – Closure of glottis or mouth by insertion of soft cloth, paper - Gagging Impaction of a bolus of food or foreign body deep into the air passages - Choking .

33. Smothering…

34. Smothering Violent mechanical asphyxia resulting from closure of mouth and nostril by means of hand, plastic bags or soft pillows Medicolegal significance Suicide – tying a polythene bag over head Accident – infants Homicide – there need to be considerable physical disparity between assailant and victim

35. Post mortem findings Injuries absent when a soft material is used Bruising around mouth, nostrils and face Abrasion due to finger nail scratches when hands are used to smother, contusions and lacerations over the inner aspect of lip Internal organs may show asphyxial signs

36. Chocking Asphyxial death resulting from obstruction of airway internally Medicolegal Significance Seen in very Young, elderly, psychiatric and intoxicated patients when the ability to chew or to swallow is impaired Causes of chocking Inhalation of foreign body in the glottis Inhalation of vomited material

37. CAFE CORONARY This is the accidental entry of bolus of food or food particle into the air passage obstructing the larynx and death is due to reflex vagal inhibition . This may happen when the person is eating food in a restaurant and people may think death is due to cardiac arrest, hence the name.

38. Causes –Café coronary Accidental chocking may occur in adult to due suppression of gag reflex under the influence of alcohol. Mentally ill persons who are under antipsychotic drugs. Elderly patients suffering from neuro -degenerative diseases Children under 5 years

39. Cause of death The protective cough reflex is depressed -> impact of foreign material in laryngeal and pharyngeal mucosa -> stimulation of vagal nerve -> bradycardia -> death Postmortem findings Object causing choking is present in the airway Tissue reaction on the bolus Local inflammatory reaction in the tissues Petechiae seen if significant retching occurred Complete autopsy and toxicological examination needed to confirm the event leading to death

40. Heimlich’s Maneuver

41. GAGGING Asphyxial death resulting from stuffing pad or any piece of cloth into the mouth Medicolegal Significance: Seen in sexual crimes and robbery to prevent the victim from shouting Postmortem findings Injuries to lips gums and tongue in the form of contusions or tears of buccal mucosa Loosing of the teeth can be seen resulting from resistance offered to prevent forceful stuffing of oral cavity.

42. TRAUMATIC ASPHYXIA Crush Asphyxia / Positional Asphyxia / Compression Asphyxia

43. Traumatic Asphyxia Death results from pressure and fixation of the chest and/or abdomen. The normal movement of the chest wall is prevented . E.g.:- A person is crushed under a vehicle, in a house collapse, an earthquake, in a stampede,in a overturned car.

44. Sequence of events leading to traumatic asphyxia

45. Postmortem findings Severe congestion and cyanosis above the level of compression and pallor below the level of compression , with sharp line of demarcation Displacement of blood to the valveless veins of head and neck form SVC, which causes rupture of the distal venules and cappilaries . Bleeding from mouth and nostrils Fracture of ribs and sternum

46. BURKING

47. BURKING This term is derived from the notorious criminal Burke , who with his accomplice Hare, who robbered dead bodies from grave and sold them to medical school in Edinburgh Death was by a combination of smothering & traumatic asphyxia They would invite the victim and give them alcohol ,and later throw him to the ground

48. Burking… Burke would sit on the chest and smother the victim and Hare would hold the legs This method got its name after conviction of William Burke Autopsy findings- Nail marks around mouth and nostrils, livid face, SC hemorrhage Rib fracture All internal organs are congested and edematous

49. Form of violent Asphyxial death due to the submersion of the mouth and nostrils in a liquid medium DROWNING

50. Drowning Classification 1.Typical / Wet drowning/ Primary drowning Fresh water drowning Salt water drowning 2.Atypical / Dry drowning 3.Secondary drowning

51. 2.ATYPICAL / DRY DROWNING Here death occurs without water entering the lungs: Laryngeal spasm , Sudden inhalation of water Reflex spasm of the larynx Early unconsciousness and a rapid asphyxia Sudden death without any asphyxial signs. Immersion Syndrome / Hydrocution- Sudden contact with cold water over epigastric region or tympanic membrane can cause death due to vagal stimulation Bradycardia Sudden cardiac arrest.

52. 3.SECONDARY DROWNING Previously submerged victim survives for atleast 24 hours after being rescued . The individual may or may not be conscious He may develop pulmonary odema , hemoglobinuria , cardiac arrhythmias , pnemonitis , fever sepsis as well as symptoms related to cerebral hypoxia

53. 01. TYPICAL / WET DROWNING : Typical / Primary drowning Fresh water drowning Salt water drowning

54. Drowning in FRESH water Struggle to respire and save life Fresh water enters the alveoli-acts as a semipermeable membrane Fresh water present in alveoli is hypotonic in relation to blood Increase in blood volume Hemodilution Swelling of RBC’s -Rupture of RBC’s-Increase in K+ Ventricular fibrillation Myocardial Failure Cerebral anoxia Death within 4-5minutes .

55. Drowning in SALT water Struggle to respire and save life-salt water enters the alveoli Alveoli lining membrane is semipermeable Saltwater present in alveoli is hypertonic in relation in blood Water passes from blood to alveoli Hemoconcentration & Massive pulmonary oedema Crenation of RBC Myocardial anoxia Death within 8-12 minutes .

56. Post mortem findings in drowning

57. External Appearences The clothing is wet. Skin appears Goose- skin,Cutis anserine Skin of hands and feet appears shriveled and pale( washerwoman’s hands ) Post mortem lividity confined to head, neck and front of chest . Face down, buttocks up, hands and feet dangling down – usual position of body floating in water after purification Rigor mortis sets in early due to early depletion of ATP

58. Froth in drowning Mouth nostrils and airways Produced by churning of air water and mucus surfactant during struggle Copious in quantity white and tenacious Resembles that of shaving lather It reappers if wiped off from nose and mouth,especially if chest is pressed These bubbles does not collapse on touching bcz of surfactant coating

59. Cadaveric spasm: Hands affected by cadaveric spasm may contain various objects grasped such as sea weed, sand, straw which shows that the person was alive on entering water and was struggling. Washerwoman’s hands and feet: After 12-24hrs , the skin of the palms and the soles becomes bleached, wrinkled and soddened. The epidermis separates from the dermis in glove and stocking fashion from the hands and feet. This is a sign of submersion.

60. Internal Findings LUNGS Voluminous,bulky and odematous Ballooned appearance with rib markings Pits on pressure C/s Oozing of large quantity of frothy fluid indicating active respiration Algae mud sand debris in distal airways

61. Paltauff’s Haemorrhage Subpleural haemorrhages seen in lower lobes of lungs 1-5cm in diameter Emphysema aquosum . This condition develops only when the conscious victim of drowning struggles for survival. Oedema aquosum – Develops when the body is passively immersed in water or when a victim is unconscious. Usually no froth will be formed, since there is no violent respiratory efforts .

62. Causes of Death in Drowning Asphyxia Ventricular Fibrillation Myocardial anoxia Laryngeal spasm Vagal inhibition Exhaustion Head injuries ( From striking against objects during a fall into river, well, etc).

63. FRESH WATER DROWNING SEA WATER DROWNING Time required for fatality 2 to 3 min 4 to 5 min Changes in blood Haemodilution Hyponatraemia Hyperkalaemia Haemoconcentration Hypernatremia Changes in the lungs Ballooned out and lighter pinkish,Emphysematous , Crepitant,less froth,retains shape after removal from body Ballooned out and heavier purplish/bluish, soft and jelly-like ,No crepitus,Copious froth, Flattens out on removal from body.

64. Antemortem drowning Postmortem drowning Froth Fine, persistent froth at the mouth& nose, which increases by pressure on chest No froth Cadaveric spasm May be seen rarely, with the victim clutching weeds,etc. Absent Water in stomach/small intestine May be present, which suggests active peristalsis Absent Sand particles May be present till secondary bronchioles Absent Haemorrhage in mastoid air cells of middle ear Present, though difficult to demonstrate Absent

65. Drowning tests Gettler Test / Chloride Test Is done by withdrawing 10 ml of blood from each ventricle of the heart and subjecting it to estimation of chlorides .Helps in diffentiating salt water from fresh water drowning. Normal value of chloride – 600 mg/100ml in both chambers. In seawater drowning – 30 to 40% increase of the chloride level in LEFT ventricle while in freshwater drowning chlorides will be 50%less than normal A difference of 25%in chloride between the two chambers is significant.

66. Other tests… Plasma specific gravity: left arterial blood has a lower specific gravity than the right atrium in fresh water drowning Plasma magnesium level:High levels of plasma magnesium in left heart is seen in salt water drowning Blood strontium level: Salt water drowning have higher strontium levels than fresh water drowning Diatoms test:

67. Diatom Test: Diatom – microscopic unicellular algae or plankton. Possess silicaceous cell membrane vary in size from 10 – 80 micron due to hard cell wall resistant to heat and acids. In wet drowning diatoms aspirated into the lungs with inhaled water. Pass into the venous circulation through ruptured pulmonary capillaries distributed to various organs of the body and bone marrow .

68. Diatoms… Interpretation If both the medium and marrow contain same type of diatom – corroborative evidence of death due to drowning in that medium. Diatoms are present even in highly decomposed bodies. ( Diatom test is only a corroborative test and not confirmatory test ,? )

69. Acid digestion method- A sample of bone marrow (minimum 50g) taken from the sternum or long bones digested with nitric acid kept at room temp for 1 – 2 days Centrifuged, deposit is examined microscopically. CONTROL A sample of drowning medium (1000ml)should also be treated with few drops of tincture iodine / Lugol’s iodine is added to water sample and allowed to stand for 24 hours, centrifuged and deposit is examined microscopically.

70. Medico legal Aspects of Drowning

71. Medico legal Aspects of Drowning Accidental Children may accidently fall in water during playing.Person under influence of alcohol/Epileptic may accidently fall in water . Death occurring in shallow water should be considered as homicide unless otherwise proved . If injuries are found – should be carefully evaluated with regard to the location, nature etc. Bodies in water may be attacked by fish and various types of postmortem injuries can occur. Suicidal

72. When person goes with S elf C ontained U nderwater B reathing A pparatus that deep,more nitrogen from apparatus gets dissolved in blood and tissues at high pressure . When the person from a high to low atmospheric level, causes air embolism( DECOMPRESSION SICKNESS ) Signs and symptoms:Dyspnoea,headache,Vertigo , epileptiform convulsions and paraplegia without sensory loss. Barotrauma is the mechanical damage caused to the tissue by the gas which is been released. SCUBA DIVING

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