Asphyxia

Hypoxia
and
Neck compression

Asphyxia
Asphyxia literally means
absence of pulsation,
but now is used to denote anoxia or
hypoxia.

Respiration requires
an intact airway,
functioning ribcage and muscles (intercostal
and accessory), and diaphragm
intact CNS,
healthy lungs for effective alveolar/capillary
exchange,
good circulation and transport
mechanism(Hb.).

Causes of hypoxia
Mechanical asphyxia struggling to breath against some
kind of interference with the mechanism of respiration.
Pathological conditions, predisposing to tissue anoxia
lung pathology, bronchitis, emphysema, pulmonary fibrosis.
Can compound the effects of other asphyxial mechanisms.

ASPHYXIA
SIGNS
deep congestion of face & neck
cyanosis
petechiae, scleral haemorrhages

MECHANICAL ASPHYXIA
1. Obstruction of the nose and mouth; smothering,
suffocation
2. Obstruction of the air passages; gagging, choking,
inhalation/aspiration, cervical positional
asphyxia, drowning.
3. External pressure on the neck/ Neck compression;
hanging, manual/ligature strangulation, arm lock,
choke hold.
4. External pressure on the chest; traumatic
asphyxia.

1. SUFFOCATION
Obstruction of the nose or mouth,
occludes the external airways and is commonly
referred to as smothering or suffocation.
Oxygen is not delivered to the alveoli and gas
exchange cannot take place.
Oxygen levels fall and carbon dioxide levels rise.

1. SUFFOCATION
Environmentalclosed chamber eg Silo
(CO2), Hold of Ship (N2)
Smothering---mechanical obstruction of
nose & mouth---e.g. plastic bags, gagging
In Infants--- pillows or pinching nose &
clamping mouth

SUFFOCATION
Smothering/suffocation is more common in the very
young, the very old, or debilitated, or
incapacitated, individuals, accidentally or
homicidally.
The nose and mouth can be covered by a pillow, gag,
hand etc.
.

SUFFOCATION
Plastic bag asphyxia is a relatively common method
of suicide, a plastic bag or sheet of plastic covering
the face.
Death is usually rapid due sudden hypoxia causing
bradycardia or a cardiac arrest, without evidence of
asphyxial signs.

SUFFOCATION

Accidental suffocation can occur following an

epileptic seizure
or if acutely intoxicated by alcohol if left face down
in bedding, water or mud once unconscious.

2. Obstruction of the air passages,

pharynx to bronchi
Choking - Blockage of posterior pharynx
and larynx by food or foreign object
Can occur naturally due to epiglottitis.
Blockage of Internal Airways food,
mucous, blood

2. Obstruction of the air passages,

pharynx to bronchi
Commoner in certain situations;
elderly due to dementia or neurological injury, especially if
edentulous or wearing ill-fitting dentures and unable to chew,
therefore swallowing a bolus of food;
children - prone to putting small objects in their mouths;
mentally handicapped who do not chew food;

2. Obstruction of the air passages,

pharynx to bronchi
Commoner in certain situations associated with cerebral
cepression;
acute alcohol intoxication; caf coronary due to a combination
of swallowing poorly chewed food and alcohol intoxication
Drug intoxication e.g. heroin etc.
HEAD INJURIES concussion/unconscious, with slowed
neurological reflexes.

3. Compression of the neck

Strangulation is a form of asphyxia
characterised by closure of the blood
vessels and/or air passages of the neck as
a result of external pressure on the neck.
3 types
Ligature constricting band + force
Hanging constricting band + body/head weight
Manual hands, forearms, or other limbs

3. Compression of the neck

a). Hanging
b). Sexual asphyxia
c). Ligature strangulation
d) Manual strangulation
e) Arm lock- choke hold
-carotid sleeper

3. Compression of the neck

Associated with external markings on the neck,
depending on the mechanism, and there may be
internal bruising and damage to the larynx.
Asphyxial signs (petechiae, congestion and cyanosis)
may be present if death is not instantaneous.
In some cases death will be sudden and asphyxial
signs are absent.

3a. Hanging
Defined as a form of strangulation
Pressure on the neck is applied by a
constricting band
Tightened by the gravitational effect of the
body or part of the body

3a. Hanging
Hanging is a common method of suicide,
occasionally accidental.
Complete suspension not essential,
Suspension from a low level
weight of the head sufficient to produce the
compressive force necessary.
.

3a. Hanging
Asphyxial signs not always present
Full suspension,
face more commonly pale
due to complete obstruction of the neck
vessels
Partial/incomplete suspension,
petechiae more commonly seen
due to partial obstruction of veins only

3a. Hanging
The ligature mark forms an abraded groove around the
neck
Mark may completely encircle the neck if the noose is
secured with a slip style knot.
If the noose has a fixed circumference, mark present only
where the ligature contacts with the neck, leaving a gap
corresponding to the suspension point, usually in the
midline at the back of the neck or behind one of the ears.
At the front of the neck the mark is typically at thyro-hyoid
level, rising obliquely upward on either side of the neck to
the point of suspension.
Mark deepest opposite the suspension point, max weight
bearing

3a. Hanging
The tongue is lifted by ligature and may protrude from
the mouth and be clamped between the teeth.
If the body is left suspended after death postmortem
lividity, influenced by gravity, present over the lower
half of the body.
Little or no bruising into the soft tissues of the neck
Fractures of the thyroid cartilage or hyoid bone are less
common than in strangulation.

Hanging
Rapidity of onset of asphyxial signs depends on
situation of ligature on the neck
Between lower jaw and hyoid disturbs breathing
Death delayed when ligature does not encircle neck

Consciousness lost early

Lactic acidosis and cerebral oedema compromise
the brain
Cardiac arrest occurs later (unless vasovagal etc.)

Hanging
If spinal cord intact and stoppage of air is
not complete, 5-8mins is typical fatal period
Resuscitation may be successful if instituted
prior to cardiac arrest

3c. Ligature strangulation

Usually homicidal, rarely suicidal or accidental.
The victim of homicidal strangulation is more
commonly female or because of age, infirmity or
incapacitation a person who can be easily overcome.
The ligature used depends on what is at hand e.g. tights,
flex, rope. External force is used to tighten the ligature.
A ligature mark will be evident on the neck in most
cases, although a soft ligature may not leave a mark.

3c. Ligature strangulation

The mark tends to be horizontal across the
neck at a lower level than in hanging, about
midthyroid level i.e. lower than in hanging.
The mark tends to be fairly uniform in depth
and can be narrower or wider than the ligature
used and has a golden, or parchmented
appearance, sometimes with a pattern
corresponding to that of the ligature.
Depending on how the ligature is applied to the
neck the mark may or may not encircle the neck
and may even show a crossover point.

3c. Ligature strangulation

Above the level of the ligature there are usually florid
asphyxial signs.
Internally there is usually bruising under the skin, as
well as at the base of the tongue and on the posterior
pharynx.
Depending on flexibility and the amount of force
used the thyroid cartilage and/or hyoid bone may
be fractured.

3d. Manual strangulation

Manual strangulation is usually homicidal as it is
impossible to manually strangle oneself.
However it is often not premeditated and may follow a
sexual assault, the victims women and children or the
elderly.

3d. Manual strangulation

Often there are very few external marks on the neck but the
classic injuries are fingertip bruises and fingernail marks.
These bruises are small and circular, about 1-2cm.
The nail marks are either small curved linear abrasions due
to the assailants nail ends pressing into the skin. Fingernail
scratches tend to be long abrasions, grouped in 2s or more,
and may be caused by the assailant or the victim.
The pattern of bruises and scratches will depend on
whether one or two hands were used.
Clothing or jewellery on the neck may be pressed into the
neck during the act leaving a matching imprint abrasion.

3d. Manual strangulation

There are usually florid asphyxial signs above
the neck, particularly as compression of the
neck is intermittent as the hands are released
and then reapplied.
In cases were the asphyxial signs are
prominent there can be bleeding from the nose
and ears.

3d. Manual strangulation

Internally there will be fingertip bruises in the
muscles of the neck and bruising behind the
larynx where it is pressed against the spine as well
as at the base of the tongue.
Fractures of the superior horns of the thyroid
cartilage are due to pressure from the thumbs but
fractures of the hyoid bone may also occur if
violent force is used.
In extreme violence the body of the thyroid
cartilage may be fractured.

3e. Arm lock - Choke hold

Due to the forearm being pressed into the neck from
front or behind.
The force occludes the upper airway and compresses
the carotids, causing cerebral hypoxia.
Externally there may be a broad band of abrasion on
the front of the neck often without significant internal
injury.
Asphyxial signs may be the only indicator that the
neck has been compressed.

3e. Arm lock Carotid sleeper

Due to the neck being compressed in the crook of the
arm, the assailant behind his victim.
This has the effect of compressing the sides and not
the front of the neck and therefore the vessels, carotid
arteries, are occluded causing cerebral ischaemia.
Unconsciousness supervenes within 10-15secs.

4. CHEST COMPRESSION
Traumatic Asphyxia
Pressure on chest & abdomen restricts respiratory
movement and inspiration
This may be due to being pinned beneath rubble,
masonry, sand, earth or coal, even if the head is free,
or even under vehicles.
It can be due to crushing in crowds e.g. Hillsborough.
In some instances the body may be wedged in a
narrow space, the trunk or neck also acutely flexed,
accelerating the asphyxiating processsuspended
upside-down, crucifiction, wedged between furniture,
infants wedged in cots

4. CHEST COMPRESSION
Traumatic Asphyxia
Burking is due to compression of the chest, in association
with occlusion of the nose and mouth, usually when the
victim is asleep or intoxicated.
Overlaying of infants--indistinguishable from SIDS
Stamping, kneeling, sitting astride in assaults/homicides

4. CHEST COMPRESSION
Traumatic Asphyxia
Blood is forced up into the neck veins causing
gross asphyxial signs with intense cyanosis and
congestion of the head and neck with florid
petechiae and bleeding from the nose and ears.
Internally, depending on the age of the victim
and rigidity of the ribcage, there may be no
injuries or multiple rib fractures and
crushing of the internal organs.

Positional asphyxia
Death from postural or positional asphyxia takes
place in circumstances when the victims body
assumes an abnormal position, compromising the
process of respiration
Associated with
Intoxication
Disability
Restraint

Diagnosis of exclusion

Positional asphyxia
Sustained compromise of respiration due to
Interference with the chest/diaphragm preventing normal
respiratory excursion
Occlusion of the upper airway due to sustained abnormal
positioning of the body

Positions of entrapment include

jackknife position, wedged head down,
Under fallen vehicles,
Heavily intoxicated + occlusion of airway, but no upper airway
protection
In combination with conditions of muscular weakness and/or
obesity

Restraint asphyxia
Positional asphyxia as a result of restraint
modalities
Police-public interaction
Patient restraints

No other cause for death identified

Temporal association of death with episode
of restraint

Mechanisms of death
Trachea occluded (33lb. of pressure) causing generalised
hypoxia.
Obstruction of venous return (4.4lb. of pressure) localised
hypoxia, cerebral hypoxia.
Pressure on the carotid vessels (11lb. of pressure) cerebral
ischaemia.
Vagal inhibition / pressure on the carotid sinus / sudden
sensory stimulation due to fracture of the laryngeal
cartilages cardiac arrest / arrythmia.
Possibly Phrenic nerve injury (C3,4,5), on surface of the
scalenus anterior muscle, affecting function of the diaphragm

Mechanisms of death
Immediate death
Cerebral hypoxia
Obstruction of the neck vessels

Vagal inhibition
Stimulation of the carotid sinus

Death sudden (cardiac arrest)

or in 4-5mins in uncomplicated hypoxia,
depends on individual circumstances

Mechanisms of death
Vagal inhibition / pressure on the carotid
sinus / sudden sensory stimulation due to
fracture of the laryngeal cartilages cardiac
arrest / arrythmia.
Cardioinhibitory reflex is an arterial
baroreflex controlling heart rate
Fundamental physiologic mechanism of
cardiovascular homeostasis.

Mechanisms of death
In theory - Compression of neck may cause carotid sinus
reflex
Internal carotid artery/bifurcation pressed against the spine
Carotid sinus = pressoreceptor
Baroreceptors
Reflex stimulation of the parasympathetic area of the
medulla oblongata + inhibition of sympathetic areas
Bradycardia, decrease blood pressure, vasodilatation
Circulatory failure to asystole
In practice the association between cardioinhibitory reflex
and death is difficult or even impossible to prove.

Mechanisms of death
Late death
Non fatal cerebral hypoxia
Persistent vegetative state

Thrombosis, or rupture, of neck vessels

Cerebral infarction or airway obstruction

Surgical emphysema
Trauma to air passage
Cerebral infarction or airway obstruction

How long does it take to suffer

irreversible brain damage?
Filmed sequences (Working Group Human Asphyxia)
Rapid loss of consciousness 10+/-3secs
Mild generalised convulsions 14+/-3secs
Decerebrate rigidity 19+/-5secs
Multiple phases of decorticate rigidity 38+/-15secs
Loss of muscle tone 1min 17+/-25secs
Isolated muscle movements end 4min 12+/-2min 29secs
Deep rythmic abdominal respiratory movements start
19+/-5secs, end 1min 51+/-30secs

How long does it take to die?

Estimate - Death occurs within 3 to 5mins of
complete respiratory arrest
But, depends on the effectiveness of the
asphyxia and the individuals underlying
natural disease
No scientific basis for this statement