ASPHYXIAL DEATHS

DEATHS FROM ASPHYXIA

AND DROWNING
 Main objective: To recognize the information
needed to determine the cause and mechanism of
death from asphyxia and drowning
 Specific objectives
 To enumerate and describe the different causes of death from
asphyxia
 To determine how each of the cause of death from asphyxia be
considered: suicide, accident, homicide
 To describe what issues to consider in the investigation of
deaths from drowning
 To define the evidence to gather in the investigation of deaths
from drowning
 REFERENCES
1. Asphyxia in Simpson’s Forensic Medicine by Shepherd R, 12th ed.
(2003), p94-102
2. Immersion and Drowning in Simpson’s Forensic Medicine by
Shepherd R, 12th ed. (2003), p103-106
3. Injury and Death in Water. Chapter 9. Lecture Notes in Forensic
Medicine by Derrick Pounder, University of Dundee, p32-34.
http://www.dundee.ac.uk/forensicmedicine/notes/Lecture%20Notes
%20in%20Forensic%20Medicine%20Derrick%20Pounder%2048pa
ges.pdf
4. Bodies from Water. Lecture Notes by Derrick Pounder, Department
of Forensic Medicine. University of Dundee (1992)
5. Asphyxial Deaths. Lecture Notes, Department of Forensic
Medicine, University of Dundee.
http://www.dundee.ac.uk/forensicmedicine/notes/asphyxia.pdf
Normal Airway
ASPHYXIA
 ‘Absence of pulse’
 Describes a range of conditions for which
the lack of oxygen is considered the cause
 partial O2 lack : hypoxia
 complete O2 lack : anoxia
 Mechanism O2 lack
 Obstructive
 Non-obstructive
 ‘ASPHYXIAL’ CONDITIONS
Underlying cause of death Name

Lack of oxygen in the inspired air Suffocation

Blockage of the external orifices Suffocation/smothering

Blockage of the internal airways by obstruction Gagging/choking

Blockage of the internal airways by external pressure Strangulation/hanging

Restriction of chest movement Traumatic asphyxia

Failure of oxygen transport e.g., CO poisoning

Failure of oxygen utilization e.g., cyanide poisoning

 ASPHYXIA
 Forensic context
 obstructive in nature
 physical barrier prevents access of air to the
lungs
 obstruction can occur at any point from the
nose and mouth to the alveolar membranes
 Classical features
 air passages have been obstructed by pressure
applied to the neck or to the chest
 there has been a struggle to breathe
ASPHYXIA
 Classical features (not
diagnostic)
 Facial congestion
 Facial edema
 Facial cyanosis
 Petechial hemorrhages in
the skin of the face & the
eyes
ASPHYXIA
 Tardieu spots
 petechiae on the pleural surface of the lungs,
epicardium, thymus in children
 described in the 19th century by Prof.
Ambroise Tardieu
 NOT an infallible hallmark of asphyxia
 seen in many other conditions
 NOT INTERPRETED AS EVIDENCE OF
EXTERNAL RESPIRATORY
OBSTRUCTION
ASPHYXIA: Sequence of events
 Increased efforts to breathe
 facial congestion
 onset of cyanosis
 Deep, labored breathing or attempts at
breathing with a heaving chest
 deepening congestion & cyanosis
 appearance of petechiae if venous return is
impaired
ASPHYXIA: Sequence of events
 Loss of consciousness and possible
convulsions
 evacuation of bladder & vomiting
 Reduction in the depth and frequency of
respiration
 irreversible brain damage begins
 pupils dilate
 death
SUFFOCATION
 Conditions lack of O2 in inspired air
 deep tanks of ships: rust formation has removed O2
 farm silos containing grain
 deep wells in chalk where CO2 has accumulated
 plastic bag placed over the head, either as a deliberate
suicidal act or accidentally by children
 Quick death
 Minimal signs of asphyxia
 facial pallor (plastic bag incidents)
SMOTHERING
 Struggling victim fighting for
breath against obstructed airways
 petechiae, significant cyanosis or
congestion
 bruises & abrasions to the face,
on the lips or inside the mouth
(where lips are pressed against
teeth)
 Non-struggling victim
 difficult to diagnose smothering
 GAGGING
 Obstruction of the air passages
 cloth or soft object is pushed into
the mouth
 cloth or soft object place across the
mouth
 Initially: breathing takes place
through the nose
 As time goes: nasal mucus &
edema close to the posterior nares
& progressive asphyxia develops
 CHOKING
 Internal obstruction of the upper air passages
by on an object or substance impacted in the
pharynx or larynx
 Commonly accidental
 Causes
 inhalation of food
 dentures in adults, inhaled objects in children
 extracted teeth or blood from dental or ENT
operations in sedated or anesthesized persons
 Respiratory distress with congestion &
cyanosis of the head and face
 PRESSURE ON THE NECK
3 forms of prime forensic importance
1. manual strangulation
2. ligature strangulation
3. hanging

'Classic' asphyxial signs No asphyxial signs

Relatively slow death Sudden cardiac arrest
PRESSURE ON THE NECK:
Effects & events
 Depend on
 method used
 site(s) of
pressure
 force with
which the
pressure is
applied
PRESSURE ON THE NECK:
Effects & events
 Obstruction of the
jugular veins
impaired venous
return of blood from
the head to the heart
cyanosis, congestion,
petechiae, etc.
 Obstruction of the
carotid arteries, if
severe
cerebral ischemia
PRESSURE ON THE NECK:
Effects & events
 Stimulation of the
baroreceptor nerve endings
in the carotid sinuses (in the
internal carotid artery) vagal
inhibition on the heart
profound bradycardia
reflex cardiac arrest
 Elevation of the larynx &
tongue closes the airway
at pharyngeal level
no entry of air
MANUAL STRANGULATION
 Common mode of homicide used by a man
against a woman or child
 sometimes associated with sexual attack
 unusual for a man to strangulate another man
 women rarely strangle except as a means of
infanticide
MANUAL STRANGULATION
 May be performed by one or
both hands, from the front or
the back
 hand or hands may be applied,
loosened & reapplied over &
over again during the course of
an attack
difficulty in interpreting the
injuries on the neck
 MANUAL STRANGULATION
 External signs: abrasions,
bruises on the front & sides of
the neck
 each side of the laryngeal
prominence & just below the
jaw line
 may extend onto the upper part
of the sternal area
 fingertip bruising may be seen:
disc-shaped or oval-shaped
bruises, 0.5-1.0cm in size
MANUAL STRANGULATION
 External signs: abrasions, bruises on the front & sides
of the neck
 linear abrasions or scratches from fingernails
 assailant’s nails: vertically oriented
 victim’s nails: horizontally oriented (prise away the
assailant’s fingers)
 More prolonged pressure
 classic ‘asphyxial’ signs on the face which may
extend to the neck structures
 bleeding from nose, ears (sometimes)
 Bleeding into the posterior neck tissues
 Laryngeal damage is common
LIGATURE STRANGULATION
 Constricting band is tightened around the neck
marked congestion & cyanosis, extensive petechiae
in the face
 Types of ligature: rope, wire, string, electric &
telephone cable, scarves, stockings, pieces of cloth, etc.
 Mark on the neck will usually reflect the material
used
 wire or thin cord: deep, clear-cut mark with sharply defined
edges
 soft fabric: series of firm ridges or bands that may produce
interlacing deeper areas of bruising on the neck
LIGATURE STRANGULATION
 Ligature mark: vital piece of evidence
 Ligature taken away from victim’s neck
 mark pattern of the object
 width of the mark size of the ligature
 Ligature left on after death or if sliding friction
has occurred
 mark: brownish, dried leathery band, sometimes,
deeply sunk into the tissues
 red flare of ‘vital reaction’ on either side of the
mark
 LIGATURE STRANGULATION
 Ligature mark
 position of the mark: just above the laryngeal
prominence
 goes around the circumference of the neck
unless clothing or hair has become interposed
between the ligature and the skin
 site of crossover of the ligature mark or any
knots (front, back, side) relative position of
the assailant
 lie horizontally or at an angle
 will not have a suspension point (found in
hangings)
LIGATURE STRANGULATION
 Scratches, bruises on the neck
 caused by victim in trying to remove the
ligature
 attempts at manual strangulation prior or
following application of the ligature
 Internal injuries
 similar to those seen in manual strangulation,
but of lesser severity
 areas of bruising less localized
LIGATURE STRANGULATION
 Best treated as homicide until it is shown
conclusively not to be so
 Accidents
 Suicide events
HANGING or SELF SUSPENSION
 Form of ligature strangulation in
which the pressure of the ligature on
the neck is produced by the weight
of the body itself
 Need not be from a high point of
suspension
 ‘Classical’ signs of asphyxia
 None: in most hangings, especially
the free swinging positions
 Common: low-point hangings
HANGING or SELF SUSPENSION
 Cause of death in the hanging for judicial execution
 arrested drop of several meters complete
disruption of the cervical spine
 no asphyxial signs
 Mark on the neck in free-swinging suicidal hanging
 somewhat sloped
 does not run around the full circumference of the
neck : junction of the noose and the vertical part of
the rope of the noose is pulled upwards & away from
the skin no mark is left
 HANGING or SELF SUSPENSION
 Mark on the neck in free-swinging suicidal hanging
 apex of the triangle formed – ‘peak’ or ‘point’:
indicates the position of the junction of the noose and
the vertical part of rope
 suspension peak or point
 distinguishing feature from ligature strangulation
 Manner of death (except for judicial execution)
 Suicidal act of males most commonly
 Accidental entanglements with cords, ropes, leather or plastic
restraint harnesses
SEXUAL ASPHYXIAS
 When the most common accidental
hangings occur
 May be mislabeled as suicide or homicide
 Men
 between puberty and middle age
 Belief: cerebral hypoxia achieved by
pressure on the neck increases the sexual
experience
TRAUMATIC ASPHYXIA
 One of the purest type of asphyxia
 Fixation of the thorax by external pressure
preventing respiratory movements
 Classic signs of asphyxia (congestion, cyanosis,
petechiae) often seen in their most gross form
 florid red or blue congestion of the face and neck up
to the level of the clavicles
 extensive petechiae & ecchymoses in the eyes
TRAUMATIC ASPHYXIA
 Immobilization of respiratory movements
failure of chest expansion blood from
above the chest unable to return to the heart
marked rise in venous pressure
 Injuries from the compressing agent
 if pressure has been broad – there may be no
mark of trauma
‘POSTURAL’ ASPHYXIA
 A related condition in which an
unconscious or disabled person lies with
the upper half of the body lower than the
rest (e.g., drunk who slides out of bed so that his head is on the
floor)
 abdominal viscera is pushed up against and
splint the diaphragm death
 A slow process marked cyanosis,
congestion, petechiae in the face, neck
TRAUMATIC ASPHYXIA
POSTURAL ASPHYXIA
Police officer or prison guard force prisoner to the
ground and kneel on or somehow press on their
thorax

Difficulty in raising some of the prisoner’s body weight

with his respiratory muscles to breathe
+
Additional pressure of another pressing his chest

Asphyxial death with minimal or absent signs

POSTURAL ASPHYXIA
CHOKING: Café coronary
 Entry of food into the airways during swallowing
choking symptoms of coughing, distress &
cyanosis
 fatal unless the obstruction is cleared by coughing or
some rapid treatment
 Food large enough to occlude the larynx
breathing, speech, coughing, are prevented
 rapid & silent death
 cause of death in unknown until the autopsy
café coronary
UNCHOKING MANEUVERS
IMMERSION & DROWNING
BODIES RECOVERED FROM WATER

 Died of natural causes before entering the

water
 Died of natural causes while in the water,
having entered the water either voluntarily or
accidentally
 Died of injuries or other unnatural cause
before entering the water
 Died from exposure & hypothermia in the
water
BODIES RECOVERED FROM WATER

 Died of injuries after entering the water

 Died from submersion, but not
drowning
 Died from true drowning as a result of
aspiration of water into the lungs
SIGNS OF IMMERSION
 Unrelated to drowning
 any body, whatever the cause of death, will show signs
of immersion if left for a sufficient time in water
 ‘Washerwoman’s fingers’
 develop after a few hours in cold water (shorter time in
warm water)
 maceration: skin of fingertips, keratin layers of palms &
soles white, wrinkled
 Separation of macerated skin after a few days
 Skin peels off hand & feet within 1-2 weeks
SIGNS OF IMMERSION
 Signs of decomposition of the body
 after 1 week: bloating of the body; face, abdomen,
genitals will be distended with gas
 after 2 weeks: skin, hair become loose & will begin to
detach
 adipocoere
 Time at which bodies immersed will float to the
surface
 variable
 dependent on the extent of gas accumulation & on
the body weight
SIGNS OF IMMERSION

 Post-mortem artefactual damage, effects

of predators increase rate of
decomposition
 Post-mortem artefactual injuries
 must be differentiated from ante-mortem
injuries that may be evidence of criminal
violence
 e.g., parallel sliced lacerations from rapidly
revolving propeller of a motorboat
DROWNING
 Death secondary to asphyxia while immersed in a
liquid, usually water, or within 24 hours of
submersion(Shepherd S, Martin J. Submersion Injury, Near Drowning, www.emedicinehealth.com/)
 Effects of drowning depend on type of water
 Fresh water drowning
 Seawater drowning
 Water in the lung/alveolar spaces deprivation
of oxygen hypoxia
 Post-mortem findings, on external observation or
at autopsy: variable mode of death difficult to
prove at post-mortem
AIRWAY
DROWNING (CLASSIC):
5 Stages
1. Submersion  struggle  exhaustion 
drowning starts
2. Holding breath  CO2  stimulates
respiration  inhalation
3. Gulping of water  coughing, vomiting  loss
of consciousness
4. Profound unconsciousness, convulsions with
involuntary respiratory movements & aspiration
of water
5. Respiratory arrest & heart failure
Bodies from Water. Lecture Notes. Dept. of Forensic Medicine, Univ. of Dundee
 DROWNING
Initial gasping, aspiration
Hyperventilation

Voluntary apnea

Laryngospasm

Hypoxemia
Acidosis

Cardiac arrest
CNS ischemia

Maintained laryngospasm
(10-20%)

W ater does not enter the lungs

("DRY DROW NING")

Relaxation of the airway

W ater enters lungs

("W ET DROW NING")
DROWNING

 Froth at the mouth and nostrils, may be

blood-tinged
 froth fills the air passages
 composed of water containing plasma protein &
surfactant that has been whipped into a froth by
the violent terminal respiratory actions
 more common is seawater drowning
 may be absent if the body has been dead for
some time
DROWNING

 Internally
 froth may be found in the trachea &
bronchi disappears as decomposition
begins
 autopsy: overdistended lung which my
have a ‘doughy’ texture, remain inflated
and spongy to touch
DROWNING

 Internally
 sand, silt, weed, other foreign matter in
the airways
 may constitute proof of immersion during life
 + large quantities of water & debris in the
stomach: strongly suggests immersion during
life
 absence of water in the stomach suggests
either rapid death by drowning, or death prior
to submersion
DROWNING

 Mechanism of death in persons who die

as a result of submersion is not always
classical drowning.
 majority of cases die quickly
 mode of death: cardiac arrest
DROWNING

 Laboratory tests for drowning

 diatom test – may provide corroborative evidence
of death by drowning
 NO universally accepted diagnostic laboratory
tests
 Forensic pathology
 water in the lungs = victim was still alive during
drowning
 absence of water in the lungs = “dry drowning” or
death prior to submersion
INVESTIGATION

 Questions to answer
 Was the victim alive or dead when he/she
entered the water?
 Is the cause of death drowning? If not,
what is the cause of death?
 Why did the victim enter the water?
 Why was the victim unable to survive in
the water?

Bodies from Water. Lecture Notes. Dept. of Forensic Medicine, Univ. of Dundee
INVESTIGATION

 Correlate the following information

 Circumstances preceding the death
 Circumstances of recovery of the body
 Autopsy findings
 To consider the circumstances revealed by the
investigation
 To determine if the autopsy findings are
consistent with those circumstances

Bodies from Water. Lecture Notes. Dept. of Forensic Medicine, Univ. of Dundee