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ASPHYXIA AND

WOUNDS
In Forensic Pathology
By
Dr C A Okolo MBBS, FMCPath.

Asphyxia

Suffocation
Entrapment/Environmental suffocation
Smothering
Choking
Mechanical Asphyxia
Suffocating Gases
Strangulation
Ligature Strangulation
Manual Strangulation
Chemical Aspyxiants
Sexual Asphyxia (Autoerotic Asphyxia/Death)

Wounds

Blunt wounds

Abrasions
Dating of Abrasions
Contusions
Dating of Contusions
Post-mortem Bruising
The Eyes and Eyelids
Decomposed Bodies
Lacerations
Defense wounds due

to Blunt force
Determination of whether a wound is Ante- or Post-mortem
Fractures
Wounds caused
by pointed or sharps
Stab wounds
Incised stab wounds
Incise neck wounds
Chop wounds
Therapeutic or Diagnostic wounds

Asphyxial

deaths are caused by the failure of


cells to receive or utilize 02. The deprivation
of oxygen can be partial (hypoxia) or total
(anoxia).
The classical signs of asphyxia are visceral
congestion, petechiae, cyanosis and fluidity
of blood. These are non-specific and can
occur in deaths from other causes.

Petechiae

are pinpoint haemorrhages


produced by rupture of small vessels,
predominantly small venules. Rupture appears
to by mechanical in etiology and is caused by
sudden over distension and rupture of the
vessels following abrupt increases in
intravascular pressure. These are most
common in visceral pleural and epicardium
(Tardieu spots).

In

asphyxial deaths from strangulation,


petechiae are classically seen in the
conjunctivae and sclerae.
Cyanosis is non-specific and caused by an
increase in the amount of reduced
haemoglobin. It does not become observable
until at least 5g of reduced haemoglobin is
present.

Postmortem

fluidity of blood is the result of


a high rate of fibrinolysis that occurs in rapid
deaths possibly by high agonal levels of
catecholamines.

Asphyxial deaths can be loosely


grouped into three categories:

Suffocation - This refers to deaths caused by reduction of 02


in the respired atmosphere. There is failure of 02 to reach the
blood. It can be by the following:
- Entrapment/Environmental suffocation Chinese suicide
in cars.
- Smothering mechanical obstruction of external airway
(nose, mouth) plastic bag.
- Choking mechanical obstruction within the air passages.
- Mechanical asphyxia Riot-crush, stampede snake
python.
- Mechanical asphyxia combined with smothering.
- Suffocating gases Displacement of O2. E.g. C02 and
methane.

Environmental

suffocation due to reduced


environmental oxygen.
Normal atmospheric 02 20.95%
At O2 Conc of 10 15% - Impairment in
judgement & coordination.
At O2 Conc of 8 10% - Loss of
consciousness
At O2 Conc of > 8% - Death.
At O2 Conc of 4 6% - LOC within 40 sec and
death within few minutes.

Strangulation:
This

is characterised by closure of the blood


vessels and air passages of the neck as a
result of external pressure on the neck.
There are three forms
Hanging Usually suicide, Except in Judicial
Hanging dislocation of C2 C3 veterbrae.
Ligature strangulation - Usually homicide
Manual strangulation - Usually homicide.

Cause of death instrangulation - Cerebral hypoxia secondary

to compression and thereby occlusion of the vessels supplying


blood to the brain.

Arterial supply to the brain


- internal carotids
- The vertebrates
- The small spinal arteries
- Anastomosis of branches of external carotid and subclavian
arteries

Venous drainage mainly jugular veins and cervicalis profunda


veins.

Direct pressure to the front of the neck compression of


carotids.
Lateral flexion or rotation of the neck compression of
vertebral arteries e.g. in hanging.
Compression & Occlusion of carotids LOC in 10 sec
If pressure is released regain of consciousness in 10-12 sec.

Smothering:
Asphyxia

by smothering is caused by the


mechanical obstruction or occlusion of the
external airways i.e nose and mouth.

Chemical Asphyxiants

In chemical asphyxia, inhalation of a gaseous


compound prevents utilization of O2 at the cellular
level. Common chemical asphyxiants include
Carbon Monoxide (CO) poisoning - Most common.
Hydrogen cyanide by ingestion causes asphyxia
by binding with ferric iron atom of intracellular
cytochrome oxidase.
Hydrogen Sulfide (H2S) found in sewers, sewage
plant as well as oil and chemical industries. Causes
reduction of Oxyhaemoglobin and the formation of
methemoglobin.

Sexual Asphyxia (Autoerotic


Asphyxia)
Sexual

asphyxia is principally caused by


hanging. Here, transitory anoxia is
intentionally induced to enhance sexual
arousement produced by masturbation.
Death is usually accidental and occurs most
commonly in males and is very rare.

Crucifixion:
The

victim is nailed to a cross, hands and


feet. Death is caused by shock, both
hypovolaemic and secondary to pain of
nailing plus dehydration and asphyxia.

Death By Upside Down


Suspension:
If

an individual is suspended upside down for


long enough period of time, death can result.
The mechanism of death might be either
acute cardiac or respiratory failure on
combination of both. The length of time it
takes for death to occur depends on the
health of the individual. It could range from a
few hours to a day or more

Deaths from choke or Carotid


Holds
Neck

holds are used by law enforcement


agencies to subdue violent individuals.
Rarely, one will encounter a death alleged to
have occurred due to application of either a
choke hold or a carotid sleeper hold.

Wounds:

Blunt trauma wounds.


The severity, extent and appearance of blunt
trauma injuries depend on
- The amount of force delivered to the body.
- The time over which the force is delivered.
- The region struck.
- The extent of body surface over which the
force is delivered.
- The nature of the weapon.

Blunt

force injuries fall into four categories:

Abrasions

Contusion

Lacerations

Fractures

of the skeletal system.

Abrasion
This

is an injury to the skin in which there is


removal of the superficial epithelial layer of
the skin (epidermis) by friction against a
rough surface or destruction of the superficial
layer by compression. Antemortem
abrasions have reddish brown appearance
and heal without scaring. Post mortem
abrasions are yellow and translucent with a
parchment-like appearance.

There

are 3 types of abrasion:


Scrape or brush abrasion blunt
objects scrapes off the superficial layers of
the skin leaving denuded surface.
Impact abrasions the blunt force is
directed perpendicular to the skin crushing it.
Patterned abrasion imprint of either the
offending object or intermediary material is
imprinted on the skin.

Dating of Abrasions (Histologic). In the living.


There are four stages in the healing of abrasions:
Scab formation 4-6hrs 24 hrs.
Epithelial regeneration 30-72 hrs.
Subepithelial granulation and epithelial hyperplasia
5-8 days.
Regression of epithelium and granulation tissue
12 days.

Contusions or Bruises
This

is an area of haemorrhage into soft


tissue due to rupture of blood vessels caused
by blood trauma. It may be present in skin,
and internal organs like lung, heart, brain and
muscle etc. The overlying epithelium is
intact.

Dating of Contusion

Consistent microscopic dating of contusions has


been found to be impossible. Colour change is the
most reliable method of dating:- Red-purple colouration - visible soon after bruise.
- Involution of the colour occurs as the bruise ages
with degradation of haemoglobin. Red Violet
green dark yellow pale yellow
disappearing.
NB : Contusion cannot be formed after death.

The

Eyes and Eyelids


Surgical removal of corneas or the globes of
the eyes shortly after death can result in
haemorrhage into the eyelids
undistinguishable from antemortem traumas.
Confluent haemorrhages in eyelids can occur
after death in cases of head trauma with
fracture of the orbital plates.

Lacerations

This is a tear in tissue caused by either a shearing


or a crushing force. Laceration of the skin tends to
be irregular with abraided contused margins. They
are caused by blows from blunt objects, falls or
impact or from vehicles. The appearance of
laceration may not accurately reflect the instrument
that produced it. Lacerations occur most commonly
over bony prominence e.g. head where the skin is
fixed and can more easily be stretched and torn.

Determination of whether a wound is


Antemortem or post-mortem
This is done by gross and microscopic
examination:
Haemorrhage
)
Inflammatory response
) Antemortem

Fractures
Commonly

caused by assaults and motor


vehicle accidents. Can be from direct or
indirect application of force.

Wounds caused by Pointed or


Sharp Objects
These

wounds could fall into the following


categories:
Stab wounds
Incised wounds
Chop wounds
Therapeutic/Diagnostic wounds

Stab Wounds
Stab

wounds are produced by pointed


instruments. Most are homicidal. In stab
wounds, the depth of the wound in the body
exceeds its length in the skin. The edges of
the wound in the skin are typically sharp,
without abrasion or contusion. The term
laceration is not appropriate as a laceration is
a tear in the skin caused by blunt force.

The most commonly used weapon to produce a stab


wound is a knife usually a flat-bladed, single edge
kitchen, pocket or folding knife with a 4 to 5 inch
blade. Other devices include ice picks, scissors,
screw drivers, broken glass, forks, pens and
pencils.
The force needed for a knife to perforate the skin
depends on the configuration and sharpness of the
tip of the knife. The sharper, more needle-like the tip,
the more readily it will perforate the skin. Once the
tip has perforated the skin, the rest of the blade will
slide into the body with ease except if it contacts
bone.

Depth of Stab Wounds


The

depth of a stab wound can be equal, less


or greater than the width and length of the
knife. The depth a stab wound needs to
achieve to produce life threatening or fatal
wound depends on the area of the body
stabbed.

Appearance

of Stab wound in skin


The size and shape of a stab wound in the
skin depends on the following:
- Nature of blade and knife (sharp or blunt).
- The direction of the thrust.
- The movement of the blade in the wound.
- The movement of the individual stabbed.
- The state of relaxation or tension of the
skin.

PleuraPericardiumLiverSpleenKidneyThoracic
aortaAbd aortaFemoral artery
Minimum101591219316513Maximum48453639799
310225

Parts of a single edged knife

Handle or Hilt

Back
Point

Ricasso
Spine
Grip

Guard

Edge

Stab

Wounds from Weapons other than


knives
The stab wounds in such cases have a
characteristic appearance that tallies with the
shape, length and width of the stabbing
object. Edge of broken bottle, screw driver,
forks, etc.

Identifying

the weapon
The doctor is often asked to give an opinion
as to the characteristics of the weapon used
in a killing, was it a knife, was it single or
double edged. What was the length of the
blade, the width, etc. One should be
extremely cautious in giving answer to such
questions

Incised

stab wounds:
An incised-stab wound is a stab wound that is
converted to an incised (slashing) wound.
The wounds starts out as a stab wound with
the knife plunged into the body. The knife
instead of being immediately withdrawn is
pulled toward the assailant, slicing through
the tissue, extending the length of the wound
in the skin such that the wound is now longer
than deep.

Incised

Neck Wounds
Most commonly homicidal but occasionally
accidental and rarely suicidal. The wounds
may be of varying depths and severity.
Death from incised wounds of the neck may
be due not only to exsanguinations but to
massive air embolism.
The length of time it takes to die following an
incised wound of the neck depends on
whether the venous or arterial systems are
severed and whether there is air embolism.

Physical

Activity Following a Fatal Stab

Wound
The question of whether an individual is
capable of physical activity i.e able to walk or
run away from the assailant after receiving a
fatal stab wound depends on the organs
injured, the extent of injury, the amount of
blood lost and the rapidity with which the
blood is lost. With profuse bleeding, physical
activity is limited or lost rapidly with slow
bleeding, the victim is capable of walking
away from the assailant.

Chop

Wounds
Chop wounds are produced by heavy
instruments with a cutting edge e.g axes,
machetes and meat cleavers. The
presence of an incised wound of the skin with
an underlying communited fracture or deep
groove in the bone indicates that one is
dealing with a chopping weapon.

Therapeutic

or Diagnostic Wounds
These are wounds produced by medical
personnel during the treatment of a patient.
Common examples are thoracotomy
incisions, surgical stab wounds of the chest
or abd for insertion of tubes and drains,
laparotomy incision, cut down of the wrists
etc. These must be sufficiently differentiated
from homicidal and suicidal wounds.