A case report of Traumatic Asphyxia

Journal of College of Medical Sciences-Nepal, 2014, Vol-10, No-3 A case report of Traumatic Asphyxia Sah B1, Yadav B.N.2, Jha S.3 Assistant Professor, 2Professor, 3Additional Professor, Department of Forensic Medicine & Toxicology B.P. Koirala Institute of Health Sciences, Dharan. 1 ABSTRACT: Traumatic asphyxia is a condition presenting with cervicofacial cyanosis and edema, subconjunctival hemorrhage, and petechial hemorrhages of the face, neck, and upper chest that occurs due to a compressive force to the thoracoabdominal region. In this case report a 52 years old lady who was brought to the mortuary because of death due to traumatic asphyxia as a result of being stampeded by her own cows upon her chest was discussed. Congestion on both the conjunctiva, cyanosis on chin and adjacent upper left side of neck found with a well demarcated area observed between the cyanosed area over face and the normal area of neck. Hematoma was present in the chin and the adjacent neck region. Apart from quickly eliminating organ pathologies and initiation of supportive therapy in a case of traumatic asphyxia, possibility of formation of hematoma in neck after few hours of getting injured should also be considered, as this type of hematoma may contribute to the cause of death. Keywords: Autopsy, Cyanosis, Hematoma, Stampede, Traumatic asphyxia INTRODUCTION Traumatic asphyxia is a rare condition presenting with intrathoracic pressure just at the moment of the event. cervicofacial cyanosis and edema, subconjunctival The fear response, which is characterized by taking hemorrhage, and petechial hemorrhages of the face, and holding a deep breath and closure of the glottis, neck, and upper chest that occurs due to a compressive also contributes to this process1, 4 This back pressure force to the thoracoabdominal region . It was first 1 is transmitted ultimately to the head and neck veins reported by Olivier approximately 170 years ago in and capillaries, with stasis and rupture producing victims trampled by crowd in Paris 2, 3. Although the characteristic petechial and subconjunctival exact mechanism is controversial, it is probably due to hemorrhages 4. Traumatic asphyxial deaths can occur thoracoabdominal compression causing increased in variety of situations, such as motor vehicle accidents, Correspondence: Dr Bikash Sah railway-related fatalities, elevator accidents, buildings E-mail: [email protected] 51 Journal of College of Medical Sciences-Nepal, 2014, Vol-10, No-3 collapse, landslides and stampede. However, motor was immediately resuscitated but could not be saved. vehicle accidents are the most common cause of Postmortem examination was conducted 2 traumatic asphyxial deaths . In patients with traumatic approximately 8 hours after her death. Death in this asphyxia, injuries associated with other systems may case was because of traumatic asphyxia contributed also accompany the condition. Jongewaard et al. by neck hematoma. She was not known to have been reported chest wall and intrathoracic injuries in 11 suffering from any diseases that could have either patients, loss of consciousness in 8, prolonged caused or contributed to death. confusion in 5, seizures in 2, and visual disturbances in 2 of 14 patients with traumatic asphyxia 5. In this case report a female patient with traumatic asphyxia because AUTOPSY FINDINGS of being stampeded by her own cows was discussed. Autopsy examination revealed distinct cyanotic, edematous, and multiple petechiae on the chin, upper left side of neck of the victim. Bilateral subconjunctival CASE HISTORY hemorrhage was detected. A well demarcated area In this case report, a 52-years-old female who was was observed between the congested area over face brought to the mortuary after death due to traumatic and the normal area of neck along with linear abrasion asphyxia was discussed. From the anamnesis of the present on the left side of mid neck region (Figure 1). patient, the lady was stampeded by her own cows on Left seventh, eighth, ninth and tenth ribs were fractured. the evening of 9th March 2014. As per eyewitnesses, Internally, hematoma was present in the chin and the the mishap took place when she was about to put adjacent neck region; the lungs were congested and fodder for the cows. One cow suddenly turned her cut surface revealed oozing of frothy blood. The rest head and tried to hit the lady by her horns. Sensing of the internal organs were unremarkable. something wrong, the lady suddenly turned and tried to run away to save herself. However, due to sudden turning, she lost her balance and fell near the legs of the cow. Three cows eventually stampeded upon her. She was then rescued and brought to the hospital (BP Koirala Institute of Health Sciences). As per her relatives, she was declared normal by the clinical examinations and radiological investigations (X-rays and Ultrasonography) done by the attending doctor and because of no any organ pathology being detected, she was suggested to go back home the same day but because of request from the relatives, she was kept in Figure 1: Linear abrasion in the mid of the neck observation for that day. Next morning at about 9 am, and contusion in the chin region. she was not responding to the attending nurse. She 52 Journal of College of Medical Sciences-Nepal, 2014, Vol-10, No-3 DISCUSSION the subclavian vein 11, 12. The VVs along with the deep cervical veins (DCVs) represents the major non-jugular Traumatic asphyxia is a rare condition presenting with cerebrovenous drainage pathway. VV is formed in cervicofacial cyanosis and edema, petechial, and suboccipital triangle from where it goes through the subconjunctival hemorrhages of the face, neck, and canal formed by the foramina transversaria of cervical upper chest that occurs usually due to a compressive vertebra to open at the root of neck into the force to the thoracoabdominal region but has also been brachiocephalic vein. The DCV is also formed in the associated with asthma, paroxysmal coughing, suboccipital region and ends in the lower part of VV.12 protracted vomiting, and jugular venous occlusion 6, 7. However, for these signs to be present, the following Regarding the function of craniocervical venous valves, two processes should occur simultaneously 8. The first it has been proved that competent valves of the IJV 13, is mechanical reflux of blood from chest into EJV 14 and VV15 prevent the retrograde flow of cephalic cervicofacial region. The second is vasomotor paralysis venous blood in these veins. However, the sudden due to pressure on thoracic sympathetic nerves resulting thoraco-abdominal compression in traumatic asphyxia in distension of vessels with desaturated blood. causes acute incompetence of these valves resulting in Additionally, reflex closure of glottis, which occurs to characteristic venous discoloration of the head and brace against the impending force as the victim has neck. In contrast to this, the congestion and petechiae warning of being crushed 9, 10 , also augments the venous are not seen over lower body due to the inferior vena reflux. The venous reflux into cervico-facial region cava compression as a result of Valsalva maneuver occurs through the competent venous valves of the produced subsequent to pre-impact fear response 16. internal jugular veins (IJVs), external jugular veins In the present study, the case showed unusual facial (EJVs) and vertebral veins (VVs). Thus for better congestion in the form of involvement of chin and comprehension of cervico-facial congestion and adjacent neck region especially in the upper left neck petechiae, description of anatomical pathway of the region only. The reason for such left sided neck IJV, EJV, VV and function of valves is undertaken. congestion may be due to compression of chest on left The IJVs are considered to be the main pathways of side. However, it showed well demarcated area blood drainage from the brain, the superficial part of between the congested area and normal area. This the face and the neck. It begins at the base of skull and demarcation is characteristic of venous congestion then runs down the side of the neck along the carotid caused by circumstances that are compatible with artery. At the root of the neck, IJV unites with the traumatic asphyxia such as entrapment beneath or within subclavian vein to form the brachiocephalic vein, which motor vehicles, or under heavy objects 17. Abrasion meets the superior vena cava. 11, 12 The EJVs mainly present in the left side of mid neck region suggest the drains the scalp and the deep part of face. It begins congestion in the chin and upper left neck region might near the mandibular angle, and then descends from be due direct trauma also. However, the congestion is the mandibular angle to the mid-clavicle superficial to at higher level than abrasion that is at the traumatic the sternocleidomastoid. At the root of neck it ends in site. 53 Journal of College of Medical Sciences-Nepal, 2014, Vol-10, No-3 In this case, all the clinical examinations and REFERENCES investigations revealed no any abnormality that may 1. lead to death. However, death occured within 24 hours Richards CE, Wallis DN., Asphyxiation: a review. Trauma 2005;7:37–45. of declaring that she was alright. The cause of death as per postmortem examination was found to be traumatic 2. asphyxia contributed by compression of trachea by Conroy C, Stanley C, Eastman BA. Asphyxia: a rare cause of death for motor vehicle crash occupants, Am J upper neck haematoma. The reason behind Forensic Med Pathol 2008;29:14–8. undetectable neck haematoma found at postmortem 3. examination, by ultrasonography might be due to USG Lowe L, Rapini RP, Johnson TM. 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