Asphyctic Deaths – Overview and Pathophysiology

CM Milroy, University of Ottawa, Ottawa, ON, Canada

ã 2013 Elsevier Ltd. All rights reserved.

Glossary Valsalva maneuver Forceful exhalation against a closed

Sphygmomanometer Equipment to measure blood upper airway.
pressure.

Introduction these findings has led to inappropriate diagnoses of deaths from

asphyxia.
Asphyxia is a very commonly used term in medicine, and Petechiae have been stated to be associated with raised
particularly forensic medicine, though the characteristics that intravascular pressure, hypoxia, and raised carbon dioxide. Of
are used to diagnose asphyxia are poorly defined and often these mechanisms, only raised intravascular pressure has any
absent in cases of classic ‘asphyxia.’ The term asphyxia derives scientific evidence to support it, in the absence of a bleeding
from ancient Greek and etymologically means absence of the diathesis. Raised intravascular pressure accounts for why they
pulse (sjugmόB – sphygmós). (Sphygmomanometer has the are seen in compression of the neck, coughing, retching, and
same origin.) However, it has come to mean deaths associated similar acts that raise venous pressure, but not, for example, in
with deprivation of oxygen. While most deaths will ultimately most smothering deaths or suffocation. In compression of the
result by starvation of oxygen to vital organs, ‘asphyxial’ deaths neck, one of the common scenarios that petechiae are seen in,
are separately classified in Forensic Medicine. Different texts they result from obstruction of the venous return with contin-
have classified asphyxial deaths into different ways, so there is ued arterial pressure, resulting in engorgement of the vascular
a lack of uniformity in definition. system and rupture of venules resulting in petechiae appearing.
Although petechiae are sometimes said to arise from rupture
of capillaries, it has been pointed out that these structures are
too small to result in macroscopically visible hemorrhage.
Signs of Asphyxia The most common places to observe petechiae are in the
conjunctivae, in the external eyelids, on facial skin, behind
Asphyxial deaths have been associated with specific patholog- the ears, and on the mucosal surface of the oral cavity.
ical findings. Classically, the literature has reported five so- Petechiae are invariably seen on the inside of the scalp
called signs of asphyxia as follows: following reflection at autopsy. These subscalp petechiae are
an artifact of dissection and are not diagnostic of anything.
1. Congestion
In deaths where there has been a head down postmortem
2. Cyanosis
position, the scalp, face, and neck can become very congested,
3. Fluidity of blood
and petechiae and confluent areas of bleeding may be seen.
4. Dilatation of the right side of the heart
Artefactual bleeding may be seen in the neck, even with careful
5. Petechiae
dissection after draining the blood.
None of these signs is specific and is so commonly found in
nonasphyxial deaths and absent in asphyxial deaths that they
have been referred to by Lester Adelson in a memorable quote
Mechanisms of Asphyxia
as the obsolete quintet.
Of these signs, congestion and cyanosis are almost universal
In classifying deaths from asphyxia, rather than referring to
findings to a greater or lesser degree in most autopsies. Fluidity
deaths from asphyxia, a more accurate approach is one where
of blood has long been shown to correlate with the rapidity of
the mechanism of the production of asphyxia is described.
death rather than whether there has been deprivation of
The deaths that fall into the category of ‘asphyxia’ deaths
oxygen or dilation of the right side of the heart is a nonspecific
can be broadly categorized as follows:
and subjective finding.
Of Lester Adelson’s obsolete quintet, petechiae merit some 1. Suffocation (breathing in a nonviable environment)
discussion as the mechanism of their causation and their sig- 2. The mechanical asphyxias
nificance has been more debated. Petechiae are pinhead-sized (a) Smothering
hemorrhages most commonly associated with compression of (b) Plastic bag asphyxia
the neck but may be seen in natural deaths including cardiac (c) Choking
disease. Petechial bruising describes a separate type of appear- (d) Compression of the neck
ance to a bruise. Other causes of petechiae include clotting (e) Traumatic asphyxia
disorders, coughing, retching, and vomiting. They may be seen (f) Positional/restraint asphyxia
in internal organs, typically in thoracic organs. Over-reliance on (g) Drowning

Encyclopedia of Forensic Sciences, Second Edition http://dx.doi.org/10.1016/B978-0-12-382165-2.00157-4 15

16 Forensic Medicine/Causes of Death | Asphyctic Deaths – Overview and Pathophysiology

(h) Autoerotic sexual asphyxia intoxicated people or in patients with neurological disorders
(i) The ‘choking game’ that prevent adequate swallowing. Occasionally, cases are en-
3. Chemical ‘asphyxiants.’ countered where material is forced into the mouth and airway,
either by an assailant or by a self-infliction. Such acts may be
encountered in psychiatrically disordered patients and people
Suffocation determined to commit suicide, such as by stuffing a sock or
tissue paper into the throat.
The term suffocation is best reserved for cases where there has
been inhalation of a vitiated atmosphere. These deaths can
occur when a person enters an atmosphere where there is Compression of the Neck
inadequate oxygen or where the oxygen gets used up. Typical
examples include mines and silos, where there has been a Compression of the neck is a broad category of actions that
reduction in environmental oxygen and a buildup of carbon result in obstruction of the vasculature and airway. These
dioxide. Collapse can be very rapid and coworkers may die deaths are classified and described in the sections below.
when they enter the same atmosphere in an attempt to rescue
them. Characteristically asphyxial signs are absent. One case
seen by the author involved three men in the cable room of a Hanging
ship where the anchor was stored. These rooms typically have
low oxygen levels as the iron in the cable rusts and oxygen is There is a compression of the neck by suspension by a ligature.
used up in making iron oxide. A worker entered the room Hanging can be separated into short-drop and long-drop
without appropriate breathing apparatus and collapsed. His suspension. The latter, most typified by judicial execution, is
two colleagues attempting to rescue him without breathing meant to result in fracture of the neck rather than compression
apparatus also collapsed and all three died. Subsequent of the vasculature and airway, which occurs in ‘short-drop’
analysis of the oxygen level in the room showed it to be suspension. Long-drop hangings may be seen in suicides,
reduced. This illustrates that the autopsy must be interpreted such as hangings off bridges and similar structures. If the
with other information, as the autopsies did not disclose the drop is of sufficient length, decapitation may occur.
cause of death. Hanging may be achieved even though a significant part of
Another scenario encountered is when people become the victim’s body is on the ground, as there is sufficient weight
trapped in fridges or are placed in a trunk or similar closed even in the head to achieve vascular compression. There is
environment. As the oxygen is used up and carbon monoxide characteristically a parchmented ligature mark, but where
builds up, death will occur. there is a broad ligature, such as a sheet, the ligature mark
can be subtle or absent. In compression with full suspension,
petechiae are typically absent and the face appears pale. In
Smothering these cases, there is complete compression of the carotid
arteries with no blood flowing above the level of the compres-
The term smothering should be used when an external object sing force. In contrast, in partial suspension, petechaie and
has been used to obstruct the upper airway. This obstructs congestion above the level of the ligature are more commonly
normal respiration. It is often achieved with soft material and encountered.
when autopsy signs are absent. If duct tape or similar material Hanging is typically suicidal but may occur by accident or
has been used and removed, there may be adhesive material rarely be homicidal. With homicidal hanging, either the victim
still present around the mouth, which can give a clue to the is incapacitated or there is a significant disparity in strength
previous presence of the tape and other injuries possibly being between assailant(s) and victim. Rarely homicidal hanging has
present. been reported through subterfuge. Internal findings may be
absent in hanging or include bruising of the strap muscles
and fracturing of the hyoid bone and laryngeal cartilages.
Plastic Bag Asphyxia
Ligature Strangulation
Plastic bag asphyxia is a specific form of obstruction of the
upper airway. Asphyxial signs are typically absent. It may also There is a compression of the neck without suspension.
be accompanied by the administration of the irrespirable gas Petechiae more commonly occur with ligature strangulation
helium, which has been recommended as a method of suicide than hanging as the compressive force is typically slower,
by certain euthanasia supporters. allowing congestion of vessels to occur. External signs of the
ligature may be subtle where the ligature is broad. This is
commonly homicidal but may occur in suicides or by accident.
Choking Where a low suspension hanging has occurred, differentiating
ligature strangulation may be extremely difficult, where the
Choking is a term best used when there is obstruction of the person has been cut down and the ligature removed. Where a
internal airway by food or other obstructing material, though it stick or similar object is placed under the ligature and twisted
has been used for external compression of the neck. The ‘chok- to constrict the ligature, the mechanism is referred to a Spanish
ing game’ is described below. It is commonly encountered in windlass. Garroting is a special form of ligature strangulation
 Forensic Medicine/Causes of Death | Asphyctic Deaths – Overview and Pathophysiology 17

where the intention is to fracture the neck. It was used as a form injuries indicating the site of compression may be present.
of judicial execution. These deaths often have the most florid congestion and pete-
chiae of all the asphyxial death.
Manual Strangulation
This is also called throttling and occurs when the hands (hence Burking
manual) are used to compress the neck. External marks of
violence can be quite subtle, but usually finger pressure bruises Burking is a special type of asphyxial death derived from the
and abrasions from fingernails are seen. The abrasions may be activities of the early nineteenth century body snatchers Burke
from the victim’s own fingernails, where they have attempted and Hare. Burke and Hare killed 16 victims and sold the bodies
to remove the assailants compressing hands. Internally, there is for anatomical dissection. Hare turned King’s evidence (state
typically bruising in the strap muscles. Damage to the hyoid immunity) and gave a description of the method of killing. He
bone and laryngeal cartilages is more common in manual stated that Burke ‘got stridelegs on the top of the woman on
strangulation, but depends on age, with younger people having the floor, and she cried out a little, and he kept in her breath. . ..
elastic cartilage. Fractures are invariably present in people over He pressed down her head with his breast. . . He put one hand
50 years of age. under the nose and the other under the chin, under her
mouth. . ..’ External injury was absent. It is noteworthy that
Christison stated one of the victims – ‘presented the signs of
Palmar Strangulation
asphyxia – vague enough in general and in this instance
Polson describes a method of neck compression where the particularly so, because the murderers left no external local
accused denied gripping the neck but stated that he had placed marks. . .’ illustrating the problem of identifying many deaths
one palm on the mouth and another on the front of the neck, classified as asphyxia.
so that pressure is over the larynx. The victim, a 52-year-old
woman, had fractures of both superior horns and bruising in
the neck. Polson was able to reproduce the fractures on Positional and Restraint Asphyxia
cadavers.
The term positional asphyxia has been used in two main ways
in Forensic Medicine. First, it has been used in people who
Neck Holds
manage to get themselves into a position where they then
There are two basic neck holds, ‘choke’ holds and the carotid cannot properly breathe. This may be because they are intoxi-
sleeper. With the carotid sleeper, when correctly applied, the cated or are otherwise incapacitated, such as from a head
neck is held in the crook of the arm and then the arm is injury, and so cannot extricate themselves from the position.
compressed so that the carotid arteries are obstructed. When The second usage has been in deaths associated with
used in law enforcement hold and martial arts, once the person restraint. In these often controversial cases, it has been argued
has become unconscious, the hold is released. If the hold is that these deaths are not from the restraint/position the person
continued then death will result from a lack of blood supply to has been placed in, but the underlying condition that caused
the brain. The airway is supposed to be maintained with this the person to become involved in the struggle. These people are
hold. The term mugging was originally applied to this hold, typically intoxicated with cocaine or have an underlying major
though it has become a term used for any street robbery. This is psychiatric disorder and die following a struggle with law
in contrast to the ‘choke’ hold or bar hold, where either the enforcement or health care personnel. Research on healthy
forearm or a similar shaped object such as a police truncheon is volunteers has shown that placing someone on their back
placed across the neck and then forced onto the neck. This and compressing the back with a weight is equivalent to a
causes compression of the airway with collapse of the trachea person placing their knee on the back does not significantly
rather than just obstruction of the carotid arteries. alter their clinical respiratory function. It is thus argued that the
position these people are placed in does not cause their death.
One hypothesis made is that these people are dying of restraint
Traumatic (Crush) Asphyxia asphyxia. One proposed mechanism of death has been
catecholamine excess causing cardiac arrhythmia, possibly
Traumatic asphyxia, also known as crush asphyxia, occurs when combined with a degree of deoxygenation during the struggle.
there is pressure placed on the chest so that normal respiration Another evolving possibility is that these are vulnerable people
cannot occur. Traumatic asphyxia may occur when there is with associated underlying disorders such as cardiac conduc-
crushing in a crowd, as has happened in a number of sports tion and long-QT syndrome. Whether these deaths are true,
stadia disasters, such as in Hillsborough, Sheffield, UK in 1989 asphyxia deaths remains disputed. The science of these deaths
in which 96 people lost their lives. Ninety four died on the day is evolving and many of these deaths are likely multifactorial.
and only 14 of the victims arrived in hospital.
Individual cases of traumatic asphyxia may be encountered
in such scenarios as vehicular collisions, collapse of trenches, Drowning
and industrial equipment incidents.
At autopsy, there is typically prominent congestion of the Drowning can be considered a form of an asphyxial death,
upper half of the body with prominent petechiae. Other though it is separated because of the special circumstances.
18 Forensic Medicine/Causes of Death | Asphyctic Deaths – Overview and Pathophysiology

However, in wet drowning, there is obstruction of normal cyanide, there is a failure to use up oxygen, so blood remains
respiration by liquid in the airway. Dry drowning, where oxygenated. While cyanide and hemoglobin combine to form
there is no evidence of fluid present in the airway, has been a compound in vivo, which has a red color, little is produced in
proposed to be due to a reflex cardiac arrest or possibly by fatal cyanide poisoning. A similar reddening of the skin can be
laryngeal spasm. seen in bodies that have been refrigerated and where no chem-
ical asphyxiant has been administered. Hydrogen sulfide is
another chemical asphyxiant, which may be encountered. It
Autoerotic Sexual Asphyxia has the unusual feature of turning the brain green. It has been
used in suicides by combining polysulfide-containing fungi-
It is well recognized that some deaths involve sexual activity cides with a strong acid.
and restriction of oxygen supply. The victims are almost
exclusively male. The mechanisms of production of asphyxia
encompass those described above but with the intention of
producing temporary asphyxia for sexual pleasure and not Conclusions
death. They are commonly hangings, but other mechanisms
may occur, including the use of plastic bags and combined Deaths from deprivation of oxygen are one of the main mech-
with drug or volatile substance use. Bizarre mechanisms are anisms of death in forensic medicine. There are no specific
occasionally encountered and knowledge of the possibility of findings of asphyxia at autopsy. While terminology may vary
self-inflicted injury may enlighten the investigation. Sexual slightly, as long as the proposed mechanism of production of
asphyxia produced by couples may also occur. the deprivation is explained, then confusion should be
eliminated.

The Choking Game

See also: Forensic Medicine/Causes of Death: Immersion
Deaths; Strangulation.
As well as autoerotic asphyxia, induced asphyxia for nonsexual
pleasure may be seen and is known as the ‘choking game.’ This
is most commonly seen in adolescents. The mechanism of
production of asphyxia most often involves compression of
the neck or compression of the chest. Subjects may also hyper- Further Reading
ventilate and then perform the Valsalva maneuver. Adelson L (1974) The Pathology of Homicide: A Vade Mecum for Pathologist,
Prosecutor and Defense Counsel. Springfield: Charles C Thomas.
DiMaio VJ and DiMaio D (2001) Forensic Pathology. Boca Raton: CRC.
Chemical Asphyxiants Ely SF and Hirsch CS (2000) Asphyxial deaths and petechiae: A review. Journal of
Forensic Science 45: 1148–1150.
Linkletter M, Gordon K, and Dooley J (2010) The choking game and YouTube:
There are two main chemical asphyxiants encountered in A dangerous combination. Clinical Pediatrics 49: 274–279.
forensic medicine, such as carbon monoxide poisoning and Milroy CM and Parai JL (2011) Images in Forensic Pathology. Hydrogen sulphide
cyanide. These two substances may be encountered together in discolouration of the brain. Forensic Medicine, Science and Pathology 7: 225–226.
Pollanen MS, Perera SD, and Clutterbuck DJ (2009) Hemorrhagic lividity of the neck:
fires or as separate poisons. Their mechanism of depriving cells
Controlled induction of postmortem Hypostatuic hemorrhages. American Journal of
of oxygen is different. Carbon monoxide combines with Forensic Medicine and Pathology 30: 322–326.
hemoglobin to produce carboxyhemoglobin and prevents Polson CJ, Gee DJ, and Knight B (1985) The Essentials of Forensic Medicine, 4th edn.
oxygen reaching cells. In comparison, cyanide stops cellular Oxford: Pergamon.
metabolism by interfering with cytochrome c oxidase. Both are Saukko P and Knight B (2004) Knight’s Forensic Pathology, 3rd edn. London: Arnold.
Sauvageau A and Boghossian E (2010) Classification of asphyxia: The need for
associated with lividity being redder than normal. This is be- standardization. Journal of Forensic Science 55: 1259–1267.
cause of the formation of carboxyhemoglobin in carbon mon- Spitz WS and Spitz DJ (eds.) (2006) Spitz and Fisher’s Medico-legal Investigation of
oxide, which imparts a cherry red appearance to blood. With Death, 4th edn. Springfield: Charles C Thomas.