Asphyxia

Asphyxial deaths are caused by the failure of cells to receive or utilize oxygen.
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 nonspecific, however, and can occur in deaths from
other causes. Visceral congestion is due to obstructed venous return and capillovenous
congestion. The latter is a result of the susceptibility of these vessels
to hypoxia, with resultant dilatation of the vessels and stasis of blood.
Petechiae are pinpoint hemorrhages produced by rupture of small vessels,
predominantly small venules. Rupture appears to be mechanical in
etiology and is caused by sudden over distention and rupture of the vessels
following abrupt increases in intravascular pressure. 1,2 These are most common
in the visceral pleura and epicardium. In asphyxial deaths from strangulation,
petechiae are classically seen in the conjunctivae and sclerae.
Petechiae, as nonspecific markers,1,2 may be seen in the conjunctivae and
sclerae in association with many different conditions, not all fatal, and not
just in asphyxial deaths. They are routinely seen in the reflected scalp in all
types of death and are of no diagnostic significance in this area. Petechiae of
the epiglottis are also of no significance. Gordon and Mansfield documented
development of epicardial petechiae after death. 2
Petechiae can develop after death in dependent areas of the body e.g., an
arm hanging over the side of a bed. Here, gravity causes increased intravascular
congestion and pressure with resultant mechanical rupture of small vessels. If
the petechiae become larger or confluent, they are called ecchymoses.
Cyanosis is, of course, nonspecific and caused by an increase in the amount
of reduced hemoglobin. It does not become observable until at least 5 g of
reduced hemoglobin is present. Postmortem fluidity of blood is not characteristic
of asphyxia or any cause of death, but rather the result of a high rate of fibrinolysis
that occurs in rapid deaths, possibly by high agonal levels of catecholamines. 3
Asphyxial deaths can be loosely grouped into three categories:
1. Suffocation
2. Strangulation
3. Chemical asphyxia
These deaths might be accidental, suicidal or homicidal in manner. Compared
with other causes of homicide, homicides via asphyxia are relatively
uncommon in the U.S. They predominantly involve strangulation — manual
and ligature strangulation. In the last ten years, murders ascribed to strangulation
have averaged 286 a year, with a range of 366 to 211. There seems
to have been a gradual decrease in the number of such cases over the years.
Murders caused by “asphyxiation” (no further description but excluding
strangulation) have averaged 107 a year, with this number being fairly constant
over the ten-year period.4
Suffocation
In deaths from suffocation, there is failure of oxygen to reach the blood.
There are six general forms of suffocation:
1. Entrapment/environmental suffocation
2. Smothering
3. Choking
4. Mechanical asphyxia
5. Mechanical asphyxia combined with smothering
6. Suffocating gases
Entrapment / Environmental Suffocation
In suffocation by entrapment or environmental hazard, asphyxia is caused
by inadequate oxygen in the environment. These deaths are almost exclusively
accidental in nature. In
entrapment
, individuals find themselves trapped in
an air-tight or relatively air-tight enclosure. Initially, there is sufficient oxygen
to breathe. However, as respiration continues, they exhaust the oxygen and
asphyxiate. The best example of this is a child trapped in a discarded refrigerator.
Fortunately, this specific form of death by entrapment is becoming
rare, as modern refrigerators do not have a latch system of locking and can
be pushed open from the interior. Suicide and homicide by entrapment are
rare, but do occur.
In
environmental suffocation
, an individual inadvertently enters an area
where there is gross deficiency of oxygen. This deficiency is not due to
displacement of the oxygen by suffocating gases, which will be discussed in
another section, but rather that the oxygen has been depleted by some mechanism.
Thus, the authors reported two deaths caused by lack of oxygen in
an underground chamber.5 The normal percentage by volume of oxygen in
the atmosphere is 20.946%. In this particular case, the percentage by volume
was 9.6%. This lethal atmosphere was caused by fungus-like organisms and

low forms of plant life present on the vault walls and in the sediment on the
floor. The metabolic processes of the fungi and plant life resulted in depletion
of oxygen by these organisms, with production of carbon dioxide. Thus,
carbon dioxide, which is normally 0.033% in air, in this case, was 7.0%. The
increased quantity of carbon dioxide, however, was insufficient in itself to
have caused death by displacement of oxygen. It was the absolute lack of
oxygen that caused death. At oxygen concentrations of 10 to 15%, there is
impairment in judgment and coordination. Loss of consciousness occurs at
8 to 10%; death at 8% and less. At oxygen concentrations of 4 to 6%, there
is loss of consciousness in 40 sec and death within a few min.
In deaths due to
entrapment or
environmental suffocation, the cause
of death cannot be determined by autopsy alone, because there are no specific
findings.
All that one finds is nonspecific acute visceral congestion. It is only by
an analysis of the circumstances leading up to and surrounding death, and
the exclusion of other causes, that one can make a determination as to the
cause of death.
Smothering
Asphyxia by smothering is caused by the mechanical obstruction or occlusion
of the external airways, i.e., the nose and mouth. Deaths such as these are
usually either homicide or suicide, very rarely accident (Figure 8.1).
The most common form of suicidal smothering is the placing of a plastic
bag over an individual’s head (Figure 8.1 A). If it is heavy plastic, it may be
secured at the neck. More commonly, suicides employ the thin, filmy plastic
bag used by dry cleaners. Here, there is often no necessity to secure the bag
at the neck, because it clings to the face, occluding the airways. These filmy
plastic bags also account for the rare accidental deaths by smothering when
these bags are used to cover a mattress or pillow in a crib of a young child.
The child becomes enmeshed in the bag and smothers. In all the deaths that
the authors have seen in which plastic bags have been placed over the head,
there have been no specific autopsy findings. Petechiae of the face, sclerae,
and conjunctivae were virtually always absent. Petechiae of the epicardium
or pleural surfaces of the lung were sometimes present, but these are so
nonspecific that the authors do not give any weight to them. If an individual
commits suicide by use of a plastic bag and the bag is removed prior to
notification of the authorities, a medical examiner cannot determine the
cause of death by the autopsy.
There are occasional allegations of infants smothering in their cribs because
of heavy blankets or bedding placed over them. The authors feel that these
cases are examples of sudden infant death syndrome (SIDS) and that it is just
coincidental that they are found covered by bed clothes. One can pile a number
of blankets on an infant without causing any respiratory difficulty

Occasionally, an alcoholic is found face down on a pillow, dead. Circumferential

oral and nasal pallor is noted and death is attributed to
smothering. This pallor, however, can be caused post mortem by passive
pressure of the dependent head on the pillow. Thus, the diagnosis cannot
be made on this “evidence.” The authors have grave reservations about this
diagnosis. An individual would have to be in an alcoholic coma to smother
this way. Alcoholic coma, however, puts them in grave danger of death
anyway and this is more likely the cause of death, rather than the alleged
suffocation.
Accidental smotherings can occur with defective cribs. Here, an infant
is trapped either between a too-small mattress and the frame of the crib, or
between a defective crib and mattress, with the face wedged against the
mattress (Figure 8.2). The child is unable to move and smothers.
Gags obstructing the nose and mouth can cause death by smothering.
Such deaths, though unintentional, are still homicides if the victims die
during the commission of a crime. Typically, a gag is placed around the face
obstructing the mouth and nose (Figure 8.3). Victims are usually elderly
individuals who are either unable to struggle sufficiently to move the gag or
who are unusually susceptible to the anoxia by virtue of natural disease.
Mucus and fluids may accumulate in the nasal cavities and airways, contributing
to asphyxia. In the elderly, there may be congestion of the face withscattered fine petechiae of the
sclerae, conjunctivae, and skin of the face. This
has not been the case in young individuals in whom petechiae are usually
absent. It is the discovery of the gag obstructing the airways that makes the
diagnosis, not alleged signs of asphyxia.
In homicide by smothering, the implements used are usually pillows,
bedding, and the hands. Infants may be placed in plastic bags. The victims
tend to be very young, very old, debilitated, or incapacitated by restraints,
disease or drugs. It is extremely difficult to smother adults in full control of
their faculties.
When a pillow is used, it is placed over the face and pushed down. This
causes obstruction of the nose and mouth, asphyxia, and death. There are
usually no marks on the face. The face is not congested and there are no
petechiae of the sclerae or conjunctivae (Figure 8.4). Abrasion injuries of the
face will occur only if the victim puts up a vigorous resistance. In a review
of 15 smothering deaths involving children below the age of 2 years, of the
13 who could be evaluated for the presence of petechiae, only one had
findings. This child had a single petechia of the conjunctiva and a single area
of scleral hemorrhage. Because of the circumstances of this case, there was
the possibility that the child might also have been choked. Pushing the face
into the bedding will accomplish the same end as using a pillow.
Smothering can also be accomplished using the hands. The nose is
pinched off with one hand, while the other hand is used to push the jaw closed.
In small children, one hand can accomplish both these tasks. In infants and
adults unable to put up any effective resistance, an autopsy will fail to disclose
any injury due to this process. In adults, even those who can muster only a
minimal struggle, there may be abrasions on the nose or chin from the fingernails,
and contusions of the lips from pressure of the palm (Figure 8.5).
The sequence of physiological events in smothering is:
• Bradycardia (decrease in heart rate)
• Decrease in respiration to agonal gasps with eventual cessation of
respiration
• Slowing and finally flattening of the electroencephalogram (EEG)
The heart will continue to beat even after flattening of the EEG. In infants,
bradycardia has been observed to start 30 sec after the initiation of smothering,
and flattening of the EEG at 90 sec.6 If, after cessation of respiration,
the pillow or hand is removed from the face, respiration will not usually
restart spontaneously. The individual must be resuscitated. Violent struggles
with increased utilization of oxygen can speed up this sequence of events,
just as natural disease could make the individual more susceptible to the
effects of hypoxia