Chapter 3

Asphyxia
Summary
The mechanism of death in asphyxia is impairment of oxygen and carbon dioxide exchange.
Mechanical asphyxia (i.e., physical interference with breathing and/or circulation) is frequently
encountered in medicolegal death investigations. Although the presence of external and internal
petechiae is considered a hallmark of an asphyxial death, this finding is not invariable in different
types of mechanical asphyxia. Consequently, debate continues about the relative roles of impaired
breathing and circulation in the formation of petechiae. Hanging is a common type of mechanical
asphyxia, occurring under various circumstances, some unusual. A range of external and internal
postmortem findings is observed. Other types of mechanical asphyxia can have more subtle physical
signs stressing the importance of the systematic approach of the “complete autopsy” in these cases.
In deaths caused by inhalation of toxic gas (e.g., carbon monoxide), confirmation of the cause of
death is only by toxicological testing.

Key Words: Asphyxia; petechiae; carbon monoxide.

1. INTRODUCTION
1.1. Mechanisms of Asphyxia
The word asphyxia is of Greek derivation and means “a stopping of the pulse” (1).
Any death is asphyxial in nature, but in a forensic pathology setting, asphyxia means
interference with the exchange of oxygen and carbon dioxide in the body (1).
Interference of oxygen and carbon dioxide exchange can be by mechanical means
(mechanical asphyxia). Obstruction to airflow can occur at any level from the nose and
mouth down to the alveoli (anoxic anoxia [2]). In cases of neck compression, laryngo-
tracheal obstruction and occlusion of the posterior pharynx by displacement of the
tongue are possible but are not the only reasons for asphyxia (3–5). Ligature placement
has been observed above tracheostomy sites of hanged individuals (6,7). Also, vomitus
is seen in airways of suicidal hanging cases (3). Compression of the neck causes vascu-
lar constriction. Narrowing of the carotid and vertebral arteries decreases flow of oxy-
genated blood to the brain; compression of the jugular veins diminishes flow of carbon

From: Forensic Science and Medicine: Forensic Pathology of Trauma:

Common Problems for the Pathologist
By: M. J. Shkrum and D. A. Ramsay © Humana Press Inc., Totowa, NJ

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66 The Forensic Pathology of Trauma

dioxide and waste metabolites from the brain (stagnant hypoxia [2]). The amount of
force required to compress neck structures has been determined experimentally: jugu-
lar vein, 2 kg (4.5 lb); carotid artery, 5 kg (11 lb); trachea, 9 kg (20 lb); and vertebral
artery, 30 kg (66 lb [8]). These observations imply that venous flow is decreased before
arterial and airway obstruction occur (3). The loss of consciousness due to venous
obstruction leads to loss of muscle tone and consequent flaccidity, allowing more pres-
sure on the neck and narrowing of the carotid artery and airway (3). Impairment of
breathing by hindering chest wall movement is also a type of mechanical asphyxia.
Abnormalities of inspired air cause asphyxia. Lack of oxygen is another form of
anoxic anoxia. Inhalation of noxious gases (chemical asphyxia) leads to either impaired
interaction between oxygen and hemoglobin, i.e., anemic anoxia (e.g., as a result of carbon
monoxide inhalation) or the inability of tissues to utilize oxygen, i.e., histotoxic anoxia
(e.g., caused by cyanide; see Subheading 3.9.; Chapter 4, Subheading 4.1., and ref. 2).

1.2. Classification of Mechanical Asphyxia

The following is a classification of mechanical asphyxia based on the level of
obstruction:
• Smothering (suffocation)—gagging (mouth and nose).
• Choking (mouth, oropharynx, larynx).
• Strangulation, including hanging (neck including larynx, trachea, and major blood
vessels).
• Positional asphyxia (neck).
• Drowning (upper and lower respiratory tract).
• Traumatic asphyxia—overlaying (chest).
• Wedging—interposition (chest).

1.3. Asphyxial Stigmata

Certain external and internal postmortem findings have been associated with
asphyxia but are nonspecific:
• Cyanosis (purple discoloration of nailbeds and face, including lips and earlobes).
• Fluidity of blood.
• Pulmonary congestion and edema.
• Dilation of right ventricle (see Subheading 1.5.).
• Petechiae on serosal surfaces (epicardium, visceral pleura) and certain organs (e.g., thy-
mus; see Heading 6 and Fig. 1). Care must be taken in interpretation of apparent
petechiae on the pleural surface. Subpleural petechiae may appear or disappear during
the course of an autopsy. The latter occurs when the lungs have been removed from the
mediastinum. “Pseudopetechiae” can also be misinterpreted. These can be the result of
engorged venous channels in the pleura, small areas of thickened pleura, or subpleural
collections of carbon pigment (9).

1.4. Neck Compression and Petechiae

A petechia is a pinpoint, nonraised, round purple or red spot (<2 mm or 0.125 in.) that
results from capillary rupture (10). Areas of the body lacking relative tissue support are
prediposed to petechiae (11). Various nonasphyxial mechanisms can cause petechiae (e.g.,
widespread cutaneous and visceral petechiae in fulminant infections such as meningococ-
cemia associated with direct capillary damage and consumption coagulopathy [10]).