Topic 5.

Asphyxial Deaths
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. 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,
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.
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. Such an increase in venous blood pressure
certainly can and does occur with some (but not all) forms of asphyxia, but it can also occur
with various natural disease states (such as heart disease) and has even been described in
association with resuscitation (CPR). 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.
There are three major categories of asphyxia, each of which has several subtypes. The first
is suffocation, where there is failure of oxygen to reach the blood. The second is strangulation,
where there is traumatic compression of the neck, including blood vessels and the airway.
Hence, with neck compression, there is lack of oxygen from airway compression and lack of
oxygenated blood being delivered to the brain due to blood vessel compression. The third is
chemical asphyxia, where oxygen can get to the blood, but poisoning of a vital cell process
prevents tissues from receiving or utilizing the available oxygen.
Suffocation
In deaths from suffocation, there is failure of oxygen to reach the blood.
There are six general forms of suffocation:
 1. Simple Asphyxia (environmental suffocation)
2. Smothering
3. Choking
4. Mechanical asphyxia
5. Positional Asphyxia
6. Combination Forms of Suffocation
Simple Asphyxia (environmental suffocation)
“Simple asphyxia” is a term that is used by some to describe a lack of environmental
oxygen. This can occur in a variety of settings. In one, a person is confined within a space that
initially contains oxygen, but is such that no additional oxygen can enter the space. With time,
the oxygen is used up by the person, without subsequent environmental replacement. Some
refer to this situation as “entrapment,” as might occur if a person becomes trapped inside of an
older refrigerator. A second setting also typically involves a relatively enclosed space, such as a
grain silo, or an underground tunnel or room. The typical scenario is that the oxygen within
these environments has been used up (by micro-organism metabolism or a chemical reaction)
or displaced by other gases. As such, there is insufficient oxygen within the local environment. If
a person enters the environment, they will typically collapse within seconds. Note that the
collapse is due to lack of oxygen, not the presence of a poison or toxin. It should be noted that
first responders (and sometimes death investigators) may be at risk in such environments.
Extreme care should be exercised when attempting to recover a body that is within an enclosed
or otherwise secluded space.
In some deaths that initially appear to be related to carbon monoxide poisoning, the
presence of a very efficient catalytic converter may prevent carbon monoxide levels from
elevating significantly. Instead, abundant carbon dioxide (not a lethal poison like carbon
monoxide) is produced and can displace oxygen, thus resulting in death.
Another variation of the “simple asphyxia” category involves a localized enclosed space
that encompasses the victim’s head/face region. The classic example involves a plastic bag over
the head. Once all the oxygen within the bag is consumed, unconsciousness ensues, followed by
death. This category overlaps, to an extent, with the next category (external airway
obstruction), particularly if the bag actually occludes the mouth and nose. Autopsy findings are
typically absent in simple asphyxia deaths. As such, scene investigation is of particular
importance in diagnosing these deaths. Petechiae are not typically observed.
Smothering (External Airway Obstruction)
Smothering occurs when there is an external, mechanical obstruction of the nose and
mouth. A variety of scenarios and objects/substances can be involved in smothering
deaths.Scenarios can be accidental, suicidal, or homicidal. Accidental smothering deaths include
young infants with external airway obstruction by large, soft bedding material (example:
face-down on an adult pillow), infants/young children with plastic bags over their heads, and
drug-abusing adolescents or adults, where they have used a large plastic bag to assist in
drug-abusing behavior. The classic “Final Exit” suicide involves a drug overdose in combination
with placing a plastic bag over the head. Homicidal smothering deaths involve someone else
covering or occluding the mouth and nose; items that can be used include pillows, bedding,
gags, hands, etc. Homicidal and accidental smothering deaths in infants frequently have no
physical findings whatsoever. In older homicidal smothering victims, there may be evidence of
face, chin, lip and intraoral (tongue, inner cheek) trauma. Facial and conjunctival petechiae may
also be seen in homicidal smothering deaths, but typically not in the accidental or suicidal
forms.
Choking (Internal Airway Obstruction)
When the external mouth and nose allow air flow, but air cannot move into (or out of) the
lungs because of an obstruction of the back of the mouth (oropharynx), the throat (pharynx),
the voicebox area (larynx), or the trachea (windpipe) and mainstem bronchi (the air tubes that
split from the trachea to supply air to each lung), then death can occur. The mechanism of these
asphyxial deaths is referred to as “choking” or “internal airway obstruction (occlusion).” Most
choking deaths are accidental, although homicidal, suicidal, and even natural cases can occur.
Accidental choking via a foreign body tends to occur in one of several general scenarios.
The first is in infants and small toddlers, where the child places something in their mouth and
subsequently chokes on it. Examples include balloons, small toys, and pieces of food. The
second is in intoxicated individuals, whose gag and other reflexes are suppressed by the
intoxicant. The usual occluding substance in such cases is food. The third scenario involves a
person with some type of underlying neurologic, psychiatric, or physical disorder that prevents
normal swallowing and/or breathing. Again, the most common obstructing substance in these
cases is food. Regarding food, a variety of types can be involved, although hotdogs and nuts are
said by some to be common. Another type of accidental internal airway obstruction death
involves the development of an allergic reaction, or “anaphylaxis”, with subsequent massive
laryngeal edema (swelling). It should be noted that frequently other non-asphyxial, systemic
mechanisms, such as markedly reduced blood pressure, are also at play in deaths due to
anaphylaxis.
An example of a homicidal choking death involves the use of a gag forcibly stuffed into a
victim’s mouth and throat. In such cases, the relative inability of the person to swallow oral
secretions likely plays a role in the mechanism of death. Cases of infanticide have been reported
where a mother stuffs tissue or other substances into the mouth/throat of her newborn.
An example of a suicidal choking death involves a person intentionally forcing themselves
to “swallow”/ “aspirate” an obstructive object, such as a balloon or latex glove.
Examples of natural death due to internal airway obstruction include infections of the
epiglottis (particularly in small children), with associated swelling and spasm of the epiglottis
and larynx, as well as the occlusion of the internal airway by tumors or hemorrhage.
 Mechanical Asphyxia (Traumatic Asphyxia)
Mechanical asphyxia is also referred to as traumatic asphyxia. In this type of asphyxial
death, pressure on the chest and/or abdomen prevents the victim from being able to expand
their chest to breath. As such, air (oxygen) cannot reach the bloodstream. Such deaths are
usually accidental. In many adult cases, petechiae are very extensive (face, conjunctiva,
anywhere on the skin above the level of compression). Examples include a person crushed
under a car or other structure, a worker crushed by the earth contained in the walls of a
collapsing trench, and a person killed in an avalanche of snow. Certain types of infant death
probably involve a mechanical asphyxial component. Cases of overlay, where a larger person’s
body (or body part) lays atop an infant, represent such a case. Petechiae are far less common in
such instances. In adult and infant cases, for the death to be solely related to mechanical
asphyxia, internal examination must not reveal the presence of other lethal traumatic injuries
(blunt force, etc.). If such injuries exist, and an element of traumatic asphyxia is also present, it
is perfectly acceptable to include both traumatic asphyxia and blunt force injuries as the cause
of the death. Occasional traumatic asphyxia cases involving marked distortion of the neck will
demonstrate extensive neck muscle hemorrhage.
Positional Asphyxia
The term “positional asphyxia” refers to cases where the victim’s neck is kinked (bent) in
such a way that breathing is compromised, or when the position of the entire body is such that
breathing is compromised. While oxygen may initially be able to reach the lungs (and blood),
the neck and/or body position either acutely or eventually leads to a reduction of lung and/or
blood oxygenation. Probably the most common scenario involves an extremely intoxicated
individual who somehow ends up in an upside-down position. Another relatively common
scenario involves persons who end up in an inverted position from which they cannot escape in
a motor vehicle collision. Very young children, the elderly, and persons with various physical
disabilities may also be at risk for such deaths. Interviewing the person who discovered the
body in these cases is of utmost importance, because the autopsy findings may be essentially
negative. Petechiae may or may not be present. Another example of positional asphyxia
involves a rollover vehicular accident, in which a vehicle occupant is suspended upside-down for
a prolonged period of time, resulting in death. Crucifixion and other ancient methods of torture
can involve a component of positional asphyxia (body position resulting in compromised
breathing).
Combination Forms of Suffocation
A variety of examples have already been provided wherein a combination of asphyxial
types play a role in death. A few additional comments will be presented here. Overlaying occurs
when a larger person’s body (or body part) lays atop an infant, usually when both are sharing a
sleeping location. Besides involving an element of mechanical asphyxia, overlaying cases may
also involve elements of positional asphyxia as well as smothering, and possibly even
environmental asphyxia (rebreathing air containing elevated levels of carbon dioxide).
“Wedging” is a term used by some forensic pathologists to describe a situation in which an
infant is trapped in-between two objects, such as a wall and a mattress or a couch cushion and
the back of a couch. Like the overlaying cases, these cases may include elements of smothering,
environmental, mechanical, and positional asphyxia. “Burking” is a term that is not frequently
encountered. It describes a situation where a victim, who is usually intoxicated, is thrown to the
ground, on their back, with the assailant straddling the victim and sitting on the victim’s
chest/abdomen. While doing this, the attacker holds their hands over the victim’s mouth and
nose. Consequently, burking is a combination of smothering and mechanical asphyxia.
Strangulation
Strangulation is a form of asphyxia characterized by closure of the blood vessels and air
passages of the neck as a result of external pressure on the neck. The neck contains two major
anatomic structures whose function and integrity are necessary for proper tissue oxygenation.
These structures are the internal upper airway (pharynx, larynx, and upper trachea) and the
blood vessels that supply oxygenated blood to the head (carotid and vertebral arteries) and
drain blood from the head (veins). With strangulation, compression of either or both of these
anatomic components may play a major role in death. A third neck component that deserves
mention is the “carotid body,” which is a specialized group of cells within the wall of the carotid
artery that, when stimulated, for example by pressure, can result in significant changes in heart
rhythm and rate, as well as blood pressure. There are three forms of strangulation:
1. Hanging
2. Ligature strangulation
3. Manual strangulation
Hanging
The term “hanging” refers to a neck compression situation where the person’s own body
weight (or part of their body weight) contributes to the compressive force on the neck. Most
hanging deaths involve a “ligature,” something that either completely or partially encircles the
neck. When the ligature only partially encircles the neck, the front (anterior) and front-sides
(anterolateral) of the neck are typically in contact with the ligature. Ligatures are usually
flexible, relatively narrow (so that pressure can be relatively focused on the neck), and fairly
sturdy.
For an asphyxial hanging death to occur, it is not necessary for the body to be completely
suspended (with feet off the ground). In fact, partial suspension hangings, in which the feet (or
other body parts) are touching the ground, are quite common. In many of these, it is likely that
the original intent of the individual was a full-suspension hanging, but because of stretching of
the ligature, the victim’s feet are actually touching the ground when the body is discovered.
There is frequently an object adjacent to the body that the victim stood upon to affix the
ligature to an overhead object. The pressure necessary to compress and totally occlude the
jugular veins is said to be around 4–5 pounds, compared to about 9–11 pounds for the carotid
arteries, around 33 pounds for the trachea, and about 66 pounds for the vertebral arteries.
As mentioned above, ligatures can be quite variable. Examples include ropes, belts,
scarves, bedsheets, clothing, shoelaces, and electrical cords, although anything that can be
looped around the neck could theoretically act as a ligature. The indented mark on the skin of
the neck, produced by the ligature, is referred to as a “furrow” mark. Frequently, the furrow
mark in a hanging death has a dry, yellow appearance, and it can be quite deep, especially in
complete suspension hangings . Occasionally, subcutaneous fat liquefies under the pressure of
the ligature and exudes through the skin. In most hanging deaths, the furrow mark is relatively
horizontal across the front of the neck, but it then angles upward (toward the point of ligature
suspension) on the sides of the neck. If a body has remained suspended for a long enough time,
intense lividity with Tardieu spots can develop in the lower extremities. If the case is a partial
suspension hanging, blanching of lividity may be evident on the portions of the body touching
the ground. Protrusion (with drying) of the tongue is another frequent finding in hanging
deaths. Petechial hemorrhages of the face and eyes are comparatively rare in suicidal hanging
deaths. In males, reflex ejaculation may occur during the hanging process. On internal neck
examination, suicidal hanging deaths rarely demonstrate neck strap muscle hemorrhage or
hyoid bone/laryngeal injury. Exceptions occur when the suicidal hanging has a significant “drop”
associated with it. For example, if a person commits suicide by hanging by using a rope tied to a
bridge railing, placing the noose end of the rope around their neck, and then jumping from the
bridge, such that the entire body weight comes to an abrupt stop when the rope tightens, there
may be evidence of internal neck injury. In fact, if the drop is of sufficient length, the
mechanism of death is more likely to be related to cervical spinal cord disruption related to a
fractured neck, rather than asphyxia. This is the desired mechanism of death in judicial hanging.
The more typical suicidal hanging death does not involve a significant body drop; instead, the
person steps off of a chair or a ladder, etc. In such cases, internal neck injury is extremely rare.
Ligature Strangulation
If a ligature is involved, the case is referred to as a “ligature strangulation” death. A
majority of such deaths are homicidal in nature; however, suicidal and accidental ligature
strangulation deaths do occur. The key in differentiating these from hanging deaths relies on the
recognition that the person’s body weight (or part thereof) did not contribute to the neck
compression.
In most homicidal ligature strangulation cases, there are ligature marks on the neck. The
perpetrator may or may not leave the ligature around the neck. Intense congestion of the skin
and tissues may be evident above the level of the ligature. Because there is frequently a
struggle involved in such cases, the ligature marks tend not to be as distinct and “simple” in
appearance as the ligature furrow marks seen with hanging deaths. There may be additional
abrasions and contusions in homicidal ligature strangulation cases as well, created when the
victim desperately attempts to pull the ligature away from the neck. Small, curvilinear abrasions
may result from the victim’s own fingernails as they attempt to loosen the ligature. In contrast
to hanging ligature marks, which generally have an upward angle toward a suspension point,
such upward angling is frequently absent in ligature strangulation cases. In fact, the ligature
marks are frequently more horizontal about the neck. Conjunctival petechiae, as well as facial
and sometimes intraoral and/or laryngeal petechiae, are frequently observed in homicidal
ligature strangulation cases. Internally, focal or multifocal anterior neck strap muscle
hemorrhage is the rule, and hyoid bone and/or thyroid cartilage injuries may be present,
particularly in older individuals, where the cartilage and bone tend to be more susceptible to
breakage.
Manual Strangulation
Manual strangulation is a form of homicidal strangulation in which the perpetrator uses
their hands to compress the neck of the victim. In such cases, ligature marks will be absent.
Frequently, there will be evidence of abrasions and contusions on the anterior and/or lateral
neck. These result from the hands of the perpetrator, as well as the hands of the victim, as they
attempt to fend off the attack. Curvilinear abrasions representing fingernail marks can be seen
as in ligature strangulation cases. Conjunctival and other petechiae are frequently present in
manual strangulation cases, and internal examination tends to reveal anterior neck injuries as
described in homicidal ligature strangulation cases. Posterior neck hemorrhage can occur in
both manual and ligature strangulation cases.
Chemical Asphyxia
The third major category of asphyxial deaths, besides suffocation and strangulation, is
called “chemical asphyxia.” In chemical asphyxia, oxygen is able to reach the bloodstream;
however, a toxin prevents either the transport of oxygen within the blood or the utilization of
oxygen at the cellular level, such that death occurs.
Carbon Monoxide
Carbon monoxide (CO) is a tasteless, odorless, poisonous gas that is lighter than oxygen. It
is produced via the incomplete combustion of carbon-containing fuels. As such, it is produced
via the operation of internal combustion engines, as well as via the burning of organic
substances. Carbon monoxide that is breathed into the lungs is able to quickly diffuse into the
bloodstream, where it binds to hemoglobin, the molecule within red blood cells that normally
binds to and transports oxygen to the tissues of the body. CO binds to hemoglobin with an
affinity that is several hundred times stronger than oxygen’s. Consequently, even if there is
some oxygen within the air that is breathed in, the CO will still bind to and “poison” the
hemoglobin, thus effectively shutting down the blood’s ability to transport oxygen to the cells of
the body. The two most common settings where carbon monoxide causes death are in cases of
automobile exhaust inhalation (usually suicidal) and in structural fires, in the form of smoke and
soot inhalation (usually accidental). Also CO-related deaths include any other type of situation
where combustion of a fuel takes place, and the exhaust/smoke is not properly expelled or the
local environment is not properly ventilated.
The most impressive autopsy finding in cases of carbon monoxide poisoning is the bright
red (sometimes called “cherry red”) discoloration of tissues. This bright red color is typically
evident in the lividity, as well as internally, involving the organs and tissues. It should be noted
that CO is not the only source of bright red lividity and tissue discoloration: such finding can
occur with cyanide, very cold temperatures, and certain other substances. If someone initially
survives CO poisoning, they may develop necrosis (death of cells) within a deep part of the brain
called the “globus pallidus,” which is part of the “basal ganglia.”
Postmortem toxicology testing is able to reliably determine the carbon monoxide level in
blood. The test, sometimes referred to as the “carboxyhemoglobin” test, shows the percentage
of hemoglobin that is bound to CO. Normally, the level is less than around 3%, while smokers
can have levels two to three times as much. In exhaust deaths, the CO levels are usually well
over 50%, frequently within the 70s. In fire deaths, the CO levels are often greater than 50%,
although in some cases the levels are less than 50%. In these cases, other toxic gases, the
absence of oxygen, coexisting thermal injuries, or underlying severe natural diseases are
probable contributing factors in death.
Cyanide
Cyanide, in a variety of chemical forms, is a deadly poison that functions as a cellular
asphyxiant. Cyanide binds to “cytochrome oxidase,” an enzyme molecule within our cells that is
required for the normal utilization of oxygen in the very important biochemical process known
as “oxidative phosphorylation.” When cyanide binds to cytochrome oxidase, the enzyme is
essentially poisoned and unable to function properly. As such, oxygen is unable to be utilized at
the cellular level, and cell death occurs.
Depending on its source, cyanide can be ingested, injected, or inhaled as a gas. Certain
preparations have an odor that is said to be “almond”-like; however, only a certain percentage
of the population is physiologically able to detect that odor. A general autopsy feature that is
sometimes noted in cyanide cases is a bright red discoloration of tissues (similar to that which
occurs in CO cases). If the cyanidecontaining substance is ingested, a frequent autopsy finding is
hemorrhage of the lining of the stomach.