Asphyxia

Definition: Asphyxia (Greek, ‘pulselessness’ or ‘absence of pulse’) is a condition caused by interference

with the exchange of oxygen and carbon dioxide in the body.
Asphyxia literally means ‘defective aeration of blood’ due to any cause.

Hypoxia – lack of O2 at tissue level

TYPES DEFINITION CAUSES
HYPOXIC HYPOXIA Reduced oxygenation of blood Asphyxia (mechanical
↓PaO2 obstruction) – strangulation,
hanging, choking, smothering
Suffocation (lack of O2 in
atmosphere) – high altitude,
trapped in closed space, plastic
bag over head
Other causes
ANEMIC HYPOXIA reduced O2 carrying capacity of blood Anemia
Methemoglobinemia
CO poisoning
STAGNANT HYPOXIA O2 in blood cannot reach tissues CCF
Shock
Vasoconstriction
Thromboembolism
HISTOTOXIC HYPOXIA tissues cannot extract O2 from blood CN poisoning
H2S poisoning
Beriberi

Hypoxemia – lack of O2 in blood

Ischemia – inadequate blood supply
Infarction – tissue necrosis due to lack of blood supply

Modes of asphyxia
Nose and mouth Neck Suffocation
 Smothering  Hanging  Smothering
 Gagging  Strangulation  Choking
o Manual/throttling  Gagging
o Ligature
 Overlying
o Mugging
 Traumatic asphyxia
o Garroting
 Burking
Air passage Others
 Choking  Traumatic
 Drowning  Postural
 Burking
 Sexual
Pathophysiology
mechanical interference to respiration causes anoxia and
cyanosis. Cyanosis is seen under nails, lips, ears, tongue,
lungs, meninges

failure of Na+/K+ pump in endothelium due to anoxia →

↑Na+ in cell → swelling and weakening of cell adhesions →
↑capillary permeability → extravasation of fluid and edema

hemoconcentration → slow flow → congestion →

accumulation of deoxyhemoglobin → deepening cyanosis

congestion → raised venous pressure → tissues break up

capillaries and venules: petechial hemorrhages
CNS: focal liquefaction

Petechiae are found in lax, unsupported tissue – pleura (esp. on interlobular fissures & hilum),
pericardium, conjunctiva, around eyes, behind ears, undersurface of scalp, larynx, thymus

Tardieu spots: petechiae on the surface of viscera. Nonspecific feature. Also, in anaphylaxis, snake bites,
viral fevers, IHD, other congestive deaths

anoxia involves specialized tissues early and extensively (e.g. CNS)

in CNS, higher functions lost first (judgement before consciousness)

Main 4 general features of asphyxia

1. Cyanosis
2. Congestion
3. Petechiae
4. Oedema
Clinical features
Early dyspneic stage (body react to counteract asphyxia): Sympathetic activation ↑RR and depth of
respiration, BP, PR; cyanosis; eyes bulge, pupils dilate; anxiety
Late dyspneic stage (intermediate between reacting and succumbing): ↓ RR and breathing labored, BP,
PR and thread; deepening cyanosis and congestion; loss of judgement and incoordination
Apneic stage (succumbing): gasping, voiding urine & feces, irregular pulse, nose bleed, seminal
discharge, convulsions, loss of consciousness, death
Stages cannot be clearly demarcated

Postmortem features:
1. General features – common for all modes of asphyxia. Also, in electrocution, OP poisoning, CN
poisoning
2. Specific features – depend on mode of asphyxia

General features

External
Petechial hemorrhages in conjunctiva, inner aspects of lips and other areas of the skin
Conjunctiva injected
Bleeding from the nose and ears
Froth in the nose and mouth
Cyanosis is marked
Passage of stool & urine
Ejaculation

Internal

Anterior neck structures are examined at the end of autopsy—following removal of tissues and organs,
and collection of toxicology samples—to allow drainage of blood and reduce the possibility of artifactual
hemorrhage.

Incision "U" or "V" shaped made from sternal notch to the back of
each ear (also, called modified Y incision)
Darkened blood and profuse bleeding may be noted while making
the skin incision.

Chest cavity
Subcapsular hemorrhage in thymus of children
Pleural effusion (put hand into pleural cavity to check for fluid
before evisceration)

RS:
Blood tinged pleural fluid
Congested mucosa with petechiae
Froth in trachea and bronchi (due to hyperfunctioning bronchial glands)
pleura glistening due to oedema
Petechiae in pleura (interlobar fissures)
Lungs congested
Excess fluid squeezed out of lungs (pleural oedema)

CVS:
Pericardial effusion (may be blood tinged)
R heart – enlarged, fluid blood
L heart – contracted, comparatively empty
Visceral pericardium may have petechiae (on post surface of AV groove)
(subendocardial hemorrhages not usu. seen)

Abdomen:
Peritoneal effusion & congestion
Internal organs – congested (of stomach may be mistaken for irritant poisoning), edematous, petechiae,
bladder & rectum may be empty

CNS:
Cerebral oedema
Petechiae in white matter
Subarachnoid pooling of blood

Problems with estimating time of death

Errors in cooling method – struggling/convulsions raise temperature

Timing of onset of rigor also change due to above reasons

Hypostasis takes longer time to fix – CO2 enhance fibrinolysis

Early putrefaction – due to congested organs

Strangulation
Hanging
Asphyxia caused by suspension of the body by a ligature which encircles the neck
Constricting force = whole/part of the body weight

Near-hanging: Patients who survive a hanging injury long enough to reach the hospital.

Classification
1. Position of knot
a. Typical: knot at occiput in the midline of the back
of the neck
b. Atypical: knot placed elsewhere
2. Degree of suspension
a. Complete: feet off the ground (constricting force = whole weight)
b. Incomplete/partial: Lower part of the body is touching the ground (constricting force =
weight of head)

Circumstances
Suicidal
Point of suspension remains approachable to the person.
Partial hanging is almost always suicidal in nature
more common in males
A history of a previous attempt may be present, and
generally committed in a secluded place (victim’s
home is the most frequent site). Suicidal note may be left behind.

Accidental
Infants and children
Hanging deaths in children < 6 years
while ‘playing hanging’ (e.g. pretending to be a cowboy) or playing ‘Lasso’ or getting suspended from
playground equipment (swings), getting entangled in cradles
Sexual asphyxia in adults (usu. males)
Rarely occupational
Homicide:
Very rare. Not ordinarily possible in an adult victim, unless aged, intoxicated or made unconscious or the
victim is either a child or a debilitated person.
Homicide should be suspected where:
 Signs of violence/disorder of furniture
 Clothes torn or disarranged
 offensive or defensive injuries

Judicial Hangman’s fracture: when the

ligature is looped around neck
hangman’s knot is submental, death
knot under the chin (submental) or below auricle (subaural)
occurred rapidly because of fracture
drop is at least the height of the person
complete hanging of the pedicles/lamina of C2 vertebra
causes a forceful jerky impact on the neck at the end of the and a traumatic spondylolisthesis of
fall to cause fracture of cervical column the C2 over C3
(fracture dislocation of C2 from C3, rarely C3 and C4
vertebrae—hangman fracture)
stretching or tearing of cervical spinal cord; no decapitation.
A postmortem examination including a neck and spinal cord
dissection is performed subsequently.

Postmortem hanging/suspension
Person may be murdered, and body suspended to simulate
suicide.
Usu. follow homicide by manual/ligature strangulation;
death in police custody due to battery

Cause of death
1. Asphyxia:
a. Floor of the mouth is pushed up and backwards.
b. Tongue is pressed against the pharynx, obstructing the airway.
2. Cerebral ischemia:
a. Compression of the arteries supplying the brain.
b. Survivors may be in a permanent vegetative state.
3. Cerebral congestion:
a. compression of the veins and blocking the venous drainage of the brain.
b. Veins, capillaries and arteries get congested. Death is due to stagnant hypoxia.
4. Vagal inhibition:
a. Carotid bodies are compressed/stimulated
b. carotid vessels are pulled up suddenly stretching the aorta and its baroreceptors.
c. stimulation of the vagus INHIBITS the heart.
d. At PM, even a ligature mark may be absent (negative post mortem).
5. Fracture dislocation of upper cervical vertebral column:
a. occurs when the drop is great such as in judicial hanging.
b. Death is caused by damage to the upper cervical spinal cord.
Medicolegal investigation of a case of hanging
Visit site – house, building, locked room, garden, forest, prison
Photograph, sketch, describe

History – eye witness, P/H of mental or physical illness, previous suicidal attempts, social history (living
alone, sexual relationships)

Identify
Total/partial hanging
Point of suspension and its accessibility
Supports used to reach site of suspension
Distances: ground to point of suspension, ground to feet, neck to point of suspension, highest height the
person could have reached
Disturbance at the scene - footprints
Evidence of struggle, blood stains
Suicide note
Evidence of sexual asphyxia: naked body, female clothing on male, pornographic material, evidence of
masturbation

External examination
General features
 Ligature: in situ/removed
 Intense congestion and signs of asphyxia (oedema,
petechiae, eyes bulging out, tongue swollen and
protruding between clenched teeth, face swollen,
cyanosis)
 Dilated pupils - ligature compresses on cervical
sympathetic chain (Antemortem hanging)
 Subconjunctival hemorrhage
 Froth in nose & mouth
 Dribbling of saliva due to pressure on salivary glands Conjunctival petechiae
(Surest sign of antemortem hanging)
 Bleeding form nose, urine, feces
 Engorgement of penis and seminal discharge
 Hypostasis – lower limbs, pelvis
 Any other injuries – suspect struggle, may occur due to convulsions
 Look for causes of PM injuries – rats, red ants
 Clothing – nature, trace material (semen, feces)
 Hand restraints (usu. suicide)

Previous attempts of suicide: self-inflicted injuries, poisoning

If body is warm, record rectal temperature at ½ hrly intervals without moving it
Collect trace evidence if indicated (debris underneath nails, vaginal swab if suspecting rape)

At mortuary
Preliminary procedure – photograph, X-ray, trace material, blood for toxicology if indicated
Ligature description
 Material: coir rope, nylon, saree, sarong, bed sheet
 Circumference of noose
 Width
 Nature of knot: slip-knot or fixed (granny/reef knot). Sometimes it is a running noose without a
knot.
o If, in situ, it should be cut away from knot and reconstructed by joining cut ends with a
string
o Slip knot & running noose – faster tightening, ligature mark at a lower level
o Fixed knot – slow tightening

Ligature mark/furrow
 Number of ligature marks
 Course (angled or straight)
 Width
 Skin changes – Usually depressed/grooved, pale in color,
but later becomes yellowish brown, dry, hard and
parchment-like with small abrasions at its edges,
corresponding to the thickness and edges of the rope.
These abrasions, known as rope burns, are due to
frictional force. Ligature mark is a perimortem injury;
 Peri-ligature injuries - blisters, bruise, abrasion (in therefore, it is pale brown and
antemortem hanging) parchment-like.
o abraded area below the furrow may indicate
upward slippage of the ligature, usually seen when suspension is complete
 Relation to thyroid cartilage
 Pattern if imprint abrasion (agrees with pattern of ligature)
 Neck circumference at level of furrow (to determine degree
of neck constriction) Knot may leave separate imprint
 Neck veins above the furrow may be distended
 Mark may be absent if wide piece of cloth is used (E.g. saree)
or if ligature has been removed soon after death

The spiral weave of the rope can be

seen in this horizontal ligature
Petechiae, ecchymosis and nail marks around ligature (pattern of ligature reproduced in
mark. Note abrasion at base of neck due to upward furrow)
slippage of the ligature and a rope burn at the left
most corner
Typical complete hanging: Running noose/partial hanging/prominent
Deeper most par of ligature mark in the upper most Adam’s apple - ligature mark placed lower
part of the neck (behind the chin), between angles to thyroid cartilage
of the jaw and tapers obliquely on either side
extending upwards (does not encircle the neck),
usually there is a gap posteriorly
The mark has a ‘V’ shape.

Homicidal ligature strangulation

masquerading as suicidal hanging.
Note two furrows on posterior neck
(arrow)—faint hanging furrow canted
up; arrowhead—horizontal furrow
from strangulation.
 There may be nail marks in neck caused by the
diseased in attempting to release the ligature

Dimension of neck: Due to prolonged suspension,

the neck becomes slender and increases in length.

Bending of neck: Neck gets flexed to the side

opposite to the knot
When the knot is in contact with the skin,
ligature mark is usually inverted ‘V’ shaped,
due to extension of ligature material
downward on both sides from the knot above

Internal findings

A special neck dissection is needed

First, the skull is opened and blood from the neck drained. A 'U’ or ‘V’ shaped incision on the neck is
made. Keeping the field blood less is important to visualize contusions and petechia

The neck is dissected layer by layer with fine instruments looking for hemorrhage and injures.

Neck
Subcutaneous tissue underneath the ligature mark is dry, white, firm and glistening.
Platysma and sternomastoid may show hemorrhages and are sometimes ruptured.

Hyoid fracture is less common in hanging

Hyoid bone may be fractured in persons above the age of 40 years.
 traction fracture of the greater horns due to pull by thyrohyoid ligaments
 ligature forcing the hyoid bone backwards, which results in increased divergence of greater
horns (AP compression fracture) – abduction and AP compression

Amussat’s sign: Transverse carotid intimal tears may be seen in obese victims, long drops,
atheromatous arteries and posteriorly placed knots.

Vertebral artery injuries—rupture, intimal tear and subintimal hemorrhage (most frequent)

Larynx and trachea are congested with submucosal hemorrhages.

Fracture of superior horns of thyroid cartilage

Froth may be seen throughout respiratory tract

Lungs: congested, distended, emphysematous,

numerous Tardieu’s spots subpleurally, particularly at the interfaces of the lobes.
Brain: Congested and shows multiple petechiae.
Viscera: All the abdominal organs are congested.
Blood: Fluid and purplish in color.
 AM vs PM hanging
Feature AM PM
Type of hanging Atypical Typical
Salivary dribbling + -
Dilation of pupil + -
Fecal/urinary stain May be + -
Ligature mark Oblique, V shaped, Circular, continuous
Parchment-like Not Parchment-like
Vital reaction - Vital reaction -
Knot Single, simple Multiple, fixed
Hypostasis Above ligature & glove and -
stocking
Evidence of injury Self-inflicted Struggle
Tear of carotid intima + -
Imprint abrasion + Imprint abrasion ±
Elongation of neck + -
Cyanosis Deeply + - or faintly +
Emphysematous bullae in - +
lungs
Point of suspension Compatible with self-suspension No

Yoshikawa lines

Ligature strangulation
pressure on the neck is applied by a constricting band that is tightened by a force other than the body
weight
F>M
Motive – rape
Incomplete occlusion of arteries – vertebral arteries are patent and supply the head with blood while
other vessels are obstructed (↑intravascular pressure → congestion & rupture of vessels → more
petechiae and subconjunctival hemorrhage)

Circumstances
Virtually all cases are homicides - most common method of homicidal asphyxia. In infanticide, a cord
around the neck is utilised
Suicides and accidents are rare
Accident
 tie/scarf/cloth caught in a moving machine (e.g. fan, automobile wheel, motorcycle,
snowmobile, ski lifts, massage devices),
 children may get entangled in ropes when playing,
 nuchal cord in utero
Suicidal
 Some individuals remain conscious for 10-15s after complete occlusion of carotid arteries giving
them time to tie at least one (if not more) knots
  some individuals tightly wrap a ligature several times around the neck, securing it in place by the
overlapping loops.
 tourniquet method: a ligature is loosely wrapped around the neck, knotted, and then tightened
by a stick inserted beneath the ligature and twisted multiple times. Clothing or the individual’s
own weight on the stick holds it in place, maintaining the “tourniquet.
Pseudo ligature marks
 skin folds of neck skin in infants; more confusing in neonates as petechiae are found naturally if
delivered vaginally due to compression of the chest
 Elderly - pale crease marks caused by overlapping rolls of skin, petechiae of the sclerae and
conjunctivae (caused by cardiac failure/acute heart failure is an uncommon cause of death in
the elderly) — with the addition of retropharyngeal hemorrhage.
 tight collar/buttoned up shirt/neck tie/necklace around neck of decomposing body

Cause of death
Asphyxia
Occlusion of carotid arteries/venous congestion causing cerebral anoxia (LOC in 10-15s)
Vagal inhibition
Fracture dislocation is rare

Ligature material: electrical cords, neck ties, ropes, telephone cords, hose, towel,

Autopsy findings

External features

Face
Marked congestion, swollen, cyanosed
Fine petechiae on the face, esp. in the periorbital region (more abundant than in hnging)
Eyes: prominent, wide open, conjunctiva congested, pupils dilated, Confluent scleral hemorrhage &
conjunctival petechiae
Hypostasis prominent above ligature
Tongue: swollen, dark, protruding, bitten
Ear and nose bleed common
Blood stained froth in mouth and nostrils

Ligature mark
 Transverse/horizontal plane, circular, continuous
 At or below thyroid cartilage
 Base is red, surrounding ecchymosis and congestion, imprint of ligature material
 Indistinct or absent
o in young children or incapacitated adults
o if ligature is soft and broad or removed soon after death (need to examine under UV
light)
 Cheese cutter method: narrow ligature material (narrow cord or electric wire), ligature is deeply
embedded and upon removal leaves a deep groove. Initially, it has a yellow parchment-like
appearance that turns dark brown.
Nail marks around ligature mark
Internal findings

Neck
Contusion of SC tissue and muscles
Fracture of thyroid cartilage (superior horn and wings)
Fracture of cricoid cartilage (less common)
Fracture of hyoid (rare)
Fracture of tracheal rings if great force is applied
Subcapsular and interstitial thyroid hemorrhage
Bruising of root of tongue and floor of mouth
Hemorrhagic infiltration of mucous membranes of larynx and pharynx
Blood stained froth in larynx, trachea and bronchi
Fracture/dislocation of cervical vertebrae not common – occur in infants if associated with twisting of
the neck

Lungs are congested, edematous with numerous subpleural petechial hemorrhages.

Brain is congested with petechiae in white matter.
All other organs are congested.

Strangulation by towel.
Ligature mark is barely visible.

Trace evidence
In victims of homicidal ligature strangulation, hair is often found clutched in the hands. This should be
recovered and retained. A control sample of the victim’s hair should be obtained for comparison,
because the hair found in the hands almost invariably turns out to be that of the victim.

Fingernail scrapings or cuttings (the latter are preferred) should be taken to look for tissue of the
perpetrator under the nails. Unfortunately, such scrapings or cuttings have traditionally been of little
help, with foreign tissue rarely identified.
Manual strangulation/Throttling

Strangulation is produced by pressure of the hand, forearm, or other limb against the neck, compressing
the internal structures of the neck.

Cause of death
Vaso-vagal inhibition from pressure on carotid nerve plexus consisting of fibers of vagus nerve,
sympathetic and glossopharyngeal nerves (50% cases)
Cerebral anoxia from occlusion of blood vessels
Asphyxia (probably plays a minor role)

Pressure must be applied for 2 minutes (min) or more to cause death.

Death can be caused by vasovagal
Circumstances
reaction in a person with a
Virtually, all are homicide – motive = rape, domestic violence, robbery; F>M
hypersensitive carotid sinus just by
Suicide - One cannot commit suicide by manual strangulation because, as touching, grasping or striking the
soon as consciousness is lost, pressure is released, and consciousness neck. However, there is no objective
regained. evidence to prove this.

A choke hold can result in manual strangulation if it is maintained long

enough.

Compression of carotid sinuses → ↑BP in sinus → bradycardia and vasodilation → hypotension (most
cases)
Compression below carotid sinuses → ↓BP in sinus → tachycardia and vasoconstriction → hypertension

Postmortem features

Fingertip bruises (oval or round and 1.5–2 cm in size)

Nail scratch abrasions
Depend on method of strangulation
one hand, attacking the victim from the
front
two hands, attacking the victim from the Erythematous marks and contusions or nail marks on
front
variation using pressure applied
by two thumbs on the
central aspect of the neck
One/two hands, attacking the victim
from the back
Fingers: small contusions and erythematous marks in
association with nail marks on one side of the front of the
neck
Thumbs: erythematous mark or contusion and, less
commonly, a nail mark on the opposite side of the neck
both sides of the front of the neck
usually posterior to the sternocleidomastoid muscles
Contusions of the anterior aspect of the neck in bilateral
parasagittal plane or confluent across the midline
Fingernail marks, contusions, and erythematous marks
caused by the fingers will be on the lateral aspects of the
neck
Contusions from the fingertips & nail marks found on the
front of the neck between the larynx and SCM.

Palm of hand, attacking the victim from
the front (uncommon)
Bruises from the thumbs will be present on the back of
the neck.
Victims - unconscious through acute alcohol intoxication,
or young children
no evidence of external trauma

Nail marks
Impression Regularly curved, comma-like, exclamation mark-like, like, or oval, triangular,
rectangular epidermal injuries measuring 10–15 mm
Fingertip digs into the skin at a right angle to it with the fingernails penetrating
through the epidermis to the dermis.
Claw marks U-shaped injuries of both the epidermis and dermis, variable length (3-4 mm)
Fingernails dig into the skin at a tangential angle, cutting the epidermis and dermis
tangentially and undermining it.
Scratch Parallel linear abrasions or erythematous bands in the epidermis up to 1.0 cm wide
marks Fingernails dig into the epidermis at a vertical angle and then are drawn across the
skin, producing an elongated injury.

abrasions and bruises on the front and sides of the neck and are commonly at each side of the laryngeal
prominence and just below the jaw-line. The injuries may extend onto the upper part of the sternal
area.

Because of struggle and resistance, bruising and abrasions may be found over the face of the victim.
These can also be caused to stop the victim from shouting or crying for help.

Sphincter incontinience + (not characteristic)

Trace evidence
examine the nails of the victim and fingernail scrapings of the alleged assailant when possible, so that
these can be compared with tissue type of the victim.

Internal findings

Extravasation of blood in subcutaneous tissues underneath the external marks of bruising and
abrasions - most significant internal sign
Tear/laceration of platysma or SCM
Tongue - bruised/lacerated, may protrude out and bitten by teeth.
Hemorrhages (pinpoint to extensive extravasation) inn mucous membrane of larynx, epiglottis, pharynx
and peritonsillar region.
Inward compression fracture of hyoid bone (most diagnostic finding of throttling)
Fracture of superior horns of thyroid cartilage is common, though both horns do not get fractured
simultaneously.
Laceration of carotid sheath and tear of inner coat of carotid artery.
Cricoid is usually not fractured (if #, almost pathognomic of throttling)
Hyoid
Calcifies with aging, so more prone for #
Movement of the noncalcified portion resemble a fracture
Fracture can easily occur postmortem if calcified
AM # - spec of blood at # site
Take X-rays of neck before autopsy to visualize cartilages when minimal strangulation is suspected
The U shape of the hyoid does make it susceptible to fracture by compression. Thus, fractures of the
hyoid are, as a rule, seen only in strangulation. Whether the fractured ends of the hyoid bone are driven
inward or outward is immaterial.
Suffocation

Smothering
mechanical occlusion of nose and mouth by hand, cloth, plastic bag, pillow or other material.
Mechanism of death – asphyxia

Sequence of physiological events:

bradycardia
Decrease in respiration to agonal gasps with eventual cessation of respiration
Slowing and finally flattening of the electroencephalogram (EEG)

Circumstances
Homicide - pillows, bedding, and the hands (nose pinched off and mouth closed); victims tend to be very
young, very old, debilitated, or incapacitated by restraints, disease or drugs.
Suicide – plastic bag over the head, commonly employ the thin, filmy plastic bag used by dry cleaners
which clings to the face easily
Accidental - occur with defective cribs.
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.

Post mortem examination (Prinsloo Gorden method)

External features - Specific features can be identified.
Finger nail abrasions, fingertip contusions around the mouth, face with underlying bruises
Lacerations of lips, gums and mucosal layer of oral cavity - can be present or absent
Dislocation/ fracture of teeth

Internal findings - Non-specific

Acute emphysema, pulmonary edema

Associated criminality must be examined - e.g. Sexual assaults

Toxicology to be done to identify intoxication
Scene investigation help to identify the circumstance, Time since death, etc.

A 9-month-old child who

slipped between frame and
mattress of defective crib.
Face wedged against
mattress.
Choking
obstruction within the air-passages by a foreign object

The phases of acute fatal airway obstruction are:

i. Penetration of the object into the airway.
ii. Obstruction of the airway.
iii. Failure to expel once the obstruction has occurred.

Pathophysiology
Initially, there is stridor, respiratory distress, coughing and the inability of the victim to speak.
This is followed by a rapid, deep inhalation, which causes the foreign object to pass further down the
airway.
Laryngospasm occurs, followed by vagal stimulation, leading to arrhythmia, apnea and death.

Signs:
 Stridor Risk factors for choking in adults
 Respiratory distress  Alcohol/drug intoxication
 Coughing  Bad fitting dentures
 Choking  Neurological injury
 Inability to speak  Senility
 Mental retardation
Circumstances
 Anaesthesia/unconscious
Accidental – commonest
 Children – small toys, balls, seeds, stones, button
 Adults – almost always involve food, vomitus (during anesthesia or if unconscious)
Homicidal – robbery; gags sometimes are used to mute the victim can travel posteriorly to the pharynx
and occlude the airway

Natural – acute epiglottitis, Café coronary

anaphylaxis causing laryngeal
edema, epilepsy (tongue may fall
back on to
posterior pharyngeal wall causing
choking)

Mechanism of death Bolus of food produces complete obstruction of the larynx

 Asphyxia.
 Vagal inhibition.
 Laryngeal spasm.
 Delayed death from
pneumonia, lung abscess
or bronchiectasis.
Mimics MI and is usually seen in an intoxicated restaurant patron
Clinical findings: Victim who was apparently healthy suddenly
stops talking, stands up, and collapses turning blue while eating
at a dining table
CPR ineffective as larynx is obstructed

It is a case of accidental death (asphyxia) as opposed to natural,

so additional insurance claims can be made
Treatment (for choking)
i. If there is difficulty in breathing and cyanosis, give
first aid by application of pressure on the abdomen
(Heimlich maneuver) till the patient recovers or
loses consciousness

A blow on the back or on the sternum may cause

coughing and expel the foreign body.
iii. The victim is placed in a supine position and the
mouth is opened to perform a finger sweep.
iv. If this is not successful, the foreign body should
be removed from hypopharynx with the middle
and index fingers or with forceps.
v. If the object cannot be removed, the person may
need a tracheotomy/cricothyrotomy.

PM findings