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Asphyxial deaths (view source)

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An introduction to forensic pathology is in the ''[[forensic pathology]]'' article.
An introduction to forensic pathology is in the ''[[forensic pathology]]'' article.


==Overview==
=Overview=
==Classification==
===DiMaio classification<ref>{{Ref HoFP|155-64}}</ref>===
===DiMaio classification<ref>{{Ref HoFP|155-64}}</ref>===
{{familytree/start}}
{{familytree/start}}
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{{familytree | C01 | | C02 | | C03 | | | | C05 | | C07 | | | | | |C01=Hanging|C02=Ligature|C03=Manual|C05=Abnormal<br>skin colour|C07=No abnormality|}}
{{familytree | C01 | | C02 | | C03 | | | | C05 | | C07 | | | | | |C01=Hanging|C02=Ligature|C03=Manual|C05=Abnormal<br>skin colour|C07=No abnormality|}}
{{familytree/end}}
{{familytree/end}}
==Mechanism of death==
The mechanism of death in [[asphyxial death]]s seems to be an exam favourite.
===Short answer===
*Brain stem hypoxia due to ischemia caused by venous obstruction in the neck.<ref>URL: [http://www.forensicmed.co.uk/pathology/mechanisms-of-death/ http://www.forensicmed.co.uk/pathology/mechanisms-of-death/]. Accessed on: 1 May 2012.</ref><ref>URL: [http://www.forensicmed.co.uk/pathology/pressure-to-the-neck/ http://www.forensicmed.co.uk/pathology/pressure-to-the-neck/]. Accessed on: 1 May 2012.</ref><ref name=pmid20456578/>
===Long answer===
*It depends on who one asks.
*Other explanations include:<ref name=pmid20456578>{{Cite journal  | last1 = Clément | first1 = R. | last2 = Redpath | first2 = M. | last3 = Sauvageau | first3 = A. | title = Mechanism of death in hanging: a historical review of the evolution of pathophysiological hypotheses. | journal = J Forensic Sci | volume = 55 | issue = 5 | pages = 1268-71 | month = Sep | year = 2010 | doi = 10.1111/j.1556-4029.2010.01435.x | PMID = 20456578 }}</ref>
**"Cardiac inhibition secondary to nerve stimulation".
**"Respiratory asphyxia".


==The obsolete asphyxia quintet==
==The obsolete asphyxia quintet==
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*''Fluid blood'' is considered totally useless as a sign of anything.
*''Fluid blood'' is considered totally useless as a sign of anything.


=Specific types of asphyxial deaths=
==Hanging==
==Hanging==
===General===
===General===
*Common way to suicide.
*Common way to suicide.
*May be accidental in the context of adolescents playing - see ''[[choking]]''.


===Gross (classic)===  
===Gross===  
Classic findings:
*V-shaped furrow on the neck.
*V-shaped furrow on the neck.
*V "open" at the point of suspension.
**V "opens" at the point of suspension.
*+/-Tongue sticking-out.
 
Note:
*Hyoid bone fracture - uncommon in hanging.<ref name=pmid20206574>{{Cite journal  | last1 = Mukhopadhyay | first1 = PP. | title = Predictors of hyoid fracture in hanging: Discriminant function analysis of morphometric variables. | journal = Leg Med (Tokyo) | volume = 12 | issue = 3 | pages = 113-6 | month = May | year = 2010 | doi = 10.1016/j.legalmed.2010.01.002 | PMID = 20206574 }}</ref>


Documentation (The Rose method):<ref>TR. 28 September 2010.</ref>
Documentation (The Rose method):<ref>Rose, T. 28 September 2010.</ref>
*Anterior mid-line:
*Anterior mid-line:
**Measure distance from angle of neck to superior aspect of ligature mark.
**Measure distance from angle of neck to superior aspect of ligature mark.
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**Measure distance from C7 (???) to inferior aspect of ligature mark.
**Measure distance from C7 (???) to inferior aspect of ligature mark.
**Measure width of ligature mark.
**Measure width of ligature mark.
DDx:
*[[Ligature strangulation]].
==Choking==
===General===
*Typical accidental.
*May be part of game adolescents play known as the ''choking game''.<ref name=pmid19190276>{{Cite journal  | last1 = Macnab | first1 = AJ. | last2 = Deevska | first2 = M. | last3 = Gagnon | first3 = F. | last4 = Cannon | first4 = WG. | last5 = Andrew | first5 = T. | title = Asphyxial games or the choking game: a potentially fatal risk behaviour. | journal = Inj Prev | volume = 15 | issue = 1 | pages = 45-9 | month = Feb | year = 2009 | doi = 10.1136/ip.2008.018523 | PMID = 19190276 }}</ref>
**Known by many synonyms, e.g. ''asphyxial game'', ''fainting game'', ''black-out game''.
Associations:
*[[Ethanol]] intoxication.<ref name=pmid20666919>{{Cite journal  | last1 = Nikolić | first1 = S. | last2 = Zivković | first2 = V. | last3 = Dragan | first3 = B. | last4 = Juković | first4 = F. | title = Laryngeal choking on food and acute ethanol intoxication in adults--An autopsy study. | journal = J Forensic Sci | volume = 56 | issue = 1 | pages = 128-31 | month = Jan | year = 2011 | doi = 10.1111/j.1556-4029.2010.01510.x | PMID = 20666919 }}</ref>
*Neurologic disease.<ref name=pmid17209932>{{Cite journal  | last1 = Dolkas | first1 = L. | last2 = Stanley | first2 = C. | last3 = Smith | first3 = AM. | last4 = Vilke | first4 = GM. | title = Deaths associated with choking in San Diego county. | journal = J Forensic Sci | volume = 52 | issue = 1 | pages = 176-9 | month = Jan | year = 2007 | doi = 10.1111/j.1556-4029.2006.00297.x | PMID = 17209932 }}</ref>
Epidemiology:
*Extremes of age.<ref name=pmid17209932/>
**Old - often associated with neurologic disease or [[alcohol]].
**Young - may be foreign body ingestion.
===Gross===
Features:
*Foreign object that obstructs the airway.
**Usually a large laryngeal bolus of food - typically meat.<ref name=pmid17209932/>


==Drowning==
==Drowning==
===General===
===General===
Classic:
*Drowning is difficult to prove on autopsy.<ref name=pmid16378701>{{cite journal |author=Piette MH, De Letter EA |title=Drowning: still a difficult autopsy diagnosis |journal=Forensic Sci. Int. |volume=163 |issue=1-2 |pages=1–9 |year=2006 |month=November |pmid=16378701 |doi=10.1016/j.forsciint.2004.10.027 |url=}}</ref>  The diagnosis is often based on circumstance, i.e. the scene.
*Autopsy is often negative, i.e. there is no anatomical cause of death.
**The [[autopsy]] is often negative, i.e. there is [[negative autopsy|no anatomical cause of death]].


Drowning is difficult to prove on autopsy.<ref name=pmid16378701>{{cite journal |author=Piette MH, De Letter EA |title=Drowning: still a difficult autopsy diagnosis |journal=Forensic Sci. Int. |volume=163 |issue=1-2 |pages=1–9 |year=2006 |month=November |pmid=16378701 |doi=10.1016/j.forsciint.2004.10.027 |url=}}</ref>  The diagnosis is often based on circumstance, i.e. the scene.
====Laboratory====
There are a few tests of debated value:<ref name=pmid16378701/>
*Diffusion of particulates into the blood (left ventricle) from the water.
**Diatom test.
*Haemodilution.  
**Mostly useless - CPR interferes with it, not reliable if there putrefaction or autolysis.
*Transport of aveolar element into blood circulation.


===Macroscopic===
===Gross===
External:
====External findings====
*''[[Plume of froth]]'' ([[AKA]] ''cone of foam'') at the mouth/nostrils (fresh drowning only).<ref name=pmid16378701/><ref name=pmid12134758>{{cite journal |author=Bohnert M, Ropohl D, Pollak S |title=[Forensic medicine significance of the fluid content of the sphenoid sinuses] |language=German |journal=Arch Kriminol |volume=209 |issue=5-6 |pages=158–64 |year=2002 |pmid=12134758 |doi= |url=}}</ref>
*''[[Plume of froth]]'' ([[AKA]] ''cone of foam'') at the mouth/nostrils (fresh drowning only).<ref name=pmid16378701/><ref name=pmid12134758>{{cite journal |author=Bohnert M, Ropohl D, Pollak S |title=[Forensic medicine significance of the fluid content of the sphenoid sinuses] |language=German |journal=Arch Kriminol |volume=209 |issue=5-6 |pages=158–64 |year=2002 |pmid=12134758 |doi= |url=}}</ref>
**Classic DDx for this finding is: narcotics, [[congestive heart failure]].
**Classic DDx for this finding is: narcotics, [[congestive heart failure]].
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*Wrinkled skin ([[AKA]] ''washerwoman skin'' and ''hydration changes'') - changes due to water immersion; changes may be present in the context of immersion post-mortem.<ref name=pmid6741294>{{cite journal |author=Reh H |title=[Early postmortem course of washerwoman's skin of the fingers] |language=German |journal=Z. Rechtsmed. |volume=92 |issue=3 |pages=183–8 |year=1984 |pmid=6741294 |doi= |url=}}</ref>
*Wrinkled skin ([[AKA]] ''washerwoman skin'' and ''hydration changes'') - changes due to water immersion; changes may be present in the context of immersion post-mortem.<ref name=pmid6741294>{{cite journal |author=Reh H |title=[Early postmortem course of washerwoman's skin of the fingers] |language=German |journal=Z. Rechtsmed. |volume=92 |issue=3 |pages=183–8 |year=1984 |pmid=6741294 |doi= |url=}}</ref>


Internal:<ref name=pmid12134758>{{cite journal |author=Bohnert M, Ropohl D, Pollak S |title=[Forensic medicine significance of the fluid content of the sphenoid sinuses] |language=German |journal=Arch Kriminol |volume=209 |issue=5-6 |pages=158–64 |year=2002 |pmid=12134758 |doi= |url=}}</ref><ref>URL: [http://netk.net.au/Forensic/Drowning.pdf http://netk.net.au/Forensic/Drowning.pdf]. Accessed on: 20 September 2010.</ref>
====Internal findings====
Features:<ref name=pmid12134758>{{cite journal |author=Bohnert M, Ropohl D, Pollak S |title=[Forensic medicine significance of the fluid content of the sphenoid sinuses] |language=German |journal=Arch Kriminol |volume=209 |issue=5-6 |pages=158–64 |year=2002 |pmid=12134758 |doi= |url=}}</ref><ref>URL: [http://netk.net.au/Forensic/Drowning.pdf http://netk.net.au/Forensic/Drowning.pdf]. Accessed on: 20 September 2010.</ref>
*Lung emphysema; "kissing lungs" = lungs touch one another -- on opening the chest.  
*Lung emphysema; "kissing lungs" = lungs touch one another -- on opening the chest.  
*Froth in the trachea.
*Froth in the [[trachea]].
*Paltauf spots -- light-red washed-out appearing fingertip-sized spots.<ref>URL: [http://www.mijnwoordenboek.nl/EN/theme/ME/EN/DE/P/3 http://www.mijnwoordenboek.nl/EN/theme/ME/EN/DE/P/3]. Accessed on: 20 September 2010.</ref>
*Paltauf spots -- light-red washed-out appearing fingertip-sized spots.<ref>URL: [http://www.mijnwoordenboek.nl/EN/theme/ME/EN/DE/P/3 http://www.mijnwoordenboek.nl/EN/theme/ME/EN/DE/P/3]. Accessed on: 20 September 2010.</ref>
**Thought to arise from hemolysis + fluid decedent drown in.
**Thought to arise from hemolysis + fluid decedent drown in.
*Fluid in the paranasal sinuses.<ref name=pmid8643988>{{cite journal |author=Hottmar P |title=[The presence of fluid in the paranasal sinuses in comparison with other diagnostic signs of drowning] |language=Czech |journal=Soud Lek |volume=40 |issue=4 |pages=34–6 |year=1995 |month=December |pmid=8643988 |doi= |url=}}</ref>
*Fluid in the paranasal sinuses.<ref name=pmid8643988>{{cite journal |author=Hottmar P |title=[The presence of fluid in the paranasal sinuses in comparison with other diagnostic signs of drowning] |language=Czech |journal=Soud Lek |volume=40 |issue=4 |pages=34–6 |year=1995 |month=December |pmid=8643988 |doi= |url=}}</ref>


===Microscopic/Laboratory===
===Microscopic===
There are a few tests of debated value:<ref name=pmid16378701/>
*None that are specific.
*Diffusion of particulates into the blood (left ventricle) from the water.
**Diatom test.
*Haemodilution.
**Mostly useless - CPR interferes with it, not reliable if there putrefaction or autolysis.
*Transport of aveolar element into blood circulation.


==Carbon monoxide toxicity==
==Carbon monoxide toxicity==
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*CO binds to myoglobin.
*CO binds to myoglobin.


===Gross findings===
===Gross===
*External: salmon pink skin.
====External findings====  
*Internal - general: organs pink hue.
*Salmon pink skin.
**Brain: globus pallidus [[necrosis]].<ref name=pmid21150349>{{Cite journal  | last1 = Fielding | first1 = J. | last2 = Lang | first2 = W. | last3 = White | first3 = OB. | title = Carbon monoxide poisoning: impact on ocular motility. | journal = Cogn Behav Neurol | volume = 23 | issue = 4 | pages = 256-61 | month = Dec | year = 2010 | doi = 10.1097/WNN.0b013e3181c5e2c1 | PMID = 21150349 }}</ref>
 
 
DDx of pink skin includes:
*[[Hypothermia]].
*Cyanide poisoning.
*Fluoroacetate poisoning.
 
====Internal findings====
*General: organs pink hue.
*Brain: globus pallidus [[necrosis]] - bilateral.<ref name=pmid21150349>{{Cite journal  | last1 = Fielding | first1 = J. | last2 = Lang | first2 = W. | last3 = White | first3 = OB. | title = Carbon monoxide poisoning: impact on ocular motility. | journal = Cogn Behav Neurol | volume = 23 | issue = 4 | pages = 256-61 | month = Dec | year = 2010 | doi = 10.1097/WNN.0b013e3181c5e2c1 | PMID = 21150349 }}</ref>
 
Notes:
*Bilateral necrosis of the putamen is seen in [[methanol toxicity]].


Note:
Image:
*The DDx of pink skin includes [[hypothermia]].
*[http://i.dailymail.co.uk/i/pix/2011/02/14/article-1357042-0D0AEDBC000005DC-598_468x286.jpg CO toxicity of the brain (dailymail.co.uk)].


===Microscopic===
===Microscopic===
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*Carboxyhemoglobin.<ref>{{Ref OPMfP|18}}</ref>
*Carboxyhemoglobin.<ref>{{Ref OPMfP|18}}</ref>


==Hydrogen sulfide==
==Hydrogen sulfide toxicity==
===General===
===General===
*Fashionable for suicides; has high mortality and may be toxic to responders/death investors.<ref name=pmid20920221>{{cite journal |author=Morii D, Miyagatani Y, Nakamae N, Murao M, Taniyama K |title=Japanese experience of hydrogen sulfide: the suicide craze in 2008 |journal=J Occup Med Toxicol |volume=5 |issue= |pages=28 |year=2010 |pmid=20920221 |pmc=2954931 |doi=10.1186/1745-6673-5-28 |url=}}</ref>
*Fashionable for suicides; has high mortality and may be toxic to responders/death investors.<ref name=pmid20920221>{{cite journal |author=Morii D, Miyagatani Y, Nakamae N, Murao M, Taniyama K |title=Japanese experience of hydrogen sulfide: the suicide craze in 2008 |journal=J Occup Med Toxicol |volume=5 |issue= |pages=28 |year=2010 |pmid=20920221 |pmc=2954931 |doi=10.1186/1745-6673-5-28 |url=}}</ref>
*Lab: ''thiosulfate'' - not available in Canada as of 2010.
**Can be generated by mixing a source of sulfide with an acid ''or'' ingesting the sulfide which will then react with stomach acid.
**Can be generated by mixing a source of sulfide with an acid ''or'' ingesting the sulfide which will then react with stomach acid.
*Mechanism: bonds to mitochondrial cytochrome enzymes.<ref name=pmid18695173>{{cite journal |author=Truscott A |title=Suicide fad threatens neighbours, rescuers |journal=CMAJ |volume=179 |issue=4 |pages=312–3 |year=2008 |month=August |pmid=18695173 |pmc=2492967 |doi=10.1503/cmaj.080878 |url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492967/?tool=pubmed}}</ref>
*Mechanism: bonds to mitochondrial cytochrome enzymes.<ref name=pmid18695173>{{cite journal |author=Truscott A |title=Suicide fad threatens neighbours, rescuers |journal=CMAJ |volume=179 |issue=4 |pages=312–3 |year=2008 |month=August |pmid=18695173 |pmc=2492967 |doi=10.1503/cmaj.080878 |url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492967/?tool=pubmed}}</ref>
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===Toxicology===
===Toxicology===
*Classically has the smell of "rotten eggs".<ref name=pmid20920221>{{cite journal |author=Morii D, Miyagatani Y, Nakamae N, Murao M, Taniyama K |title=Japanese experience of hydrogen sulfide: the suicide craze in 2008 |journal=J Occup Med Toxicol |volume=5 |issue= |pages=28 |year=2010 |pmid=20920221 |pmc=2954931 |doi=10.1186/1745-6673-5-28 |url=}}</ref>
*Classically has the smell of "rotten eggs".<ref name=pmid20920221>{{cite journal |author=Morii D, Miyagatani Y, Nakamae N, Murao M, Taniyama K |title=Japanese experience of hydrogen sulfide: the suicide craze in 2008 |journal=J Occup Med Toxicol |volume=5 |issue= |pages=28 |year=2010 |pmid=20920221 |pmc=2954931 |doi=10.1186/1745-6673-5-28 |url=}}</ref>
*Lab: ''thiosulfate'' - not available in Canada as of 2010.
*Lab: ''thiosulfate''.
 
===Gross===
*Green discolourization of the skin.<ref name=Ref_Shkrum33>{{Ref Shkrum|33}}</ref>


==Manual strangulation==
==Manual strangulation==
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*Hyoid bone fracture.
*Hyoid bone fracture.
*Thyroid cartilage fracture.
*Thyroid cartilage fracture.
*Haemorrhage in strap muscles of the neck.
*Hemorrhage in strap muscles of the neck.
*Patterned ovoid contusions (from the fingers).
*+/-Defensive-type injuries.
 
====Image====
<gallery>
Image:Hofmann_Lehrbuch_suidide_hanging.jpg | Drawing of suicide by hanging. (WC/National Library of Medicine)
</gallery>


===Microscopic===
===Microscopic===
*Usually not contributory.
*Usually not contributory.


==See also==
Features:
*+/-Siderophages.
*+/-Inflammation - esp. [[neutrophil]]s.
 
==Ligature strangulation==
===General===
*May be suicide ''or'' homicide.
*In females may be associated with a sexual assault.<ref name=pmid10739219/>
*More likely to be a homicide than a [[hanging]].
 
===Gross===
Features:
*Horizontal furrow/depression on the neck - due to ligature.
*Petechiae - very common.<ref name=pmid10739219>{{Cite journal  | last1 = DiMaio | first1 = VJ. | title = Homicidal asphyxia. | journal = Am J Forensic Med Pathol | volume = 21 | issue = 1 | pages = 1-4 | month = Mar | year = 2000 | doi =  | PMID = 10739219 }}</ref>
*+/-Fractures of the hyoid, thyroid or cricoid cartilage - more common in males.<ref name=pmid10739219/>
 
DDx:
*[[Hanging]] - furrow/depression typically rises to a point of suspension.
 
=See also=
*[[Forensic pathology]].
*[[Forensic pathology]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}
=External links=
*[http://failuremag.com/index.php/feature/article/the_game_that_makes_parents_gasp/ The choking game (failuremag.com)].


[[Category:Forensic pathology]]
[[Category:Forensic pathology]]
Michael
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