Fatal Asphyxia Research Articles

Lung densitometry in postmortem computed tomography - comparison across different fatal asphyxia groups.

Asphyxia as a cause of death poses a diagnostic challenge in forensic medicine due to both the diversity of underlying mechanisms, and lack of specific markers. Acute emphysema or acute alveolar dilation have long been debated as potential findings in these asphyxia cases. To further explore the supplementary findings in our forensic asphyxia cases, this study applied lung densitometry to pulmonary postmortem computed tomography (PMCT) data. Twenty asphyxia cases (including hanging (n = 9), manual strangulation (n = 4), ligature strangulation (n = 1), smothering (n = 3), and choking (n = 3)) and 21 matched control cases were analysed using lung densitometry parameters - specifically quantification of low attenuation areas (LAA) and the 15th percentile point of lung density (Perc15). Our data revealed statistically significantly higher lung % volume falling within LAA at -950HU (p = 0.04) and - 910HU (p = 0.043) in the asphyxia cases compared to matched controls. The Perc15 values observed were trending towards a lower attenuation corresponding to a lower density in the asphyxia group, although this result was not statistically significant (p = 0.13). A subgroup analysis highlighted potential differences within the asphyxia categories, notably, higher Perc15 values were observed in the choking cases. In conclusion the results from the study support the existing evidence of low pulmonary density as a potential finding in asphyxia cases and demonstrate the potential of applying lung densitometry on pulmonary postmortem computed tomography data.

Forensic value of soft tissue detachments from the hyoid bone in death due to strangulation asphyxia.

There are no unequivocal histopathological findings for the diagnosis of fatal asphyxia due to neck compression. From the observation of a series of asphyxiation cases, we noted, during microscopic analysis, a high frequency of "detachment" of soft tissues from the hyoid bone. This specifically refers to the presence of an optical space between the surface of the hyoid bone and soft tissues. We aimed to evaluate the detachment of soft tissues from the hyoid bone as specific histological evidence of death due to strangulation asphyxia. Ten blocks were taken from deaths due to external mechanical compression of the neck (strangulation asphyxia, group A), 22 blocks were taken from deaths for other causes without trauma to the neck (group B), and 38 blocks were obtained from living subjects that have undergone laryngectomies (group C). The presence/absence of detachments were compared between the 3 groups (A, B and C) using Fisher's exact test. The detachment of soft tissues from the hyoid bone was observed in 5 cases (50%) in group A, 6 cases (27.2%) in group B, and 17 cases (44.3%) in group C. The sensitivity and specificity of the presence of the detachment in group A were 0.5 (95% confidence interval (95% CI): 0.38-0.62) and 0.57 (95% CI: 0.45-0.69), respectively. The comparison between the 3 groups and the presence/absence of soft tissue detachment showed no statistically significant differences between the groups (p = 0.329), clarifying that soft tissue detachment is a nonspecific variable for all 3 situations. Detachment of soft tissues has poor value as a single element to favor the diagnosis of asphyxia due to violent compression of the neck and should be interpreted as an artifactual finding, unrelated to the neck injury or injury vitality.

Hereditary C1-inhibitor deficiency angioedema (C1-INH-HAE) in children – practical considerations

Hereditary angioedema is a rare, autosomal dominant, potentially life-threatening disorder usually resulting from C1-esterase deficiency or dysfunction. Clinical manifestations include unpredictable, acute, recurrent episodes of well-demarcated oedema occurring without pruritus, most commonly affecting the face, trunk, extremities, but also, due to mucosal involvement, the respiratory and gastrointestinal systems. Although oedema resolves spontaneously within 2–5 days, the skin lesions are disfiguring, painful and disrupt daily functioning, while abdominal attacks are very painful and often lead to hospital admissions and unnecessary surgery. In addition, laryngeal oedema, which affects at least half of patients, is life-threatening and, in many cases, leads to fatal asphyxia. Therefore, early diagnosis and implementation of proper therapeutic management as soon as possible are crucial. In recent years, significant advances have been made in the treatment of hereditary angioedema. Initially, only intravenous drugs administered during attacks were available in medical facilities. Patient education has allowed for home therapy. The next step was the introduction of subcutaneous injections, which were more convenient for patients. Finally, long-term prophylactic treatment, which completely relieves symptoms and allows for a normal life, has gained importance. Unfortunately, the high cost of these therapies remains a problem. This paper reviews in detail the clinical picture and differential diagnosis of the disorder, as well as modern treatment approaches, with special focus on the distinctive features in children.

Crushed, uncooked egg in the oropharynx: a café coronary?

BackgroundObstruction of the upper respiratory airway can terminate in fatal asphyxia. Autopsy findings in asphyxial deaths as described in literature are not necessarily pathognomonic. A complete autopsy with ancillary studies is necessary to establish the cause, time, and manner of death.Case presentationThe authors present a 44-year-old male who was found dead in his car. He had been remanded in prison for drug trafficking 1 year prior to his death. No other history or death scene findings were provided by the police. Autopsy revealed a crushed, uncooked egg in his oropharynx. Postmortem radiology and toxicology were not done due to nonavailability of the required facilities. Death was ascribed to asphyxia due to a crushed, uncooked egg in the oropharynx.The manner of death could not be ascertained because pertinent information regarding the deceased’s medical records, locus report, and other ancillary investigations was not available.ConclusionsThis report presents an unusual cause of mechanical upper airway obstruction that has never been documented and discusses some of the deficiencies of autopsy practice in resource-limited countries.

Further explorations into the role of mast cells in deaths associated with fatal asphyxia: an immunohistochemical study utilizing CD 117 marker

Asphyxia-related deaths have always been a challenging task in the speciality of forensic pathology. Apart from helpful macroscopical signs (e.g., strangulation mark, cyanosis, petechial haemorrhage, and lung oedema), recent literature indicates that prolonged asphyxia is sufficient to induce an increase in mast cells (MC). Inflammatory cells migrate from the bone marrow to the lungs, aiding in the diagnosis of fatal asphyxial deaths. HIF1-α, a key regulator protein, is released from lung tissue capillaries during catastrophic hypoxia circumstances, as previously demonstrated in immunohistochemistry (IHC) research. The present study analyzed lung samples from 164 medico-legal autopsy cases, including 57 asphyxia/hypoxia deaths and 107 controls (non-asphyxial deaths). Peribronchial, perivascular and perialveolar MCs were detected using CD117 antibody, and the average of MCs in each of these locations was noted in each case. The results indicated a statistically significant increase in peribronchial and perialveolar mast cells (MC) in fatal asphyxial deaths, including those caused by hanging, drowning, or postural asphyxia. Peri-bronchial MC in lung sections of asphyxial deaths were in the range of 0.2–5.4 and in non-asphyxial samples were in the range of 0.0–2.2. Peri-alveolar MCs in lung sections of asphyxial deaths were in the range of 0.0–0.6 and in non-asphyxial samples were in the range of 0.0–0.2. Our data suggest that mast cells (MC) play an important role in fatal hypoxia-related mortality and CD 117 may be a reliable marker for detection of mast cells in asphyxial deaths. It could be very beneficial to forensic pathologists tasked with differentiating fatal asphyxia fatalities from other causes of death.

Socio – Demographic & Medico – Legal Profile Among the Victims of Acute Fatal Asphyxia Cases at S.M.S Medical College, Jaipur

Background: Asphyxia is typically relevant in a forensic setting when it involves mechanical asphyxia. Thereare various means in which mechanical asphyxia is carried out like pressure over the neck in form of hanging,ligature/ manual strangulation, mugging, garrotting, and, some other forms as smothering, suffocation, chokingetc.Aims & objective: Assessment of socio – demographic profile& medico – legal profile among the victims of acute fatalasphyxia cases at S.M.S hospital, Jaipur.Material & methodology: a cross-sectional descriptive observational prospective study that used inclusion and exclusioncriteria was conducted. 160 (4.90%) autopsies were of these acute asphyxia fatalities (n=3261) were taken in the study.Thepresent study had been conducted in the Mortuary, Department of Forensic Medicine & Toxicology, S.M.S Hospital, Jaipurduring the period from June 2018 to October 2019.Result & observation: The majority of 63 cases (39.37%) were found to be between the ages of 21 and 30. 109 cases(68.13%) were predominantly male. 142 cases (88.75%) were literate & 18 cases (11.25%) were illiterate. Students made upthe majority of fatalities with 44 cases (27.5%), followed by homemakers with 41 cases (25.6%). Hanging was responsiblein majority of cases (85%). Suicidal manner was present in majority of cases (86.87%).Conclusion: Majority of victims was of productive age group of society and most of them were students andhouse makers. The main causes are high expectations, an unhealthy and stressful lifestyle, and less tolerantbehaviour in families and social groups. Justice, compassion, educational initiatives, and individual, communal,and societal approaches are required to reduce these cases.

A Case of Fatal Asphyxia by a Barbell during a Bench Press

The bench press is a widespread form of weight training with few scientific reports on its associated fatalities. We herein report a case of an individual performing bench press training who was found deceased in a supine position on the bench with the shaft of the barbell resting on his neck. The bench press safety bars were set at bench height. On the basis of the postmortem computed tomography imaging and the autopsy, the cause of death was determined to be fatal traumatic asphyxia caused by a cervical compression. We wish to highlight the importance of correctly using safety devices during weight training as well as the need for developing and disseminating safe equipment that is not dependent on the manner of use. We also wish to highlight the need for a form of legal regulation on the design of devices.

Study of external and internal injuries to the neck structure in cases of hanging

Introduction: Asphyxia could occur in various situations like: Traumatic asphyxia, Hanging, Choking, Smothering, Strangulation, poisoning, etc. There are both external and internal general features to diagnose fatal asphyxia macroscopically such as: a) External (i) ligature mark (ii) congestion, cyanosis & petechial hemorrhages. b) Internal – fluidity of blood, dilatation of right chamber of heart and visceral congestion. Materials and Methods: An observational Cross sectional study was carried out in Department of Forensic Medicine & Toxicology, Santosh Medical College, Ghaziabad. A total 58 cases of fatal neck compression were included in this study during. All the cases with alleged history of fatal neck compression were included in the study, except where the dead body was severely decomposed, that would effect the observation of findings. In study the aim was to find out the different associated lesions, injuries / fracture of the organo-complex of the larynx, bleeds in the tongue, hemorrhage in the tonsils and tonsilar beds. Results: Majority cases of hanging were seen in young adult age group of 20 ± 30 years. The overall male : female ratio in cases of hanging was 11:1. Majority cases of hanging were suicidal. Neck compression and hanging were seen between time interval of 6 + AM to 12 noon. Congestion of the face was observed in 60.86%. Hemorrhage in Sub-conjunctiva, strap muscle, tongue, epiglottis and tonsil were seen in 13%, 23.91%, 13.04%, 20% and 15.21% cases respectively. Hyoid bone fracture was present in 13.04% while thyroid cartilage fracture was present in 4.34%. Conclusion: According to the present study hanging is more common in young adults mostly suicidal in nature. congestion of face is most significant external feature in hanging while tonsillar heamorrage is significant internal feature. Keywords: Hanging, Asphaxia, External neck injury, Internal neck injury, Ligature mark.

Cases of asphyxia in children and adolescents: a retrospective analysis of fatal accidents, suicides, and homicides from 1998 to 2017 in Hamburg, Germany

PurposeInjury-related asphyxia is one of the most common causes of death in children in Germany. However, only a few systematic studies have analyzed the causes and circumstances of asphyxia in children and adolescents.MethodsAll cases of asphyxia in children and adolescents (0–21 years of age) among the Hamburg Legal Medical Department’s autopsy cases from 1998 to 2017 were retrospectively analyzed with special focus on how often external findings were completely absent.ResultsAmong 249 cases of fatal asphyxia, 68% were accidents, 14% were suicides, and 13% were homicides. Most of the cases involved boys. Adolescents and young adults aged 15–21 years represented the main age group. Drowning was the leading mechanism of asphyxia. Younger age was associated with less frequent detection of external signs of asphyxia in the postmortem external examination. Petechial hemorrhages were the most common visible external indication of asphyxia. No external findings indicative of asphyxia were present in 14% of the cases.ConclusionAsphyxia in children and adolescents often involves accidents. However, postmortem external examination alone is insufficient to identify asphyxia and the manner of death.

Fatal asphyxia due to laryngeal displacement by large-sized prey in a Guiana dolphin (Sotalia guianensis), Brazil

ABSTRACT: The Guiana dolphin (Sotalia guianensis) is a small odontocete distributed from Santa Catarina state, Brazil, to Honduras. Although it is currently considered “near threatened” by the International Union for Conservation of Nature, considerable knowledge on health and disease aspects of this species has been gained over the last decade. The main threats for the species are represented by multiple anthropic factors. Guiana dolphins feed on a variety of taxa, primarily teleosts, crustaceans, and cephalopods. Herein, we reported a case of severe laryngeal displacement and esophageal impaction with ulceration associated with a deglutted adult leatherjacket (Oligoplites sp.). This fish species is not a common prey item of Guiana dolphins’ diet. Severe upper aerodigestive compromise likely led to death by mechanical asphyxia (choke) in this dolphin. This report attested the occurrence of upper aerodigestive dysfunction due to overzealous feeding in Guiana dolphin and contributed to general knowledge on pathology of the species.

Surge of corticocardiac coupling in SHRSP rats exposed to forebrain cerebral ischemia.

Sudden death is an important but underrecognized consequence of stroke. Acute stroke can disturb central control of autonomic function and result in cardiac dysfunction and sudden death. Previous study showed that bilateral common carotid artery ligation (BCCAL) in the spontaneously hypertensive stroke-prone rat strain (SHRSP) is a well-established model for forebrain ischemic sudden death. This study aims to investigate the temporal dynamic changes in electrical activities of the brain and heart and functional interactions between the two vital organs following forebrain ischemia. EEG and ECG signals were simultaneously collected from nine SHRSP and eight Wistar-Kyoto (WKY) rats. RR interval was analyzed to investigate the cardiac response to brain ischemia. EEG power and coherence (CCoh) analysis were conducted to study the cortical response. Corticocardiac coherence (CCCoh) and directional connectivity (CCCon) were analyzed to determine brain-heart connection. Heart rate variability (HRV) was analyzed to evaluate autonomic functionality. BCCAL resulted in 100% mortality in SHRSP within 14 h, whereas no mortality was observed in WKY rats. The functionality of both the brain and the heart were significantly altered in SHRSP compared with WKY rats after BCCAL. SHRSP, but not WKY rats, exhibited intermittent surge of CCCoh, which paralleled the elevated CCCon and reduced HRV, following the onset of ischemia until sudden death. Elevated brain-heart coupling invariably associated with the disruption of the autonomic nervous system and the risk of sudden death. This study may improve our understanding of the mechanism of forebrain ischemia-induced sudden death. NEW & NOTEWORTHY This study demonstrates a marked surge of corticocardiac coupling in rats dying from focal cerebral ischemia, consistent with our earlier data in rats exposed to fatal asphyxia. Since the bidirectional electrical signal coupling (corticocardiac coherence) and communication (corticocardiac connectivity) between the brain and the heart are only identified in dying animals, they could be used as potential biomarkers to predict the risk of sudden death.

Postmortem computed tomography findings of airway occlusion caused by a plastic bag: A case report of suspected fatal asphyxia

Postmortem computed tomography findings of airway occlusion caused by a plastic bag: A case report of suspected fatal asphyxia

Could the screening for correct oral health reduce the impact of death due to bolus asphyxia in adult patients? A forensic case report

Introduction“Bolus death” or “Café Coronary syndrome” refers to death due to asphyxia caused by an occlusion of the upper airways due to food. In this kind of asphyxia, the food bolus obstructs the larynx or the bronchial branches. This kind of event often affects subjects with acute intoxication due to alcohol or drugs, or with edentulism and with neurological or psychiatric diseases. Case reportAn elderly woman, suffering from schizophrenia, was found dead in her house due to food bolus asphyxia. The post-mortem toxicological analysis on the deceased’s biological fluids revealed the presence of tricyclic antidepressants, antipsychotics and neuroleptics. Study of the oral cavity showed the presence of partial edentulism and periodontal disease. HypothesisWe hypothesize that this kind of asphyxia in adults can be prevented. We believe that there are two major preventable factors: edentulism and salivation disorders in elderly and neuropsychiatric patients. The primary prevention of these pathologies would deal with the basic physician, similarly to other screenings already effectively in place. ConclusionsIt is possible to prevent fatal asphyxia in subjects who suffer from this kind of diseases through appropriate screening. This prevention strategy would greatly reduce the amount of choking deaths in adults.

Stomach gas as a useful matrix for detecting ante-mortem gas exposure. A case of asphyxia by helium inhalation

Identification of helium in cases of fatal asphyxia induced by helium is sometimes difficult, due to its low solubility in water and high diffusibility. Lung tissue and intratracheal gas have been reported as suitable matrices for toxicological examination. This report suggests the utility of stomach gas as a matrix for forensic analysis of the presence of helium. Language: en

Alterations of Ca(v)1.2 and 5-hydroxytryptamine in rat hearts after positional asphyxia

We investigated alterations of cardiac Ca(v)1.2 and 5-hydroxytryptamine (5-HT) associated with positional asphyxia. Male rats were divided into five groups: a control group with no restraint, group 1 restrained for 1 h, group 2 restrained for 2 h, group 3 restrained for 4 h, and group 4 restrained for 8 h. The rats that were restrained for 8 h ultimately suffered fatal asphyxia. After the restraint periods, the rats were sacrificed and immunohistochemistry was performed to evaluate the expressions of Ca(v)1.2 and 5-HT in the heart. Sections were analyzed by digital image analysis. Cardiac expression of Ca(v)1.2 and 5-HT proteins were significantly decreased by positional asphyxia in the rat, shown by integrated optical density (IOD) compared to controls. Our findings indicate that Ca(v)1.2 and 5-HT alterations could cause abnormal cardiac function, and the proteins investigated here may be useful for investigating the mechanisms underlying positional asphyxia.

Identification and quantitation of 5-fluoro-ADB, one of the most dangerous synthetic cannabinoids, in the stomach contents and solid tissues of a human cadaver and in some herbal products

Since late September 2014, there have been approximately 10 cases in Japan where people have died from inhaling smoke from herbal blends containing a newly emerged synthetic cannabinoid. Although the drug was tentatively identified by some drug-monitoring institutions as 5-fluoro-ADB, to our knowledge, its data have not been published in any scientific context. We recently encountered an autopsy case in which 5-fluoro-ADB was involved. The deceased was a 34-year-old man who was found dead in his room. The postmortem interval was estimated at 35–40 h. The direct cause of the death was asphyxia due to aspiration of stomach contents into the trachea, which likely took place during vomiting under low-consciousness conditions provoked by inhalation of the 5-fluoro-ADB smoke. The cadaver was subjected to autopsy at our department. Femoral vein blood, right heart blood, left heart blood, urine, stomach contents, and nine solid tissues including the adipose tissue were collected and frozen until analysis. The extraction of 5-fluoro-ADB and internal standard 5-fluoro-AMB was performed using a modified QuEChERS method plus filtration through Captiva ND Lipids cartridges, followed by liquid chromatography–tandem mass spectrometry (LC–MS–MS) analysis. Because this study dealt with various kinds of human matrices, we used the standard addition method for quantitation to overcome the matrix effects. The levels of 5-fluoro-ADB in the cadaver specimens were generally low; it could not be detected from blood or urine specimens. The levels of 5-fluoro-ADB in solid tissues were 1.17–7.95 ng/g. Because the highest levels were found for the adipose tissue and heart muscle, the final extracts of the adipose tissue and/or heart muscle were concentrated 10- and 200-fold to obtain product ion mass spectra of 5-fluoro-ADB using LC–MS–MS and its mass spectrum by gas chromatography–mass spectrometry, respectively. Both spectra completely coincided with those obtained from the reference standard 5-fluoro-ADB, confirming that the target compound was 5-fluoro-ADB. The quantitative results obtained by selected reaction monitoring of LC–MS–MS showed the highest level, at 7.95 ng/g, in the adipose tissue, followed by stomach contents, brain, heart muscle, pancreas, and spleen. For the lung, liver, kidney, and skeletal muscle, levels were below the quantitation limit (about 0.5 ng/g), although very small peaks above the detection limit (about 0.1 ng/g) could be observed for all of the above solid tissues. The low levels of 5-fluoro-ADB in the solid tissues were likely as a result of only a small amount of 5-fluoro-ADB incorporated into the body via the lungs due to the short period from the beginning of smoking the herb to the fatal asphyxia resulting from aspiration of a massive amount of stomach contents into the trachea under low-consciousness conditions. In addition, we measured the content of 5-fluoro-ADB in three packages, all of which were opened, that were found under a pillow near the deceased; their levels of 5-fluoro-ADB were 49.2 mg/g, 12.2 μg/g, and 0.77 μg/g. To our knowledge, this is the first reported identification and quantitation of 5-fluoro-ADB in human specimens and herbal products.

Usefulness of intratracheal gas analysis in an autopsy case of helium inhalation

A case of fatal asphyxia by helium inhalation from inside a plastic bag closed around the neck with tape is presented. Helium was identified by headspace gas chromatography in the intratracheal gas, lung tissue and blood. Severe congestion of the organs was also observed. We concluded that the cause of death was asphyxia due to inhalation of helium, and identification of helium from intratracheal gas was useful for making this diagnosis.

Fatal asphyxia by complete laryngeal obstruction due to chewing-gum aspiration in an adult woman. Case Report

In the present study, a 42 y.o. woman lethal case by aspiration of a foreign body is reported. During the autopsy, a large chewing-gum piece was found above the aditus ad laringem, so as to completely obstruct its access, causing a lethal respiratory insufficiency. The anatomopathological exam of the lungs showed the signs of acute asphyxia. The toxicological analyses of blood and urine samples were negative for drugs and/or ethanol. An accurate literature study allowed to show that this case represents the second lethal event related to the aspiration of a chewing gum in an adult subject, and the first related to the complete obstruction of the aditus ad laringem.

An unusual death of a masochist: Accident or suicide?

“Autoerotic asphyxia” typically involves an individual hanging or ligature, resulting in self-induced oxygen deprivation brought about by neck compression during sexual activity. Little about the so-called “ atypical forms” of autoerotic asphyxia, which also involve compression of the chest or abdomen, has been published in forensic literature. When death results from such practices, they are usually deemed accidental, however, suicide or homicide must also be considered. The authors present a single case of accidental fatal asphyxia by the simultaneous compression of the neck, chest, and abdomen using a chair-bed. The victim was known to have had masochistic tendencies. In order to confirm the hypothesis of accidental death, the results of crime scene investigations, and autopsy findings, including histological and toxicological analysis, are summarized here.

Tooth aspiration: Its relevance in medicolegal autopsies

Tooth aspiration in adulthood is an uncommon autopsy finding. The paper presents two cases in which maxillary incisors had been avulsed and inhaled during hospital treatment and in the course of maxillofacial trauma, respectively. In the first case, repeated attempts to remove the aspirated tooth by means of flexible bronchoscopy led to perforation of the bronchial wall with consecutive bleeding into the deep airways and fatal asphyxia. In the second case, the fact of tooth aspiration remained undetected throughout the 3-day survival time until death from craniocerebral trauma. The paper points out the forensic aspects of tooth aspiration against the background of the relevant clinical literature.