Asphyxia

What is Asphyxia

The word asphyxia means absence of oxygen, which can be caused by various mechanisms. In Greek, it is called as pulselessness or absence of pulsation. According to Adelson's definition, asphyxia is "the physiologic and chemical state in a living organism in which an acute lack of oxygen available for cell metabolism is associated with an inability to eliminate excess carbon dioxide"(1^✔).

Medicolegal Types of Asphyxia

From a legal and medical point of view, asphyxia can be categorized into mechanical and non-mechanical asphyxia. Mechanical asphyxia results from physical obstructions like neck pressure, suffocation, or chest compression. Non-mechanical asphyxia is linked to physiological problems such as oxygen shortages due to gases like carbon monoxide or exposure to chemicals like cyanide(1^✔).

Causes of Asphyxia

• Drowning - submersion in water
• Hanging - suspension of a body by ligature(2^✔, 9^✔)
• Strangulation - occurs when something tight, like a rope, is wrapped around the neck
• Throttling - compressing the neck firmly with hands
• Choking - obstruction of air passage by a foreign body(5^✔)
• Garroting - tightening a rope or cord around the neck, sometimes using a lever or a spike, causing quick harm(2^✔)
• Smothering - blocking breathing by hand or other means, or by covering the nose and mouth with foreign substances like mud or cloth(2^✔)
• Bansdola - using sticks or feet to squeeze the neck or chest, making it difficult to breathe and causing harm(4^✔)
• Mugging - encircling and compressing the neck using an elbow
• Gagging - a cloth is forced into the mouth or tied around the head obstructing the mouth and nose, causing asphyxia
• Cafe coronary - meal or food particles stuck inside the air passage, leads to choking that appears like a sudden heart attack. Commonly seen in alcoholic and psychiatric patients(8^✔)
• Positional asphyxia - abnormal position of the body like neck twisting, compression of air passage, hindrance of respiratory movements by compressing the diaphragm, and chest leads to asphyxia(7^✔, 11^✔)
• Traumatic asphyxia - due to injuries(6^✔)
• Chemical asphyxia - certain drugs or chemical compounds like carbon monoxide, cyanide, hydrogen sulfide can cause asphyxia(3^✔)
• Anaphylaxis - allergic reaction(3^✔, 2^✔)
• Medical conditions like chronic obstructive pulmonary disease (COPD), asthma, pneumonia, bronchitis, and tracheomalacia.
• Electrical asphyxia - occurs as a result of electric shock, which leads to respiratory arrest(12^✔)

Signs of Asphyxia

A person suffering from asphyxia may present with specific signs, which can be explained as asphyxia stigmata.These signs are seen in mechanical asphyxia, which includes cyanosis, petechiae, and edema(1^✔, 2^✔).

Cyanosis

Cyanosis occurs when there is insufficient oxygen supply or utilization in the body, leading to the formation of reduced hemoglobin and causing the blood to darken. This darkening is noticeable in areas with abundant circulation, such as the lips, tip of the tongue, nail beds, and ear lobes. For cyanosis to be visible, a minimum of 5 grams of reduced hemoglobin per 100 milliliters of capillary blood is required.

Petechiae

Petechiae, also known as Tardieu spots, result from increased intravenous pressure causing the rupture of thin-walled capillaries and venules.

Edema

Oedema and stasis occur due to increased capillary permeability when there's damage to the capillary membrane due to asphyxia. This damage weakens the cementing substance between endothelial cells, creating gaps that enhance capillary permeability. Consequently, fluid leaks from the capillary walls into the surrounding soft tissues resulting in edema.

Symptoms of Asphyxia

• Difficulty breathing
• Cough
• Seizures
• Disorientation
• Loss of consciousness(3^✔)

Diagnosis of Asphyxia

As there are many mechanisms and causes of asphyxia, diagnosis does not rely on a single investigation. It includes history, clinical signs and symptoms, blood tests, bronchoscopy, radiological investigations like chest X-rays and CT chest, and postmortem examination in cases of death(3^✔).

Treatment of Asphyxia

• CPR-Cardio Pulmonary Resuscitation
• Heimlich maneuver - applying pressure over the abdomen to dislodge the obstructed particle
• Bronchoscopy-assisted removal of foreign body
• Oxygen therapy
• Medications depend on pathology(3^✔)
• Surgical intervention, if required

Prevention of Asphyxia

• Precautionary measures while swimming
• Eat slowly and carefully with adequate quantity and small bites
• Seek counseling if you have suicidal thoughts of hanging
• Routine medical checkup for lung diseases
• Avoid contact with antisocial activities
• Supervise children's activities(3^✔, 10^✔)

References:

1. Textbook of forensic medicine and toxicology: principles and practice - (https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=Textbook+of+Forensic+Medicine+and+Toxicology%2C+Principles+and+practice%2C+Krishan+vij%2C+5th+edition.&btnG=)
2. The essentials of forensic medicine and toxicology - (https://scholar.google.com/scholar_lookup?title=The+essentials+of+Forensic+Medicine+&+Toxicology&author=KSN+Reddy&author=OP+Murthy&publication_year=2017&)
3. Asphyxiation - (https://my.clevelandclinic.org/health/diseases/24725-asphyxiation)
4. Distinction between Strangulation, throttling, Mugging, Bansdola, and Garrotting under medical jurisprudence explained - (https://www.daaman.org/jd/javed-abdul-rajjaq-shaikh-vs-state-of-maharashtra/distinction-strangulation-throttling-mugging-bansdola-garrotting-medical-jurisprudence-explained#:~:text=A%20form%20of%20strangulation%2C%20known,strongly%20fastened%20t%20one%20end)
5. Choking: First Aid and Prevention - (https://www.hopkinsmedicine.org/health/wellness-and-prevention/choking-first-aid)
6. Traumatic asphyxia - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047851/)
7. Sudden deaths from positional asphyxia - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6023692/)
8. Cafe coronary syndrome - case report and medicolegal implications - (https://pubmed.ncbi.nlm.nih.gov/34763548/)
9. Mechanism of death in hanging: a historical review of the evolution of pathophysiological hypotheses - (https://pubmed.ncbi.nlm.nih.gov/20456578/)
10. Choking and Suffocation Prevention, Children Ages Birth to 19 Years - (https://www.health.ny.gov/prevention/injury_prevention/children/fact_sheets/birth-19_years/choking_and_suffocation_prevention_birth-19_years.htm)
11. Asphyxia (From Medicolegal Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation - (https://www.ojp.gov/ncjrs/virtual-library/abstracts/asphyxia-medicolegal-investigation-death-guidelines-application)
12. Physiological Changes during Electrical Asphyxiation - (https://www.jstor.org/stable/27722613)
13. Birth Asphyxia - (https://www.ncbi.nlm.nih.gov/books/NBK430782/)
14. Birth asphyxia - (https://www.ucsfbenioffchildrens.org/conditions/birth-asphyxia)
15. APGAR Score - (https://www.ncbi.nlm.nih.gov/books/NBK470569/)
16. What Is the Apgar Score? - (https://kidshealth.org/en/parents/apgar0.html)
17. Birth asphyxia as the major complication in newborns: moving towards improved individual outcomes by prediction, targeted prevention and tailored medical care - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3405378/)
18. Suffocation attack - (https://pubmed.ncbi.nlm.nih.gov/8488380/)
19. What is cerebral palsy? - (https://www.ninds.nih.gov/health-information/disorders/cerebral-palsy)
20. Birth Asphyxia Is Associated With Increased Risk of Cerebral Palsy: A Meta-Analysis - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381116/)
21. Microbial Translocation and Perinatal Asphyxia/Hypoxia: A Systematic Review - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8775023/)

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