All about asphyxia in forensic medicine.

1. Asphyxia
Dr.M Qadeer Naqvi

2. ASPHYXIA
It is a condition in which oxygen supply
to the blood and tissues is reduced
because of interference with respiration.
It can lead to
AnoxiaAnoxaemiaHypoxia.

3. Causes of asphyxia
•Obstruction to the air passages due to hanging,strangulation or
throttling.
•Occlusion of the air passages as in drowning or laryngeal
spasm.
•Pressure on the chest,as in traumatic asphyxia
•Inhalation of irrespirable gases like carbon monoxide.
•Spasm of the respiratory muscles,as in strychnine poisoning.
•Paralysis of the respiratory center,as by narcotics and
anesthetics.
•Obstruction to the upper respiratory passage in cases of
angioneurotic oedema.

4. Features of asphyxia
Cyanosis,capillary dilatation,capillary
stasis,rise of capillary pressure.
Increased capillary permeability

5. Mechanical asphyxial deaths or Violent asphyxial deaths
• Hanging
• Strangulation
• Suffocation
• Drowning

6. Hanging or 'self-suspension' is a
form of asphyxia caused by
suspension of the body by a
ligature which encircles the neck,
the constricting force being at
least part of the weight of the
body. It may be either complete
(feet are not touching the
ground) or partial (feet are
touching the ground).

7. Types
Complete hanging.
Partial hanging.
Typical hanging.
Atypical hanging.

8. Complete hanging
When feet do not touch the ground and
the weight of the body acts as a
constricting force.
Partial hanging
When the weight of the head and not
the whole body acts as a constricting
force is known as partial hanging.

9. Typical hanging
The ligature is situated in the midline
above the thyroid cartilage and runs
symmetrically upwards on both sides of
the neck to the occipital region.
Atypical hanging
Any variation of this standard position.

11. Symptoms
So rapid that they are rarely observed.
Flashes of lights before the eyes,ringing
in the ears.
Unconsciousness and death.
Respiration stops before the heart
which may continue for 10-15min.

12. Causes of death
Asphyxia
Ligature forces the tongue up and
occludes air,15kg tension occludes the
trachea.
Cerebral congestion
Obstruction of jugular veins by
compression with 2kg wt tension.

13. Cerebral anoxia
Carotid artery occludes with 4-5kgs tension
and vertebral artery with 20kgs tension.
Reflex vagal inhibition.
Fracture dislocation of cervical spine at
the level of 2,3,and 4 vertebrae.
Combination of any of the above.

14. Diagnosis
Ligature mark around the neck.
Presence of abrasions,echymosis and
redness around the ligature mark.
Trickling saliva from the mouth.
Echymosis of larynx and trachea.
Rupture of intima of carotids.
Signs of asphyxia.

15. Medico-Legal Aspects
Was the death due to hanging?
Whether hanging was suicidal,homicidal or
accidental?
Typical oblique,non-continuous,high up
ligature mark.
Abrasions and echymosis above and below
the ligature mark.
Extravasation-tear of the intima of the
carotids.
Saliva and signs of asphyxia.

16. Suicidal
 Usually full suspension.
 Ligature tied to beam,hook,fan,tree etc.
 Suspension without any platform is unusual in
suicide.
 Occasional nail mark-may be self inflicted while trying
to free himherself.
 Suicidal note.

18. Homicidal
 Extremely rare,except in case of lynching.
 Difficult,unless the victim is unconscious by injury or
by drugs.
 Marks of violence may be seen on the body.

21. Postmortem hangingSuspension
 Person murdered and the dead body suspended to simulate
suicide.
 Usually the rope is tied first to the neck and then around the
beamhook.
 Ligature mark may be produced if the body is suspended within
2hrs after death.

22. Judicial hanging
 Drop of 5-7meters.
 Fracture dislocation at cervical 2-3 or 3-4.
 Transection of spinal cord.
 Tear of intima of carotid artery.
 Injury to pons and medulla

23. Causes of death
• Asphyxia
• Anoxia
• Congestion
• Vagal inhibition
• Combination of any of the above

24. Homicide
Common form of murder-associated
with sexual offences.
Infanticide-by strangulation with
umbilical cord.
Evidence of struggle,surprise
attack,under intoxication,weak
personality.

25. Strangulation is a form of
asphyxia caused by
mechanical disruption of
blood flow through the
vessels of the neck and/or
blockage of air passage
through the trachea by
means of a ligature or by
any means other than
suspension of the body.

26. CLASSIFICATION OF STRANGULATION
Manual strangulation or throttling:
When human fingers, palms or hands
are used to compress the neck.

27. CLASSIFICATION OF STRANGULATION
Ligature strangulation:
When ligature material is used to
compress the neck. It includes the
use of any type of cord-like object,
such as an electrical cord or purse
strap.

28. CLASSIFICATION OF STRANGULATION
Mugging:
Strangulation caused by holding
the neck of the victim in the bend
of elbow (i.e. the ‘sleeper hold’) or
knee of the assailant.

29. CLASSIFICATION OF STRANGULATION
Garroting:
Strangulation is caused by compression
of the neck by a ligature which is
quickly tightened by twisting it with a
lever (rod, stick or ruler) known as
Spanish windlass which results in
sudden loss of consciousness and
collapse.

30. Common methods of Homicidal strangulation
Throttling
 Compression of neck by hands.
 Bruises produced by tips of fingers.
 More force is used than is necessary.
 Marks of thumb on one side and fingers on other side.
 Pressure of nails produce crescentic marks with or without incision.
 Hyoid bone fracture and bruising can be seen with careful neck dissection.

31. Accidental strangulation
Children may get entangled during play.
Infants are strangled in their cots,when the
neck is caught in sidebars.
Alcoholics,epileptics and insane persons are
susceptible for accidental strangulation.

32. ASPHYXIAL CONDITIONS-DEFINITIONS
Suffocation is a form of asphyxia
caused by mechanical obstruction to the
passage of air into the respiratory tract
by means other than constriction of neck
or drowning. It can also caused by lack
of oxygen in the environment or

33. CLASSIFICATION OF SUFFOCATION
Smothering is caused by mechanical occlusion of
external air passages from outside, i.e. the nose
and mouth by hand, cloth, pillow, plastic bag or
other material

34. CLASSIFICATION OF SUFFOCATION
Choking is caused by an
obstruction within the trachea, either
partially or completely, from inside
by a foreign body, like coin, fruit
seed, toffees, candies, fish or any
other material.

35. CLASSIFICATION OF SUFFOCATION
Gagging results from pushing a
gag (rolled up cloth or paper balls)
into the mouth, sufficiently deep to
block the pharynx. It combines the
features of smothering and
choking.

36. CLASSIFICATION OF SUFFOCATION
Overlaying results from
compression of the chest, nose
and mouth, so as to prevent
breathing.

37. CLASSIFICATION OF SUFFOCATION
Traumatic asphyxia results from respiratory
arrest due to mechanical fixation of chest, so
that the normal movements of chest wall are
prevented.

38. CLASSIFICATION OF SUFFOCATION
Confined space entrapment occurs when there
is inadequate oxygen in the enclosed space
due to consumption or displacement by other
gases.

39. CLASSIFICATION OF SUFFOCATION
Burking is a combination of
homicidal smothering and
traumatic asphyxia.

40. Café coronary
Impaction of food in the larynx causes sudden death
Healthy intoxicated person in hotel while eating suddenly
turns blue,coughs violently-collapses and dies.
At autopsy a large food bolus seen in the respiratory tract-
larynx obstructing air passage.
Post-mortem appearance-the foreign body is embedded in
a thick mucus in the trachea.

41. Traumatic asphyxia
 Its due to respiratory arrest due to mechanical fixation of chest so that the
respiratory movements are prevented.
 E.g.:Stampede in a theatre or in places where crowded gatherings are there.Fall
of earth-coal mines,tunneling accidents etc.
Post-mortem appearances
 An intense deep purple red colour of the head,neck and upper part of chest
above the level of constriction.

42. EPIDEMIOLOGY
 The rate of suicide is far higher in
men than in women (3-4: 1) with
suicidal hangings more common.
However, recent trends suggest
that women are gradually using
hanging than other methods of
suicide.
 Women are more likely than men
to be victims of strangulation
(domestic violence or sexual
assault).
 Nearly all reported autoerotic
strangulation incidents involve
men.
 Accidental strangulation may
occur in both men and women.

43. CAUSES
 Several populations are at risk
of hanging or strangulation.
 Toddlers: The neck may get
caught and strangled in ill-
constructed cribs as they put
their heads out.

44. CAUSES
 Adolescents: Incidence of
accidental hanging,
throttling or strangulation
due to ‘choking game’
(voluntary asphyxia in
order to enjoy the altered
sensations due to cerebral
hypoxia).
 Playground slide tie rope
has been implicated in
accidental strangulation.
 Emulating TV shows and
depression can also lead
to hanging.

45. CAUSES
 Adults: Autoerotic
accidents, assaults, and
suicidal depression are
common causes (e.g.
prisons, where hanging is
easier and available
method).
 Accidental strangulation
from scarfs and by cotton
cloth entangled in the
rotor of a machine have
been reported.
 Elderly: Depression can
lead to hanging.

46. CAUSES
Isadora Duncan syndrome:
The world famous dancer
Isadora Duncan died on 14
September 1929 as a result
of her long scarf which she
was wearing got caught in
the spoke wheels of her car.
She was declared dead in
the hospital.

47. PATHOPHYSIOLOGY
The proposed
mechanisms of the
observed features seen
in most of the asphyxial
conditions (whether by
hanging, manual
strangulation,
application of ligature,
or postural asphyxiation
(in children whose
necks are caught in an
object such as a crib)
includes the following:

48. PATHOPHYSIOLOGY
Venous obstruction
leading to cerebral
congestion, hypoxia and
unconsciousness, which
in turn, produces loss of
muscle tone leading to
airway obstruction, occurs
if ligature is made up of
broad and soft material.
For manual strangulation
and suicidal near-hanging
victims, it is a significant
factor that produces loss
of consciousness.

49. PATHOPHYSIOLOGY
Arterial blockage
due to pressure on carotid artery,
leading to cerebral anoxia and
collapse due to low cerebral
blood flow.

50. PATHOPHYSIOLOGY
Reflex vagal inhibition caused by
pressure to the carotid sinuses
and increased parasympathetic
tone leading to sudden cardiac
arrest (less common)

51. Hyoid bone fracture
 Inward fracture.
 Antero-posterior fracture.
 Avulsion fracture.

52. Inward fracture
Seen in throttling-main force is an
inward compression on the hyoid bone.
Fingers squeeze the greater horns
towards each other,due to which the
bone may be fractured and post
fragments displaced inwards.

53. Antero-posterior compression fracture
In case of hanging,the hyoid bone is
forced directly backwards due to
which,the divergence of greater horns is
increased which may fracture with
outward displacement of the posterior
small fragments.
Ligature strangulation,run over
accidents.

54. Avulsion fracture
Very rare and is due to over activity of
neck muscles without direct action or
injury to hyoid bone.
Incidence-
Hanging 15-20% above 40yrs age.
Very common in throttling.

55. Drowning
Drowning is a form of asphyxial death due to
aspiration of fluid into the air passages by
submersion of the body in water or fluid
medium.
Complete submersion not
necessary,submersion of nose and mouth is
enough.

56. Classification
Typical
Atypical
Typical drowning
Obstruction of air passages and lungs
by inhalation of fluid and is known as
“Wet drowning”.
Typical signs are found at autopsy.

57. Atypical drowning
Conditions in which there is very little or
no inhalation of water or fluid in the air
passages.
Dry drowning.

58. Vicious cycle of drowning
 Deep inspiration
Need for air
 Water enters
resp.passage
Air driven out of lungs
Cough reflex

59. SEQUENCE OF EVENTS IN DROWNING
 1. SENSE OF PANIC
 Expressed by:
 Violent struggle
 Automatic swimming movements
 Usually followed by:
 2. PERIOD OF VOLUNTARY APNOEA
 Duration: 1-2 minutes.
 Hypoxemia, hypercapnia, R & M acidosis.

60.  3. ATTEMPT AT TAKING A BREATH
 WATER:
 May be freely inhaled
 Or, may cause glottic spasm due to impingement.
 In 10-15 % victims: glottic spasm severe asphyxia water may not enter the lungs unless
subcouncious.
Dry drowning
 In 85-90 % victims: water is swallowed inducing vomiting, gasping & aspiration of water into lungs.
When expiratory effort is made: fine froth, sometimes blood stained (due to overdistension of liquid
coloumn)
Wet drowning

61. 4. Cessation of constant struggling
5. Stage of convulsive spasms, twitching,
dilation of pupils
6. Clinical death

62. Freshwater Drowning
The Mechanism + Resp Pathophysiology

63. Freshwater moves rapidly
across
into circulation
disrupts & denatures surfactant
Surface tension increased
compliance decreased
atelectasis

64. More liquid in the circulation
Hemodilution, decrease in Na+, Cl & Ca
conc.
Liquid/ water goes inside RBCs
Hemolysis
Release of K+
Increase in K+ conc.

65.  Marked Ventilation perfusion mismatch
 Shift Acute hypervolemia
 Experimental Vs Reality
Increase in K+ irritates myocardium
Arrythmias (VF) occurs

66. Effect on CVS
Increase in circulatory volume but till
plateau.
Decrease in blood density
Dec in Na, Cl

67. Salt water Drowning
Pulling out of water  Hemoconc. Inc. in
Na, Cl and Mg
No hemolysis, No VF
Death within 5-12 minutes (later than
freshwater)

68.  Pulmonary edema within minutes
 Shift Hypovolemia
Hypertonic liquid
Draws water out through mb
Into pulmonary alveoli
Damage to basement mb + Dilution & washing out
of Surfactant
compliance decreased

69. Pulmonary edema X ray

70. Effect on CVS
CVS effects are secondary to:
1. Changes in arterial oxygen tension
2. Changes in acid base balance.
Acute hypoxemia Catecholamine release Transient tachycardia and hypertension.
Followed by bradycardia and hypotension as hypoxemia intensifies.
Hypoxemia may directly reduce myocardial contractility
Hypoxia + Acidosis: increase the risk for arrythmias( VT, VF, Asystole)
Note: VF as an immediate cause of death is uncommon in both forms of human drowning.

71. Effects on Brain
Hypoxia ischemic damage to brain
Window period of 4-6 minutes before
irreversible neuronal damage.

72. Effects on other organs
Acute renal and hepatic insufficiency
GI injuries
DIC

73. Complications
Immediate
Complications
Cardiac Arrhythmias (VF,
Asystole)
Cardiogenic Shock
Delayed Complications
1.Liquiddamages
pulmonary ARDS
Primary pulmonary
edema
2. Cerebral hypoxia
Neurogenic pulm edema
3.Hypoxic
encephalopathy Brain
death
4.Pneumonia
(aspiration, chemical,
bacterial)
5.Sepsis
6.Multi Organ failure

74. Medico legal aspects
Whether the death was due to drowning or
other cause?
Length of time the body was in water.
Whether it was accidental/suicidal/homicide?

75. Postmortem findings
External findings
Fine froth at the nose and mouth.its white or
rarely blood stained,leather-like,abundant
and increases in amount with compression
of the chest.
Rarely the presence of weeds,mud etc in the
tightly clinched hand.

76. MACRO-MORPHOLOGICAL CHANGES
1. FOAM/ FROTH:
 1. Mushroom like froth from mouth, nostrils.
 2. Foam inside mouth, in upper airways.
 Drowning liquid+ edema liquid+ fine air bubbles (resistant to collapse)
 Blood stained: mechanism?
 3. External foam: most valuable finding
 D/D:
 1. Cardiogenic PE
 2. Epilepsy
 3. Drug intoxication
 4. Electrical shock

77. Tongue: may be protruded or swollen
Cutis Anserina: goose flesh?
Reaction Phenomenon?
Weed, grass, gravel in hand: due to
cadaveric spasm.
Soddening of skin of hands, feet/ shoes.
Wrinkling Bleaching of epidermis in 4-8

78. Comparison of forensic pathology of lungs
Trait Fresh water drowning Sea water drowning
1. Size and weight Balloned but light Balloned and heavy;
weight upto 2kg
2. Color Pale pink Purplish or bluish
3. Consistency Emphysematous Soft and jelly like
4. Shape after removal
from the body
Retained but do not
collapse
Not retained; tend to
flatten out
5. Sectioning Crepitus is heard.
Little froth and no fluid
No crepitus. Copius fluid
and froth.

79. Cause of death
Asphyxia
Ventricular fibrillation
Laryngeal spasm.
Vagal inhibition.
Exhaustion.
Injuries.
Fatal period 4-8min.

80. Diagnosis of drowning
Froth
Weeds & gravel/soil in hand.
Voluminous lungs.
.

81. Asphyxia
CLINICAL EFFECTS OF ASPHYXIA
Sphincter
relaxation
Voiding of
urine,
stools,
semen
Decreased
oxygen
tension and
reduced Hb
Cyanosis
Capillary
endotheliu
m damage
Increased
capillary
permeability
Pulmonary
edema
Unconscio
usness
Loss of
muscle
power
Capillary stasis
and
engorgement
Increased
intracapillary
pressure
Capillary
rupture
Tardieu’s
spots

82. Triad of asphyxial stigmata may be seen
Cyanosis: Bluish discoloration of
skin, face (particularly in the
lips, tip of nose, ears lobules),
nailbeds and mucous
membranes

83. Triad of asphyxial stigmata may be seen
Petechial hemorrhages (Tardieu’s
spots) are found in those parts
where capillaries are least
supported, e.g. conjunctiva,
face, epiglottis, on the face.
They tend to be better made
out in fair skinned persons.

84. Triad of asphyxial stigmata may be seen
Congestion and edema of the
face due to raised venous
pressure.

85. EVALUATION AND DOCUMENTATION
HISTORY
In practice, it has been observed
that manually strangled or
garroted or suicidal hanging
victims are brought to the hospital
in unconscious state for the
purposes of treatment. Such cases
are brought to the emergency
department after being found by
strangers, friends, family members
or sometimes police. On many
occasions the exact history may
not be disclosed by the relatives.
The history in such cases is
lacking, vague or cooked up. In
such cases, the doctor must try to
extract the history from different
sources available.

86. EVALUATION AND DOCUMENTATION
Even if the victim is conscious,
she may not always report the
attempted strangulation
episode. As is common with
cases of domestic violence,
the victim may be hesitant to
fully describe what happened
or will minimize the severity of
the attack. Moreover, visual
evidence of force applied to
the neck during such incident
is often absent or minimal on
initial medical evaluation. The
lack of physical findings may
lead authorities to discount the
patient’s report. Hence,
specific questions often are
required to elucidate the
history.

87. EVALUATION AND DOCUMENTATION
The victim should be asked about the
method or manner of
strangulation, whether hands,
elbow and forearm, knee, ligature
or any other method was used.
Whether the victim attempted
hanging? The number of such
episodes, whether single, multiple
or repeated with different methods.
Other circumstances should also
be enquired like whether the victim
also smothered, shaken, knocked
or pounded into a wall or the
ground? Was the victim also hit or
physically sexually or assaulted?
Whether the victim has consumed
any alcohol, drug or any other
poison (any smell from breath)?

88. EVALUATION AND DOCUMENTATION
The practitioner has to
enquire about specific
symptoms like whether
the victim lost
consciousness, if there is
any neck pain, any
difficulty in breathing or
swallowing, any change of
voice, headache, and if
there was any urinary
and/or fecal incontinence.

89. EVALUATION AND DOCUMENTATION
Hanging victims are more
likely to arrive in the
emergency department
with a depressed level of
consciousness than are
victims of manual
strangulation. This is
presumably due to the
more intensive and
prolonged compressive
force applied to the neck
due to hanging than is
typically seen with
manual pressure.

90. CLINICAL PRESENTATION
The victim may present with deceptively
harmless signs and symptoms with no
or minimal external signs of soft tissue
injury because of the slowly
compressive nature of forces involved
in non-lethal strangulation. The upper
airway may also appear normal beneath
intact mucosa, despite hyoid bone or
laryngeal fractures. It takes time for
hemorrhage and edema to develop after
compressive injuries (may take 36
hours after the episode), and the patient
can develop edema of the supraglottic
and oropharyngeal soft tissue, leading
to airway obstruction.

91. SIGNS AND SYMPTOMS
The clinical presentations
can vary according to
the method, force and
duration of
asphyxiation. The
following specific
clinical manifestations
are possible in
asphyxiation victims:

92. SIGNS AND SYMPTOMS
Dysphonia or hoarseness
of voice is commonly seen.
Patient may sometimes
present with aphonia.

93. SIGNS AND SYMPTOMS
Dyspnea is very common,
but often a late development.
Respiratory distress is seen
in 2 weeks which may be due
hyperventilation or
psychogenic (anxiety, fear,
depression). Difficulty
breathing can also be due to
laryngeal edema or
hemorrhage, although those
injuries are less common in
surviving victims.

94. SIGNS AND SYMPTOMS
Dysphagia or
swallowing difficulty
may occur due to injury
to larynx or hyoid bone
which is not common
symptom on initial
assessment, but may be
reported subsequently
in 2 weeks. Sometimes
it may be painful
(odynophagia).

95. SIGNS AND SYMPTOMS
Pain and swelling in the throat or
neck is common after attempted
strangulation. The patient may be
able to localize it to a specific area
of injury, or it may be diffuse and
poorly localized. Edema may be
caused by internal hemorrhage,
injury to underlying neck
structures or fracture of the.
Laryngeal fracture can manifest as
severe pain on gentle palpation of
the larynx or subcutaneous
emphysema over or around the
laryngeal cartilage.

96. SIGNS AND SYMPTOMS
Altered mental status:
Restlessness, confusion, loss
of orientation or
combativeness due to cerebral
hypoxia or from concomitant
intracranial injury or ingestion
of drugs or ethanol.

97. SIGNS AND SYMPTOMS
Neurologic symptoms
include changes in vision,
tinnitus, ptosis, facial droop, or
unilateral weakness, paralysis
or loss of sensation. In many
patients, the findings are
transient and believed to be
caused by focal cerebral
ischemia produced by the
strangulation process that
resolves with time. In rare
cases, damage to the internal
carotid artery may induce
thrombosis with a delayed
neurologic presentation.

98. SIGNS AND SYMPTOMS
Petechiae can occur at or above the
area of compression and are most
frequently seen on the face,
periorbital region, eyelids, scalp
and conjunctiva. Facial and
conjunctival petechiae are
evidence of prolonged elevated
venous pressure. It has been
found that the jugular vein needs
to be occluded for at least 15-30
seconds for the development of
facial petechiae. Subconjunctival
hemorrhage is usually seen after a
vigorous struggle between the
victim and assailant.

99. SIGNS AND SYMPTOMS
Neck: Injury to the soft tissues
in the neck may manifest
with abrasions (scratches),
hyperemia, ecchymoses and
edema. The hyperemia may
be transient and not visible
by the time of assessment.
Ecchymoses and swelling
may take time to develop and
may not be visible on initial
assessment.

100. SIGNS AND SYMPTOMS
Attempted throttling: Fingertips
may produce faint oval or round bruises
1.5-2 cm in size (may be more in case of
continued bleeding). A grip from right
hand produces a bruising due to bulb of
pressing thumb over the cornue of
hyoid/thyroid on anterolateral surface of
right side of victim's neck and several
fingertip bruising marks and overlying
nail scratch abrasions over left side. A
single bruise on the victim’s neck is
most frequently caused by the
assailant’s thumb as bruises made by
tips of thumbs are more prominent than
with other fingers.

101. SIGNS AND SYMPTOMS
Multiple abrasions
on the neck may be
defensive in nature from
use of victim's own
fingernails in an effort to
dislodge the assailant's
grip but commonly are a
combination of lesions
caused by both the victim
and the assailant’s
fingernails.

102. SIGNS AND SYMPTOMS
Chin abrasions may
also occur from the defensive
actions as the victim tries to
protect their necks from the
manual strangulation of the
assailant.

103. SIGNS AND SYMPTOMS
Attempted throttling: Fingertips may
produce faint oval or round bruises 1.5-
2 cm in size (may be more in case of
continued bleeding). A grip from right
hand produces a bruising due to bulb of
pressing thumb over the cornue of
hyoid/thyroid on anterolateral surface of
right side of victim's neck and several
fingertip bruising marks and overlying
nail scratch abrasions over left side. A
single bruise on the victim’s neck is
most frequently caused by the
assailant’s thumb as bruises made by
tips of thumbs are more prominent than
with other fingers.

104. SIGNS AND SYMPTOMS
Lungs: Aspiration pneumonitis
may occur due to inhalation of
vomitus during the episode.
Pulmonary edema is a seen
generally in comatose hanging
victims. The cause of the
pulmonary edema can either be
due to anoxic injury to the central
nervous system (neurogenic
pulmonary edema) or from the
large negative intrathoracic
pressures seen when the victim
struggles to breathe in against an
occluded airway (obstructive
pulmonary edema).

105. SIGNS AND SYMPTOMS
Involuntary urination or
defecation, expulsion
of fetus (if pregnant)
may occur.

106. SIGNS AND SYMPTOMS
Fractures of the
thyroid cartilage or
hyoid bone in victims
of accidental
strangulation and direct
injury to the trachea is
rare with strangulation.
Carotid artery injury is
also uncommon after
attempted hanging and
strangulation.

107. LIGATURE MARK (‘FURROW’) IN ATTEMPTED
HANGING AND STRANGULATION
S. No. Features Hanging Strangulation
1. Direction Oblique Transverse
2. Continuity Non-continuous Continuous
3. Level in the neck Above thyroid At or below thyroid
4. Base Pale, hard,
parchment-like
Soft and reddish

108. Diagnosis
The majority of the victims present with
some common features, a combination of
these findings should be taken into
consideration for diagnosis:
Hyperemia and/or ecchymosis
Facial or conjunctival petechiae
Change of voice or difficulty in breathing
Marks on the neck
Loss of consciousness or altered mental
status

109. DIAGRAMS AND PHOTOGRAPHS
It is important to document the injuries through
diagrams and photograph that may be seen at the time
of examination for evidence purpose. The injuries should
be mentioned in the pictograph given along with the
medico-legal report. The following photographs may
also be taken:
Distance photo: Full body photograph to identify the
victim and location of injury.
Close-up photo: Photographs of injuries along with a
ruler from different angles to maximize visibility and to
document the size.
Follow-up photo: As the injuries may take time to
develop, taking follow-up photographs at different time
intervals will document injuries as they evolve.

110. MANAGEMENT
Like any other traumatic
injuries, the management of
a strangulation victim starts
with the ABCs
 Airway
 Breathing
 Circulation Fluid
resuscitation must be done
judiciously as there is risk of
subsequent ARDS and
cerebral edema.

111. MANAGEMENT
The choice and sequence of
imaging is dependent on
patient’s clinical
condition, suspected
injuries and availability of
the specific modalities in
that set-up. An ENT
consultation can
establish both the need
for, and the timing of,
these studies.

112. MANAGEMENT
Like any other traumatic
injuries, the management
of a strangulation victim
starts with the ABCs—
airway, breathing,
circulation. Fluid
resuscitation must
be done judiciously as
there is risk of subsequent
ARDS and cerebral edema.

113. MANAGEMENT
Orotracheal
intubation should be done
preferably by an anesthetist. It can
be difficult if laryngeal edema is
present or if direct traumatic
disruption of the larynx has
occurred. Cricothyroidotomy is
indicated for any patient with
severe respiratory distress and
completely obstructed airway. If
associated neck injuries render
cricothyroidotomy difficult,
percutaneous translaryngeal
ventilation may be used to
temporarily oxygenate a patient.

114. MANAGEMENT
The definitive airway
management is
laryngotomy which
must be done at the earliest

115. COMPLICATIONS
Respiratory
system: Both aspiration
pneumonia and ARDS may
develop; tracheal stenosis in
case of rupture.

116. COMPLICATIONS
Neurologic sequelae
including muscle spasms,
transient hemiplegia,
central cord syndrome
and seizures. Long-
term paraplegia or
quadriplegia and
short-term autonomic
dysfunction may be seen
in spinal cord injury.

117. COMPLICATIONS
Psychiatric
symptoms:
Encephalopathy,
insomnia, nightmares
and anxiety and an
inclination for violence are
seen in such victims.
Psychosis, depression,
suicidal ideation, Korsakoff
syndrome, amnesia and
progressive dementia may
develop.