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SUFFOCATION DEFINATION- Form of asphyxia caused by lack of oxygen in an atmosphere or by mechanical obstruction of the air passage by means other than constriction of neck & drowning .
SUFFOCATION CLASSIFICATION  1.SMOTHERING  2.GAGGING  3.CHOKING  4.TRAUMATIC ASPHYXIA  5.BURKING  6.POSITIONAL ASPHYXIA  7.ASPIRATION  8.INHALATION OF IRRESPIRABLE GASES  9.GOING TO HIGH ALTITUDES
SMOTHERING  Mechanical occlusion of ext. air passage (Nose & mouth) by hands , cloths, plastic bags, duct tape etc.
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FINDINGS IN SMOTHERING  Livid face  Frothy bloody discharge from mouth and nostrils  Patechial hemorrages on face,subconjunctival hemorrhages in both eyes  Tongue may be protruded  Flattened nose due to fracture of nasal septum  Cresentic nail marks with concavity inwards,straight and nail marks having outward concavity can be seen
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.  Contusion or even lacerations can be seen under aspect of lips due to contact with teeth  Tearing of frenulum of upper and lower lips  Circum-oral pallor seen around the mouth and nostrils,due to pressure and blanching  Circum oral pallor more conspicuous in children and infants due to less resistance and constant uninterrupted pressure  Sometimes dislocation of anterior teeth
SIGN OF GENERAL VIOLENCE  Contusion on upper arms due to restraining the victim  Abrasion on back of elbow,ankles,legs if the victim is lying on ground  Injuries are less if the victim is weak person,child or person under influence of drugs
OTHER FINDINGS 1.All the internal organs are congested LUNGS- congested,edematous,may show bullae and petechial hemorrhages on their surfaces BRAIN- subarachnoid and petechial haemorrhages can be seen
CIRCUMSTANCES OF SMOTHERING Homicidal • Homicidal smothering is common. • Usually, the victims are females. • It may be associated with sexual assaults. • It is a common method of infanticide. • Persons incapacitated due to extreme age, drugs, or alcohol may be killed by smothering.
HOMICIDAL
ACCIDENTAL • Accidental smothering can occur in newborns by the membranes (birth with a caul, en caul delivery). • Smothering can also occur in infants by turning over and the face getting buried in a sofa or bed. • Similar incidents may happen in persons under the influence of alcohol or drugs or in epileptics and old persons.
• Infants may die accidentally by their mouth and nostrils getting pressed on the breast while feeding by inexperienced mothers. • Accidental death may occur in children who playfully cover their face with plastic bags. • This can also occur during auto-erotic practice (sexual asphyxia) or using volatile inhalants like chloroform, propane, trichloroethane, etc.
ACCIDENTAL
SUICIDAL • Suicidal smothering by hands is not possible since the loss of power in the initial stage of asphyxia will cause release of the hands. • Suicide by burying the face in a spongy sofa or bed has been reported. • Suicide is also possible by self-wrapping of the mouth and nostrils with clothes or adhesive tapes.The person might have been suffering from mental illness.
GAGGING • Gagging is a method of asphyxial death produced by pushing foreign objects like rolled-up cloth or paper into the throat, obstructing the air passage.
EXTERNAL FINDINGS • Livid face. • Petechial hemorrhages on the face and subconjunctival hemorrhages. • Fecal and urinary discharge may be present. • The material used for gagging may be seen in situ or might have been removed by the assailant.
• Injuries inside the mouth due to forceful thrusting of the material. • Contusions and abrasions on the hard palate, root of the tongue, and uvula. • If the material is removed, particles of it (paper or cloth) may still be found in the mouth and pharynx. • Dislocation of teeth may be present.
FINDINGS IN GAGGING Marks of GeneralViolence • May be present on the body. • Minimal in weak persons, infants, and persons under the influence of alcohol and drugs. Other Findings • Lungs will be congested and edematous with petechiae and emphysematous bullae. • All internal organs will be congested.
MEDICO-LEGAL ASPECTS OF GAGGING • Almost always homicidal, with the victim usually being an infant or an elderly person. • Gagging is usually done to prevent the victim from shouting for help; death is usually unintended. • Gags have been used to suppress screams by victims attempting painful methods of suicide (e.g., self-immolation).
CHOKING Defined as form of asphyxia death produced by entry of a foreign body in the air passage hindering respiration Always accidental
Common situations In children, while eating food or putting some foreign bodies in the mouth by themselves (Creche coronary) as in children under 5yrs, gag reflex is not well developed In acute alcohol intoxication Psychiatric patients under tranquilizing drugs Elderly persons suffering from neuro-degenerative disorders Impaction of solid bodies such as large bolus of food, piece of meat, seeds button, coin etc. may cause choking Accidental death may occur due to choking by dislodged teeth in facial injuries
Phases of acute fatal airway obstruction: 1. Penetration of object into airway 2. Obstruction of airway 3. Failure to expel once obstruction has occurred Mechanism: Initially, stridor, respiratory distress, coughing and inability to speak. Followed by, rapid, deep inhalation, causing the object to pass further down the airway. Laryngospasm occurs, followed by vagal stimulation, arrhythmia, apnea and death
Cause of death: I. Asphyxia II. Vagal inhibition III. Laryngeal spasm IV. Delayed death from pneumonia, lung abscess or bronchiectasis
Café Coronary Accidental entry of bolus of food into the air passage causing complete obstruction of the larynx. It is so called, as it mimics a heart attack and is usually seen in an intoxicated restaurant patron The term, was coined by Dr. Roger Haugen in 1963 Causes: •Predisposing factors : decreased protective airway reflex, resulting from aging, poor dentition, tendency to swallow food whole, alcohol consumption, and ingestion of large doses of tranquilizers and other CNS depressants impairing gag reflex •Reflex cardiac arrest from vagal inhibition as a consequence of stimulation of laryngeal nerve endings
Treatment First aid 1. Heimlich Maneuver: Apply pressure on the abdomen if the patient has trouble breathing or turns blue until they recover or lose consciousness. In the case of a baby, lift by legs up and strike on the back of chest. 2. Back or Chest blows: A strong hit on the back or sternum may help expel the object 3. Finger Sweep: Lay the patient on their back, open their mouth, use a finger to clear the blockage 4. Manual Removal: If needed, remove the object from the throat using fingers or forceps 5. Emergency Procedure: If the object cannot be removed, a tracheotomy or cricothyrotomy may be required
Post mortem findings Bolus of food or such material found impacted in larynx or trachea Litmus paper test of bolus can be made to determine the acidity to ascertain its origin Medicolegal Aspect: It is a case of accidental death as opposed to natural, so additional insurance claims can be made
TRAUMATIC ASPHYXIA
Patient - 20yrs old male Incident- unconscious under his car while repairing Symptoms on arrival - • Deep blue discolouration of face and upper chest • Swollen , bloodshot eyes • Petechial hemorrhages • Dyspnea & Altered consciousness CASE STUDY: MYSTERY OF CRUSHED MECHANIC Sam
WHAT HAPPENED? Traumatic Asphyxia A condition caused by sudden , forceful compression of chest or abdomen , leading to VENOUS CONGESTION & CAPILLARY RUPTURE COMMON CAUSES A. JACK SLIPS WHILE WORKING UNDER VEHICLE B. STEERING VEHICLE COMPRESS OF CHEST IN RTA C.LANDSLIDE AND BUILDING COLLAPSE D. STAMPEDE F. OVERLYING BY MOTHER ON BABY DURING SLEEP E. BURYING THE PERSON IN SAND TILL NECK Sam
Detective notes: WHY DOES IT HAPPEN? A. Sudden compression of thorax —Prevent Respiratory Movement and increased pressure in veins B. Cerebral Venous Congestion —Due to displacement of blood from superior vena cava to Head & Neck — Obstruction of venous flow from head and arms C. Capillaries rupture - Petechiae appear D. Oxygen supply decreases - Cynaosis Relating to our case : This explains why our patient had a blue face , swollen eyes, and diffculty breathing m
A. Florid red or blue congestion of face and neck B. Petechial hemorrhages in skin of face and neck , eyelids , conjunctivae and mouth mucous C. Deep cynaosis of face D. May be bleeding from nostril and ears E. Demarcation line F. Pallor of both lower limb , abdomen , chest WHAT DOES AUTOPSY REVEAL EXTERNAL FINDINGS Sam
A. Eyes: Purtscher's retinopathy B. Pharyngeal petechiae and edema of glottis C.Lungs: Congested and heavy with contusions , subpleural petechiae and pneumothorax. D. Heart: Petechial hemorrhages on epicardium E. CNS: Edema of brain with petechiae F. Abdomen: Liver or spleen may belacerated G. Bones: Multiple rib fractures, fracture of clavicle and pelvis. INTERNAL FINDINGS WHAT DOES AUTOPSY REVEAL SAM
📌 Real-World Examples: STAMPEDE A. A stampede is a sudden, uncontrolled crowd movement, often causing crushing injuries and asphyxia. B.Victims at the bottom of the pile experience severe chest compression, leading to traumatic asphyxia. Major Risk Factors: • High population density • Panic & sudden movement • Lack of crowd control measures ✔ Mina Stampede (2015) – Hajj pilgrimage, ~2,400 deaths. ✔ Seoul Halloween Crowd Crush (2022) – 159 deaths. ✔ Travis Scott Astroworld Disaster (2021) – Concert crush leading to 10 deaths
BURKING -It is the combination of homicidal smothering by hands and traumatic asphyxia. -This method got its name after the conviction of William Burke. -William Burke and William Hare made their living by robbing dead bodies from the graves and supplying them to medical schools for study. -Later, they killed 16 people in Edinburgh during the years 1827 and 1828 and supplied to Dr. Robert Knox for his anatomy dissection classes.
-They would invite the victim to their house and would give alcohol. -When the victim was under the influence, they would throw him to the ground. -Burke would sit on the chest and smother the victim while Hare would hold the legs. -Burke was convicted for judicial execution by hanging, and in the judgement it was specially mentioned that his body should be given to school for Anatomy for dissection purpose and the skeleton should be preserved for study. -His skeleton is still preserved in Edinburgh Medical School.
BURKING
1. There may be nail marks around the mouth and nostrils, as evidence of smothering, livid face and subconjunctival haemorrhage. 2. In association with this, there may be rib fractures due to pressure on the chest. 3. All the internal organs will be congested and edematous. AUTOPSY FINDINGS IN BURKING
POSITIONAL ASPHYXIA (POSTURAL ASPHYXIA) -Positional Asphyxia is a form of asphyxia which occurs when someone’s position prevents the person from breathing adequately. -Positional Asphyxia may be a factor in significant number of people’s death during restraint by police, prison officers or health care staff in psychiatric hospitals. -It is a potential danger of some physical restraint techniques. -Face down positions and prone positions with bending of body are potentially dangerous.
HOBBLE PRONE POSITION -Many cases of death have been reported in hogtie or hobble prone restraint position.
JACK-KNIFE POSITION -The victim’s thighs and knees are brought against the chest. -The person may die due to positional asphyxia.
PERSON PINNED BY HIS OWN SHIRT ON A GATE -On March 1999 an autopsy was conducted on the body of a 29 year old male in the department of forensic medicine in Medical College Thrissur, Kerala State. -He was found in the morning, entangled on a gate by his own shirt with his toes just touching the ground. -It is supposed that he was trying to enter the compound by climbing over the gate and accidentally slipped.
-On examination, there was a pressure abrasion on the back of chest due to his own shirt tightening the body. -Death was due to compression of chest.
CRUCIFIXION  It is a method of execution in Roman times • On the cross the hands were nailed and the legs were pulled down and nailed • In this position the chest was indirectly fixed which made the person unable to breathe properly
• This method produced slow asphyxia • After many hours ,if the death had not occurred, the bones of both legs would be broken by hammer • This made death by asphyxia faster because the person lost support on feet • Dehydration is an additional factor which contributed death because no water would be given to drink
Crucifixion:his legs were not broken since he was found already dead ( John 19.33)
• A person gets suffocated due to inhalation of irrespirable gases like carbon monoxide ,carbon dioxide ,sulphur dioxide etc • In unused wells the air is concentrated with carbon dioxide(Ghost Wells) the person may get asphyxiated • In the sewages the person may die due to inhalation of gases like hydrogen sulphide,sulphur dioxide INHALATION OF IRRESPIRABLE GASES
 When the head and face is covered with plastic bag ,tied or otherwise , death can occur due to anoxia  This can be suicidal or homicidal  It can also be accidental as in solvent abuse ( glue sniffing )cases
• In Suicidal cases there may not be any injuries ,since it produces slow asphyxia ,unconsciousness and death without much struggle for life • Signs of asphyxia are faint or lacking in case of plastic bag suffocation • Moisture collects in the bag which cannot be taken as an antemortem sign because condensation inside the bag can occur post mortem • In Homicidal cases there will be injuries due to struggling and Suicidal Death due to helium inhalation
Drowning Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. ie, a liquid-air interface is present at the entrance to the victim’s airway, which prevents the individual from breathing oxygen.
Types of Drowning Primary/Typical/Wet Drowning Typical drowning with water entering the lungs. • Fresh water • Salt water Atypical Drowning Variations with different mechanisms. • Dry Drowning • Immersion Syndrome • Secondary Drowning • Submersion of the unconscious
Wet Drowning Process Initial Submersion Person sinks due to gravity. Struggle and Inhalation Rising, crying for help, inhaling water. Repeated Cycle Sinking and rising, water replaces air in the lungs. Final Submersion Convulsions, suspended animation, death.
Fresh Water Drowning 1 Water Entry Fresh water enters the lungs. 2 Hemodilution Dilution of blood. 3 Hemolysis Red blood cell rupture. 4 Cardiac failure Ventricular fibrillation
Salt Water Drowning Water Entry Salt water enters the lungs. Osmotic Effect Fluid drawn into the lungs. Pulmonary Edema Fluid accumulation in lungs. Cardiac failure Asystole
Dry Drowning 1 Laryngospasm Vocal cords spasm, blocking airway. 2 Limited Water Entry Little to no water enters lungs. 3 Asphyxia Oxygen deprivation due to blockage.
Immersion Syndrome Sudden Immersion Sudden cold water shock. 1 Vagal Stimulation Overstimulation of vagus nerve. 2 Cardiac Arrest Potential for heart stoppage. 3
Secondary Drowning/Near drowning Refers to survival beyond 24hr after a submersion episode. Death is caused by complications (eg. ARDS, pneumonia, sepsis, cerebral edema, DIC etc.) Secondary drowning sometimes refers to a victim who initially responds well to resuscitation but then suffers respiratory decompensation.
Submersion of the unconscious/Shallow water drowning Alcoholics, drugged, epileptics, infants, children and unconscious persons may die due to drowning in shallow water in a pit or drain.
Pathophysiology of Drowning and Fatal period Pathophysiology of Drowning and Fatal period
Drowning Drowning is defined as a process of respiratory impairment due to submersion or immersion in a liquid medium. It can be classified into freshwater drowning and saltwater drowning, with different physiological effects due to differences in osmolality.
Pathophysiology of drowning 1. Freshwater drowning 2. Saltwater drowning
1.Freshwater Drowning Freshwater has a lower osmolality than plasma, leading to significant physiological changes. The pathophysiology is primarily based on the experiments conducted by Swann and collaborators, who studied its effects on the body.
Mechanism of Freshwater Drowning: 1.Water enters the lungs: Freshwater is rapidly absorbed across the alveolar-capillary membrane due to its low osmolarity. 2. Hemodilution: The influx of hypotonic water into the bloodstream leads to a decrease in plasma osmolality and dilution of blood components. 3. Red Blood Cell (RBC) Rupture: Due to osmotic swelling, RBCs undergo hemolysis, releasing intracellular contents such as potassium (K⁺) into the levels, which affects cardiac
4. Hyperkalemia: The release of potassium leads to a sharp increase in serum potassium levels, which affects cardiac function. 5. Cardiac Overload & Arrhythmias: The increased blood volume causes ventricular tachycardia and ventricular fibrillation, leading to cardiac arrest. 6. Hypoxia & Death: Ultimately, lack of oxygen supply results in respiratory failure and death.
2.SALT WATER DROWNING Saltwater drowning occurs when a person inhales seawater, leading to oxygen deprivation and potential complications. The high salt content in seawater affects the body's physiology differently than freshwater drowning
Physiology of Saltwater Drowning 1. Osmotic Effect: Seawater has a higher salt concentration than blood. When inhaled, it draws water out of lung tissues into the alveoli (tiny air sacs), causing pulmonary edema (fluid accumulation in the lungs). This makes breathing even harder and reduces oxygen absorption. 2. 2. Hypoxia (Oxygen Deprivation): The inability to get enough oxygen leads to loss of consciousness and, if untreated, cardiac arrest.
2. Hypoxia (Oxygen Deprivation): The inability to get enough oxygen leads to loss of consciousness and, if untreated, cardiac arrest. 3. Electrolyte Imbalance: Absorbing large amounts of saltwater into the bloodstream can cause hypernatremia (high sodium levels), leading to brain swelling, confusion, seizures, and coma. 4. Cardiovascular Collapse: If the heart and lungs fail to deliver oxygen, the body shuts down, leading to multi-organ failure.
FATAL PERIOD The fatal period of saltwater drowning refers to the estimated time it takes for drowning to become fatal after submersion. This can vary based on factors like water temperature, the victim’s health, and rescue efforts FRESH WATER DROWNING - 4 – 5 MINUTES SALT WATER DROWNING - 8 - 12 MINUTES
EXTERNAL POSTMORTEM APPEARANCES
● Clothes : Wet ● Face : Congested with petechiae on the face. ● Eyes : May be congested. ● Postmortem staining :On face, shoulders and front of upper part of chest(body usually remains in water in a head down position.) Light pink in color(due to absence of deoxygenation of blood) Sometimes blue due to cyanosis. No staining if the body is recovered from turbulent water.
● Froth : fine leathery tenacious froth at the mouth and nostrils. Forms a mushroom like mass.
Mechanism of froth ● Formed in the lungs due to churning effect of air, water and mucous in the alveoli ● Froth will be in copious amount. ● Froth may be blood stained due to congestion and intra pulmonary hemorrhage.
● Cutaneous anserina Or Goose skin or Puckered appearance of skin : Due to spasm of pili muscles and contact of skin with cold water. Not an ante mortem feature. Also occur due to rigor mortis.
● Cadaveric spasm : Weed particles, twigs, leaves may be seen firmly grasped. Definite ante mortem sign if drowning
● Washerwoman’s hands and feet:
Bleaching and soddening of both hands and feet. 1. Wrinkling of tips of fingers - about 2hrs 2.Bleaching of the cuticle - by 12 hrs 3.Bleaching and soddening of hands and feet - about 24 hrs Due to softening and imbibition of water into the superficial layers of skin.
● Scrotum and penis : Get retracted in contact with cold water.
POSTMORTEM APPEARANCE INTERNAL
LUNGS On opening the chest wall:- ● Lungs fully occupy the chest cavity. ● Lungs appear congested, edematous, ballooned, and crepitant. ● Crepitus is felt when touched with gloved fingers. Surface features of the lungs:- ● Pale pink appearance with subpleural hemorrhages (1–5 cm in diameter), called Paltauf's hemorrhages, especially on the lower lobes. ● Rib markings may be visible. ● Lungs will pit on pressure
LUNGS CONTD Specific lung characteristics in fresh water drowning:- ● Emphysematous changes are more pronounced than edema. ● This type of lung is referred to as Emphysema Aquosum Lung. ● Classical appearance in 80% of fresh water drowning cases (Taylor et al.). Other findings:- ● Froth extrudes upon cutting the lung. ● Lung contour is maintained. ● Tardieu's spots are minimal or absent in drowning cases.
DIFFERENCE Salt water drowning lungs: Edematous, weigh double. Edema fluid oozes on cutting. Flattened, lose contours. Edema > emphysema, water-logged (Edema Aquosum Lung). Water drawn into alveoli from blood (C.J. Polson, Reinhard B. et al.). Edema Aquosum Lung in fresh water drowning: Seen in unconscious or intoxicated individuals. Lungs flood with water, no violent respiratory effort. No froth formation.
OTHER FINDINGS ● Foreign bodies in airways:- ● Weed, sand, and mud in trachea, bronchi, or bronchioles confirm drowning. ● Foreign particles may reach pharynx/upper trachea postmortem, not bronchioles (Gordon et al.). ● Regurgitated food may be present due to agonal aspiration. Stomach:- ● Water found in 70% of cases. ● Muddy water in the stomach is significant if not used for drinking. Brain and organs:- ● Brain: Congested, edematous, rarely subarachnoid hemorrhage. ● All other internal organs are congested.
Atypical Drowning In these types of drowning, the classical features described in wet drowning are missing e.g.. a) Dry drowning b) Secondary drowning e) Immersion syndrome d) Shallow water drowning
DRY DROWNING
Secondary drowning (Near drowning) If the victim survives more than 24 hrs. He may develop secondary complications of drowning. This is called secondary drowning. The person may develop the following complications. 1) The person may or may not be conscious. 2) He may develop pulmonary edema and ARDS, pneumonia and septicemia. 3) There may be hypoxic brain damage; the survivors may have neurologic damage like paraplegia also. 4) There may be hemoglobinuria due to lysis of red cells. 5) There may be myocardial anoxia and cardiac arrhythmias.
Immersion syndrome (Hydrocution or Submersion inhibition) ● When the person enters cold water, vaso-vagal inhibition and cardiac arrest occurs due to stimulation of cutaneous nerves of the chest and abdomen. This is called immersion syndrome. ● Vaso-vagal stimulation may also be due to cold water touching ear drums or nasal mucosa. ● At autopsy, the classical signs of drowning are not seen in the lungs.
Submersion of the unconscious (Shallow water drowning) ● Under the influence of alcohol or drugs, epileptics and unconscious persons may get drowned in shallow water. When they fall into water, the struggling movements are lacking and as a result, the classical features of drowning will be absent. Mere flooding of lungs with water occurs which is known as edema aquosum.
Hydrostatic Lung ● If a dead body is put into water and remain under water, due to hydrostatic pressure, water may pass into lungs. This is called Hydrostatic lung, and its appearance may be that of "Drowning Lung" but the classical signs of drowning are absent. ● According to Eisele, a lung similar to "Drowning Lung" can be produced by keeping a dead body at a depth of 2 meters for 20 hrs.
LABORATORY TEST IN DROWNING No single test is confirmatory of drowning. 1. Gettler's Test (Chloride Estimation) ● Blood is extracted from right and left ventricles and chloride is estimated. ● Normal value of chloride is 600 mg per 100 ml. ● In salt water drowning, the chloride content in the left ventricle is 42% higher than normal due to hemoconcentration.In fresh water drowning the chloride content in left ventricle will be 50% less than normal value due to hemodilution. ● A difference of 25% in chloride between two chambers of heart is supposed to be significant. Gettler's test is of no help if there is advanced decomposition, patent foramen ovale and in dry drowning. This test have many fallacies and not done nowadays. ● Estimation of potassium, zinc, magnesium etc. in the right and left ventricles of heart can also be done but are not confirmatory.
DIATOM TEST ● Diatoms are unicellular algae present in fresh water and salt water. There are about 15000 types of diatoms and are of different size and have shapes like circular, triangular, rectangular, spindle shaped, oval etc. ● Their size varies from 2 microns to 500 microns. ● The diatoms are have thick silica cell wall and contain chlorophyll and la brown pigment diatomin.* Hoffman (1896) first discovered diatoms in lung fluid. Later on, Rovenstorf (1904) first attempted to use diatoms as a test for drowning. ● Diatoms may enter the lungs while drowning and pass to the blood stream and may enter all the internal organs. They can be demonstrated in internal organs and bone marrow.
Technique (Acid digestion method)
INTERPRETATION ● If same type of diatoms is obtained in bone marrow (10-20 diatoms/el. from 10 gm of tissue) and water sample, it can be taken as a corrobontive evidence of drowning. ● Researchers have shown that diatons are obtained in non drowning cases also, since they are present in the dust in air (diatomaceous earth). ● It is also shown that during drinking also diatoms may enter the body (Bernard knight et.al). ● So, diatom test is only a corroborative test and not a confirmatory test.
Water in Sinuses ● During drowning, water will enter into all the sinuses. Water can be extracted from these sinuses. ● Water in the sinuses cannot be taken as a sign of drowning since water may reach the sisuses after death also when the body is under water. ● Water can be extracted from the sphenoid sims by breaking the bone just in front of sella tursica (jugum sphenoidale) and using a wide bored needle and syringe
ANTEMORTEM FEATURES OF DROWNING During autopsy the opinion as to the cause of deals is made by the antemortem features of drowning 1. Fine white froth at the mouth and nostrils 2. The presence of weeds or other things in water firmly grasped in hands due to cadaveric spesm 3. Presence of sand or mud or weed in the air passages seen in the lower respiratory tract 4. Voluminous congested and edematous, crepitant and ballooned up lings 5. Presence of identical diatoms in the bone marrow can be taken as corroborative
CIRCUMSTANCE OF DROWNING Accidental: ● Children may accidentally fall into water during playing ● Intoxicated persons may accidentally fall into water especially in unprotected wells. ● Persons under the influence of alcohol or epileptic persons may accidentally drown in shallow water In shallow water drowning the lung may be edematous and give features of edema aquosum. Women may fall into unprotected wells while drawing water. ● Divers may get drowned when their head strikes on some hard object and become unconscious.
SCUBA DIVING ●In SCUBA diving, a diver uses a Self-Contained Underwater Breathing Apparatus (SCUBA) to breathe underwater. ●At greater depths, higher pressure causes more nitrogen from the breathing gas to dissolve in the blood and tissues. ●During ascent, pressure decreases, and dissolved nitrogen comes out of solution as bubbles, similar to opening a soda bottle. ●This can lead to decompression sickness (DCS) or air embolism, causing pain, dizziness, or serious health issues. ●The condition is similar to what happens to people at high altitudes due to rapid pressure changes.
SIGNS AND SYMPTOMS ●Air entrapment in various body sites can cause serious symptoms. ●Respiratory issues: Dyspnoea (chokes), due to trapped air. ●Neurological symptoms: Headache, vertigo (staggers), temporary scotoma, epileptiform convulsions, and paraplegia (without sensory loss). ●Joint pain: Known as "bends" (Caisson’s Disease). ●Lung-related issues: 》 Extra-alveolar air syndrome from trapped air in the lungs during ascent. 》 Air escAir entrapment in various body sites can cause serious symptoms. ●Barotrauma:Mechanical tissue damage due to gas release
TREATMENT ●Administer 100% oxygen to help remove excess nitrogen. ●Rapid transportation to a medical facility for immediate care. ●Decompression treatment in a hyperbaric oxygen chamber to reduce nitrogen bubbles. ●Hydration therapy to manage plasma deficits and support circulation. Supportive measures as needed for symptoms. ●Use of helium in deep dives instead of nitrogen, as it dissolves less in tissues, reducing the risk of decompression sickness.
POSTMORTEM EXAMINATION EXTERNAL FINDINGS: 》 Cyanosis and facial edema 》 Froth at the nostrils 》 Crepitations due to subcutaneous emphysema 》 Ruptured tympanic membrane 》 Gas in retinal vessels
INTERNAL FINDINGS: 》 Pneumothorax and pneumomediastinum 》 Pulmonary edema and petechiae on lung surfaces 》 Air embolism in the heart (can be demonstrated)
Diagnostic Tests: 》 Pyrogallol test: Confirms air embolism (solution turns brown) 》 Histopathology: Air bubbles found in lungs and other internal organs 》 Extra-alveolar air in pleural, pericardial, and intravascular locations is better detected by CT scan than standard postmortem examination.
Suicidal Drowning ●Common in India, especially among women, due to easy access to water bodies (sea, rivers, ponds, canals, wells). ●Women often avoid exposing their bodies when drowning. ●Swimmers may tie their hands and feet before entering the water to prevent escape. ●The knot should not be disturbed by investigators. ●Postmortem should determine if the victim could have tied it themselves.
●Some may attach heavy objects (e.g., stones) to conceal their death. ●Others may cut their throat or consume poison before drowning. ●Falls into wells can cause fatal or nonfatal injuries. ●Circumstances of death must be carefully examined in each case. ●Even small water sources (e.g., buckets, cisterns) can be used for suicide if the person is determined.
FEATURES ANTEMORTEM DROWNING POSTMORTEM SUBMERSION Froth over mouth and nostrils Fine, lathery froth, appears spontaneously Absent. But if present, coarse, not spontaneous Cadaveric spasm in hands Aquatic vegetations, mud Not observed Trachea and bronchioles Algae, mud, frothy mucus Absent Lungs Ballooned up, bulky, edematous, bear indentations of ribs Collapsed, decomposed Mud & algae in stomach &small intestine May be present Absent Diatom & Gettler’s tests Positive Negative Injuries If present, consistent with drowning Inconsistent with drowning Other suggestive signs Water in middle ear, retracted genitals,cutis anserina, washer- woman’s hands, wet clothing, mud & sand Water never present in middle ear, others are not valuable and corroborative findings
HOMICIDE ●It is possible to kill infants and children by putting them into water ●Adult persons can be pushed to river, sea, or well ●Homicidal drowning is possible by forcefully dipping the head in shallow water.
CONTD… ●In such cases there may be - Abrasions - Nail marks and - Contusions on the nape of neck - Injuries due to general violence ●If the person is under the influence of alcohol, marks of violence may be minimal or absent
Brides in the bath ●Mr. R.V. Smith married many women & they were found dead in the bathtub. ●Later proven to be homicides. ●Playfully lift both of the legs; would die of drowning w/o injuries. ●Killed 3 women this way ●Motive - to get the insurance claims of the victims
INJURIES & DROWNING ●Injuries on the body should be carefully attended. ●Injuries may be sustained before/during/after entry into water. ●The injuries may be simple abrasions or grave injuries like head injury. ●Injuries on the body may occur during a fall into a well or pond or a rocky place. ●There is a possibility of the person getting the injury in an assault.
DISPOSAL OF DEAD BODIES IN WATER ●Criminals may use local ponds, wells and other water bodies to dispose the dead body after killing. ● Sometimes heavy objects like stones or concrete blocks are tied on the body. ●On examination, there may be other causes of death like strangulation, stab wounds etc.
FLOTATION OF DEAD BODY IN WATER ●Tropical countries, dead body floats by ~24 hours. ●Clothed body may float earlier if air trapped in it. ●Female bodies float early ; more fat content. ●Even heavy weight attached, body float due to the pressure of decomposition gases. ●In the depth of the sea, body may not float because of equal water pressure from all sides. ●When body is dismembered and put into water, limbs’ll float & the head may not float.
MEDICOLEGAL QUESTIONS
Whether downing was accidental, suicidal or homicidal? ●ACCIDENTAL ●At risk groups - sailors - fisherman -dockworkers etc. ●Information regarding inability to swim, trauma, seizure, heart disease, exhaustion, alcohol or drug abuse should be sought
●SUICIDAL ●Suicide by drowning common in India. ●Women often tie clothes to ensure modesty after death. ●Methods include tying limbs, adding weights, poisoning, or self harm before jumping. ●Shallow water drownings in adults are usually presumed suicides unless proven otherwise.
●HOMICIDAL ●Homicidal drowning is rare, but common in infanticide, esp. with newborns. ●Lack of injuries ; drowning can be inflicted w/o marks, especially on non-swimmers intoxicated individuals or those bathing ●Postmortem disposal ; bodies of homicide victims may be placed in water after death to hide the crime.
Thankyou !!!

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Presentation based on methods of suffocation.pptx

  • 1.
    SUFFOCATION DEFINATION- Form ofasphyxia caused by lack of oxygen in an atmosphere or by mechanical obstruction of the air passage by means other than constriction of neck & drowning .
  • 2.
    SUFFOCATION CLASSIFICATION  1.SMOTHERING 2.GAGGING  3.CHOKING  4.TRAUMATIC ASPHYXIA  5.BURKING  6.POSITIONAL ASPHYXIA  7.ASPIRATION  8.INHALATION OF IRRESPIRABLE GASES  9.GOING TO HIGH ALTITUDES
  • 3.
    SMOTHERING  Mechanical occlusionof ext. air passage (Nose & mouth) by hands , cloths, plastic bags, duct tape etc.
  • 4.
  • 5.
    FINDINGS IN SMOTHERING Livid face  Frothy bloody discharge from mouth and nostrils  Patechial hemorrages on face,subconjunctival hemorrhages in both eyes  Tongue may be protruded  Flattened nose due to fracture of nasal septum  Cresentic nail marks with concavity inwards,straight and nail marks having outward concavity can be seen
  • 6.
  • 7.
    .  Contusion oreven lacerations can be seen under aspect of lips due to contact with teeth  Tearing of frenulum of upper and lower lips  Circum-oral pallor seen around the mouth and nostrils,due to pressure and blanching  Circum oral pallor more conspicuous in children and infants due to less resistance and constant uninterrupted pressure  Sometimes dislocation of anterior teeth
  • 8.
    SIGN OF GENERALVIOLENCE  Contusion on upper arms due to restraining the victim  Abrasion on back of elbow,ankles,legs if the victim is lying on ground  Injuries are less if the victim is weak person,child or person under influence of drugs
  • 9.
    OTHER FINDINGS 1.All theinternal organs are congested LUNGS- congested,edematous,may show bullae and petechial hemorrhages on their surfaces BRAIN- subarachnoid and petechial haemorrhages can be seen
  • 10.
    CIRCUMSTANCES OF SMOTHERING Homicidal •Homicidal smothering is common. • Usually, the victims are females. • It may be associated with sexual assaults. • It is a common method of infanticide. • Persons incapacitated due to extreme age, drugs, or alcohol may be killed by smothering.
  • 11.
  • 12.
    ACCIDENTAL • Accidental smotheringcan occur in newborns by the membranes (birth with a caul, en caul delivery). • Smothering can also occur in infants by turning over and the face getting buried in a sofa or bed. • Similar incidents may happen in persons under the influence of alcohol or drugs or in epileptics and old persons.
  • 13.
    • Infants maydie accidentally by their mouth and nostrils getting pressed on the breast while feeding by inexperienced mothers. • Accidental death may occur in children who playfully cover their face with plastic bags. • This can also occur during auto-erotic practice (sexual asphyxia) or using volatile inhalants like chloroform, propane, trichloroethane, etc.
  • 14.
  • 15.
    SUICIDAL • Suicidal smotheringby hands is not possible since the loss of power in the initial stage of asphyxia will cause release of the hands. • Suicide by burying the face in a spongy sofa or bed has been reported. • Suicide is also possible by self-wrapping of the mouth and nostrils with clothes or adhesive tapes.The person might have been suffering from mental illness.
  • 16.
    GAGGING • Gagging isa method of asphyxial death produced by pushing foreign objects like rolled-up cloth or paper into the throat, obstructing the air passage.
  • 17.
    EXTERNAL FINDINGS • Lividface. • Petechial hemorrhages on the face and subconjunctival hemorrhages. • Fecal and urinary discharge may be present. • The material used for gagging may be seen in situ or might have been removed by the assailant.
  • 18.
    • Injuries insidethe mouth due to forceful thrusting of the material. • Contusions and abrasions on the hard palate, root of the tongue, and uvula. • If the material is removed, particles of it (paper or cloth) may still be found in the mouth and pharynx. • Dislocation of teeth may be present.
  • 19.
    FINDINGS IN GAGGING Marksof GeneralViolence • May be present on the body. • Minimal in weak persons, infants, and persons under the influence of alcohol and drugs. Other Findings • Lungs will be congested and edematous with petechiae and emphysematous bullae. • All internal organs will be congested.
  • 20.
    MEDICO-LEGAL ASPECTS OFGAGGING • Almost always homicidal, with the victim usually being an infant or an elderly person. • Gagging is usually done to prevent the victim from shouting for help; death is usually unintended. • Gags have been used to suppress screams by victims attempting painful methods of suicide (e.g., self-immolation).
  • 21.
    CHOKING Defined as formof asphyxia death produced by entry of a foreign body in the air passage hindering respiration Always accidental
  • 22.
    Common situations In children,while eating food or putting some foreign bodies in the mouth by themselves (Creche coronary) as in children under 5yrs, gag reflex is not well developed In acute alcohol intoxication Psychiatric patients under tranquilizing drugs Elderly persons suffering from neuro-degenerative disorders Impaction of solid bodies such as large bolus of food, piece of meat, seeds button, coin etc. may cause choking Accidental death may occur due to choking by dislodged teeth in facial injuries
  • 23.
    Phases of acutefatal airway obstruction: 1. Penetration of object into airway 2. Obstruction of airway 3. Failure to expel once obstruction has occurred Mechanism: Initially, stridor, respiratory distress, coughing and inability to speak. Followed by, rapid, deep inhalation, causing the object to pass further down the airway. Laryngospasm occurs, followed by vagal stimulation, arrhythmia, apnea and death
  • 24.
    Cause of death: I.Asphyxia II. Vagal inhibition III. Laryngeal spasm IV. Delayed death from pneumonia, lung abscess or bronchiectasis
  • 25.
    Café Coronary Accidental entry ofbolus of food into the air passage causing complete obstruction of the larynx. It is so called, as it mimics a heart attack and is usually seen in an intoxicated restaurant patron The term, was coined by Dr. Roger Haugen in 1963 Causes: •Predisposing factors : decreased protective airway reflex, resulting from aging, poor dentition, tendency to swallow food whole, alcohol consumption, and ingestion of large doses of tranquilizers and other CNS depressants impairing gag reflex •Reflex cardiac arrest from vagal inhibition as a consequence of stimulation of laryngeal nerve endings
  • 26.
    Treatment First aid 1. HeimlichManeuver: Apply pressure on the abdomen if the patient has trouble breathing or turns blue until they recover or lose consciousness. In the case of a baby, lift by legs up and strike on the back of chest. 2. Back or Chest blows: A strong hit on the back or sternum may help expel the object 3. Finger Sweep: Lay the patient on their back, open their mouth, use a finger to clear the blockage 4. Manual Removal: If needed, remove the object from the throat using fingers or forceps 5. Emergency Procedure: If the object cannot be removed, a tracheotomy or cricothyrotomy may be required
  • 28.
    Post mortem findings Bolusof food or such material found impacted in larynx or trachea Litmus paper test of bolus can be made to determine the acidity to ascertain its origin Medicolegal Aspect: It is a case of accidental death as opposed to natural, so additional insurance claims can be made
  • 29.
  • 30.
    Patient - 20yrsold male Incident- unconscious under his car while repairing Symptoms on arrival - • Deep blue discolouration of face and upper chest • Swollen , bloodshot eyes • Petechial hemorrhages • Dyspnea & Altered consciousness CASE STUDY: MYSTERY OF CRUSHED MECHANIC Sam
  • 31.
    WHAT HAPPENED? Traumatic Asphyxia A conditioncaused by sudden , forceful compression of chest or abdomen , leading to VENOUS CONGESTION & CAPILLARY RUPTURE COMMON CAUSES A. JACK SLIPS WHILE WORKING UNDER VEHICLE B. STEERING VEHICLE COMPRESS OF CHEST IN RTA C.LANDSLIDE AND BUILDING COLLAPSE D. STAMPEDE F. OVERLYING BY MOTHER ON BABY DURING SLEEP E. BURYING THE PERSON IN SAND TILL NECK Sam
  • 32.
    Detective notes: WHY DOESIT HAPPEN? A. Sudden compression of thorax —Prevent Respiratory Movement and increased pressure in veins B. Cerebral Venous Congestion —Due to displacement of blood from superior vena cava to Head & Neck — Obstruction of venous flow from head and arms C. Capillaries rupture - Petechiae appear D. Oxygen supply decreases - Cynaosis Relating to our case : This explains why our patient had a blue face , swollen eyes, and diffculty breathing m
  • 33.
    A. Florid redor blue congestion of face and neck B. Petechial hemorrhages in skin of face and neck , eyelids , conjunctivae and mouth mucous C. Deep cynaosis of face D. May be bleeding from nostril and ears E. Demarcation line F. Pallor of both lower limb , abdomen , chest WHAT DOES AUTOPSY REVEAL EXTERNAL FINDINGS Sam
  • 34.
    A. Eyes: Purtscher'sretinopathy B. Pharyngeal petechiae and edema of glottis C.Lungs: Congested and heavy with contusions , subpleural petechiae and pneumothorax. D. Heart: Petechial hemorrhages on epicardium E. CNS: Edema of brain with petechiae F. Abdomen: Liver or spleen may belacerated G. Bones: Multiple rib fractures, fracture of clavicle and pelvis. INTERNAL FINDINGS WHAT DOES AUTOPSY REVEAL SAM
  • 35.
    📌 Real-World Examples: STAMPEDE A. Astampede is a sudden, uncontrolled crowd movement, often causing crushing injuries and asphyxia. B.Victims at the bottom of the pile experience severe chest compression, leading to traumatic asphyxia. Major Risk Factors: • High population density • Panic & sudden movement • Lack of crowd control measures ✔ Mina Stampede (2015) – Hajj pilgrimage, ~2,400 deaths. ✔ Seoul Halloween Crowd Crush (2022) – 159 deaths. ✔ Travis Scott Astroworld Disaster (2021) – Concert crush leading to 10 deaths
  • 36.
    BURKING -It is thecombination of homicidal smothering by hands and traumatic asphyxia. -This method got its name after the conviction of William Burke. -William Burke and William Hare made their living by robbing dead bodies from the graves and supplying them to medical schools for study. -Later, they killed 16 people in Edinburgh during the years 1827 and 1828 and supplied to Dr. Robert Knox for his anatomy dissection classes.
  • 37.
    -They would invitethe victim to their house and would give alcohol. -When the victim was under the influence, they would throw him to the ground. -Burke would sit on the chest and smother the victim while Hare would hold the legs. -Burke was convicted for judicial execution by hanging, and in the judgement it was specially mentioned that his body should be given to school for Anatomy for dissection purpose and the skeleton should be preserved for study. -His skeleton is still preserved in Edinburgh Medical School.
  • 38.
  • 40.
    1. There maybe nail marks around the mouth and nostrils, as evidence of smothering, livid face and subconjunctival haemorrhage. 2. In association with this, there may be rib fractures due to pressure on the chest. 3. All the internal organs will be congested and edematous. AUTOPSY FINDINGS IN BURKING
  • 41.
    POSITIONAL ASPHYXIA (POSTURAL ASPHYXIA) -PositionalAsphyxia is a form of asphyxia which occurs when someone’s position prevents the person from breathing adequately. -Positional Asphyxia may be a factor in significant number of people’s death during restraint by police, prison officers or health care staff in psychiatric hospitals. -It is a potential danger of some physical restraint techniques. -Face down positions and prone positions with bending of body are potentially dangerous.
  • 42.
    HOBBLE PRONE POSITION -Manycases of death have been reported in hogtie or hobble prone restraint position.
  • 43.
    JACK-KNIFE POSITION -The victim’sthighs and knees are brought against the chest. -The person may die due to positional asphyxia.
  • 44.
    PERSON PINNED BYHIS OWN SHIRT ON A GATE -On March 1999 an autopsy was conducted on the body of a 29 year old male in the department of forensic medicine in Medical College Thrissur, Kerala State. -He was found in the morning, entangled on a gate by his own shirt with his toes just touching the ground. -It is supposed that he was trying to enter the compound by climbing over the gate and accidentally slipped.
  • 45.
    -On examination, therewas a pressure abrasion on the back of chest due to his own shirt tightening the body. -Death was due to compression of chest.
  • 46.
    CRUCIFIXION  It isa method of execution in Roman times • On the cross the hands were nailed and the legs were pulled down and nailed • In this position the chest was indirectly fixed which made the person unable to breathe properly
  • 47.
    • This methodproduced slow asphyxia • After many hours ,if the death had not occurred, the bones of both legs would be broken by hammer • This made death by asphyxia faster because the person lost support on feet • Dehydration is an additional factor which contributed death because no water would be given to drink
  • 48.
    Crucifixion:his legs werenot broken since he was found already dead ( John 19.33)
  • 49.
    • A persongets suffocated due to inhalation of irrespirable gases like carbon monoxide ,carbon dioxide ,sulphur dioxide etc • In unused wells the air is concentrated with carbon dioxide(Ghost Wells) the person may get asphyxiated • In the sewages the person may die due to inhalation of gases like hydrogen sulphide,sulphur dioxide INHALATION OF IRRESPIRABLE GASES
  • 50.
     When thehead and face is covered with plastic bag ,tied or otherwise , death can occur due to anoxia  This can be suicidal or homicidal  It can also be accidental as in solvent abuse ( glue sniffing )cases
  • 51.
    • In Suicidalcases there may not be any injuries ,since it produces slow asphyxia ,unconsciousness and death without much struggle for life • Signs of asphyxia are faint or lacking in case of plastic bag suffocation • Moisture collects in the bag which cannot be taken as an antemortem sign because condensation inside the bag can occur post mortem • In Homicidal cases there will be injuries due to struggling and Suicidal Death due to helium inhalation
  • 52.
    Drowning Drowning is theprocess of experiencing respiratory impairment from submersion/immersion in liquid. ie, a liquid-air interface is present at the entrance to the victim’s airway, which prevents the individual from breathing oxygen.
  • 53.
    Types of Drowning Primary/Typical/WetDrowning Typical drowning with water entering the lungs. • Fresh water • Salt water Atypical Drowning Variations with different mechanisms. • Dry Drowning • Immersion Syndrome • Secondary Drowning • Submersion of the unconscious
  • 54.
    Wet Drowning Process InitialSubmersion Person sinks due to gravity. Struggle and Inhalation Rising, crying for help, inhaling water. Repeated Cycle Sinking and rising, water replaces air in the lungs. Final Submersion Convulsions, suspended animation, death.
  • 55.
    Fresh Water Drowning 1Water Entry Fresh water enters the lungs. 2 Hemodilution Dilution of blood. 3 Hemolysis Red blood cell rupture. 4 Cardiac failure Ventricular fibrillation
  • 56.
    Salt Water Drowning WaterEntry Salt water enters the lungs. Osmotic Effect Fluid drawn into the lungs. Pulmonary Edema Fluid accumulation in lungs. Cardiac failure Asystole
  • 57.
    Dry Drowning 1 Laryngospasm Vocalcords spasm, blocking airway. 2 Limited Water Entry Little to no water enters lungs. 3 Asphyxia Oxygen deprivation due to blockage.
  • 58.
    Immersion Syndrome Sudden Immersion Suddencold water shock. 1 Vagal Stimulation Overstimulation of vagus nerve. 2 Cardiac Arrest Potential for heart stoppage. 3
  • 59.
    Secondary Drowning/Near drowning Refersto survival beyond 24hr after a submersion episode. Death is caused by complications (eg. ARDS, pneumonia, sepsis, cerebral edema, DIC etc.) Secondary drowning sometimes refers to a victim who initially responds well to resuscitation but then suffers respiratory decompensation.
  • 60.
    Submersion of theunconscious/Shallow water drowning Alcoholics, drugged, epileptics, infants, children and unconscious persons may die due to drowning in shallow water in a pit or drain.
  • 61.
    Pathophysiology of Drowningand Fatal period Pathophysiology of Drowning and Fatal period
  • 62.
    Drowning Drowning is definedas a process of respiratory impairment due to submersion or immersion in a liquid medium. It can be classified into freshwater drowning and saltwater drowning, with different physiological effects due to differences in osmolality.
  • 63.
    Pathophysiology of drowning 1.Freshwater drowning 2. Saltwater drowning
  • 64.
    1.Freshwater Drowning Freshwater hasa lower osmolality than plasma, leading to significant physiological changes. The pathophysiology is primarily based on the experiments conducted by Swann and collaborators, who studied its effects on the body.
  • 66.
    Mechanism of FreshwaterDrowning: 1.Water enters the lungs: Freshwater is rapidly absorbed across the alveolar-capillary membrane due to its low osmolarity. 2. Hemodilution: The influx of hypotonic water into the bloodstream leads to a decrease in plasma osmolality and dilution of blood components. 3. Red Blood Cell (RBC) Rupture: Due to osmotic swelling, RBCs undergo hemolysis, releasing intracellular contents such as potassium (K⁺) into the levels, which affects cardiac
  • 67.
    4. Hyperkalemia: Therelease of potassium leads to a sharp increase in serum potassium levels, which affects cardiac function. 5. Cardiac Overload & Arrhythmias: The increased blood volume causes ventricular tachycardia and ventricular fibrillation, leading to cardiac arrest. 6. Hypoxia & Death: Ultimately, lack of oxygen supply results in respiratory failure and death.
  • 68.
    2.SALT WATER DROWNING Saltwaterdrowning occurs when a person inhales seawater, leading to oxygen deprivation and potential complications. The high salt content in seawater affects the body's physiology differently than freshwater drowning
  • 70.
    Physiology of SaltwaterDrowning 1. Osmotic Effect: Seawater has a higher salt concentration than blood. When inhaled, it draws water out of lung tissues into the alveoli (tiny air sacs), causing pulmonary edema (fluid accumulation in the lungs). This makes breathing even harder and reduces oxygen absorption. 2. 2. Hypoxia (Oxygen Deprivation): The inability to get enough oxygen leads to loss of consciousness and, if untreated, cardiac arrest.
  • 71.
    2. Hypoxia (OxygenDeprivation): The inability to get enough oxygen leads to loss of consciousness and, if untreated, cardiac arrest. 3. Electrolyte Imbalance: Absorbing large amounts of saltwater into the bloodstream can cause hypernatremia (high sodium levels), leading to brain swelling, confusion, seizures, and coma. 4. Cardiovascular Collapse: If the heart and lungs fail to deliver oxygen, the body shuts down, leading to multi-organ failure.
  • 73.
    FATAL PERIOD The fatalperiod of saltwater drowning refers to the estimated time it takes for drowning to become fatal after submersion. This can vary based on factors like water temperature, the victim’s health, and rescue efforts FRESH WATER DROWNING - 4 – 5 MINUTES SALT WATER DROWNING - 8 - 12 MINUTES
  • 74.
  • 75.
    ● Clothes :Wet ● Face : Congested with petechiae on the face. ● Eyes : May be congested. ● Postmortem staining :On face, shoulders and front of upper part of chest(body usually remains in water in a head down position.) Light pink in color(due to absence of deoxygenation of blood) Sometimes blue due to cyanosis. No staining if the body is recovered from turbulent water.
  • 76.
    ● Froth : fineleathery tenacious froth at the mouth and nostrils. Forms a mushroom like mass.
  • 77.
    Mechanism of froth ●Formed in the lungs due to churning effect of air, water and mucous in the alveoli ● Froth will be in copious amount. ● Froth may be blood stained due to congestion and intra pulmonary hemorrhage.
  • 78.
    ● Cutaneous anserinaOr Goose skin or Puckered appearance of skin : Due to spasm of pili muscles and contact of skin with cold water. Not an ante mortem feature. Also occur due to rigor mortis.
  • 80.
    ● Cadaveric spasm: Weed particles, twigs, leaves may be seen firmly grasped. Definite ante mortem sign if drowning
  • 81.
  • 82.
    Bleaching and soddeningof both hands and feet. 1. Wrinkling of tips of fingers - about 2hrs 2.Bleaching of the cuticle - by 12 hrs 3.Bleaching and soddening of hands and feet - about 24 hrs Due to softening and imbibition of water into the superficial layers of skin.
  • 84.
    ● Scrotum andpenis : Get retracted in contact with cold water.
  • 85.
  • 86.
    LUNGS On opening thechest wall:- ● Lungs fully occupy the chest cavity. ● Lungs appear congested, edematous, ballooned, and crepitant. ● Crepitus is felt when touched with gloved fingers. Surface features of the lungs:- ● Pale pink appearance with subpleural hemorrhages (1–5 cm in diameter), called Paltauf's hemorrhages, especially on the lower lobes. ● Rib markings may be visible. ● Lungs will pit on pressure
  • 87.
    LUNGS CONTD Specific lungcharacteristics in fresh water drowning:- ● Emphysematous changes are more pronounced than edema. ● This type of lung is referred to as Emphysema Aquosum Lung. ● Classical appearance in 80% of fresh water drowning cases (Taylor et al.). Other findings:- ● Froth extrudes upon cutting the lung. ● Lung contour is maintained. ● Tardieu's spots are minimal or absent in drowning cases.
  • 88.
    DIFFERENCE Salt water drowninglungs: Edematous, weigh double. Edema fluid oozes on cutting. Flattened, lose contours. Edema > emphysema, water-logged (Edema Aquosum Lung). Water drawn into alveoli from blood (C.J. Polson, Reinhard B. et al.). Edema Aquosum Lung in fresh water drowning: Seen in unconscious or intoxicated individuals. Lungs flood with water, no violent respiratory effort. No froth formation.
  • 91.
    OTHER FINDINGS ● Foreignbodies in airways:- ● Weed, sand, and mud in trachea, bronchi, or bronchioles confirm drowning. ● Foreign particles may reach pharynx/upper trachea postmortem, not bronchioles (Gordon et al.). ● Regurgitated food may be present due to agonal aspiration. Stomach:- ● Water found in 70% of cases. ● Muddy water in the stomach is significant if not used for drinking. Brain and organs:- ● Brain: Congested, edematous, rarely subarachnoid hemorrhage. ● All other internal organs are congested.
  • 92.
    Atypical Drowning In thesetypes of drowning, the classical features described in wet drowning are missing e.g.. a) Dry drowning b) Secondary drowning e) Immersion syndrome d) Shallow water drowning
  • 93.
  • 94.
    Secondary drowning (Neardrowning) If the victim survives more than 24 hrs. He may develop secondary complications of drowning. This is called secondary drowning. The person may develop the following complications. 1) The person may or may not be conscious. 2) He may develop pulmonary edema and ARDS, pneumonia and septicemia. 3) There may be hypoxic brain damage; the survivors may have neurologic damage like paraplegia also. 4) There may be hemoglobinuria due to lysis of red cells. 5) There may be myocardial anoxia and cardiac arrhythmias.
  • 95.
    Immersion syndrome (Hydrocutionor Submersion inhibition) ● When the person enters cold water, vaso-vagal inhibition and cardiac arrest occurs due to stimulation of cutaneous nerves of the chest and abdomen. This is called immersion syndrome. ● Vaso-vagal stimulation may also be due to cold water touching ear drums or nasal mucosa. ● At autopsy, the classical signs of drowning are not seen in the lungs.
  • 96.
    Submersion of theunconscious (Shallow water drowning) ● Under the influence of alcohol or drugs, epileptics and unconscious persons may get drowned in shallow water. When they fall into water, the struggling movements are lacking and as a result, the classical features of drowning will be absent. Mere flooding of lungs with water occurs which is known as edema aquosum.
  • 97.
    Hydrostatic Lung ● Ifa dead body is put into water and remain under water, due to hydrostatic pressure, water may pass into lungs. This is called Hydrostatic lung, and its appearance may be that of "Drowning Lung" but the classical signs of drowning are absent. ● According to Eisele, a lung similar to "Drowning Lung" can be produced by keeping a dead body at a depth of 2 meters for 20 hrs.
  • 98.
    LABORATORY TEST INDROWNING No single test is confirmatory of drowning. 1. Gettler's Test (Chloride Estimation) ● Blood is extracted from right and left ventricles and chloride is estimated. ● Normal value of chloride is 600 mg per 100 ml. ● In salt water drowning, the chloride content in the left ventricle is 42% higher than normal due to hemoconcentration.In fresh water drowning the chloride content in left ventricle will be 50% less than normal value due to hemodilution. ● A difference of 25% in chloride between two chambers of heart is supposed to be significant. Gettler's test is of no help if there is advanced decomposition, patent foramen ovale and in dry drowning. This test have many fallacies and not done nowadays. ● Estimation of potassium, zinc, magnesium etc. in the right and left ventricles of heart can also be done but are not confirmatory.
  • 99.
    DIATOM TEST ● Diatomsare unicellular algae present in fresh water and salt water. There are about 15000 types of diatoms and are of different size and have shapes like circular, triangular, rectangular, spindle shaped, oval etc. ● Their size varies from 2 microns to 500 microns. ● The diatoms are have thick silica cell wall and contain chlorophyll and la brown pigment diatomin.* Hoffman (1896) first discovered diatoms in lung fluid. Later on, Rovenstorf (1904) first attempted to use diatoms as a test for drowning. ● Diatoms may enter the lungs while drowning and pass to the blood stream and may enter all the internal organs. They can be demonstrated in internal organs and bone marrow.
  • 101.
  • 102.
    INTERPRETATION ● If sametype of diatoms is obtained in bone marrow (10-20 diatoms/el. from 10 gm of tissue) and water sample, it can be taken as a corrobontive evidence of drowning. ● Researchers have shown that diatons are obtained in non drowning cases also, since they are present in the dust in air (diatomaceous earth). ● It is also shown that during drinking also diatoms may enter the body (Bernard knight et.al). ● So, diatom test is only a corroborative test and not a confirmatory test.
  • 103.
    Water in Sinuses ●During drowning, water will enter into all the sinuses. Water can be extracted from these sinuses. ● Water in the sinuses cannot be taken as a sign of drowning since water may reach the sisuses after death also when the body is under water. ● Water can be extracted from the sphenoid sims by breaking the bone just in front of sella tursica (jugum sphenoidale) and using a wide bored needle and syringe
  • 104.
    ANTEMORTEM FEATURES OFDROWNING During autopsy the opinion as to the cause of deals is made by the antemortem features of drowning 1. Fine white froth at the mouth and nostrils 2. The presence of weeds or other things in water firmly grasped in hands due to cadaveric spesm 3. Presence of sand or mud or weed in the air passages seen in the lower respiratory tract 4. Voluminous congested and edematous, crepitant and ballooned up lings 5. Presence of identical diatoms in the bone marrow can be taken as corroborative
  • 105.
    CIRCUMSTANCE OF DROWNING Accidental: ●Children may accidentally fall into water during playing ● Intoxicated persons may accidentally fall into water especially in unprotected wells. ● Persons under the influence of alcohol or epileptic persons may accidentally drown in shallow water In shallow water drowning the lung may be edematous and give features of edema aquosum. Women may fall into unprotected wells while drawing water. ● Divers may get drowned when their head strikes on some hard object and become unconscious.
  • 106.
    SCUBA DIVING ●In SCUBAdiving, a diver uses a Self-Contained Underwater Breathing Apparatus (SCUBA) to breathe underwater. ●At greater depths, higher pressure causes more nitrogen from the breathing gas to dissolve in the blood and tissues. ●During ascent, pressure decreases, and dissolved nitrogen comes out of solution as bubbles, similar to opening a soda bottle. ●This can lead to decompression sickness (DCS) or air embolism, causing pain, dizziness, or serious health issues. ●The condition is similar to what happens to people at high altitudes due to rapid pressure changes.
  • 107.
    SIGNS AND SYMPTOMS ●Airentrapment in various body sites can cause serious symptoms. ●Respiratory issues: Dyspnoea (chokes), due to trapped air. ●Neurological symptoms: Headache, vertigo (staggers), temporary scotoma, epileptiform convulsions, and paraplegia (without sensory loss). ●Joint pain: Known as "bends" (Caisson’s Disease). ●Lung-related issues: 》 Extra-alveolar air syndrome from trapped air in the lungs during ascent. 》 Air escAir entrapment in various body sites can cause serious symptoms. ●Barotrauma:Mechanical tissue damage due to gas release
  • 108.
    TREATMENT ●Administer 100% oxygento help remove excess nitrogen. ●Rapid transportation to a medical facility for immediate care. ●Decompression treatment in a hyperbaric oxygen chamber to reduce nitrogen bubbles. ●Hydration therapy to manage plasma deficits and support circulation. Supportive measures as needed for symptoms. ●Use of helium in deep dives instead of nitrogen, as it dissolves less in tissues, reducing the risk of decompression sickness.
  • 109.
    POSTMORTEM EXAMINATION EXTERNAL FINDINGS: 》Cyanosis and facial edema 》 Froth at the nostrils 》 Crepitations due to subcutaneous emphysema 》 Ruptured tympanic membrane 》 Gas in retinal vessels
  • 110.
    INTERNAL FINDINGS: 》 Pneumothoraxand pneumomediastinum 》 Pulmonary edema and petechiae on lung surfaces 》 Air embolism in the heart (can be demonstrated)
  • 111.
    Diagnostic Tests: 》 Pyrogalloltest: Confirms air embolism (solution turns brown) 》 Histopathology: Air bubbles found in lungs and other internal organs 》 Extra-alveolar air in pleural, pericardial, and intravascular locations is better detected by CT scan than standard postmortem examination.
  • 112.
    Suicidal Drowning ●Common inIndia, especially among women, due to easy access to water bodies (sea, rivers, ponds, canals, wells). ●Women often avoid exposing their bodies when drowning. ●Swimmers may tie their hands and feet before entering the water to prevent escape. ●The knot should not be disturbed by investigators. ●Postmortem should determine if the victim could have tied it themselves.
  • 113.
    ●Some may attachheavy objects (e.g., stones) to conceal their death. ●Others may cut their throat or consume poison before drowning. ●Falls into wells can cause fatal or nonfatal injuries. ●Circumstances of death must be carefully examined in each case. ●Even small water sources (e.g., buckets, cisterns) can be used for suicide if the person is determined.
  • 114.
    FEATURES ANTEMORTEM DROWNING POSTMORTEMSUBMERSION Froth over mouth and nostrils Fine, lathery froth, appears spontaneously Absent. But if present, coarse, not spontaneous Cadaveric spasm in hands Aquatic vegetations, mud Not observed Trachea and bronchioles Algae, mud, frothy mucus Absent Lungs Ballooned up, bulky, edematous, bear indentations of ribs Collapsed, decomposed Mud & algae in stomach &small intestine May be present Absent Diatom & Gettler’s tests Positive Negative Injuries If present, consistent with drowning Inconsistent with drowning Other suggestive signs Water in middle ear, retracted genitals,cutis anserina, washer- woman’s hands, wet clothing, mud & sand Water never present in middle ear, others are not valuable and corroborative findings
  • 116.
    HOMICIDE ●It is possibleto kill infants and children by putting them into water ●Adult persons can be pushed to river, sea, or well ●Homicidal drowning is possible by forcefully dipping the head in shallow water.
  • 117.
    CONTD… ●In such casesthere may be - Abrasions - Nail marks and - Contusions on the nape of neck - Injuries due to general violence ●If the person is under the influence of alcohol, marks of violence may be minimal or absent
  • 118.
    Brides in thebath ●Mr. R.V. Smith married many women & they were found dead in the bathtub. ●Later proven to be homicides. ●Playfully lift both of the legs; would die of drowning w/o injuries. ●Killed 3 women this way ●Motive - to get the insurance claims of the victims
  • 119.
    INJURIES & DROWNING ●Injurieson the body should be carefully attended. ●Injuries may be sustained before/during/after entry into water. ●The injuries may be simple abrasions or grave injuries like head injury. ●Injuries on the body may occur during a fall into a well or pond or a rocky place. ●There is a possibility of the person getting the injury in an assault.
  • 120.
    DISPOSAL OF DEADBODIES IN WATER ●Criminals may use local ponds, wells and other water bodies to dispose the dead body after killing. ● Sometimes heavy objects like stones or concrete blocks are tied on the body. ●On examination, there may be other causes of death like strangulation, stab wounds etc.
  • 121.
    FLOTATION OF DEADBODY IN WATER ●Tropical countries, dead body floats by ~24 hours. ●Clothed body may float earlier if air trapped in it. ●Female bodies float early ; more fat content. ●Even heavy weight attached, body float due to the pressure of decomposition gases. ●In the depth of the sea, body may not float because of equal water pressure from all sides. ●When body is dismembered and put into water, limbs’ll float & the head may not float.
  • 122.
  • 123.
    Whether downing wasaccidental, suicidal or homicidal? ●ACCIDENTAL ●At risk groups - sailors - fisherman -dockworkers etc. ●Information regarding inability to swim, trauma, seizure, heart disease, exhaustion, alcohol or drug abuse should be sought
  • 125.
    ●SUICIDAL ●Suicide by drowningcommon in India. ●Women often tie clothes to ensure modesty after death. ●Methods include tying limbs, adding weights, poisoning, or self harm before jumping. ●Shallow water drownings in adults are usually presumed suicides unless proven otherwise.
  • 126.
    ●HOMICIDAL ●Homicidal drowning israre, but common in infanticide, esp. with newborns. ●Lack of injuries ; drowning can be inflicted w/o marks, especially on non-swimmers intoxicated individuals or those bathing ●Postmortem disposal ; bodies of homicide victims may be placed in water after death to hide the crime.
  • 127.