Forensic Sci Med Pathol (2012) 8:470–472 DOI 10.1007/s12024-012-9345-y
IMAGES IN FORENSICS
Fatal positional asphyxia Takahito Hayashi • Claas Buschmann Andreas Correns • Sieglinde Herre • Michael Tsokos
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Accepted: 26 April 2012 / Published online: 12 May 2012 Ó Springer Science+Business Media, LLC 2012
Case report A 64-year-old man was found dead in an unusual prone positition on the floor close to the bed in his apartment. The upper part of the body was leaning against a bedside cabinet (approximately 40 cm in height) with the head, the left arm and the right hand lying on the top of the cabinet (Fig. 1). The neck was considerably hyperextended and rotated to the left, so that the right side of the neck was pressed firmly against the upper front edge of the cabinet. The man was not wedged in a confined narrow space, for example, a space between the bed and the cabinet. Only a duvet was spread over the lower part of his body, and there were no objects that could have fixed his body position. Police investigations revealed that the man was not known to abuse illegal substances, but to consume alcoholic beverages on a daily basis. He had no previous medical history and was last seen alive 5 days earlier. Medico-legal autopsy revealed early putrification of the 180 cm, 95 kg body. Non-blanchable post-mortem hypostasis was observed on the chest and the front medial side of the legs. Numerous petechial bleedings were noticed in the oral mucosa as well as in the conjunctivae. Corresponding
T. Hayashi (&) C. Buschmann A. Correns S. Herre M. Tsokos Institute of Legal Medicine and Forensic Sciences, University Medical Centre Charite´, University of Berlin, Turmstr. 21, Building N, 10559 Berlin, Germany e-mail:
[email protected] URL: remed.charite.de T. Hayashi Department of Legal Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan
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to the anatomic region that was pressed against the edge of the cabinet, a dried band-like abrasion (14 cm in length and 3 cm in width) was running along the inferior border of the mandible on the right cervical region (Fig. 2). There were fresh oval bruises on the left orbital region (2 cm in diameter) and on the left subclavicular region (6 9 4 cm). Layer-wise preparation of the neck revealed hemorrhages at the periostal-clavicular origin of the bilateral sternocleidomastoid muscles (Fig. 3) and in the left posterior cricoarytenoid muscle (Fig. 4) but no corresponding hemorrhages in the subcutaneous fatty tissue or the skin. No fractures of the hyoid bone, thyroid or cricoid cartilage were detected. Although the inner organs had undergone early putrefactive tissue changes, cardiomegaly (heart weight 590 g) with moderate atherosclerosis of the coronary arteries, hypertensive nephrosclerosis, fatty liver and chronic pancreatitis were found. There were no other remarkable pathological findings. Toxicology was negative except for ethanol. The concentration of ethanol was 0.1 mg/mL in the blood and 0.2 mg/mL in the urine. Additionally, 4.83 ng/mg of fatty acid ethyl esters (ethyl myristate, ethyl palmitate, ethyl oleate and ethyl stearate) were detected in a hair sample by headspace solid-phase microextraction and gaschromatography-mass spectrometry analysis.
Discussion In the present case, the unusual position of the body at the death scene and autopsy findings (e.g., numerous petechial bleedings in the conjunctivae and oral mucosa) were highly suggestive of fatal positional asphyxia. Since cases of positional asphyxia usually exhibit non-specific autopsy findings, the following three criteria for the diagnosis have
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Fig. 1 Position of the deceased at the death scene Fig. 3 Gross appearance of hemorrhages (arrow) at the periostalclavicular origin of the right sternocleidomastoid muscle
Fig. 2 Gross appearance of band-like abrasion on the right side of the neck
been suggested: (i) discovery of the deceased in a position inhibiting adequate respiration; (ii) reasonable explanation for inability of self-extrication from the position; and (iii) other causes of death must be excluded by autopsy [1]. Death from positional asphyxia has been reported in various body positions such as reverse suspension, headdown, hyperflexion or hyperextension of the neck, and a ‘jack-knife’ position [1–5]. Additionally, partial or complete external airway obstruction due to methods other than hanging or strangulation has also been included in the mechanism of positional asphyxia [6, 7]. As severe compression of the right cervical region in addition to hyperextension of the neck had compromised adequate respiration, our case meets the aforementioned criterion (i). Interestingly, our case showed hemorrhages at the origin of the bilateral sternocleidomastoid muscles, findings occasionally
Fig. 4 Gross appearance of hemorrhages (arrow) in the left posterior cricoarytenoid muscle
encountered in hanging. However, such hemorrhages can also be caused by severe neck trauma and extreme overstreching of the neck [8]. Therefore, massive hyperextention of the neck would possibly have caused the hemorrhages in our case. Taking into account the hemorrhages in the left posterior cricoarytenoid muscle, these hemorrhages can also be attributed to forced respiration attempts due to severe
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dyspnea, since both muscles are auxiliary breathing muscles. These findings underline that the man had suffered from severe asphyxia in the respective body position. Factors predisposing to positional asphyxia include impaired cognitive responses and coordination resulting from intoxication, sedation, organic illness, and physical impairment or restraint [7]. Our case showed a very low blood level of ethanol (0.1 mg/mL). In a study of 30 adult cases of positional asphyxia, alcohol intoxication was the most common causative factor and was found in 75 % of cases, with average blood ethanol concentrations of 2.4 mg/mL [1]. All of those fatalities with low blood ethanol concentrations (\0.3 mg/mL), as observed in our case, had a history of chronic alcoholism [1]. In our case, toxicological analysis of a hair sample revealed a much higher level of fatty acid ethyl esters (4.83 ng/mg), products of the nonoxidative ethanol metabolism, than that in normal drinkers (\0.5 ng/mg, [9]), indicating that the man had suffered from severe chronic alcoholism. There were no autopsy findings suggesting an illness that could cause unconsciousness/coma in chronic alcoholisms such as ketoacidosis, hypoglycemia or Wernicke’s encephalopathy. However, it is widely known that sudden unexpected death in chronic alcoholism with a negative or low blood ethanol level and only fatty liver at autopsy can also occasionally occur even in a ‘normal’ body position. Accordingly, unconsciousness/coma derived from chronic alcoholism may have contributed to inability of self-extrication from his position, although the precise mechanism could not be elucidated. In contrast, acute alcohol intoxication might also have caused consciousness/coma, because the low blood level of ethanol could be the result of continued ethanol metabolism occurring while he was unconscious and possibly alive for several hours before death, despite being in an insufficient respiratory condition. Other possible causes of death were excluded by autopsy, leading us to the assumption of fatal positional asphyxia. From the death scene investigation and autopsy findings it was hypothesized that the man must have accidentally fallen from the bed while sleeping after having consumed alcohol. Although we cannot exclude cardiac arrhythmia with collapse resulting in the given position, we found no cardiac
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pathologies pointing towards such an incident. Therefore, we favor the proposition that an impaired state of consciousness, due to alcohol consumption, made it impossible for the man to correct his position by holding onto and using the cabinet, forcing him to remain in the position he was discovered in for several hours, resulting in positional asphyxia. In our opinion, to confirm the suspicion of positional asphyxia, photographs of the unmodified scene of death, in addition to a full autopsy and toxicology screen (if possible including analysis of a hair sample), are essential. Moreover, one should not overlook positional asphyxia as a cause of death in the alcoholic who dies suddenly with nonspecific autopsy findings and low levels of drugs or ethanol detected in their blood and/or urine.
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