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Fatal suffocation: A 7-year autopsy study in Lagos, Nigeria
Forensic Science International: Reports 1 (2019) 100033
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Fatal suffocation: A 7-year autopsy study in Lagos, Nigeria Williams Oluwaseun Olatunde * , Faduyile Francis Adedayo, Soyemi Sunday Sokunle, Obafunwa John Oladapo Office of the Chief Medical Examiner, c/o Department of Pathology and Forensic Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
A R T I C L E I N F O
A B S T R A C T
Keywords: Suffocation Asphyxia Autopsy Aspiration Smothering
Background: Suffocation is a major class of asphyxial deaths encountered in forensic post-mortem examinations. Several studies have described the patterns of different types of suffocation deaths but there is a paucity of studies and autopsy findings of suffocation in the Nigerian environment. This study is aimed at determining the prevalence and pathological features of suffocation-related deaths at autopsy as seen in the Chief Medical Examiner’s Office in Lagos State, Nigeria. Methodology: This is a 7-year autopsy-based study of suffocation deaths between 1 st January 2008 and 31st December 2014. Demographic data and morphologic features of asphyxia were retrieved from autopsy reports, case notes, and extracts from Coroners’ request forms submitted by the Police. The results were analysed using SPSS Version 20. Results: Suffocation deaths accounted for 57(24.8%) of all asphyxial deaths and 0.77% of all autopsies done over the study period. The peak age group of suffocation death was 31–40 years with a male to female ratio of 2:1. Most (89.47%) of suffocation cases were due to aspiration of stomach contents. Hyperaemia of the airways, petechial haemorrhages and pulmonary oedema were the most common morphologic features seen. Conclusion: This study showed that almost all suffocation deaths were due to gastric aspiration mostly secondary to delayed medical intervention. Most of the decedents were in the 4th decade of life with a male preponderance. One case of homicidal suffocation due to combined smothering and choking was observed.
Introduction Suffocation is used to describe asphyxia cases where the sole mechanism involves the failure of oxygen to reach the bloodstream [1]. This is a non-specific term with a loose interpretation by different authors. Delmonte and Capelozzi in their classification of asphyxia, place suffocation in a separate category from aspiration [2]. According to Saukko and Knight suffocation is generally used to refer to environmental asphyxia due to depletion of atmospheric oxygen, a term which can also be used to also refer to choking and smothering [3]. For the purpose of this study, the term “suffocation” was applied to deaths due to simple (environmental) asphyxia, smothering, choking, traumatic (mechanical) asphyxia, positional asphyxia and combinations of the aforementioned, which is the classification used by most authors [1] [4–6]. Suffocation accounts for about 21% of the total annual injury deaths in studies by the Centre for Disease Control and Prevention in the United States [7]. Suffocation is the leading cause of unintentional injury mortality (21.2%) in children between the ages of 0–4 years in the United States [8]. Smothering occurs when there is a mechanical obstruction or
occlusion of the external airways such as the nose and mouth. There are a wide variety of circumstances and objects or substances involved in smothering [9], and some of them are implicated in accidental, homicidal and suicidal smothering deaths. Suicidal smothering most commonly occurs in some Western countries as a tool for euthanasia whereby a plastic bag is placed over the head, tightly secured around the neck [10]. Choking occurs when the external parts of the mouth and nose allow air flow, but air cannot move into (or out of the lungs) due to internal airway obstruction at the level of either the oropharynx, pharynx, larynx or one of the principal bronchi [9]. It is usually below the level of the epiglottis [4]. Most choking deaths are usually accidental and the victims are young children. Choking is a common cause of death in children between the ages of 1–3 years in Western Europe [11,12]. In a study by Seleye-Fubara and Ekere [13] in the Niger-Delta region of Nigeria, foreign body aspiration accounted for 4.8% of domestic accidental deaths, with pre-school children being commonly affected. Young children are more likely to aspirate food especially whilst eating and playing at the same time. The scene for most cases of childhood choking death is at home and day care centres, and it usually occurs unwitnessed [12,14]. Adult cases of
* Corresponding author at: Department of Pathology and Forensic Medicine, Lagos State University Teaching Hospital, 1 – 5 Oba Akinjobi Way, Ikeja, Lagos 100001 Nigeria. E-mail address: [email protected] (W.O. Olatunde). http://doi.org/10.1016/j.fsir.2019.100033 Received 20 July 2019; Received in revised form 1 September 2019; Accepted 2 September 2019 Available online 6 September 2019 2665-9107/© 2019 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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The data analysis was carried out with the aid of the IBM Statistical Package for Social Science (SPSS), version 20. All statistical comparisons of variables were completed using the two-sided Fisher’s exact test. A value was considered statistically significant at a p-value less than or equal to 0.05. The results were presented in tables and charts.
choking are usually accidental or homicidal. Homicidal choking is considered by some authors to occur through gagging and the victims are usually weaker individuals like the elderly and neonates [15]. Many authors however, consider gagging to be a form of smothering [3,4]. Traumatic asphyxia usually occurs as a result of a very heavy object compressing the chest as in a person crushed under a heavy vehicle such as a car or tractor, a factory worker pinned or crushed by heavy machinery [16–18], and in some cases of infant death from overlay [19]. Positional (or postural) asphyxia is a condition that occurs as a result of the adoption of a particular body position, causing mechanical interference with pulmonary ventilation [20]. Busuttil and Obafunwa reported the case of a 12-year old female child who died due to positional asphyxiation following suspension at the abdomen by a webbing band. This resulted in progressively increasing external pressure on the diaphragm, impeded movement of the lower intercostals and abdominal muscles, which finally induced progressive respiratory impairment [21]. The morphologic features seen at autopsy in suffocation deaths may include non-specific findings popularly known as the “asphyxia stigmata”, and specific findings which may be suggestive of the cause of asphyxiation [9]. Asphyxia stigmata include, cyanosis which can be defined as a purplish – blue discolouration of the skin (more readily observed in lightskinned individuals), nail bed and face, including the lips and earlobes. Petechial haemorrhages are pinpoint, non-raised, round purple or red spots (<2 mm) that results from capillary rupture [22]. They can be found on the conjunctiva, oral mucosa, auditory mucosa, subpleural interlobar and diaphragmatic surfaces of the lungs, the epicardium, brain and thymus (in children) [9]. Other features include hyperaemia of the tracheobronchial mucosa which is commonly due to aspiration of various contents into the airway, pulmonary congestion, and oedema. Specific findings include chest and/or abdominal bruising in traumatic asphyxia. The shape of the bruise may match that of the heavy object that caused compression of the chest, such as, the tyre marks from a vehicle [9,16]. Materials used for gagging may be found, occluding the nostrils and buccal cavity, and simultaneously causing both smothering and choking; such items include clothing or adhesive tapes. Aspirated substances such as foreign objects lodged in the airways especially in children [12], or gastric contents may be observed [9]. The aim of this study is to determine the demographic pattern, the causes and pathological features of suffocation deaths seen in the Medical Examiner’s Office, in Lagos, Nigeria
Results A total of 57 cases of suffocation death were recorded over the study period representing 24.8% of all asphyxial deaths comprising 230 cases (Fig. 1). These suffocation deaths represent 0.77% of the 7439 autopsies conducted during the 7-year period. The majority of suffocation-related deaths cases seen in this study were predominantly males 38 (66.7%) with a male-to-female ratio of 2:1 (Table 1). There were more males across all age categories except the category over 70 years, where 4 (80.0%) were females (p > 0.05) (Fig. 2). The average age of all suffocation cases was 35.5 19.1 with a minimum and maximum of 2 and 77 years respectively. Suffocation was more prevalent in the fourth, 17 (29.8%) and third, 13 (22.8%) age decades. Only age group 21–40 years accounted for more than half (52.6%) of all suffocation cases. There was a reduction in the number of suffocation deaths from 41 to 50 years (8, 14.8%) up to 61–70 years (1, 1.8%) before a slight increase observed in ‘above 700 age category ( 4, 7.0%) (Table 1). The principal cause of suffocation deaths was Aspiration of stomach contents, 51, followed by Aspiration of blood secondary to severe craniocerebral injury, 4, Foreign body aspiration, 1 and Combined smothering and choking 1 (Fig. 3). More than four of every five suffocation deaths in both males (89.5%) and females (89.5%) were caused by aspiration of stomach contents (Table 2). There is no significant variation of suffocation deaths across all age groups (p > 0.05) (Table 3). Most cases of aspiration of stomach contents were secondary to cerebrovascular disease (26, 51%), followed by severe head injury (15, 29%), Diabetic coma (8, 16%) and Café coronary (2, 4%), (Fig. 4). As shown in Table 4, Café coronary and Diabetic coma were insignificantly more common in males than in females while
Materials and methods This is a 7-year retrospective cross-sectional study of all deaths resulting from suffocation, and diagnosed following complete medicolegal autopsies at the Department of Pathology and Forensic Medicine, Lagos State University Teaching Hospital, between 1st January 2008 and 31st December 2014. This location accommodates the Office of the Chief Medical Examiner, established under the Coroner’s Systems Law of Lagos State [23]. The Office investigates all reportable deaths as instructed by the Coroners from across Lagos State; it provides autopsy services for the State and the immediate environs. All cases of suffocation deaths were obtained from the autopsy reports, autopsy register, hospital case notes, coroner's forms, extracts from police diary, reports by relatives, and other informants. The data retrieved include age, sex, postmortem examination findings, cause and manner of death. The exclusion criteria for the study include perinatal deaths, perioperative deaths and decomposed bodies. The limitations of this study include inability to obtain relevant history of predisposing medical conditions such as psychiatric illness and drugs or alcohol history, reliance on investigating police officers for death scene examination, and photography in most cases, inability to identify the age of unknown decedents and the lack of facilities for toxicological analysis to rule out alcohol and drug poisoning in most cases.
Fig. 1. Classes of asphyxial death.
Table 1 Gender and age distribution of suffocation cases. Demographics
Parameter
Frequency
Percentage (%)
Gender
Male Female 1–10 11–20 21–30 31–40 41–50 51–60 61–70 Above 70 Total
38 19 6 4 13 17 8 4 1 4 57
66.7 33.3 10.5 7.0 22.8 29.8 14.8 7.0 1.8 7.0 100
Age (years)
2
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Fig. 2. Bar chart showing the distribution of age within gender (Fischer’s exact p = 0.399).
Fig. 3. Bar chart showing the causes of suffocation. Table 2 Distribution of type of suffocation death within gender. Gender
Male Female Total
Type of suffocation death (p = 0.685) Aspiration of blood secondary to severe craniocerebral injury
Aspiration of stomach contents
Combined smothering and choking
Foreign body aspiration
3 (7.9%) 1 (5.3%) 4 (7.0%)
34 (89.5%) 17 (89.5%) 51 (89.5%)
0 (0.0%) 1 (5.3%) 1 (1.8%)
1 (2.6%) 0 (0.0%) 1 (1.8%)
(p > 0.05). Pulmonary oedema, hyperaemia of the airway mucosa and aspirated stomach contents represent broadly the most frequent morphologic features of suffocation deaths in both gender (Table 8) and all age categories (Table 9) (all > 70.0%). In contrast, the frequencies of petechial haemorrhages, aspirated foreign object and bruising of neck soft tissues were distinctly low for both genders ( Table 8) and across all age categories (Table 9) (all < 20.0%). Figs. 5–7 show examples of the gross morphological findings.
Cerebrovascular disease was more frequent in females than in males though not statistically significant ( p > 0.05). Severe head injury was predominant in young age groups of 1–30 years (13 of 15), Café coronary was more frequent in the older age groups 41–70 (2 cases) while the Cerebrovascular disease was more pronounced in the age groups, 21–50 (19 of 26) and diabetic coma within age group 21–40 (5 of 8) p < 0.05 (Table 5). Of the 26 cases of cerebrovascular disease, 13 were due to hypertension and 13 for sickle cell haemoglobinopathy; eight of each was seen in males and five in females (Table 6). Hypertension was significantly more common in adults (41 years and above, 12 of 13) while sickle cell haemoglobinopathy was predominant in younger age groups of 21–40 (12 of 13), p < 0.001 (Table 7). No significant differences were observed in the morphological features of suffocation deaths in both gender and all age categories
Discussion A total of 57 cases of suffocation deaths were recorded during the study period. This represents 24.8% of all the 230 asphyxial deaths. The prevalence is higher compared to the findings by Azmak in Turkey where suffocation-related deaths accounted for 14.3% of asphyxia cases [5]. As 3
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Table 3 Age distribution of suffocation deaths. Age group
1 - 10 11 - 20 21 - 30 31 - 40 41 - 50 51 - 60 61 - 70 Above 70 Total
Type of suffocation death (p = 0.797) Aspiration of blood secondary to severe craniocerebral injury
Aspiration of stomach contents
Combined smothering and choking
Foreign body aspiration
0 (0.0%) 1 (25.0%) 1 (7.7%) 1 (6.7%) 1 (12.5%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 4 (7.0%)
5 (83.3%) 3 (75.0%) 11 (84.6%) 14 (93.3%) 7 (87.5%) 4 (100.0%) 2 (100.0%) 5 (100.0%) 51 (89.5%)
0 (0.0%) 0 (0.0%) 1 (7.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.8%)
1 (16.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.8%)
presence of other subtypes of suffocation deaths that are not seen in our study. The gender distribution in this study shows a higher proportion of male to female (2:1) ratio, which is also similar, though higher than the study in India (1.47:1); however, it is lower than that in Turkey where they reported a ratio of 4:1 of all asphyxial deaths [5,6]. The male predominance may be due to the paternalistic nature of the Nigerian environment where males have a greater risk exposure on account of their higher participation in the work force, socio-political activities and crime when compared to females. The major cause of suffocation deaths seen were due to aspiration of stomach contents, constituting 51(89.5%) cases. In contrast traumatic chest compression was the major cause of suffocation in Turkey accounting for 36.8% of suffocation deaths [5] while smothering was the major cause of suffocation in India, accounting for 35.0% of cases [6]. The cases of aspiration of stomach contents in this study occurred under numerous circumstances which include unconscious victims suffering from cerebrovascular disease, severe head injury, and diabetic coma. This is similar to the study by Coffey, Pasquale-Styles and Gills in a 5-year review of 138 fatal cases of internal airway obstructions in Australia; found neurologic disease (remote cerebral vascular events, dementia and developmental disorders) was the most common risk factor for fatal choking (51%) [24]. In most of the cases observed in this study, asphyxiation
Fig. 4. Distribution of cases due to the aspiration of gastric contents.
noted, suffocation cases in this study accounted for 0.77% of all the 7439 autopsies performed during the 7-year period. This observation is still higher than the findings in India where Maddileti et al found that cases of suffocation accounted for 0.85% of the total number of asphyxial deaths and 0.18% of overall autopsies [6]. The present authors found the peak age category for suffocation deaths to be 31–40 years which is similar to the peak age seen in Turkey, but higher than the peak age of 21–30 years seen in the India study. This finding may be related to the
Table 4 Primary diagnosis of cases with aspiration of stomach contents. Gender (%)
Male Female Total
Primary diagnosis of cases of aspiration of stomach contents (p = 0.861) Café coronary
Cerebrovascular disease
Diabetic coma
Severe head injury
2 (5.9%) 0 (0.0%) 2 (3.9%)
16 (47.1%) 10 (58.8%) 26 (51.0%)
6 (17.6%) 2 (11.8%) 8 (15.7%)
10 (29.4%) 5 (29.4%) 15 (29.4%)
Table 5 Distribution of primary diagnosis of aspiration of stomach contents across age groups. Age Group
1–10 11–20 21–30 31–40 41–50 51–60 61–70 Above 70 Total
Primary diagnosis of aspiration of stomach contents (p < 0.001) Café coronary
Cerebrovascular disease
Diabetic coma
Severe head injury
0 0 0 0 1 0 1 0 2
0 (0.0%) 0 (0.0%) 5 (45.5%) 8 (57.1%) 6 (85.7%) 1 (25.0%) 1 (50.0%) 5 (100.0%) 26 (51.0%)
0 0 1 4 0 3 0 0 8
5 (100.0%) 3 (100.0%) 5 (45.5%) 2 (14.3%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 15 (29.4%)
(0.0%) (0.0%) (0.0%) (0.0%) (14.3%) (0.0%) (50.0%) (0.0%) (3.9%)
4
(0.0%) (0.0%) (9.1%) (28.6%) (0.0%) (75.0%) (0.0%) (0.0%) (15.7%)
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Maddileti et al in India [6]. This is possibly due to better provision of first aid care, emergency services and intensive care unit services when compared to Nigeria. The morphologic features seen in the present study are consistent with the “asphyxia stigmata” [9]. Most notable were petechial haemorrhages, pulmonary oedema and hyperaemia of the airway which were observed in a majority of suffocation reported in the series from Turkey [5]. The manner of death in most cases of suffocation (98.2%) was natural though preventable with prompt intervention; few cases were accidental (Aspiration of blood, foreign body aspiration, café coronary) and only one case was homicidal (Combined smothering and choking). DiMaio in a 10-year study of autopsies in a medical examiner’s office in the United States also found homicide due to asphyxia to be relatively uncommon. Twenty-six cases of suffocation were noted in 133 cases of homicidal asphyxia. Similar to this study, most of the suffocation victims (20) were found in the younger age group (2 years and below). Five deaths were due to choking. Three of the deaths involved adults who were gagged; two deaths involved infants with foreign material pushed into the mouth [26]. In a study of asphyxial homicides over a 10-year period in Norway and Denmark; Rogde, Hougen and Poulsen found seven cases of suffocation, Smothering (3 males and 3 females) and choking combined with ligature strangulation (1 female) [27]. It is notable both aforementioned studies have in common a preponderance of the homicidal victims within the young age groups and females. These victims are relatively weaker physically than their assailants. There were no cases of suicidal suffocation seen in this study. This is similar to findings of Nwosu and Odesanmi, in their study of observed patterns of suicidal behaviour in Ile-Ife, Western Nigeria where the principal methods of suicide were hanging (44%) and chemical poisoning (37%) [28]. In contrast, a report of suicides in the United States by the Centre for Disease Control found suffocation as the second commonest method behind firearms injury. The report equally found a 7.7% increase in suffocation-related suicides over a 15-year period (1999–2014). The possible reason for the seemingly low rate of suicide in the present study may be due to the under-reporting of suicides by families for cultural fear of the social stigmatisation traditionally associated with suicide in Nigeria [29].
Table 6 Primary cause of Cerebrovascular disease. Gender
Primary cause of Cerebrovascular disease (p = 0.656)
Male Female Total
Hypertension
Sickle cell Haemoglobinopathy
8 (50.0%) 5 (50.0%) 13 (50.0%)
8 (50.0%) 5 (50.0%) 13 (50.0%)
Table 7 Distribution of Cerebrovascular disease within age categories. Age category
21–30 31–40 41–50 51–60 61–70 Above 70 Total
Source of Cerebrovascular disease (p < 0.001) Hypertension
Sickle cell Haemoglobinopathy
0 (0.0%) 1 (12.5%) 5 (83.3%) 1 (100.0%) 1 (100.0%) 5 (100.0%) 13 (50.0%)
5 (100.0%) 7 (87.5%) 1 (16.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 13 (50.0%)
occurred due to a lack of prompt medical intervention at the scene or failure to keep the airway secure at the emergency centre or intensive care units. The second highest cause of suffocation deaths in the present study was due to aspiration of blood secondary to severe craniocerebral injury, which accounted for 7% of all suffocation cases. In a prospective study of aspiration in severe trauma by Lockey, Coats and Parr in Australia, there were 17 deaths within the first 4 h due to severe head injury. There was one confirmed case of aspiration of blood observed in 10 available post-mortem examination results [25]. Suffocation as a result of aspiration was not seen from both studies of Azmak in Turkey [5] and
Table 8 Distribution of morphologic features within gender. Gender
Petechial haemorrhages
Pulmonary oedema
Hyperaemia of the airway mucosa
Aspirated gastric contents
Aspirated foreign object
Bruising of neck soft tissues
Male Female Total P
4 (10.5%) 1 (5.3%) 5 (8.8%) 0.455
35 (92.1%) 17 (89.5%) 55 (94.5%) 0.545
36 (94.7%) 19 (100.0%) 52 (91.2%) 0.440
34 (89.5%) 18 (94.7%) 52 (91.2%) 0.455
1 (2.6%) 0 (.0%) 1 (1.8%) 0.667
0 (0.0%) 1 (5.3%) 1 (1.8%) 0.333
Table 9 Distribution of morphologic features within age categories. Gender
Petechial haemorrhages
Pulmonary oedema
Hyperaemia of the airway mucosa
Aspirated gastric contents
Aspirated foreign object
Bruising of neck soft tissues
1–10 11–20 21–30 31–40 41–50 51–60 61–70 >70 Total p
6 (100.0%) 4 (100.0%) 13 (100.0%) 11 (73.3%) 8 (100.0%) 3 (75.0%) 2 (100.0%) 5 (100.0%) 52 (91.2%) 0.185
5 (83.3%) 3 (75.0%) 13 (100.0%) 13 (86.7%) 7 (87.5%) 4 (100.0%) 2 (100.0%) 5 (100.0%) 52 (91.2%) 0.575
6 (100.0%) 3 (75.0%) 13 (100.0%) 15 (100.0%) 7 (87.5%) 4 (100.0%) 2 (100.0%) 5 (100.0%) 55 (96.5%) 0.234
5 (83.3%) 3 (75.0%) 12 (92.3% 14 (93.3%) 7 (87.5%) 4 (100.0%) 2 (100.0%) 5 (100.0%) 52 (91.2%) 0.847
1 (16.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.8%) 0.368
0 (0.0%) 0 (0.0%) 1 (7.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.8%) 0.737
5
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prompt medical intervention and critical care. The findings in this study, therefore highlights the fact that suffocation constitutes a public health challenge in Nigeria. Recommendation There should be improvement in the public emergency (ambulance) response and intensive care services, in order to provide prompt intervention that will save the lives of victims of preventable causes of suffocation deaths. Scene investigation as a vital component of the postmortem examination, should be carried out for all cases. Expert personnel with relevant skills in the forensic sciences should be utilised. These experts should be equipped with relevant tools such as forensic photography and topographic analysis of the scene. There should be provision and maintenance of forensic toxicology facilities to detect possible contributions of toxic substances to the deaths, especially as it relates to drugs of abuse. Fig. 5. Conjunctival petechial haemorrhages.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of interest None declared.
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Fig. 6. Pulmonary petechial haemorrhages.
Fig. 7. Hyperaemia of the laryngeal and tracheal mucosa with aspirated partially digested food particles.
Conclusion This study showed that suffocation-related deaths are common in the young and male population. Aspiration of gastric contents is the main cause of suffocation and this is very preventable with availability of 6
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[18] J.R. Gill, K. Landi, Traumatic asphyxia deaths due to an uncontrolled crowd, (Am. J. Forensic Med. Pathol. 25 (4) (2004) 358–361. [19] J.F. Kraus, Effectiveness of measures to prevent unintentional deaths of infants and children from suffocation and strangulation, (Public Health Rep 100 (1985) 231–240. [20] M. Belviso, A. De Donno, L. Vitale, F. Introna Jr., Positional asphyxia: reflection on 2 cases, (Am. J. Forensic Med. Pathol. 24 (2003) 292–297. [21] A. Busuttil, J.O. Obafunwa, Recreational abdominal suspension: a fatal practice. A case report, (Am. J. Forensic Med. Pathol. 14 (1993) 141–144. [22] F.A. Jaffe, Petechial hemorrhages. A review of pathogenesis, (Am. J. Forensic Med. Pathol. 15 (1994) 203–207. [23] Lagos State House of Assembly, Coroner System Law Vol. 2, 2007 [Internet] [cited 2018 Jul 23]. Available from, Lagos State House of Assembly, Lagos State, Nigeria,
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https://www.lagoshouseofassembly.gov.ng/download/coroners-system-law-vol-2/, 2008. A. Coffey, M.A. Pasquale-Styles, J.R. Gill, Fatalities due to choking: internal occlusion of airway, (Acad Forensic Pathol. 4 (2014) 94–99. D.J. Lockey, T. Coats, M.J. Parr, Aspiration in severe trauma: a prospective study, (Anaesthesia. 54 (1999) 1097–1098. V.J. DiMaio, Homicidal asphyxia, (Am. J. Forensic Med. Pathol. 21 (2000) 1–4. S. Rogde, H.P. Hougen, K. Poulsen, Asphyxial homicide in two Scandinavian capitals, (Am. J. Forensic Med. Pathol. 22 (2001) 128–133. S.O. Nwosu, W.O. Odesanmi, Pattern of suicides in Ile-Ife, Nigeria, (West Afr. J. Med. 20 (2001) 259–262. T. Asuni, Suicide in Western Nigeria, (Br. Med. J. 2 (1962) 1091–1097.
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Fatal suffocation: A 7-year autopsy study in Lagos, Nigeria Williams Oluwaseun Olatunde * , Faduyile Francis Adedayo, Soyemi Sunday Sokunle, Obafunwa John Oladapo Office of the Chief Medical Examiner, c/o Department of Pathology and Forensic Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
A R T I C L E I N F O
A B S T R A C T
Keywords: Suffocation Asphyxia Autopsy Aspiration Smothering
Background: Suffocation is a major class of asphyxial deaths encountered in forensic post-mortem examinations. Several studies have described the patterns of different types of suffocation deaths but there is a paucity of studies and autopsy findings of suffocation in the Nigerian environment. This study is aimed at determining the prevalence and pathological features of suffocation-related deaths at autopsy as seen in the Chief Medical Examiner’s Office in Lagos State, Nigeria. Methodology: This is a 7-year autopsy-based study of suffocation deaths between 1 st January 2008 and 31st December 2014. Demographic data and morphologic features of asphyxia were retrieved from autopsy reports, case notes, and extracts from Coroners’ request forms submitted by the Police. The results were analysed using SPSS Version 20. Results: Suffocation deaths accounted for 57(24.8%) of all asphyxial deaths and 0.77% of all autopsies done over the study period. The peak age group of suffocation death was 31–40 years with a male to female ratio of 2:1. Most (89.47%) of suffocation cases were due to aspiration of stomach contents. Hyperaemia of the airways, petechial haemorrhages and pulmonary oedema were the most common morphologic features seen. Conclusion: This study showed that almost all suffocation deaths were due to gastric aspiration mostly secondary to delayed medical intervention. Most of the decedents were in the 4th decade of life with a male preponderance. One case of homicidal suffocation due to combined smothering and choking was observed.
Introduction Suffocation is used to describe asphyxia cases where the sole mechanism involves the failure of oxygen to reach the bloodstream [1]. This is a non-specific term with a loose interpretation by different authors. Delmonte and Capelozzi in their classification of asphyxia, place suffocation in a separate category from aspiration [2]. According to Saukko and Knight suffocation is generally used to refer to environmental asphyxia due to depletion of atmospheric oxygen, a term which can also be used to also refer to choking and smothering [3]. For the purpose of this study, the term “suffocation” was applied to deaths due to simple (environmental) asphyxia, smothering, choking, traumatic (mechanical) asphyxia, positional asphyxia and combinations of the aforementioned, which is the classification used by most authors [1] [4–6]. Suffocation accounts for about 21% of the total annual injury deaths in studies by the Centre for Disease Control and Prevention in the United States [7]. Suffocation is the leading cause of unintentional injury mortality (21.2%) in children between the ages of 0–4 years in the United States [8]. Smothering occurs when there is a mechanical obstruction or
occlusion of the external airways such as the nose and mouth. There are a wide variety of circumstances and objects or substances involved in smothering [9], and some of them are implicated in accidental, homicidal and suicidal smothering deaths. Suicidal smothering most commonly occurs in some Western countries as a tool for euthanasia whereby a plastic bag is placed over the head, tightly secured around the neck [10]. Choking occurs when the external parts of the mouth and nose allow air flow, but air cannot move into (or out of the lungs) due to internal airway obstruction at the level of either the oropharynx, pharynx, larynx or one of the principal bronchi [9]. It is usually below the level of the epiglottis [4]. Most choking deaths are usually accidental and the victims are young children. Choking is a common cause of death in children between the ages of 1–3 years in Western Europe [11,12]. In a study by Seleye-Fubara and Ekere [13] in the Niger-Delta region of Nigeria, foreign body aspiration accounted for 4.8% of domestic accidental deaths, with pre-school children being commonly affected. Young children are more likely to aspirate food especially whilst eating and playing at the same time. The scene for most cases of childhood choking death is at home and day care centres, and it usually occurs unwitnessed [12,14]. Adult cases of
* Corresponding author at: Department of Pathology and Forensic Medicine, Lagos State University Teaching Hospital, 1 – 5 Oba Akinjobi Way, Ikeja, Lagos 100001 Nigeria. E-mail address: [email protected] (W.O. Olatunde). http://doi.org/10.1016/j.fsir.2019.100033 Received 20 July 2019; Received in revised form 1 September 2019; Accepted 2 September 2019 Available online 6 September 2019 2665-9107/© 2019 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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The data analysis was carried out with the aid of the IBM Statistical Package for Social Science (SPSS), version 20. All statistical comparisons of variables were completed using the two-sided Fisher’s exact test. A value was considered statistically significant at a p-value less than or equal to 0.05. The results were presented in tables and charts.
choking are usually accidental or homicidal. Homicidal choking is considered by some authors to occur through gagging and the victims are usually weaker individuals like the elderly and neonates [15]. Many authors however, consider gagging to be a form of smothering [3,4]. Traumatic asphyxia usually occurs as a result of a very heavy object compressing the chest as in a person crushed under a heavy vehicle such as a car or tractor, a factory worker pinned or crushed by heavy machinery [16–18], and in some cases of infant death from overlay [19]. Positional (or postural) asphyxia is a condition that occurs as a result of the adoption of a particular body position, causing mechanical interference with pulmonary ventilation [20]. Busuttil and Obafunwa reported the case of a 12-year old female child who died due to positional asphyxiation following suspension at the abdomen by a webbing band. This resulted in progressively increasing external pressure on the diaphragm, impeded movement of the lower intercostals and abdominal muscles, which finally induced progressive respiratory impairment [21]. The morphologic features seen at autopsy in suffocation deaths may include non-specific findings popularly known as the “asphyxia stigmata”, and specific findings which may be suggestive of the cause of asphyxiation [9]. Asphyxia stigmata include, cyanosis which can be defined as a purplish – blue discolouration of the skin (more readily observed in lightskinned individuals), nail bed and face, including the lips and earlobes. Petechial haemorrhages are pinpoint, non-raised, round purple or red spots (<2 mm) that results from capillary rupture [22]. They can be found on the conjunctiva, oral mucosa, auditory mucosa, subpleural interlobar and diaphragmatic surfaces of the lungs, the epicardium, brain and thymus (in children) [9]. Other features include hyperaemia of the tracheobronchial mucosa which is commonly due to aspiration of various contents into the airway, pulmonary congestion, and oedema. Specific findings include chest and/or abdominal bruising in traumatic asphyxia. The shape of the bruise may match that of the heavy object that caused compression of the chest, such as, the tyre marks from a vehicle [9,16]. Materials used for gagging may be found, occluding the nostrils and buccal cavity, and simultaneously causing both smothering and choking; such items include clothing or adhesive tapes. Aspirated substances such as foreign objects lodged in the airways especially in children [12], or gastric contents may be observed [9]. The aim of this study is to determine the demographic pattern, the causes and pathological features of suffocation deaths seen in the Medical Examiner’s Office, in Lagos, Nigeria
Results A total of 57 cases of suffocation death were recorded over the study period representing 24.8% of all asphyxial deaths comprising 230 cases (Fig. 1). These suffocation deaths represent 0.77% of the 7439 autopsies conducted during the 7-year period. The majority of suffocation-related deaths cases seen in this study were predominantly males 38 (66.7%) with a male-to-female ratio of 2:1 (Table 1). There were more males across all age categories except the category over 70 years, where 4 (80.0%) were females (p > 0.05) (Fig. 2). The average age of all suffocation cases was 35.5 19.1 with a minimum and maximum of 2 and 77 years respectively. Suffocation was more prevalent in the fourth, 17 (29.8%) and third, 13 (22.8%) age decades. Only age group 21–40 years accounted for more than half (52.6%) of all suffocation cases. There was a reduction in the number of suffocation deaths from 41 to 50 years (8, 14.8%) up to 61–70 years (1, 1.8%) before a slight increase observed in ‘above 700 age category ( 4, 7.0%) (Table 1). The principal cause of suffocation deaths was Aspiration of stomach contents, 51, followed by Aspiration of blood secondary to severe craniocerebral injury, 4, Foreign body aspiration, 1 and Combined smothering and choking 1 (Fig. 3). More than four of every five suffocation deaths in both males (89.5%) and females (89.5%) were caused by aspiration of stomach contents (Table 2). There is no significant variation of suffocation deaths across all age groups (p > 0.05) (Table 3). Most cases of aspiration of stomach contents were secondary to cerebrovascular disease (26, 51%), followed by severe head injury (15, 29%), Diabetic coma (8, 16%) and Café coronary (2, 4%), (Fig. 4). As shown in Table 4, Café coronary and Diabetic coma were insignificantly more common in males than in females while
Materials and methods This is a 7-year retrospective cross-sectional study of all deaths resulting from suffocation, and diagnosed following complete medicolegal autopsies at the Department of Pathology and Forensic Medicine, Lagos State University Teaching Hospital, between 1st January 2008 and 31st December 2014. This location accommodates the Office of the Chief Medical Examiner, established under the Coroner’s Systems Law of Lagos State [23]. The Office investigates all reportable deaths as instructed by the Coroners from across Lagos State; it provides autopsy services for the State and the immediate environs. All cases of suffocation deaths were obtained from the autopsy reports, autopsy register, hospital case notes, coroner's forms, extracts from police diary, reports by relatives, and other informants. The data retrieved include age, sex, postmortem examination findings, cause and manner of death. The exclusion criteria for the study include perinatal deaths, perioperative deaths and decomposed bodies. The limitations of this study include inability to obtain relevant history of predisposing medical conditions such as psychiatric illness and drugs or alcohol history, reliance on investigating police officers for death scene examination, and photography in most cases, inability to identify the age of unknown decedents and the lack of facilities for toxicological analysis to rule out alcohol and drug poisoning in most cases.
Fig. 1. Classes of asphyxial death.
Table 1 Gender and age distribution of suffocation cases. Demographics
Parameter
Frequency
Percentage (%)
Gender
Male Female 1–10 11–20 21–30 31–40 41–50 51–60 61–70 Above 70 Total
38 19 6 4 13 17 8 4 1 4 57
66.7 33.3 10.5 7.0 22.8 29.8 14.8 7.0 1.8 7.0 100
Age (years)
2
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Fig. 2. Bar chart showing the distribution of age within gender (Fischer’s exact p = 0.399).
Fig. 3. Bar chart showing the causes of suffocation. Table 2 Distribution of type of suffocation death within gender. Gender
Male Female Total
Type of suffocation death (p = 0.685) Aspiration of blood secondary to severe craniocerebral injury
Aspiration of stomach contents
Combined smothering and choking
Foreign body aspiration
3 (7.9%) 1 (5.3%) 4 (7.0%)
34 (89.5%) 17 (89.5%) 51 (89.5%)
0 (0.0%) 1 (5.3%) 1 (1.8%)
1 (2.6%) 0 (0.0%) 1 (1.8%)
(p > 0.05). Pulmonary oedema, hyperaemia of the airway mucosa and aspirated stomach contents represent broadly the most frequent morphologic features of suffocation deaths in both gender (Table 8) and all age categories (Table 9) (all > 70.0%). In contrast, the frequencies of petechial haemorrhages, aspirated foreign object and bruising of neck soft tissues were distinctly low for both genders ( Table 8) and across all age categories (Table 9) (all < 20.0%). Figs. 5–7 show examples of the gross morphological findings.
Cerebrovascular disease was more frequent in females than in males though not statistically significant ( p > 0.05). Severe head injury was predominant in young age groups of 1–30 years (13 of 15), Café coronary was more frequent in the older age groups 41–70 (2 cases) while the Cerebrovascular disease was more pronounced in the age groups, 21–50 (19 of 26) and diabetic coma within age group 21–40 (5 of 8) p < 0.05 (Table 5). Of the 26 cases of cerebrovascular disease, 13 were due to hypertension and 13 for sickle cell haemoglobinopathy; eight of each was seen in males and five in females (Table 6). Hypertension was significantly more common in adults (41 years and above, 12 of 13) while sickle cell haemoglobinopathy was predominant in younger age groups of 21–40 (12 of 13), p < 0.001 (Table 7). No significant differences were observed in the morphological features of suffocation deaths in both gender and all age categories
Discussion A total of 57 cases of suffocation deaths were recorded during the study period. This represents 24.8% of all the 230 asphyxial deaths. The prevalence is higher compared to the findings by Azmak in Turkey where suffocation-related deaths accounted for 14.3% of asphyxia cases [5]. As 3
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Table 3 Age distribution of suffocation deaths. Age group
1 - 10 11 - 20 21 - 30 31 - 40 41 - 50 51 - 60 61 - 70 Above 70 Total
Type of suffocation death (p = 0.797) Aspiration of blood secondary to severe craniocerebral injury
Aspiration of stomach contents
Combined smothering and choking
Foreign body aspiration
0 (0.0%) 1 (25.0%) 1 (7.7%) 1 (6.7%) 1 (12.5%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 4 (7.0%)
5 (83.3%) 3 (75.0%) 11 (84.6%) 14 (93.3%) 7 (87.5%) 4 (100.0%) 2 (100.0%) 5 (100.0%) 51 (89.5%)
0 (0.0%) 0 (0.0%) 1 (7.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.8%)
1 (16.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.8%)
presence of other subtypes of suffocation deaths that are not seen in our study. The gender distribution in this study shows a higher proportion of male to female (2:1) ratio, which is also similar, though higher than the study in India (1.47:1); however, it is lower than that in Turkey where they reported a ratio of 4:1 of all asphyxial deaths [5,6]. The male predominance may be due to the paternalistic nature of the Nigerian environment where males have a greater risk exposure on account of their higher participation in the work force, socio-political activities and crime when compared to females. The major cause of suffocation deaths seen were due to aspiration of stomach contents, constituting 51(89.5%) cases. In contrast traumatic chest compression was the major cause of suffocation in Turkey accounting for 36.8% of suffocation deaths [5] while smothering was the major cause of suffocation in India, accounting for 35.0% of cases [6]. The cases of aspiration of stomach contents in this study occurred under numerous circumstances which include unconscious victims suffering from cerebrovascular disease, severe head injury, and diabetic coma. This is similar to the study by Coffey, Pasquale-Styles and Gills in a 5-year review of 138 fatal cases of internal airway obstructions in Australia; found neurologic disease (remote cerebral vascular events, dementia and developmental disorders) was the most common risk factor for fatal choking (51%) [24]. In most of the cases observed in this study, asphyxiation
Fig. 4. Distribution of cases due to the aspiration of gastric contents.
noted, suffocation cases in this study accounted for 0.77% of all the 7439 autopsies performed during the 7-year period. This observation is still higher than the findings in India where Maddileti et al found that cases of suffocation accounted for 0.85% of the total number of asphyxial deaths and 0.18% of overall autopsies [6]. The present authors found the peak age category for suffocation deaths to be 31–40 years which is similar to the peak age seen in Turkey, but higher than the peak age of 21–30 years seen in the India study. This finding may be related to the
Table 4 Primary diagnosis of cases with aspiration of stomach contents. Gender (%)
Male Female Total
Primary diagnosis of cases of aspiration of stomach contents (p = 0.861) Café coronary
Cerebrovascular disease
Diabetic coma
Severe head injury
2 (5.9%) 0 (0.0%) 2 (3.9%)
16 (47.1%) 10 (58.8%) 26 (51.0%)
6 (17.6%) 2 (11.8%) 8 (15.7%)
10 (29.4%) 5 (29.4%) 15 (29.4%)
Table 5 Distribution of primary diagnosis of aspiration of stomach contents across age groups. Age Group
1–10 11–20 21–30 31–40 41–50 51–60 61–70 Above 70 Total
Primary diagnosis of aspiration of stomach contents (p < 0.001) Café coronary
Cerebrovascular disease
Diabetic coma
Severe head injury
0 0 0 0 1 0 1 0 2
0 (0.0%) 0 (0.0%) 5 (45.5%) 8 (57.1%) 6 (85.7%) 1 (25.0%) 1 (50.0%) 5 (100.0%) 26 (51.0%)
0 0 1 4 0 3 0 0 8
5 (100.0%) 3 (100.0%) 5 (45.5%) 2 (14.3%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 15 (29.4%)
(0.0%) (0.0%) (0.0%) (0.0%) (14.3%) (0.0%) (50.0%) (0.0%) (3.9%)
4
(0.0%) (0.0%) (9.1%) (28.6%) (0.0%) (75.0%) (0.0%) (0.0%) (15.7%)
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Maddileti et al in India [6]. This is possibly due to better provision of first aid care, emergency services and intensive care unit services when compared to Nigeria. The morphologic features seen in the present study are consistent with the “asphyxia stigmata” [9]. Most notable were petechial haemorrhages, pulmonary oedema and hyperaemia of the airway which were observed in a majority of suffocation reported in the series from Turkey [5]. The manner of death in most cases of suffocation (98.2%) was natural though preventable with prompt intervention; few cases were accidental (Aspiration of blood, foreign body aspiration, café coronary) and only one case was homicidal (Combined smothering and choking). DiMaio in a 10-year study of autopsies in a medical examiner’s office in the United States also found homicide due to asphyxia to be relatively uncommon. Twenty-six cases of suffocation were noted in 133 cases of homicidal asphyxia. Similar to this study, most of the suffocation victims (20) were found in the younger age group (2 years and below). Five deaths were due to choking. Three of the deaths involved adults who were gagged; two deaths involved infants with foreign material pushed into the mouth [26]. In a study of asphyxial homicides over a 10-year period in Norway and Denmark; Rogde, Hougen and Poulsen found seven cases of suffocation, Smothering (3 males and 3 females) and choking combined with ligature strangulation (1 female) [27]. It is notable both aforementioned studies have in common a preponderance of the homicidal victims within the young age groups and females. These victims are relatively weaker physically than their assailants. There were no cases of suicidal suffocation seen in this study. This is similar to findings of Nwosu and Odesanmi, in their study of observed patterns of suicidal behaviour in Ile-Ife, Western Nigeria where the principal methods of suicide were hanging (44%) and chemical poisoning (37%) [28]. In contrast, a report of suicides in the United States by the Centre for Disease Control found suffocation as the second commonest method behind firearms injury. The report equally found a 7.7% increase in suffocation-related suicides over a 15-year period (1999–2014). The possible reason for the seemingly low rate of suicide in the present study may be due to the under-reporting of suicides by families for cultural fear of the social stigmatisation traditionally associated with suicide in Nigeria [29].
Table 6 Primary cause of Cerebrovascular disease. Gender
Primary cause of Cerebrovascular disease (p = 0.656)
Male Female Total
Hypertension
Sickle cell Haemoglobinopathy
8 (50.0%) 5 (50.0%) 13 (50.0%)
8 (50.0%) 5 (50.0%) 13 (50.0%)
Table 7 Distribution of Cerebrovascular disease within age categories. Age category
21–30 31–40 41–50 51–60 61–70 Above 70 Total
Source of Cerebrovascular disease (p < 0.001) Hypertension
Sickle cell Haemoglobinopathy
0 (0.0%) 1 (12.5%) 5 (83.3%) 1 (100.0%) 1 (100.0%) 5 (100.0%) 13 (50.0%)
5 (100.0%) 7 (87.5%) 1 (16.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 13 (50.0%)
occurred due to a lack of prompt medical intervention at the scene or failure to keep the airway secure at the emergency centre or intensive care units. The second highest cause of suffocation deaths in the present study was due to aspiration of blood secondary to severe craniocerebral injury, which accounted for 7% of all suffocation cases. In a prospective study of aspiration in severe trauma by Lockey, Coats and Parr in Australia, there were 17 deaths within the first 4 h due to severe head injury. There was one confirmed case of aspiration of blood observed in 10 available post-mortem examination results [25]. Suffocation as a result of aspiration was not seen from both studies of Azmak in Turkey [5] and
Table 8 Distribution of morphologic features within gender. Gender
Petechial haemorrhages
Pulmonary oedema
Hyperaemia of the airway mucosa
Aspirated gastric contents
Aspirated foreign object
Bruising of neck soft tissues
Male Female Total P
4 (10.5%) 1 (5.3%) 5 (8.8%) 0.455
35 (92.1%) 17 (89.5%) 55 (94.5%) 0.545
36 (94.7%) 19 (100.0%) 52 (91.2%) 0.440
34 (89.5%) 18 (94.7%) 52 (91.2%) 0.455
1 (2.6%) 0 (.0%) 1 (1.8%) 0.667
0 (0.0%) 1 (5.3%) 1 (1.8%) 0.333
Table 9 Distribution of morphologic features within age categories. Gender
Petechial haemorrhages
Pulmonary oedema
Hyperaemia of the airway mucosa
Aspirated gastric contents
Aspirated foreign object
Bruising of neck soft tissues
1–10 11–20 21–30 31–40 41–50 51–60 61–70 >70 Total p
6 (100.0%) 4 (100.0%) 13 (100.0%) 11 (73.3%) 8 (100.0%) 3 (75.0%) 2 (100.0%) 5 (100.0%) 52 (91.2%) 0.185
5 (83.3%) 3 (75.0%) 13 (100.0%) 13 (86.7%) 7 (87.5%) 4 (100.0%) 2 (100.0%) 5 (100.0%) 52 (91.2%) 0.575
6 (100.0%) 3 (75.0%) 13 (100.0%) 15 (100.0%) 7 (87.5%) 4 (100.0%) 2 (100.0%) 5 (100.0%) 55 (96.5%) 0.234
5 (83.3%) 3 (75.0%) 12 (92.3% 14 (93.3%) 7 (87.5%) 4 (100.0%) 2 (100.0%) 5 (100.0%) 52 (91.2%) 0.847
1 (16.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.8%) 0.368
0 (0.0%) 0 (0.0%) 1 (7.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.8%) 0.737
5
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prompt medical intervention and critical care. The findings in this study, therefore highlights the fact that suffocation constitutes a public health challenge in Nigeria. Recommendation There should be improvement in the public emergency (ambulance) response and intensive care services, in order to provide prompt intervention that will save the lives of victims of preventable causes of suffocation deaths. Scene investigation as a vital component of the postmortem examination, should be carried out for all cases. Expert personnel with relevant skills in the forensic sciences should be utilised. These experts should be equipped with relevant tools such as forensic photography and topographic analysis of the scene. There should be provision and maintenance of forensic toxicology facilities to detect possible contributions of toxic substances to the deaths, especially as it relates to drugs of abuse. Fig. 5. Conjunctival petechial haemorrhages.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of interest None declared.
References [1] J. Prahlow, Asphyxial Deaths in: Forensic Pathology for Police, Death Investigators, Attorneys and Forensic Scientists, Springer, New York, 2009, pp. 401–402. [2] C. Delmonte, V.L. Capelozzi, Morphologic determinants of asphyxia in lungs: a semiquantitative study in forensic autopsies, (Am J Forensic Med Path. 22 (2001) 139–149. [3] P. Saukko, B. Knight, Suffocation and asphyxia, Forensic Pathology, 4th ed., CRC Press, Boca Raton, London, New York, 2016, pp. 353–368 Chp.14. [4] A. Sauvageau, E. Boghossian, Classification of asphyxia: the need for standardization, (J. Forensic Sci. 55 (2010) 1259–1267. [5] D. Azmak, Asphyxial deaths: a retrospective study and review of the literature, (Am. J. Forensic Med. Pathol. 27 (2006) 134–144. [6] G.B. Maddileti, S.K. Mohanty, V. Kumar, K.B. Reddy, V. Bhuvan, K. Yamini, An epidemiological study of suffocation deaths in twin cities of South India, (J Indian Acad Forensic Med. 37 (2015) 232–236. [7] Center for Disease Control and Prevention, National Center for Injury Prevention and Control. U.S. Injury Mortality Statistics Last accessed on 22nd of July 2016, http:// www.cdc.gov/injury/wisqars/pdf/10LCID_All_Deaths_By_Age_Group_2010-a.pdf, 2010. [8] Center for Disease Control and Prevention, National Center for Injury Prevention and Control. Ten Leading Causes of Death by Age Group Last accessed on 22nd of July 2016, http://www.cdc.gov/injury/wisqars/pdf/10LCID_All_Deaths_By_Age_Group_ 2010-a.pdf, 2010. [9] M.J. Shkrum, D.A. Ramsay, Asphyxia, in: S.B. Karch (Ed.), Forensic Pathology of Trauma: Common Problems for the Pathologist., Humana Press, Totowa, New Jersey, 2007, pp. 65–179. [10] D. Humphry, Final Exit: the Practicalities of Self-deliverance and Assisted Suicide for the Dying, Dell Publishing, New York, 1992. [11] J.W. Nixon, A.M. Kemp, S. Levene, J.R. Sibert, Suffocation, choking, and strangulation in childhood in England and Wales: epidemiology and prevention, (Arch Dis Childhood 72 (1995) 6–10. [12] F. Foltran, S. Ballali, H. Rodriguez, A.B. Sebastian van As, D. Passali, A. Gulati, D. Gregori, Inhaled foreign bodies in children: a global perspective on their epidemiological, clinical, and preventive aspects, (Pediatr. Pulmonol. (November 20) (2012) , doi:http://dx.doi.org/10.1002/ppul.22701.[Epub.] Wiley Online Library. [13] S.D. Seleye-Fubara, A.U. Ekere, Domestic accidental deaths in the Niger Delta region, (Nigeria. East Afr Med J 80 (2003) 622–626. [14] R.W. Byard, Unexpected death due to acute airway obstruction in day care centers, (Pediatrics 94 (1994) 113–114. [15] V.J. DiMaio, D. DiMaio, Asphyxia, in: V.J. DiMaio, D. DiMaio (Eds.), Forensic Pathology, 2nd ed., CRC Press, Boca Raton, 2001, pp. 229–277. [16] A.R. Copeland, Vehicular-related traumatic asphyxial deaths–caveat scrutator, (Z. Rechtsmed. 96 (1986) 17–22. [17] R.W. Byard, R. Wick, E. Simpson, J.D. Gilbert, The pathological features and circumstances of death of lethal crush/traumatic asphyxia in adults – a 25-year study, (Forensic Sci. Int. 3 (2006) 200–205.
Fig. 6. Pulmonary petechial haemorrhages.
Fig. 7. Hyperaemia of the laryngeal and tracheal mucosa with aspirated partially digested food particles.
Conclusion This study showed that suffocation-related deaths are common in the young and male population. Aspiration of gastric contents is the main cause of suffocation and this is very preventable with availability of 6
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FSIR 1 (2019) 100033
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