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Journal of College of Medical Sciences-Nepal, 2014, Vol-10, No-3

INTRODUCTION

Traumatic asphyxia is a rare condition presenting with

cervicofacial cyanosis and edema, subconjunctival

hemorrhage, and petechial hemorrhages of the face,

neck, and upper chest that occurs due to a compressive

force to the thoracoabdominal region1. It was first

reported by Olivier approximately 170 years ago in

victims trampled by crowd in Paris 2, 3. Although the

exact mechanism is controversial, it is probably due to

thoracoabdominal compression causing increased

Correspondence: Dr Bikash Sah

E-mail: Bikashsa01@gmail.com

A case report of Traumatic Asphyxia

Sah B1, Yadav B.N.2, Jha S.3

1Assistant Professor, 2Professor, 3Additional Professor, Department of Forensic Medicine & Toxicology
B.P. Koirala Institute of Health Sciences, Dharan.

ABSTRACT:

Traumatic asphyxia is a condition presenting with cervicofacial cyanosis and edema, subconjunctival

hemorrhage, and petechial hemorrhages of the face, neck, and upper chest that occurs due to a

compressive force to the thoracoabdominal region.

In this case report a 52 years old lady who was brought to the mortuary because of death due to

traumatic asphyxia as a result of being stampeded by her own cows upon her chest was discussed.

Congestion on both the conjunctiva, cyanosis on chin and adjacent upper left side of neck found with

a well demarcated area observed between the cyanosed area over face and the normal area of neck.

Hematoma was present in the chin and the adjacent neck region.

Apart from quickly eliminating organ pathologies and initiation of supportive therapy in a case of

traumatic asphyxia, possibility of formation of hematoma in neck after few hours of getting injured

should also be considered,  as this type of hematoma may contribute to the  cause of death.

Keywords: Autopsy, Cyanosis, Hematoma, Stampede, Traumatic asphyxia

intrathoracic pressure just at the moment of the event.

The fear response, which is characterized by taking

and holding a deep breath and closure of the glottis,

also contributes to this process1, 4 This back pressure

is transmitted ultimately to the head and neck veins

and capillaries, with stasis and rupture producing

characteristic petechial and subconjunctival

hemorrhages 4. Traumatic asphyxial deaths can occur

in variety of situations, such as motor vehicle accidents,

railway-related fatalities, elevator accidents, buildings



Journal of College of Medical Sciences-Nepal, 2014, Vol-10, No-3

52

was immediately resuscitated but could not be saved.

Postmortem examination was conducted

approximately 8 hours after her death. Death in this

case was because of traumatic asphyxia contributed

by neck hematoma. She was not known to have been

suffering from any diseases that could have either

caused or contributed to death.

AUTOPSY FINDINGS

Autopsy examination revealed distinct cyanotic,

edematous, and multiple petechiae on the chin, upper

left side of neck of the victim. Bilateral subconjunctival

hemorrhage was detected. A well demarcated area

was observed between the congested area over face

and the normal area of neck along with linear abrasion

present on the left side of mid neck region (Figure 1).

Left seventh, eighth, ninth and tenth ribs were fractured.

Internally, hematoma was present in the chin and the

adjacent neck region; the lungs were congested and

cut surface revealed oozing of frothy blood. The rest

of the internal organs were unremarkable.

Figure 1: Linear abrasion in the mid of the neck

and contusion in the chin region.

collapse, landslides and stampede. However, motor

vehicle accidents are the most common cause of

traumatic asphyxial deaths 2 . In patients with traumatic

asphyxia, injuries associated with other systems may

also accompany the condition. Jongewaard et al.

reported chest wall and intrathoracic injuries in 11

patients, loss of consciousness in 8, prolonged

confusion in 5, seizures in 2, and visual disturbances in

2 of 14 patients with traumatic asphyxia 5. In this case

report a female patient with traumatic asphyxia because

of being stampeded by her own cows was discussed.

CASE HISTORY

In this case report, a 52-years-old female who was

brought to the mortuary after death due to traumatic

asphyxia was discussed. From the anamnesis of the

patient, the lady was stampeded by her own cows on

the evening of 9th March 2014. As per eyewitnesses,

the mishap took place when she was about to put

fodder for the cows. One cow suddenly turned her

head and tried to hit the lady by her horns.  Sensing

something wrong, the lady suddenly turned and tried

to run away to save herself. However, due to sudden

turning, she lost her balance and fell near the legs of

the cow. Three cows eventually stampeded upon her.

She was then rescued and brought to the hospital (BP

Koirala Institute of Health Sciences). As per her

relatives, she was declared normal by the clinical

examinations and radiological investigations (X-rays

and Ultrasonography) done by the attending doctor

and because of no any organ pathology being detected,

she was suggested to go back home the same day but

because of request from the relatives, she was kept in

observation for that day. Next morning at about 9 am,

she was not responding to the attending nurse. She



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Journal of College of Medical Sciences-Nepal, 2014, Vol-10, No-3

DISCUSSION

Traumatic asphyxia is a rare condition presenting with

cervicofacial cyanosis and edema, petechial, and

subconjunctival hemorrhages of the face, neck, and

upper chest that occurs usually due to a compressive

force to the thoracoabdominal region but has also been

associated with asthma, paroxysmal coughing,

protracted vomiting, and jugular venous occlusion  6, 7.

However, for these signs to be present, the following

two processes should occur simultaneously 8. The first

is mechanical reflux of blood from chest into

cervicofacial region. The second is vasomotor paralysis

due to pressure on thoracic sympathetic nerves resulting

in distension of vessels with desaturated blood.

Additionally, reflex closure of glottis, which occurs to

brace against the impending force as the victim has

warning of being crushed 9, 10, also augments the venous

reflux. The venous reflux into cervico-facial region

occurs through the competent venous valves of the

internal jugular veins (IJVs), external jugular veins

(EJVs) and vertebral veins (VVs). Thus for better

comprehension of cervico-facial congestion and

petechiae, description of anatomical pathway of the

IJV, EJV, VV and function of valves is undertaken.

The IJVs are considered to be the main pathways of

blood drainage from the brain, the superficial part of

the face and the neck. It begins at the base of skull and

then runs down the side of the neck along the carotid

artery. At the root of the neck, IJV unites with the

subclavian vein to form the brachiocephalic vein, which

meets the superior vena cava. 11, 12 The EJVs mainly

drains the scalp and the deep part of face. It begins

near the mandibular angle, and then descends from

the mandibular angle to the mid-clavicle superficial to

the sternocleidomastoid. At the root of neck it ends in

the subclavian vein 11, 12. The VVs along with the deep

cervical veins (DCVs) represents the major non-jugular

cerebrovenous drainage pathway. VV is formed in

suboccipital triangle from where it goes through the

canal formed by the foramina transversaria of cervical

vertebra to open at the root of neck into the

brachiocephalic vein. The DCV is also formed in the

suboccipital region and ends in the lower part of VV.12

Regarding the function of craniocervical venous valves,

it has been proved that competent valves of the IJV 13,

EJV 14 and VV15 prevent the retrograde flow of cephalic

venous blood in these veins. However, the sudden

thoraco-abdominal compression in traumatic asphyxia

causes acute incompetence of these valves resulting in

characteristic venous discoloration of the head and

neck. In contrast to this, the congestion and petechiae

are not seen over lower body due to the inferior vena

cava compression as a result of Valsalva maneuver

produced subsequent to pre-impact fear response 16.

In the present study, the case showed unusual facial

congestion in the form of involvement of chin and

adjacent neck region especially in the upper left neck

region only. The reason for such left sided neck

congestion may be due to compression of chest on left

side. However, it showed well demarcated area

between the congested area and normal area. This

demarcation is characteristic of venous congestion

caused by circumstances that are compatible with

traumatic asphyxia such as entrapment beneath or within

motor vehicles, or under heavy objects 17. Abrasion

present in the left side of mid neck region suggest the

congestion in the chin and upper left neck region might

be due direct trauma also. However, the congestion is

at higher level than abrasion that is at the traumatic

site.



Journal of College of Medical Sciences-Nepal, 2014, Vol-10, No-3

54

In this case, all the clinical examinations and

investigations revealed no any abnormality that may

lead to death. However, death occured within 24 hours

of declaring that she was alright. The cause of death as

per postmortem examination was found to be traumatic

asphyxia contributed by compression of trachea by

upper neck haematoma. The reason behind

undetectable neck haematoma found at postmortem

examination, by ultrasonography might be due to USG

performed immediately after the incident while the

haematoma contributing to cause of death might take

some time for its formation and enlargement to the

enough size to compress the trachea. Fractured ribs

which were not detected in X-ray might be due to

proper approximation or they might be fractured at

terminal stage resuscitation.

CONCLUSION

When characteristic findings of traumatic asphyxia are

detected in trauma patients, apart from quickly

eliminating organ pathologies and initiation of supportive

therapy, possibility of formation of hematoma in neck

after few hours of sustaining injury should also be

considered. The neck hematoma finding in this present

study suggests that the clinicians should keep on re-

examining such patient for neck hematoma for at least

24 hours of getting injured and also to make them

aware that this type of hematoma may contribute to

the cause of death. This knowledge will definitely help

the clinician to save such patients by taking the needful

steps.

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