Refrat Forensic Asphyxia (DR - Wahyu)

VIOLENT ASPHYXIA
Resti Nurfadillah G99161079

Risnu Ardian W G99161084
Salma Nadia F G99161089
INTRODUCTION
Assasination on the scaffold is the worst form of
assasination, because there it is invented with the approval
of society.
- George Bernard Shaw

Definition
Asphyxia is derrived from Greek and literally
means pulselessness
Based on Forensic practice :

A condition in which the supply of oxygen to
the blood and body tissue is reduced appreciably
below the normal working level by any interference
with respiration
Introduction - Definition
Hypoxia
Asphyxia
Hyper
capne
a
Definition
Adelson defined asphyxia, as :
a state in living organism in which there

is acute lack of oxygen available for cell
metabolism associated with inability of body to
eliminate excess of carbon dioxide.
Hypoxia
Asphyxia
Hyper
capne
a
Anoxia
A state characterized by A condition in which there

lack of oxygen supply to is an inadequate or
body and tissue Hypoxia
reduced supply of oxygen
to tissue
Anoxic Anoxia
Prevention of oxygen entering to lungs or inability of lungs to
oxygenate the blood.
Stagnant Anoxia
Slowing down of circulation with impaired oxygen delivery to
tissue.
Histotoxic Anoxia
Cells are not in a position to utilize the oxygen delivered to
them.
Anemic Anoxia
Indicates reduced oxygen carrying capacity of blood.
Type and Cause of Asphyxia
Pathological
Environmental Toxic
Traumatical
Mechanical
Introduction Type and Cause

Introduction Type and Cause
Pathophysiology
Stages of Asphyxia
Signs
Introduction Pathophysiology, Stages & Sign

Cyanosis
Congestion of organs
Petechial hemorrhages
Pulmonary edema
Fluidity of blood
Dilatation of right
chamber of heart

Stage of Dyspnea
Breathlessness
Heaviness in head
Tachycardia Stage last for a minute
Ringing in the ears
Raised Blood Pressure

Stage of Convulsion
Retention of carbon dioxide
Increase blood lactate
Sympathetic & parasympathetic effects are prominent
Clouding of conscousness and convulsions
Stage last for 1 to 2 minute

Stage of
Exhaustion & Respiratory Failure
Anoxic brain damage
Pupils are waidely dilate
Reflex are lost
Paralysis of respiratory center
Heart may continue to beat for few more minutes
Stage last for 2 to 3 minute

Dead

MECHANICAL ASPHYXIA
(Violent Asphyxia)
In violent asphyxial deaths, there is evidence on the body of some mechanical
interferece with the process of breathing
1. HANGING
Hanging is a form of violent
death produced by
suspending the body with a
ligature round the neck, the
constricting force being the
weight of the body or a
part of body weight.
Violent Asphyxia - Hanging

Type
Base on Knot Position
Typical Hanging
Atypical Hanging
Base on Degree of Suspension

Complete Hanging
Partial or Incomplete Hanging
Base on Manner of Death

Suicidal Hanging
Homicidal Hanging
Accidental Hanging

Type
In relation to death
Antemortem Hanging
Postmortem Hanging
Others
Judicial Hanging
Autoerotic Hanging
Lynching
Rescue Hanging

Mechanism of Hanging
Hanging constricting force may be
Weight of entire body
Part of body weight
Constricting pressure of
2kg = sufficient to oclude jugular venous system
causing cerebral venous congestion
5kg = can compress the carotid arteries causing
cessation of blood supply to brain
15kg = Can compress the trachea causing obstruction to
respiration
30kg = Obstruct the vertebral arteries

Cause of Death
Immediate causes
Asphyxia
Venous Congestion
Cerebral Anemia
Vagal inhibition
Combination of asphyxia and venous congestion
Fracture dislocation of cervical vertebrae

Delayed Causes
Aspiration pneumonia
Infection and septicemia
Pulmonary edema
Hypoxic encephalopathy
Laryngeal edema
Abscess of brain/enchepalitis
Fatal Period
Death occurs immediately if cervical vertebrae are
fracture-dislocated or due to Vagal inhibition
Asphyxia and others: usual period is 3 to 5 minutes

Autopsy Finding
Clothes : may bear saliva stains
External examination
Neck = ligature mark
Face = face may congested, sign of salivary
dribbling, le facie sympathique
Others = cyanosis, voiding urine/stool/semen,
glove and stock pattern of postmortem lividity

Internal Examination
Neck :
Tissue underneath the mark are dry, white and
glistening
Muscle of neck may show contusion
Carotid arteries may be injured
Hyoid bone may be fracture
Brain :
May be congested
May be pale
Lungs : congested and edematous with Tardieu
spost over pleura
Abdominal viscera congested

Medicolegal Aspect
Hanging may be suicidal, homicidal or
accidental.
Accidental hanging may occur in : workplace,
playing, sexual, professional performances
Antemortem or Postmortem?
Hanging or Strangulation ?

Hanging
VS
Strangulation
2. STRANGULATION
Form of violent asphyxial death caused by
constricting the neck by means of ligature or
by any other means without suspending the
body.
The constriction force is not just because the
weight of victims body, but also the addition
of external force such as compression of neck
by hands, by rope, by belt, by stick etc.
Violent Asphyxia - Strangulation

Types
Depending on constriction of the neck
1. Ligature strangulation
2. Manual strangulation or throttling
3. Mugging
4. Bansdola
5. Garroting
6. Palmar strangulation
Depending on manner of death

1. Homicidal
2. Accidental

Cause of Death
1. Asphyxia
2. Cerebral hypoxia
3. Cerebral congestion
4. Combined- asphyxia and venous congestion
5. Vagal inhibition
6. Fracture dislocation of cervical vertebrae

3. LIGATURE STRANGULATION
A violent form of death caused by
constricting the neck by means of a ligature
without suspending the body.
May be in form of rope, belt, wire, cable,
dhoti, dupatta etc.
Violent Asphyxia Ligature Strangulation

Autopsy ndings

External Examination
Findings in neck: the appearance of neck and ndings
produced may vary according to the means used viz.
rope, wire, cable etc.
A. Ligature mark
1. Usually well dened and grooved. The mark is
present over neck at any level but commonly it is
placed at the level or below the thyroid cartilage
and completely encircles the neck horizontally
(transversely) and may be prominent on front and
at sides.

Ligature mark in ligature strangulation

2. The mark may be multiple.
3. The mark may be oblique
4. Initially the base of mark is pale with reddish
margin. If breadth of ligature is wide, the mark
impression will be wider and supercial. If
ligature used is narrow, it may leave narrow
but deeper impression on neck skin.
5. If knot is applied, there may be a wider area of
contusion at the site of the knot.
6. The ligature mark of strangulation is not
obliterated by putrefaction, but is preserved.

B.Other signs
1. Signs of asphyxia are more prominent.
2. The face is puffy, edematous and
congested.
3. The eyes are prominent, open, bulging and
suffused with scleral hemorrhages.
4. Petechial hemorrhages may also be noted
on eyelids, face and forehead.
5. Sphincters may be relaxed with voiding of
urine, feces or semen.

Strangulation mark with different
Suffused conjunctiva
manifestation seen over face

A.Findings in neck
1. Neck structures should be examined at the end
of autopsy after examining the cranial cavity
and chest and abdomen.
2. Supercial hemorrhages may be present
underneath the ligature mark with evidence of
hemorrhages in muscle and soft tissue in and
above the area compressed.
3. If violence applied is more, there may be
extensive bruising of the deeper structures and
tissues of the neck.
4. Subcapsular and interstitial hemorrhages may
also be noted in thyroid.
5. Fracture of hyoid bone and thyroid cartilage
may be seen in some cases. Hyoid may be
fractured by:
a. Direct lateral force exerted from side of
neck.
b. Indirect violence where hyoid is drawn
upward and traction is applied through
thyrohyoid membrane called as traction
fracture or tug fracture.
6. There may be extravasations or laceration of
carotid sheath.
7. The base of tongue may show deep lingual
hemorrhages.
8. In some cases one or both superior horns of
thyroid may be fractured.
9. The cartilage of larynx or tracheal rings may be
fractured if considerable force is used.
B. Other ndings
1. Lungs may be congested and edematous and
may show fresh hemorrhages in parenchyma.
2. Pleura show petechial hemorrhages. There
may be emphysematous bullas on lung surface
due to overdistension and rupture of
interalveolar septa.
3. Abdominal viscera- congested.
Medicolegal Importance
Homicidal strangulation is more common than
accidental strangulation.
Accidental strangulation may occur if some
material like scarf, dupatta, machine belt etc. is
suddenly wrapped around the neck and
constricting the neck causing death.
The strangulation may be mistaken for hanging or
vice versa.

4. THROTTLING (MANUAL STRANGULATION)
It is violent asphyxial death produced by
compression of neck manually i.e. by using
human hands.
The neck is compressed by using hands. Either
one hand or both hands may be used to throttle
a person.
Violent Asphyxia Throttling

Autopsy Findings
The injuries are in form of contusion and/or
abrasion and depend on:
1. The relative position of victim and the assailant.
2. The number of assailant.
3. The manner of grasping the neck, either with
one hand or both hands.
4. Degree of pressure exerted on the neck.

The following patterns of injuries are present:
1. Cutaneous contusions.
2. Cutaneous abrasions.
3. Hemorrhages/contusions into the deep structure
of the neck.
4. Injury to hyoid bone and laryngeal complex.

Contusions over Neck
Contusions are produced as a result of grasping
the neck of victim by assailants ngers and
produced by tips and pads of ngers are oval or
round in shape and are of size of digits measuring
about 1.5 to 2 cm.
If one hand is used, it may be possible to have
one prominent contusion on one side of neck
(due to thumb) and three to four contusions on
the other side (due to ngers).

If both hands are used the thumb mark of one
hand and nger marks of other hand on either
side of neck may be found.
Caution should be exercised while interpreting
these bruises as many factors inuences for their
appearance.

Abrasions on Neck
Scratch abrasions may be present over neck and
are caused by ngernails of either hands of
assailant or that of victim in attempt to ward off
the assailant.
There may be crescentic or semi-lunar abrasions
over neck and are caused due to nails
embedded in the neck.

Hemorrhages/Contusions into the
Deep Structure of the Neck
On internal examination bruising of neck muscles may
be present as a direct result of force applied.
Hemorrhages are common in strap muscles and
platysma.
The pharynx, tonsils, base of tongue and upper part of
larynx may show extensive bleeding if duration and
degree of compression is more.
Hemorrhages may appear beneath the capsule of
thyroid, submaxillary and carotid lymphatic glands.

Injury to Hyoid Bone and Laryngeal
Complex
Thyroid fractures are common as maximum
pressure is likely to be effected at this site and
involves more commonly the upper horns.
The body of thyroid can be broken by a karate
blow or commando punch to the front of
neck.
The cricoid is rarely injured. If cricoid is injured, it
is associated with application of considerable
force with anteroposterior compression of cricoid
against the spine.
Hyoid bone fracture: Fracture of hyoid bone is
common in manual strangulation than ligature
strangulation.
Many of the victims of mechanical asphyxia
showed high level of plasma thyroglobulin.

Fracture of hyoid bone in throttling

5. HYOID BONE FRACTURE
1. Antero-posterior type fracture:
a. Commonly seen in hanging or ligature
strangulation.
b. The hyoid bone is forced backward due to which
divergence of greater horns are increased
resulting in fracture of greater horn with outward
displacement of the fractured fragment.
c. The periosteum is torn or disrupted on the inner
side of hyoid bone and due to which the
fractured fragment can be easily moved outward.
Violent Asphyxia Hyoid Bone Fracture

2. Inward compression fracture:
a. The force of compression is directed inward and
act over hyoid bone.
b. The ngers of grasping hand squeeze the greater
horns toward each other due to which the distal
fragment of hyoid bone (greater horn) get
fractured and the bone fragment is displaced
inwards.
c. The periosteum is broken or torn on the outer side
of the hyoid bone and due to which the bone
fragment can be easily moved inwards but cannot
move easily outward.

3. Avulsion fracture:
a. This is indirect type of fracture.
b. The hyoid bone is drawn upward and held by
muscle and thyrohyoid membrane attached to its
upper and anterior surface.
c. Violent lateral or downward movements of thyroid
cartilage or direct pressure applied between the
cartilage and the hyoid bone will exercise traction
force through the thyrohyoid membrane due to
which there is avulsion fracture of hyoid bone.

Bansdola
A wooden poles or sticks or rods or bamboos are
used.
One bamboo or stick is placed over front of neck
and another is placed behind the neck.
One end of these sticks or bamboos are tied
together by a rope and other ends are brought
forcefully together so as to squeeze or compress
the neck in between two sticks to cause death.

Bansdola

Garroting
Thugs used this method around 1867 in India. The
robbers used this method in lonely places to kill
travelers and rob them.
1. Indian method: the victim is attacked from
behind without warning. The neck is grasped by a
ligature thrown from behind and is quickly
fastened or tightened by twisting it with lever or
two sticks tied at the end of ligature.
Asphyxiation of the unaware victim causes rapid
loss of consciousness and death.
2. Spanish method: the method is a part of judicial
execution. The twisting device consists of iron
color that is placed around the neck and
tightened by screw for strangulating the victim.
Garroting

Mugging
Also known as arm lock.
It is caused by holding the neck of person in the
bend of the elbow (or bend of knee). Here
pressure is exerted over larynx or side of neck by
the forearm and arm.

Mugging

Palmar Strangulation
The palm of one hand is placed horizontally
across the mouth and nostrils and then
reinforced the pressure by placing the other
hand on the top of rst hand at right angle to
the other. Here the heel of palm of upper hand
presses the front of neck.

6. SUFFOCATION
Suffocation is a type of mechanical asphyxia
caused by:
1. Either due to lack of oxygen in the
environment.
2. By mechanical obstruction to the air passage
by means other than constriction of neck and
drowning.
Violent Asphyxia Suffocation

Causes of suffocation
1. Deprivation of oxygen in air (environmental
suffocation) such as:
a. Presence of toxic gases in air such as CO, CO2,
SO2, etc
b. Decompression
c. High altitude
2. Plastic bag suffocation
3. Obstruction to air passage by means:
a. External means: Smothering, overlying,
traumatic asphyxia
b. Internal means: Gagging, choking

Types of Suffocation
1. Smothering
2. Choking
3. Gagging
4. Traumatic asphyxia
5. Burking
6. Overlying
7. Inhalation of irrespirable gases

7. SMOTHERING
Asphyxia caused by mechanical occlusion of
the external respiratory orifices i.e. the nose
and mouth.
Death is caused by obstructing the air
passage i.e. Mouth and nostril by means of
hand, cloth, pillow, towel
Violent Asphyxia Smothering

AUTOPSY FINDING
Pale area around the mouth and nose
(circumoral and circumnasal pallor)
Face may also show congestion and/or petechial
hemorrhages
Contusions at lips, gums and tongue.
Inner surface of lips may be lacerated due to
pressure on teeth.
Foreign bodies in form of fibers or piece of cloth
may be found in oral cavity if such objects are
used to compress mouth and nose.

MEDICOLEGAL IMPORTANCE
Homicidal smothering are common
Accidental smothering is rare
Sexually perverted person may cover the head
with plastic bag during autoerotic activity and
get suffocated.
A newborn baby may die due to suffocation if
the baby is born with membrane (amniotic sac)
covered with (culde-sac birth or caul birth).

8. GAGGING
Gagging is a type of asphyxia caused by
preventing the air entry into the respiratory
tract by stuffing gag material into the mouth.
The gag material may be rolled cloth, cotton,
rug, paper etc.
Violent Asphyxia Gagging

MECHANISM
A gag is pushed into the mouth to occlude
the pharynx. Initially the airway remains
patent through nostrils but due to constant
foreign body irritation, there is pooling of
saliva and mucous secretions. These
secretions soak the gag material and swells
up. Thus due to increase in size of gag, it
obstruct the air passage.

AUTOPSY FINDING
Consist of congestion and abrasion of hard
and soft palate with edema of pharynx. Gag
may be present in the oral cavity.

Homicidal death: Gags are inserted into
mouth of infants or incapacitated person
with an intention to kill them.
Some times accidental death may occur
when a gag is inserted into the mouth of a
victim to prevent from shouting.

9. CHOKING
Choking is a form of asphyxial death caused
by mechanical obstruction of the air passage
from within.
Caused by objects like-coins, dentures, fish or
animal bone, piece of meat, seed, food bolus,
button, round worm, mud, cotton, edible
fruit seeds, toffee, candies etc.
Violent Asphyxia Choking

MECHANISM
Large foreign body may be obstructed in the
pharynx or larynx and occlude the lumen
completely thus causing asphyxia.
Small foreign body may partially block the
lumen of airway and irritates the respiratory
tract. Irritation causes increase in secretions
and may induce laryngeal spasm.
An object may also induce reflex cardiac
inhibition and causes death.

CAUSE OF DEATH
Asphyxia
Vagal inhibition
Laryngeal spasm

AUTOPSY FINDING
In addition to signs of asphyxia, following
additional findings may be noted:
Foreign body that causes obstruction will be
found in the respiratory passage.
Respiratory passage is congested and at the site
of foreign body may show edema and
inflammation.

Usually accidental. In children, choking may
occur while playing with small objects or while
eating may inhale solid particle or food bolus. In
elderly or mentally ill patient, may swallow the
food without chewing and may inhale the food
bolus.
Suicidal or homicidal choking is rare
Phenomenon. A case of homicidal choking is
reported in literature where an adult was killed
by choking using large amount of tissue paper

Caf coronary: A person under the influence of
alcohol may some time inhale food bolus or
piece of bone or meat as intoxication causes
depression of gag refl ex. The foreign body in
larynx or trachea causes parasympathetic
stimulation from laryngeal nerve that result in
cardiac arrest and death. Here, though death
occurs due to choking, the symptoms produced
resemble that of due to myocardial infarction as
a consequence of coronary blockage and thus
the name.

10. TRAUMATIC ASPHYXIA
Synonyms: Crush asphyxia, compression
asphyxia
Definition: Traumatic asphyxia is form of
violent asphyxia caused due to mechanical
fixation of the chest preventing respiratory
movements.
Violent Asphyxia Traumatic Asphyxia

CAUSES
The chest and usually abdomen are compressed by an
unyielding object so that chest expansion and
diaphragmatic movements are prevented. This may
occur in:
Person buried under rubble of collapsed building
Person buried under sand, grains, coal etc. or by falling of
timber or masonry in industrial accidents.
Person trapped under automobile or vehicle.
Crushing in crowds as occurs in stampede. Such deaths
are called as Riot crush or human pile death.

AUTOPSY FINDING
Intense congestion, petechial hemorrhages
and cyanosis over head, neck and over chest
above the site of compression are cardinal
features.
Internally there are hemorrhages over
pleura. Injuries to chest may be present with
fracture of ribs. Lungs and heart may show
contusions and/or laceration.

Deaths are usually accidental.
Death may be homicidal as in burking.

DROWNING
Drowning is a form of asphyxial death where
air entry into lungs is prevented due to
submersion of mouth and nostrils into water
or any fluid medium.
Violent Asphyxia Drowning

CAUSES OF DROWNING
Inability to utilize the buoyancy of body
Exhaustion
Hypothermia
Entrapment in whirlpool/tidal waves.

CLASSIFICATION OF DROWNING
Dry drowning
Wet drowning
Fresh water
Salt water
Shallow water drowning
Immersion syndrome
Secondary drowning

DRY DROWNING
In some cases, no or little water is inhaled in
respiratory tract. Death occurs from asphyxia
caused due to laryngeal spasm. In such cases,
death is more or less instantaneous with lung
fields are left dry.

WET DROWNING
This is a classical form of drowning either in
fresh water or salt water. Here water is
inhaled and swallowed and lungs get water
lodged.

PATOPHYSIOLOGY OF SALT WATER DROWNING
PATOPHYSIOLOGY OF FRESH WATER DROWNING

SHALLOW WATER DROWNING
Occurs in small puddle of water when depth
of water is only few inches but sufficient to
submerge the mouth and nostrils.
Mostly accidental in those persons who are
disabled or incapacitated such as small
children, epileptics, drunkards, comatosed
persons following head injury etc.

IMMERSION SYNDROME/
HYDROCUTION
Death is not due to drowning but results
from cardiac arrest due to vagal inhibition.
Sudden contact of cold water with body
surface especially epigastrium, ears, nostrils,
larynx or pharynx stimulates nerve endings
and causes vagal inhibition.

SECONDARY DROWNING/NEAR
DROWNING
Condition where there is survival of a person
following an immersion episode. The victim
may die subsequently as a result of
pathophysiological consequences.
Death occurs as a sole or combine effect of
pulmonary edema, aspiration pneumonia
and/or electrolyte imbalance

MECHANISM OF DROWNING

PATOPHYSIOLOGY
Reflex vasoconstriction pulmonary
hypertension broncoconstriction increased
airway resistance denaturation of lung
surfactant lung compliance falls decrease
lung tissue for ventilation abnormal
ventilation/perfusion ratio hypoxia
hypercapnia respiratory acidosis asphyxia.

CAUSES OF DEATH
Asphyxia
Vagal inhibition
Ventricular fi brillation
Myocardial anoxia
Laryngeal spasm
Exhaustion
Hypothermia
Concussion/head injury
Apoplexy.

AUTOPSY FINDING
External Examination:
Clothes are wet
Skin is cold, wet and pale. Skin may show cutis anserina i.e. appearance of
goosefl esh or goose skin
Washerwomans hand
Cadaveric spasm
Rigor mortis appear and passes early due to exhaustion and/or violent
struggle for life
Postmortem lividity
Conjunctiva is suffused and congested
Froth (foam cone, champigon de mousse): fi ne, whitish, leathery,
tenacious, copious froth is seen oozing from mouth and nostrils.

1. Lungs
Voluminous, oedematous, ballooned, water lodged,
bulging
Fresh water drowning: lungs retained the shape
Salt water drowning: lungs are heavy, saggy,
ballooned and cut section exudes copious frothy
uid and the cut section does not retain shape
Paltauffs hemorrhages
Emphysema aquosum
Edema aquosum
Weight of lungs around 600-700 gr

Other Findings
Respiratory passage: whitish, ne froth and may
show sand, mud, silt, grit, vegetations
Blood: dark and fluid
Stomach and proximal intestine : swallowed
water, sand, mud, grit, silt
Water may be found in middle ear and claimed
to be positive proof of antemortem drowning
Hemorrhage in middle ear and mastoid air cells

Laboratory Findings
Microscopy
Lung :
Pulmonary alveoli are distended
Alveolar septal wall appears stretched and thinned
Blood :
Fresh water drowning : low RBC count with hemolysis
Seawater drowning : relative increase in RBC count
with RBCs appear crenated and shrunken

Medicolegal Importance
Accidental drowning:
Occur in toddlers and children by fall in bath tub,
bucket, swimming pool
Occur in recreational activities such as boating,
diving, hypoxic lap
occur in boat sinking, oods
Homicidal drowning : rare

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VIOLENT ASPHYXIA

Resti Nurfadillah G99161079

- George Bernard Shaw

Based on Forensic practice :

Adelson defined asphyxia, as :

a state in living organism in which there

A state characterized by A condition in which there

Introduction Type and Cause

Introduction Pathophysiology, Stages & Sign

Introduction Pathophysiology, Stages & Sign

Introduction Pathophysiology, Stages & Sign

Introduction Pathophysiology, Stages & Sign

Introduction Pathophysiology, Stages & Sign

Introduction Pathophysiology, Stages & Sign

Violent Asphyxia - Hanging

Base on Degree of Suspension

Base on Manner of Death

Violent Asphyxia - Hanging

Violent Asphyxia - Hanging

Violent Asphyxia - Hanging

Violent Asphyxia - Hanging

Violent Asphyxia - Hanging

Violent Asphyxia - Hanging

Violent Asphyxia - Hanging

Violent Asphyxia - Hanging

Violent Asphyxia - Strangulation

Depending on manner of death

Violent Asphyxia - Strangulation

Violent Asphyxia - Strangulation

Violent Asphyxia Ligature Strangulation

Violent Asphyxia Ligature Strangulation

Violent Asphyxia Ligature Strangulation

Violent Asphyxia Ligature Strangulation

Violent Asphyxia Ligature Strangulation

Violent Asphyxia Ligature Strangulation

Violent Asphyxia Ligature Strangulation

Violent Asphyxia Ligature Strangulation

Violent Asphyxia Throttling

Violent Asphyxia Throttling

Violent Asphyxia Throttling

Violent Asphyxia Throttling

Violent Asphyxia Throttling

Violent Asphyxia Throttling

Violent Asphyxia Throttling

Violent Asphyxia Throttling

Violent Asphyxia Throttling

Violent Asphyxia Hyoid Bone Fracture

Violent Asphyxia Hyoid Bone Fracture

Violent Asphyxia Hyoid Bone Fracture

Violent Asphyxia Hyoid Bone Fracture

Violent Asphyxia Hyoid Bone Fracture

Violent Asphyxia Hyoid Bone Fracture

Violent Asphyxia Hyoid Bone Fracture

Violent Asphyxia Hyoid Bone Fracture

Violent Asphyxia Hyoid Bone Fracture

Violent Asphyxia Suffocation

Violent Asphyxia Suffocation

Violent Asphyxia Suffocation

Violent Asphyxia Smothering

Violent Asphyxia Smothering

Violent Asphyxia Smothering

Violent Asphyxia Gagging

Violent Asphyxia Gagging