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Survivor by asphyxiation due to helium inhalation

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Massimiliano Etteri
Massimiliano Etteri
Massimiliano Etteri
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Andrea Bellone at Azienda Ospedaliera Niguarda Ca' Granda
Andrea Bellone
Morena Vella
Morena Vella
Morena Vella
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Eleonora Capiaghi
Eleonora Capiaghi
Eleonora Capiaghi
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Abstract

In this rare case report we describe a 27-year-old white man survived suicide by asphyxiation using so-called suicide bag (or exit bag) filled with helium supplied through a plastic tube. He had no previous psychiatric or organic illness. At the time of presentation to our emergency department, he was awake and reported severe dyspnea with a clinical pattern of acute respiratory failure. Imaging studies showed pulmonary edema and the patient was treated with non-invasive ventilation in intensive care unit. After 15 days patient was discharged from hospital in optimal conditions. These rare cases of survivor might suggest the possible causes of death from inhaling helium.
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Survivor by asphyxiation due to helium inhalation
Massimiliano Etteri, Andrea Bellone, Morena Vella, Eleonora Capiaghi, Luca Motta, Ilaria
Malfasi
Emergency Department, Sant’Anna, Hospital, San Fermo della Battaglia, Italy
Correspondence: Massimiliano Etteri,!Emergency Department, Sant’Anna Hospital, via
Ravona 1, 22020 San Fermo della Battaglia, Italy.
Tel. +39.02.48703668 - Fax: +39.031.5855853.
E-mail: max.etteri@alice.it
Abstract
In this rare case report we describe a 27-year-old white man survived suicide by asphyxiation
using so-called suicide bag (or exit bag) filled with helium supplied through a plastic tube. He
had no previous psychiatric or organic illness. At the time of presentation to our emergency
department, he was awake and reported severe dyspnea with a clinical pattern of acute
respiratory failure. Imaging studies showed pulmonary edema and the patient was treated with
non-invasive ventilation in intensive care unit. After 15 days patient was discharged from
hospital in optimal conditions. These rare cases of survivor might suggest the possible causes
of death from inhaling helium.
Key words: Asphyxiation; Helium inhalation; Suicide.
This article has undergone full peer review and has been accepted for publication, but it has
not been processed for copyediting, typesetting, pagination and proofreading, which may lead
to differences between this version and the final one.
Please cite this article as doi: 10.4081/ecj.2016.5597
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Case Report
A 27 years old male student was rescued at home by his father: he was found to be
uncounscious with so-called "suicide bag" (or "exit bag") filled with helium supplied through a
plastic tube. Immediately he removed the bag (not really narrow neck) from the head and
called emergency number.
When ambulance arrive he was found with prompt resumption of breathing and slow recovery
of consciousness with peripheral cyanosis, pulse rate was 130/minute and blood pressure
160/90 mmHg. On arrival in emergency department of the hospital he was conscious with
hemodynamic stability, the respiratory rate was 35/min, pheripheral pulse oxymetry revealed
SpO2 of 80% in air. Past medical history was negative.
Thoracic fine crepitations were auscultated on both sides. Heart sound were normal.
Hemogasanalysis showed a severe respiratory failure with PaO2 / FiO2 value of 120.
Electrocardiogram revealed non abnormalities except sinus tachycardia. We performed a chest
X-ray and a bedside lung ultrasound with convex probe 5 MHz that revealed a bilateral B-
pattern typical of interstitial syndrome, mainly due to acute pulmonary edema. Inferior vena
cava and heart contractility were normal (studied with a cardiac phased array probe 2.5 MHz).
Moreover it was performed a thoracic CT scan which confirmed the diagnosis of bilateral
pulmonary edema that was bilateral, symmetric, ground-glass like, and not involving the
anterior areas of the chest.
A non invasive ventilation (NIV) with full-face mask was applied. Ventilatory settings were as
follows: FiO2 50%,PEEP 10 cm of H2O, PS 5 cm of H2O. Blood test were normal except
slight increase of troponins.
He was transferred to the intensive care unit. On the three day of hospitalization patient was
successfully weaned off the non invasive ventilator: pulse rate was 80/minute and blood
pressure 120/70 mm of Hg, the respiratory rate was 15/min, SpO2 of 98%. Then he was
transferred to the pulmonology ward.
Patient remained asymptomatic over the next 10 days. Blood test was normal. Chest was
clinically clear. After being subjected to a psychiatric evaluation, he was discharged from the
hospital.
Discussion
Helium is one of inert gases causing physical asphyxiation, whose excess content in the
breathing atmosphere reduces the partial pressure of oxygen and may be fatal after short-term
exposure. When breathing a mixture of an inert gas (helium, nitrogen, argon) with a small
amount of oxygen, with the possibility of exhaling carbon dioxide, no warning signs
characteristic of suffocation are perceived by the subject. Freedom from discomfort and pain,
effectiveness, rapid effect and relatively easy availability of required accessories have resulted
in the use of inert gases for suicidal purposes. This case report a suicide attempt by using a kit
consisting of the so-called "suicide bag" filled with helium supplied through a plastic tube. 1-3
This rare case survived shows the pathophysiology of pulmonary edema from pure severe
hypoxia at sea level because helium is a inert gas which only reduces the partial pressure of
oxygen. The process of hypoxic pulmonary vasoconstriction (HPV) was first identified in
1894, as a rise in pulmonary arterial pressure upon asphyxia.4 Alveolar hypoxia leads to an
adaptative vasomotor response in the form of hypoxic pulmonary vasoconstriction .5 The
pulmonary capillary pressure increases as a result of HPV, which occurs mainly in smaller
pulmonary arteries. As a result of the constriction of small pulmonary arteries, blood gets
diverted away, causing elevated blood flow and raising the pressure, which consequently leads
an the increase in capillary permeability mainly in areas more perfused:6 our pulmonary edema
was bilateral, symmetric, ground-glass like, and not involving the anterior areas of the chest
probably due to supine position of the patient.
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Another mechanism involved in pulmonary edema is a sympathetic activation: an intense
activation of the sympathetic nervous system and the release of catecholamines are the prime
contributors to exaggerated HPV. 7 Furthermore severe hypoxia causes cerebral edema and
elevation in intracranial pressure (ICP). Elevated ICP levels correlate with increased levels of
extravascular lung water (EVLW) playing an important role in the pathogenesis of neurogenic
pulmonary edema (NPE).8
Concluisions
To conclude, in this case we describe the beginning, evolution and resolution of a non-
cardiogenic pulmonary edema due to asphyxiation due to helium inhalation. Extreme hypoxia
and sympathetic activation are the main causes of the development of pulmonary edema with
high mortality and only autopsy cases post-mortem. Instead, in this rare case of survivor we
have observed the consequences of an event such as extreme hypoxia that is a reversible
process once recognized and properly treated.
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References
1. Grassberger M, Krauskopf A. Suicidal asphyxiation with helium: Report of three cases.
Wien Klin Wochenschr. 2007;119:323Y325.
2. Schon CA, Ketterer T. Asphyxial suicide by inhalation of helium inside a plastic bag. Am J
Forensic Med Pathol. 2007;28:364Y36711.
3. Ogden RD, Wooten RH. Asphyxial suicide with helium and a plastic bag. Am J Forensic
Med Pathol. 2002;23:234-237.
4. Bradford JR, Dean HP. The pulmonary circulation. J Physiol 1894; 16:34–158, 125
5.Archer S, Michelakis E. The mechanism(s) of hypoxc pulmonary vasoconstriction:potassium
channels,redox 0(2) sensors, and controversies. News Physiol Sci 2002;17:131-7
6. Bhagi S, Srivastava S,Singh SB. High-altitude pulmonary edema:review. J Occup Health
2014;56:235-43
7. Rogers FB, Shackford SR, Trevisani GT, Davis JW, Mackersie RC, Hoyt DB. Neurogenic
pulmonary edema in fatal and nonfatal head injuries. J Trauma 1995, 39:860–866.
8.Demling R, Riessen R. Pulmonary dysfunction after cerebral injury. Crit Care Med 1990,
18:768–774.
ResearchGate has not been able to resolve any citations for this publication.
High-Altitude Pulmonary Edema: Review.
Article
  • May 2014
Objective: At High altitude (HA) (elevation >2,500 m), hypobaric hypoxia may lead to the development of symptoms associated with low oxygen pressure in many sojourners. High-altitude pulmonary edema (HAPE) is a potentially fatal condition, occurring at altitudes greater than 3,000 m and affecting rapidly ascending, non-acclimatized healthy individuals. It is a multifactorial disease involving both environmental and genetic risk factors. Since thousands of lowlanders travel to high altitude areas for various reasons every year, we thought it would be interesting to review pathological aspects related to hypobaric hypoxia, particularly HAPE. Method: Since the pathogenesis of HAPE is still a subject of study, we systematically identified and categorized a broad range of facets of HAPE such as its incidence, symptoms, physiological effects, pathophysiology including physiological and genetic factors, prevention and treatment. Results: This review focuses on HA-related health problems in general with special reference to HAPE, which is one of the primary causes of deaths at extreme altitudes. Hence, it is extremely important, as it summarizes the literature in this area and provides an overview of this severe HA malady for evaluation of physiological, biochemical and genetic responses during early induction and acclimatization to HA. This article could be of broad scientific interest for researchers working in the field of high altitude medicine.
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Neurogenic Pulmonary Edema in Fatal and Nonfatal Head Injuries
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  • Nov 1995
Impaired pulmonary function is a frequent but poorly understood complication of acute head injury (HI). A potential early contributor to the pulmonary dysfunction seen in HI patients is neurogenic pulmonary edema (NPE). We hypothesized that NPE would occur early after HI and that it would have a continuum of clinical severity depending on the severity of the HI and associated intracranial hypertension. A large autopsy data base and inpatient HI data base were used to search for cases of NPE. Patients in the autopsy data base were stratified according to injury type and whether they died at the scene or within 96 hours of injury. There were significant (p < 0.0001, analysis of variance) elevations in lung weights in patients dying at the scene and within 96 hours from HI, compared with those dying from other noncentral nervous system injuries. No other organs studied showed significant weight increases. The incidence of NPE in isolated HI patients dying at the scene was 32%. In patients with isolated HI dying within 96 hours, the incidence of NPE was 50%. We found an inverse correlation (r = 0.62; p < 0.0014) between the initial cerebral perfusion pressure and the Pao2 /FIO2 ratio despite a normal-appearing chest x-ray film. We conclude that NPE occurs frequently in HI patients. The process of edema formation begins early in the clinical course and is isolated to the lung. Furthermore, surviving HI patients manifest a significantly decreased Pao2 /FIO2 ratio in the presence of a normal chest x-ray film, which seems to be related to a decrease in cerebral perfusion pressure and may be caused, in part, by NPE.
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Pulmonary dysfunction after cerebral injury
Article
  • Aug 1990
  • CRIT CARE MED
Pulmonary dysfunction is a common complication of severe head injury. The degree of initial hypoxemia which develops appears to correspond with the location and magnitude of the head injury. If unrecognized and not aggressively treated, the hypoxic insult will magnify the cerebral insult. A severe postinjury hypermetabolic state also develops and, if unrecognized and not managed aggressively with nutritional support, can also lead to severe catabolism, increased infection, and further lung dysfunction. Although supportive care is the major treatment at present, pharmacologic manipulation of the increased catecholamine activity, which is considered to be causative, may be effective in controlling both the impaired gas exchange and the hypermetabolic state. A knowledge of the various lung dysfunction states which occur in the head-injured patient population is required to optimize recovery and minimize complications.
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Neurogenic Pulmonary Edema in Fatal and Nonfatal Head Injuries
Article
  • Nov 1995
  • J TRAUMA
Impaired pulmonary function is a frequent but poorly understood complication of acute head injury (HI). A potential early contributor to the pulmonary dysfunction seen in HI patients is neurogenic pulmonary edema (NPE). We hypothesized that NPE would occur early after HI and that it would have a continuum of clinical severity depending on the severity of the HI and associated intracranial hypertension. A large autopsy data base and inpatient HI data base were used to search for cases of NPE. Patients in the autopsy data base were stratified according to injury type and whether they died at the scene or within 96 hours of injury. There were significant (p < 0.0001, analysis of variance) elevations in lung weights in patients dying at the scene and within 96 hours from HI, compared with those dying from other noncentral nervous system injuries. No other organs studied showed significant weight increases. The incidence of NPE in isolated HI patients dying at the scene was 32%. In patients with isolated HI dying within 96 hours, the incidence of NPE was 50%. We found an inverse correlation (r = 0.62; p < 0.0014) between the initial cerebral perfusion pressure and the PaO2/FIO2 ratio despite a normal-appearing chest x-ray film. We conclude that NPE occurs frequently in HI patients. The process of edema formation begins early in the clinical course and is isolated to the lung.(ABSTRACT TRUNCATED AT 250 WORDS)
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The Mechanism(s) of Hypoxic Pulmonary Vasoconstriction: Potassium Channels, Redox O2 Sensors, and Controversies
Article
  • Sep 2002
  • News Physiol Sci
Hypoxic pulmonary vasoconstriction matches perfusion to ventilation and optimizes systemic oxygenation. Alterations in PO(2) are sensed by a vascular redox O(2) sensor in the pulmonary artery smooth muscle cell, probably within the mitochondria. This creates a signal that modulates redox-sensitive K(+) channels, thereby controlling membrane potential, Ca(2+) entry, and tone.
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Asphyxial Suicide with Helium and a Plastic Bag
Article
  • Oct 2002
Suicide by helium inhalation inside a plastic bag has recently been publicized by right-to-die proponents in "how to" print and videotape materials. This article reports a suicide performed according to this new and highly lethal technique, which is also a potentially undetectable cause of death. Toxicology information could not determine helium inhalation, and drug screening did not reveal data of significance. The cause of death could be determined only by the physical evidence at the scene of death. Helium inhalation can easily be concealed when interested parties remove or alter evidence. To ensure that their deaths are not documented as suicide, some individuals considering assisted suicide may choose helium methods and assistance from helpers. Recent challenges to Oregon's physician-assisted suicide law may increase interest in helium instead of barbiturates for assisted suicide.
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Suicidal asphyxiation with helium: Report of three cases
Article
  • Feb 2007
Helium is an inert gas that among other things is used medically to alleviate the symptoms of airway obstruction, as part of a diving mix in deep-sea diving or as balloon gas. In recent years the so-called right-to-die literature has suggested suffocation with inhaled helium as an effective and peaceful means of self-deliverance for terminally ill patients. Helium displaces oxygen and carbon dioxide and can thus lead to asphyxia. We report three cases of suicidal asphyxiation with helium gas that were examined at the Department of Forensic Medicine Vienna within three months in 2006. In all three cases, autopsy was unrewarding from the point of view of gross pathology. Special autopsy techniques and devices are required for collection of the gas from the lungs. Gas-chromatography is used to examine the gas for helium; however, this requires replacement of the carrier gas, which is itself usually helium. The fact that three people in Vienna committed suicide using this method within a short period of time, together with the abundance of detailed how-to literature on the Internet, suggests a possible future increase in the number of deaths associated with the inhalation of inert gases, particularly helium. Because of the diagnostic obstacles involved, it is necessary to rely on good death-scene investigation for situational evidence when the body is discovered.
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Asphyxial Suicide by Inhalation of Helium Inside a Plastic Bag
Article
  • Jan 2008
  • AM J FOREN MED PATH
Asphyxial suicide by placing a plastic bag over the head, especially in combination with inhalation of gases, is a rarely described method of committing suicide. This article reports a case of suicidal asphyxiation by inhaling the inert gas helium inside a plastic bag. A 64-year-old man probably followed the instructions described in an article about committing suicide written by a medical practitioner from Zürich. This form of suicide is recommended by right-to-die groups and in the internet as a certain, fast, and painless suicide method. Additionally, it leaves only seldom externally visible marks or pathomorphological findings on the body. If the plastic bag and other auxiliary means are removed by another person, the forensic death investigation of cause and manner of death may be very difficult. Therefore, the death scene investigation and the inquiry ordered in the environment of the deceased are very important.
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