Subendocardial hemorrhages in a case of crush asphyxia

This case represents a 27-year-old man, who was found dead in a truckload, trapped between several coils of steel wire, each weighing 500 kg. The autopsy was remarkable for subendocardial hemorrhages in addition to Perthes' syndrome and florid internal findings: congestion/cyanosis of the cervical organs, intrathyroidal and submucosal bleedings. All this implies that compression significantly raised intrathoracic pressure. This might have reached a point that obstructed venous blood return and restricted filling of the right heart during diastole, while simultaneously preserving the function of a left ventricle for some time. A precipitous fall of the blood pressure and consequent decrease in the left ventricle filling, with a pressure gradient between the ventricular lumen and higher-pressured heart vessels could have resulted in myocardial vessel rupture - the same pathophysiologic mechanism that underlies the appearance of subendocardial hemorrhages. If this man was conscious and aware for some time prior and upon initial compression, the fight or flight response could have resulted in a sudden surge of circulating catecholamine levels - which is the second described mechanism of subendocardial hemorrhage development. However, we believe that autopsy findings favor the firstly described scenario. Nevertheless, subendocardial hemorrhages are out of the common finding in crush asphyxia.