Could this child scream so loudly after having been asphyxiated? The answer to this lies in the evolution of her death. At this point she was clearly not dead and the strangulation failed. Indeed, we shall soon see that there is reason to believe that the initial strangulation attempt was consi/derably insufficient to cause death. If so, a likely period of unconsciousness perhaps lasting several minutes would give the child time to recover sufficient oxygen and lung capacity to scream, even if that was all she could do. But the child was still in critical condition. Ironically, the scream may have once again reduced her oxygen supply. The scream is what precipitated the coup de grace; the bludgeon attack. This likely resulted in a left heart failure from strangulation by association with the head trauma (the head trauma merely sped up the process of death by strangulation which occurred when the left heart failed). In this scenario, the left heart failure comes as a result of both the strangulation and the shock of the head trauma. But it is also possible that the head trauma merely made her unconscious at first. The assailant could have resumed the strangulation and thus precipitated the left heart failure very shortly after the head trauma.
