Volume 31, Number 17 / August 2, 2010 www.emreports.com Author: Strangulation Injuries J. Stephan Stapczynski, MD, FACEP, Chair, Department of Case Scenarios Emergency Medicine, Maricopa Medical Center, Phoenix, AZ. Near Hanging From Jail. You are on duty in the ED when the paramedics bring in a patient from the county jail who had tried to hang himself. When the patient arrives, you are told by the accompanying guard that the patient Peer Reviewer: was found with a tightly twisted bedsheet around his neck and looped over the Ann M. Dietrich, MD, FAAP, bedpost of the metal bunkbed. The patient’s feet were on the floor, but his but- FACEP, Professor of Pediatrics, tocks were suspended off the floor. The patient was described as unconscious- The Ohio State University College ness, cyanotic, and not breathing. When taken out of the bedsheet and laid on of Medicine, Public Health Risk the ground, he started breathing spontaneously but remained unconscious. To Manager, Section of Emergency your examination, he does not respond to pain, and you see marks on his neck Medicine, Columbus, OH. as shown in Figure 1. DV with Manual Strangulation. The triage nurse comes to you about a patient she is evaluating. The patient was brought in by police because of a domestic violence assault. The patient was choked by her boyfriend and passed out. The patient now says her voice is hoarse and she has pain with swallowing. Adolescent Choking Game. A 13-year-old boy arrives via EMS in cardiopul- monary arrest. When you ask the paramedics for the history, you are told that the child was found in his bedroom, slumped in a corner with a belt around his neck. He was last seen about an hour prior to that when he went upstairs to his room to do homework. Introduction What do these three patients have in common? All three had pressure applied to their necks that resulted in a loss of consciousness. What caused the loss of consciousness, and how should these different cases be assessed in the emer- gency department? Strangulation is a well-recognized event in forensic science with many stud- ies in the literature devoted to that field.1-5 It has been estimated that stran- gulation accounts for 2.5% of traumatic deaths worldwide6 and up to 10% of violent deaths in the United States.7 In general, much of the forensic analysis on strangulation injuries was done on homicide victims and emphasized that Statement of Financial Disclosure serious damage to the vital structures in the neck was common. Comparatively, To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing strangulation as a specific injury did not receive as much attention in the clinical Medical Education guidelines, we disclose that Dr. literature until the 1980s with the publication of two review articles.8,9 Only a Schneider (editor) serves on the editorial board for Logical Images. Dr. Farel (CME question reviewer) owns limited number of publications have specifically focused on patients who survive stock in Johnson & Johnson. Dr. Stapczynski (editor and to emergency department arrival.10,11 As a result, textbook chapters and clini- author), Dr. Dietrich (peer reviewer), Mr. Underwood (executive editor), and Ms. Mark (specialty editor) report cal teaching tend to over-stress those rare but serious injuries and provide little no relationships with companies related to the field of guidance on how to evaluate the majority of patients who present to the emer- study covered by this CME activity. gency department. Many of the initial studies included a majority of victims with hanging as the strangulation mechanism. As discussed below, there are important differences between manual strangulation and hanging, so the results of analysis from hanging victims cannot be consistently applied to victims of manual strangulation. Executive Summary Cervical vertebral fractures are rare in patients seen in MRI is the most useful imaging modality for the major- the ED for strangulation injuries. ity of strangulation victims. Clinical features of a potentially lethal strangulation Outcome from strangulation is worse if the patient include report of loss of consciousness, urinary or fecal required CPR or intubation, is comatose on ED arrival, incontinence, and presence of facial petechiae. or has cerebral edema on CT scan.
Figure 1: Suicidal Definition and depressed or completed loss of con- Differentiation sciousness. The external force can be Incomplete Hanging the use of the bare hands (manual), The common feature in all three ligature (a cord-like object), and hanging. Accidental strangulation cases is that the functioning cells of gravity (near-hanging). The term the body — particularly the brain “garrote” or “garroting” is occa- — were deprived of oxygen for a sionally used to describe ligature period of time; this is the definition strangulation, but to be precise, of asphyxia.12 The textbook chapters the garrote was a specific form of and medical journal literature con- judicial execution formerly used cerning asphyxia can be confusing in Spain whereby the ligature was because of the different terms used slowly tightened by the twisting of to describe the specific mechanisms. a rod inserted through the loop of To provide some clarity to this con- the ligature. Accidental strangula- fusion, an article from the forensic tion from cords and clothing have literature this year proposes that been described with Venetian blind asphyxia can be divided into four cords14, playground slide tie rope15, main categories: suffocation, stran- cotton cloth16, and scarfs (termed the gulation, mechanical asphyxia, and “Isadora Duncan syndrome” after Linear ecchymoses across the 12 drowning. (See Table 1.) the circumstances surrounding her neck Suffocation describes the process accidental death).17 that impedes or halts respiration. In hanging, the external pressure Suffocation subdivides into smother- applied to the neck is supplied by the that involves a ligature being caught ing, choking, and confined spaces/ patient’s body weight. With incom- in running machinery or from a entrapment/vitiated atmosphere. plete or near-hanging, a portion of moving vehicle can apply sudden Smothering occurs when there is the patient’s body remains in con- and violent force to the neck; such mechanical obstruction of the flow tact with the undersurface or floor, victims can sustain serious injury and of air from the environment into the whereas in complete hanging, the often are dead at the scene. mouth and/or nostrils. Smothering victim is fully suspended.9 In judi- Mechanical asphyxia encompasses typically requires the use of a soft, cial hanging, there is a gravitational positional, compressive, and trau- flexible object, like a cloth or a pillow free fall or drop before the rope is matic asphyxia. Positional or postural that can be molded over the irregu- abruptly tightened, applying pressure asphyxia usually occurs in infants or lar contours of the face, occluding to the neck. In most self-inflicted small children, when the child’s neck the nostrils and mouth. Choking hangings, there is not usually a drop is caught in crib or fence slats. In describes the process whereby the and the pressure applied to the neck traumatic or compressive asphyxia, trachea is occluded, either partially is more gradual, as many suicidal there is mechanical limitation of the or completely, by a foreign body. hangings are incomplete. Also, with expansion of the lungs by external Most cases of choking are accidental, suicidal complete hangings, there is a forces. An example includes victims with only rare cases being intentional higher incidence of thyroid cartilage crushed by a crowd, as might occur suicide.13 Confined space entrapment and hyoid bone fractures as com- when a large group tries to exit a occurs when there is inadequate pared to incomplete hangings.18 crowded room through a small door, oxygen in the enclosed space due An estimation of the force applied crushing those in front against the to consumption or displacement by to the neck during the strangula- building structure or underneath the other gases. tion episode is generally not possible weight of those behind them. Strangulation describes the pro- or probably useful.2 In general, the Drowning is death due to immer- cess whereby an external force is forces applied by manual strangula- sion in liquid. It is generally agreed applied to the neck that results in a tion are less than those provided by that asphyxia plays an important
194 Emergency Medicine Reports / Volume 31, Number 17 / August 2, 2010 www.emreports.com Table 1: Classification of strangulation, ligature strangulation, Obstruction in one internal carotid Asphyxiation and hanging suicides.20,21 Older indi- artery can produce dense contralat- viduals may have an ankylosed hyoid eral hemiparesis, whereas bilateral Suffocation bone or an ossified thyroid cartilage, occlusion can produce loss of con- Smothering which renders them more brittle and sciousness. In addition, the traumatic Choking susceptible to fracture from strangu- thrombosis in the internal carotid lation. Laboratory studies on fresh artery can break off and embolize human larynges indicate that the to the distal cerebrovascular circula- Strangulation thyroid and cricoid cartilage can be tion. As thus described, the major Manual broken with static loads of 16 and morbidity from intimal injury to the Ligature 21 kg, respectively.22 With fractures, neck from strangulation or hanging Hanging hemorrhage and edema can develop is from thromboembolism, and the to affect the airway. Transient occlu- standard treatment is with antico- 29 Mechanical sion of the upper airway at the level agulation, generally with heparin. of the thyro-hyoid membrane is Fibrinolytics, either systemic or local Positional estimated to occur with a 10-kg catheter directed, have been used to force.23 But even without fracture, treat non-traumatic carotid throm- contusion to the larynx can result in bosis30 and have been suggested for Drowning hemorrhage and edema with similar use in traumatic causes.19 consequences. However, as opposed The vertebral arteries are well to victims who are dead at the scene, protected from external forces as fractures of the thyroid cartilage or they course though the transverse pathophysiological role, but it is hyoid bone are uncommon in vic- foramen of the cervical vertebrae. likely that other neurologic and car- tims of accidental strangulation who To compress the vertebral arteries, diovascular reflexes also play a part in arrive to the emergency department a horizontal encircling force equal the fatal outcome. Thus, drowning with signs of life and are even rarer to a 30- to 40-kg load is required.23 is a more complex event than simple in survivors of manual strangula- However, with extreme rotation or asphyxia. tion or hanging. Fortunately, direct flexion, flow through there arteries injury to the trachea is rare with can also be compromised and less Pathophysiology strangulation.24 external force is required to occlude When pressure is placed on the The carotid arteries, because flow. neck, the victim first experiences of their relatively superficial posi- The low-pressure jugular venous pain, followed by anxiety as the tion in the neck, can be affected by system is superficial in the anterior victim becomes distressed from a external pressure. With an anterior neck, and flow through these veins is subjective sensation of difficulty force, the carotid artery can be easily affected by external pressure. breathing. With enough force to compressed against the transverse Occlusion of venous outflow from impair respiration, the victim will process of the fourth to sixth cervical the brain produces stagnant hypoxia typically lose consciousness within vertebrae. Flow through the artery and impairment in consciousness. 10-15 seconds.19 Obviously, the can be impaired by either mechani- The force required to obstruct flow loss of consciousness is not solely cal obstruction or the induction of though the internal jugular vein is due to apnea. It is likely that arterial spasm, which narrows the vascu- estimated to be equal to a 2 kg static obstruction, venous obstruction, and lar lumen. The force required to load.23 For manual strangulation and autonomic nervous system reflexes obstruct flow through the carotid suicidal near-hanging victims, venous all play a role in the rapid loss of arteries and produce loss of con- obstruction is a significant factor that consciousness with strangulation. sciousness is estimated to be equal produces loss of consciousness. The neck is vulnerable to external to a static load between 2.5 and 10 Pressure on the carotid sinus sym- injury because it does not have bony kg, depending on the direction of pathetic ganglion (carotid body) in protection and within its relatively force.23 Forces applied to the vessel the neck is well known to produce small diameter course the airway, wall may cause hemorrhage within bradycardia and cardiac arrest by vascular supply to the brain, the the media or intimal disruption. Such the so-named “carotid sinus reflex.” spinal cord and other vital nerves, traction injuries have been reported The role this reflex plays in the and the cervical vertebral column. in up to 5% of suicidal hangings25, pathophysiology of strangulation External force can injure many of but such injury is uncommon after is believed to be uncommon, as these important structures. non-lethal hanging and strangu- force must be applied to a specific The airway is anchored at its supe- lation. The intimal damage may and localized area,2 and while bra- rior end by the thyroid cartilage induce thrombosis, which typically dycardia can occur within seconds, and the hyoid bone. Fractures of produces symptoms and signs over the force must be maintained for a both structures occur from manual the subsequent 12-24 hours.19,26-28 minimum of 3-4 minutes to induce www.emreports.com Emergency Medicine Reports / Volume 31, Number 17 / August 2, 2010 195 cardiac arrest.27 The role such reflex Clinical Presentations violence, the “choking” game, and plays in cardiac arrest and death after The clinical presentations can vary auto-erotic asphyxiation. strangulation and near-hanging is according to the method of stran- Strangulation is well described disputed. It is suggested that older gulation. Common features upon with domestic or intimate partner individuals with atherosclerosis and emergency department presenta- violence episodes.38,39 The occur- carotid artery disease are more sus- tion include evidence of pressure rence of strangulation has been ceptible to this reflex, and this may against the skin (hyperemia and/or reported in 47-68% of women who contribute to the occurrence of ecchymosis), increased venous pres- were being assessed for intimate cardiac arrest after strangulation and sure in the face (facial or conjuncti- partner violence.38,40 The occurrence near-hanging in the elderly.9 val petechiae), change in laryngeal of strangulation was identified as an Spinal fractures are rare in most function (voice change or difficulty independent risk factor for subse- strangulation victims, either manual breathing), and evidence of cerebral quent intimate partner attempted or incomplete-hanging. Analysis of hypoxia (a report of loss of con- or completed homicide in women; judicial hangings indicates that a sciousness).6,10,11,33 One study from women who reported strangulation free-fall drop of at least the victim’s the United Kingdom found that as part of a domestic violence epi- height is required to produce cervical victims of non-fatal suicide attempts sode had a six to seven times greater vertebral fractures. In these cases, the via hanging have a significantly likelihood of attempted or com- most common injury is distraction of higher suicidal intent scale score and pleted homicide during a seven-year the upper cervical vertebrae, usually a lower use of alcohol as part of the follow-up compared to abused con- the second from the third, and occa- self-harm act when compared to trols.41 Smothering or strangulation sionally the third from the fourth.31 self-poisoning controls.34 Hanging has been identified in 25% of women Pulmonary edema is a common victims are more likely to arrive in killed by an intimate partner.42 complication seen in comatose vic- the emergency department with a Studies of women who were stran- tims who survive to hospitalization. depressed level of consciousness than gled by their intimate partners have The cause of the pulmonary edema are victims of manual strangulation. found several important issues for can either be due to anoxic injury This is presumably due to the more emergency physicians. The patient, to the central nervous system (neu- intensive and prolonged compres- when initially evaluated by emer- rogenic pulmonary edema) or from sive force applied to the neck due to gency department personnel, may the large negative intrathoracic pres- hanging than is typically seen with not always report the strangulation sures seen when the victim struggles manual pressure. Facial and con- episode. As is common with cases of to breathe in against an occluded junctival petechiae are common and domestic violence, the victim may be airway (obstructive pulmonary are evidence of prolonged elevated hesitant to fully describe what hap- edema). With airway obstruction and venous pressure from the strangula- pened or will minimize the severity aggressive attempts at inspiration, tion. It has been estimated that the of the attack. Specific questions often the intrapleural pressure can fall to as jugular vein needs to be occluded for are required to elucidate the stran- low as -100 cm H2O, compared to a at least 15-30 seconds for the devel- gulation mechanism. Visual evidence range of -2 to -5 cm H2O seen with opment of facial petechiae. of force applied to the neck during quiet respiration. The excessive nega- The majority of strangulation vic- intimate partner violence strangula- tive intrathoracic pressure increases tims present with these local signs tion is often absent on initial police venous return and pulmonary blood of cervical injury and/or evidence and medical evaluation.10,43 The lack volume while also lowering interstitial of cerebral hypoxia. Injury to other of physical findings may lead authori- pressure. This results in an increased organ systems from strangulation is ties to discount the patient’s report.43 hydrostatic gradient with movement uncommon and primarily described In addition, the laws concerning of fluid from the pulmonary capil- in isolated case reports. As previously strangulation as a specific assaultive laries into the tissues. The incidence noted, pulmonary edema has been mechanism vary by state and, con- of obstructive pulmonary edema is reported following strangulation, sequently, strangulation may not be about 10% in adults who require usually from hanging. Case reports considered as serious as a punch.44 active airway intervention for acute of diaphragmatic injury35, multiple The “choking game” is an activ- airway obstruction.32 Because neu- organ failure36, and thyroid storm37 ity that has been most commonly rogenic pulmonary edema is almost after strangulation have appeared in described among adolescents, but always seen with severe if not lethal the medical literature. may be played by children as young brain injury, the presence of pul- as 6.44-47 The purpose of this activ- monary edema in a strangulation or Clinical Associations ity is to induce a euphoric state or hanging victim who is experiencing a “high” by temporarily strangling the good neurological recovery is likely with Strangulation neck, reducing cerebral blood flow, due to obstruction as opposed to Three events often involve and creating cerebral hypoxia. Once neurologic injury. strangulation as part of that activ- the initial lightheaded sensation is ity: domestic or intimate partner felt, the stranglehold is released,
196 Emergency Medicine Reports / Volume 31, Number 17 / August 2, 2010 www.emreports.com allowing return of blood flow, of strangulation by either ligature become an accepted modality for often with a second “rush.” Various or hanging to enhance sexual activ- improving neurologic outcome in ligatures, such as rope, bed sheets, ity.9 The individual is usually alone victims of out-of-hospital cardiac belts, shoelaces, cloth towels, or dog and uses a device or prop for sexual arrest who are successfully resus- collars, are reported.44-48 In addi- stimulation. The intent is that the citated but do not quickly regain tion, manual strangulation with the induced cerebral hypoxia will make consciousness.55,56 It would be antici- individual’s own hands or the hand the sexual pleasure more intense pated that therapeutic hypothermia of another can be used. If the victim and the stranglehold will be released would also be beneficial in hanging engages in this activity while alone, before permanent cerebral injury. and strangulation victims who have loss of consciousness followed by Children have been reported to sustained anoxic brain injury and do death may occur before the strangle- engage in auto-erotic asphyxiation not quickly recover consciousness. hold can be released.49 As compared activity.52 If the individual dies, it is While there are no randomized tri- to drug use among adolescents for termed an auto-erotic death. Auto- als in near-hanging victims57, based the purposes of getting “high,” anal- erotic deaths are more common in on theoretical considerations and ysis of victims of this asphyxial game males than females and, while rare limited clinical experience, it seems are more likely to be athletic, have in children, have been reported in reasonable to consider therapeutic good academic standing, and believe individuals as young as 9.53 The cor- hypothermia in all comatose victims the choking game is a safe alterna- rect identification of an auto-erotic of near-hanging.58,59 tive to drug use for the purposes of asphyxiation death from other causes With strangulation, the initial pre- achieving a euphoric high. (accidental, homicidal, or suicidal) senting symptoms and physical signs As street drugs of abuse can pos- is dependent on proper scene may be deceptively minimal. It takes sess many different slang names, the investigation. time for hemorrhage and edema to choking game is also known by other develop after compressive injuries, terms; names such as Suffocation, Physical Assessment and the full clinical manifestations Roulette, Rising Sun, California Like other traumatic injuries, the may not occur for 36 hours after the High, Flatliner, Space Cowboy, assessment of a strangulation vic- event. Passout, Tingling, Funky Chicken, tim starts with the ABCs — airway, The following specific clinical American Dream, Space Monkey, breathing, circulation. While cervi- manifestations are possible in stran- Blackout, and Gasp have been cal vertebra bony and ligamentous gulation victims: reported by clinical, forensic, and injury is rare in strangulation victims s 6OICE CHANGES ARE REPORTED IN legal authorities. The following clini- arriving to the emergency depart- up to 50% of manual strangulation cal features are described as useful in ment, cervical spine stabilization ini- victims and may range from a raspy detecting children and adolescents tially should be done and maintained or hoarse voice to complete inability who engage in this activity: a combi- until such injury is appropriately to talk.10 nation of these findings — vascular excluded.9,25 It is uncommon that s 3WALLOWING ABNORMALITY IS NOT A injection or petechiae of the con- airway injuries from strangulation common symptom on initial emer- junctiva, marks on the neck, a report or near-hanging inhibit or interfere gency department assessment, but of loss of consciousness or altered with needed standard endotracheal is reported during the subsequent mental status, or severe headache — intubation in the emergency depart- two weeks in 44% of women who especially if they occur after the child ment.25,54 Conversely, care reports survive a domestic violence stran- has spent time alone. Emergency of accidental strangulation where gulation episode.10 Swallowing may physicians are encouraged to have an the ligature was caught in moving be painful (odynophagia) or difficult awareness of this game and to have a machinery and severe, sudden force (dysphagia). low threshold for inquiry regarding was applied to the neck have docu- s "REATHING DIFlCULTIES ARE COM- its possibility. It also is important to mented distortion of the laryngeal mon, seen in up to 85% of women stress when talking to children and structures resulting in difficulty with during the initial two weeks after a parents that this activity be identi- intubation.17 Although unproven in strangulation event.10 The dyspnea fied and discussed as “strangulation cases of hanging and strangulation, it can be psychogenic in origin and activity” that can produce coma and is often recommended that comatose may be due to anxiety, fear, depres- death, as opposed to the less danger- patients who are hemodynamically sion, or hyperventilation. Difficulty ous sounding phrase “playing the stable be treated with intravenous breathing can also be due to laryn- choking game.”50 Identification of opioids (fentanyl) and lidocaine geal edema or hemorrhage, although a child who engages in this activity prior to laryngoscopy to blunt the those injuries are less common in may not only prevent future episodes cardiovascular (hypertension and surviving victims. or death in that individual, but may tachycardia) and cerebral (increased s 0AIN IN THE THROAT OR NECK IS prevent the patient from engaging in intracranial pressure) responses to common after strangulation. The this activity with others.47,51 intubation. patient may be able to localize it to Auto-erotic asphyxiation is the use Therapeutic hypothermia has a specific area of injury, or it may be www.emreports.com Emergency Medicine Reports / Volume 31, Number 17 / August 2, 2010 197 diffuse and poorly localized. hanging victims who remain coma- Table 2: Structured s -ENTAL STATUS CHANGES CAN BE tose after emergency department Assessment and Docu- due to the occurrence of cerebral arrival. mentation for Strangulation hypoxia or from concomitant intra- s .EUROLOGIC lNDINGS CAN INCLUDE Victims cranial injury or ingestion of drugs ptosis, facial droop, and unilateral or ethanol. weakness. In many patients, the Method or Manner s .EUROLOGIC SYMPTOMS ARE findings are transient and believed frequently reported in victims of to be incited by focal cerebral isch- strangulation and include changes in emia produced by the strangulation P " Q vision, tinnitus, eyelid droop, facial process that resolves with time. In Knee droop, or unilateral weakness. While rare cases, damage to the internal Ligature common, many of these reported carotid artery may induce throm- Other symptoms may not be detectable or bosis with a delayed neurologic confirmed by neurologic testing. presentation.19,26,27 Number of Episodes s )NJURY TO THE SOFT TISSUES IN THE A structured checklist can guide Single neck may manifest with edema, the assessment and documenta- hyperemia, ecchymoses, abrasions, tion.7 (See Table 2.) Regardless of the $ or scratches. Abrasions and scratches phrase or term used by the patient, % may be defensive in nature, as the it is recommended that medical victim has tried to remove the assail- personnel use the term “strangle” Other Circumstances ant’s from his or her neck.60 The or “strangulation” to describe and & ' hyperemia may be transient and not document the event. & " ' visible by the time of assessment. & " " Imaging and Ecchymoses and swelling may take time to develop and may not be vis- Laryngoscopy ' ible on initial assessment. Ligature The imaging modalities used to & marks can be hidden within the assess for internal injuries after stran- ( ( ' natural skin folds of the neck and gulation include plain radiographic, & ) ( potentially missed on cursory exami- computed tomography (CT), com- ' nation, especially if the cervical collar puted tomographic angiography is not removed and good lighting is (CTA), magnetic resonance imag- not used. Chin abrasions have been ing (MRI), Doppler ultrasound of Symptoms reported to occur from the defen- the carotid arteries, and fiberoptic sive actions of the victims as they visualization of the laryngeal struc- ' flex their cervical spines forward and tures (fiberoptic laryngoscopy). Each * " bring their chins down in an effort to of these modalities has utility for Neck swelling protect their necks from the manual detecting specific injuries. (See Table ( strangulation of the assailant. 3.) + , - (- s 0ETECHIAE CAN OCCUR AT OR ABOVE Plain radiography, with either " the area of compression and are most bone or soft-tissue technique, is Sore throat frequently reported on the face and readily available in the emergency ( conjunctiva.61,62 More extensive cuta- department. Fractures of the cervi- Pain with swallowing neous and mucosal bleeding, such cal vertebrae are extremely rare in as a subconjunctival hemorrhage, is strangulation injuries unless there has generally seen only after a particu- been a hanging with a free-fall drop . ( , ( / larly vigorous struggle between the of the body, so routine plain radio- victim and the assailant. graphs of the cervical spine are gen- s ,ARYNGEAL INJURIES CAN MANIFEST erally of low yield. Significant injuries Signs with focal tenderness of the laryngeal to the laryngeal structures may % ( cartilage or subcutaneous emphy- produce secondary signs visible on neck sema over or around the laryngeal cervical radiographs using soft-tissue Neck swelling cartilage. technique — subcutaneous emphy- * " s 0ULMONARY lNDINGS CAN BE DUE sema, tracheal deviation from edema 0 ( to aspiration pneumonitis if the vic- or hemorrhage, and associated hyoid tim vomits and then inhales during fractures. This technique is insensi- 1 2 the strangulation event. As noted tive for more subtle injuries and, 3 - - above, pulmonary edema can occur, given the availability of computed weakness but this is generally only seen in tomography, soft-tissue cervical spine
198 Emergency Medicine Reports / Volume 31, Number 17 / August 2, 2010 www.emreports.com Table 3: Imaging Modalities Useful in Strangulation Injuries $ ( 4 % ( 3 ( + 5 strangulation injuries % ( + 5 ( 2 0 ( 3 ( 6 ( - ( 6 ( 2 + 5 ( % ( 89:9 ; ( 7 ( 6 ( injuries % ( 89:9 ( + 5 ( 2 ( * 74 ( 6 $ $%; 0 ( 89:9 injury + 5 2 ( 0 ( 89:9 / 0 ( thrombosis ( 2 ( intraluminal thrombosis + 5 * ( ( 1 ( ( 2 radiographs have little routine use. with reported sensitivities as low as strangulation because it can assess Computed tomography (CT) is 47%.63 With improved CT imaging the deep soft tissues, larynx, and ves- more sensitive for bony injuries, sub- techniques and enhanced recogni- sels better than other techniques. cutaneous emphysema, soft-tissue tion, the more recent studies have Articles reporting on the use MRI edema, and internal hemorrhage. found that the sensitivity of CTA for to evaluate victims of strangulation (See Figure 2.) Importantly, CT is blunt carotid injury varies from 82% are relatively new in the medical widely available in emergency depart- (when compared to selective angiog- literature.66-68 Some of the initial ments. For optimal visualization of raphy)64 to 100% (when compared case reports were on non-survivors these soft-tissue injuries, intravenous to clinical outcome).65 These differ- of manual strangulation and often contrast is recommended. ences suggest that some blunt inju- found fractures of the larynx and Computed tomography angiogra- ries to the internal carotid artery may hyoid bone — injuries uncommon in phy (CTA) is useful to detect injury not produce clinical consequences, survivors. A small study of 14 survi- to the carotid arteries.19 As noted and detection of these asymptom- vors of manual strangulation found above, the initial injury is usually an atic events is perhaps without ben- hemorrhage into the subcutaneous intimal tear that then promotes local efit. Because blunt carotid injury is tissues, muscle (platysma), lymph thrombosis. The clot can obstruct uncommon after strangulation, there nodes and salivary glands with MRI, the carotid artery lumen and/or is not enough experience to pres- but the life-threatening potential for break off pieces that embolize the ent an evidence-based approach for these injuries remained undefined.68 distal cerebrovascular circulation. the use of CTA. The author of this An article from 2009 examined The current “gold standard” for article recommends that four-vessel 56 survivors of strangulation inju- blunt carotid injury is four-vessel cranial-cervical CTA be done for ries with MRI (without contrast) selective cervical angiography.29 The patients who remain unconsciousness to determine if there were findings ability of CTA to detect (sensitivity) after emergency department arrival that correlated with life-threatening and exclude (specificity) injury to the or exhibit unilateral neurologic signs. potential.69 Based upon their expe- internal carotid artery from blunt Magnetic resonance imag- rience with both survivors and trauma has been the subject of sev- ing (MRI) is considered the best non-survivors of strangulation, two eral articles in the medical literature, imaging modality for victims of board-certified forensic pathologists www.emreports.com Emergency Medicine Reports / Volume 31, Number 17 / August 2, 2010 199 Figure 2: Suicidal life-threatening injury. be more readily available from the Incomplete Hanging Loss of consciousness was the emergency department. clinical finding that produced the Doppler ultrasound is useful greatest correlation with MRI find- to evaluate carotid artery flow. ings. Dysphagia and sore throat had Intraluminal thrombosis is read- a moderate correlation, while hoarse- ily detected and sometimes intimal ness had no correlation with MRI injury too. The use of Doppler ultra- findings. sound has been described in care Interestingly, injuries to zone reports of traumatic carotid artery B (where the blood vessels run) thrombosis from hanging.27 One had the greatest correlation with advantage of Doppler ultrasound is life-threatening strangulation as that the technique is portable and opposed to the expected deeper the device can be brought to the zone C (where the larynx and air- bedside of unstable patients. Also, way resides).69 The authors suggest the lack of radiation and no need that this finding supports the theory for intravenous contrast enables the that death following strangulation serial use of ultrasound as needed 7 is due more to obstruction to the if the patient’s clinical condition ( - " cerebral circulation than to airway changes. The spatial resolution of 9 obstruction. The authors therefore Doppler ultrasound is on the range using clinical information judged termed zone B the “danger zone” of 1 to 2 mm, which can be up to that 15 victims had life-threatening for life-threatening injury after an order of magnitude less than for injury while 41 victims did not. In all strangulation. CT angiographic images. This lower 56 victims, the most common inju- This MRI study has several limita- resolution can lower the sensitivity ries noted were subcutaneous hem- tions. The “gold standard” for life- for intimal injury and intraluminal orrhage and edema (55%), followed threatening injury was determined thrombosis from blunt trauma to by intramuscular hemorrhage and by subjective judgment, albeit by around 80-90% when compared edema (29%), intracutaneous hem- experienced forensic pathologists to selective angiography. This pre- orrhage (29%), and swelling of the who were not aware of the MRI sumably lower sensitivity for trau- platysma (29%). The last three find- findings during their deliberation. matic carotid injury has not been ings were the best for distinguishing The number of patients is small, and compared with CT angiography in between victims with life-threatening there were no serious injuries found strangulation victims to determine and non-life-threatening injuries, but that have been described in strangu- if the difference would be clinically the sensitivity was low, with only 53% lation victims — laryngeal fracture, relevant. of these individual findings present in hyoid bone fracture, or carotid artery Fiberoptic laryngoscopy is use- those with life-threatening injury. disruption. The absence of these ful to evaluate the vocal cords and Because no single MRI finding was findings in the study may not be adjacent structures for edema and adequate to discriminate between such a shortcoming in that, while hemorrhage.6,7,9,10 In a patient who the two groups, the authors devel- rare, identification of any one of is hoarse or reports difficulty talking, oped a score based on the extent of these indicates a potential life threat this technique can identify such inju- injury within the neck.69 The neck regardless of other MRI findings. ries. However, fiberoptic laryngos- was divided into three zones, from There is not enough experience copy cannot evaluate injury to the superficial to deep. Zone A included with MRI to present an evidence- deep neck tissues (muscles and ves- the skin and subcutaneous fat. Zone based decision tool for its use in sels) that correlates with a potential B included the cervical muscles, strangulation victims. Based upon life-threat. Thus, while commonly vessels, lymph nodes, and salivary the case reports and the study dis- described as a potential modality to glands. Zone C included the larynx cussed above, the author of this arti- evaluate strangulation victims, the and surrounding tissues. A score of cle recommends that MRI be done clinical utility of fiberoptic laryn- 0 to 3 was assigned according to the in patients who are awake but report goscopy to distinguish victims with number of zones with MRI find- a loss of consciousness during the life-threatening injuries from those ings; a score of 0 indicated that no strangulation episode or have facial without remains unproven. MRI findings could be identified in or conjunctival petechiae indicating The choice and sequence of any of the three zones, while a score that significant force was applied to imaging chosen by the physi- of 3 indicated that all three zones the neck for a period of time greater cian is dependent on the patient’s were involved. A score of greater than 15-30 seconds. For patients clinical condition and availability than or equal to 2 provided the best who remain unconscious, the physi- of the specific modalities. As noted combination of sensitivity (67%) cian will have a choice between CTA in the discussion above, there is and specificity (73%) for detecting and MRI. In most settings, CTA will inadequate experience to develop
200 Emergency Medicine Reports / Volume 31, Number 17 / August 2, 2010 www.emreports.com Table 4: Imaging Recommendations for Strangulation Victims in the Emergency Department
Clinical Scenario % ; $ ( 4 ; $ ( Manual strangulation with no loss ( None None " $ MRI with contrast 1 ( ( $ / ( MRI without contrast 7 " ; 6 MRI without contrast 7 4 ( MRI without contrast 7 4 ( <6 6 7 MRI without contrast angiogram 4 ( <6 6 7 consciousness but with unilateral <6 angiogram ( a comprehensive evidence-based extreme are patients with no loss of for cardiopulmonary resuscitation approach to imaging for strangula- consciousness, minimal or no physi- at the scene and/or invasive airway tion victims. Based on the review cal evidence of soft-tissue injury to management) and degree of anoxic of the literature noted above, the the neck, a completely normal neu- brain injury (as correlated with a low author of this article offers his rec- rologic examination, a safe residence scene and emergency department ommendations. (See Table 4.) to go to, and responsible adults who Glasgow Coma Score and cerebral can watch for the late development edema on initial CT scan).71-73 Disposition of complications. Such patients can and Follow-up be discharged. Return to Case Scenarios In general, the ED disposition In the middle are those with a The patient with near-hanging of strangulation victims is primarily report of loss of consciousness, have from jail was intubated in the emer- determined by their clinical condi- evidence of vascular obstruction with gency department and admitted to tion and evidence of injury to their facial or conjunctival petechiae, or the ICU. Over the next 36 hours, deep neck structures. At one extreme have symptoms or signs of soft-tissue the patient recovered consciousness are patients who remain comatose, injury to the neck. While they may and was extubated on the second have a persistently altered mental be breathing normally, soft-tissue day. The second patient underwent status, or require ventilatory and/ swelling and/or bleeding is likely to CT scan of the neck with intravenous or cardiovascular support. These get worse. Such patients should be contrast that found edema of the patients should be admitted to an admitted for at least 12-24 hours for platysma muscle. The patient was intensive care unit for close moni- close monitoring.70 An alternative admitted for overnight observation toring and treatment. While rare, is the use of an ED-based 24-hour and did well. While in the emergency patients with laryngeal fracture observation unit. Also, victims who department, the domestic violence detected by the presence of peri- are intoxicated from ethanol or advocate evaluated the patient, and laryngeal emphysema or visible on drugs should be observed until the the domestic violence report was MRI, hyoid bone fracture, or carotid effect of those agents has dissipated. completed and filed with the police. artery injury should also be admit- The outcome of strangulation The third patient was admitted to ted to the intensive care unit, even and hanging injuries arriving to the the pediatric ICU. Discussion with if they are awake, have adequate emergency department is determined the extended family identified a spontaneous ventilation, and have by the presence of cardiopulmonary cousin who described playing the no neurologic deficits. At the other arrest (as indicated by a requirement choking game with the patient for www.emreports.com Emergency Medicine Reports / Volume 31, Number 17 / August 2, 2010 201 16. Chattopadhyay S, Pal I. Survival following (OWELL -! 'ULY (2 .EAR HANGING the purposes of getting “weird.” accidental ligature strangulation: A case presenting to an accident and emer- Unfortunately, the patient sustained report. J Forensic Leg Med 2008;15:53-5. gency department. J Accid Emerg Med severe anoxic brain injury and died 17. Gowens PA, Davenport RJ, Kerr J, et al. 1996;13:135-6. after care was withdrawn. Survival from accidental strangulation 34. Hawton K, Bergen H, Casey D, et al. from a scarf resulting in laryngeal rupture General hospital presentations of non- and carotid artery stenosis: The “Isadora fatal hanging over a 28-year period: References Duncan syndrome.” A case report Case-control study. Br J Psychiatry 1. Cartwright AJ. Degrees of violence and and review of literature. Emerg Med J 2008;193:503-4. blood spattering associated with manual 2003;20:391-3. and ligature strangulation: A retrospective 35. van de Ven K, Vanclooster P, de Gheldere study. 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Trans Sect Otolaryngol Am Fracture of the cricoid as a potential "LOCK #2 %NGEL " .AURECKAS 3- ET AL Acad Ophthalmol Otolaryngol 1975;80(4 pointer to homicide: A 6-year retrospec- The Chicago women’s health risk study: Pt 1):382-90. tive study of neck structures fractures Lessions in collaboration. Violence Against in hanging victims. Am J Forensic Med 23. Khokhlov VD. Pressure on the neck cal- Women 1999;5:1158-1177. Pathol 2010 Feb 25. [Epub ahead of culated for any point along the ligature. 'LASS . ,AUGHON + #AMPBELL * ET AL print] Forensic Sci Int 2001;123:178-81. .ON FATAL STRANGULATION IS AN IMPORTANT 7AHLEN "- 4HIERBACH !2 .EAR 24. Singh B, Kumar S, Kumar V. Blunt laryn- risk factor for homicide of women. J hanging. Eur J Emerg Med 2002;9:348- gotracheal injury following accidental Emerg Med 2008;35:329-35. 50 strangulation. Injury 2003;34:937-9. 42. Block CR, Devitt CO, Fonda D, et al. 7. Funk M, Schuppel J. Strangulation inju- 25. Kaki A, Crosby ET, Lui AC. 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McClane GE, Strack GB, Hawley D. ,AUGHON + 'LASS . 7ORRELL # 2EVIEW A review of 300 attempted strangula- 27. Clarot F, Vaz E, Papin F, Proust B. Fatal and analysis of laws related to strangula- tion cases Part II: Clinical evaluation and non-fatal bilateral delayed carotid tion in 50 states. Eval Rev 2009;33:358- of the surviving victim. J Emerg Med artery dissection after manual strangula- 69. Epub 2009 Jun 9. tion. Forensic Sci Int 2005;149:143-50 2001;21:311-5. ;.O AUTHORS LISTED= 5NINTENTIONAL STRAN- 11. Plattner T, Bolliger S, Zollinger U. 28. Chokyu I, Tsumoto T, Miyamoto T, et al. gulation deaths from the “choking game” Forensic assessment of survived strangula- Taumatic bilateral common carotid artery among youths aged 6-19 years — United tion. Forensic Sci Int 2005;153:202-7. dissection due to strangulation. A case States, 1995-2007. Centers for Disease report. Interv Neuroradiol 2006;12:149- Control and Prevention (CDC). MMWR 12. Sauvageau A, Boghossian E. Classification 54. 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202 Emergency Medicine Reports / Volume 31, Number 17 / August 2, 2010 www.emreports.com 49. Toblin RL, Paulozzi LJ, Gilchrist J, et al. an extra screening examination? AJNR 35. Which of the following statements is true? Unintentional strangulation deaths from Am J Neuroradiol 2008;29:1902-7. A. Cervical vertebral fractures are rare in the “choking game” among youths aged 66. Yen K, Thali MJ, Aghayev E, et al. survivors of strangulation. 6-19 years — United States, 1995-2007. Strangulation signs: Initial correlation of B. Hyoid bone fractures are common in J Safety Res 2008;39:445-8. MRI, MSCT, and forensic neck findings. victims of manual strangulation. 50. Katz KA, Toblin RL. Language matters: J Magn Reson Imaging 2005;22:501-10. C. Carotid artery injury is seen in about 50% of suicidal hangings. Unintentional strangulation, strangulation 67. Matsuyama T, Okuchi K, Seki T, et al. D. Because of collateral circulation, activity, and the “choking game.” Arch Magnetic resonance images in hanging. strangulation does not produce Pediatr Adolesc Med 2009;163:93-4. Resuscitation 2006;69:343-5. obstruction to venous blood flow in 51. Cowell DD. Autoerotic asphyxiation: 68. Yen K, Vock P, Christe A, et al. Clinical the neck. Secret pleasure — lethal outcome? forensic radiology in strangulation vic- Pediatrics 2009;124:1319-24. tims: Forensic expertise based on mag- 36. All of the following are common features 52. Sabo RA, Hanigan WC, Flessner K, et al. netic resonance imaging (MRI) findings. of strangulation victims upon emergency Strangulation injuries in children. Part 1. Int J Legal Med 2007;121:115-23. department presentation except: Clinical analysis. J Trauma 1996;40:68- 69. Christe A, Thoeny H, Ross S, et al. Life- 72. A. loss of consciousness threatening versus non-life-threatening B. facial petechiae 53. Sauvageau A, Racette S. Autoerotic deaths manual strangulation: Are there appropri- C. trouble swallowing in the literature from 1954 to 2004: A ate criteria for MR imaging of the neck? D. trouble speaking review. J Forensic Sci 2006;51:140-6. Eur Radiol 2009;19:1882-9. 54. Boots RJ, Joyce C, Mullany DV, et al. 70. Di Paolo M, Guidi B, Bruschini L, et al. 37. Strangulation as part of a domestic or .EAR HANGING AS PRESENTING TO HOSPITALS IN Unexpected delayed death after manual intimate partner violence episode is an Queensland: Recommendations for prac- STRANGULATION .EED FOR CAREFUL EXAMINA- independent risk factor for subsequent tice. Anaesth Intensive Care 2006;34:736- tion in the emergency room. Monaldi attempted to completed homicide by the 45. Arch Chest Dis 2009;71:132-4. same assailant. 55. Janata A, Holzer M. Hypothermia 71. Penney DJ, Stewart AH, Parr MJ. A. true after cardiac arrest. Prog Cardiovasc Dis Prognostic outcome indicators fol- B. false 2009;52:168-79. lowing hanging injuries. Resuscitation 2002;54:27-9. 56. Sagalyn E, Band RA, Gaieski DF, et al. 38. Which of the following statements con- Therapeutic hypothermia after cardiac 72. Matsuyama T, Okuchi K, Seki T, et al. cerning the “choking game” is false? arrest in clinical practice: Review and Prognostic factors in hanging injuries. A. It is commonly used in conjunc- compilation of recent experiences. Crit Am J Emerg Med 2004;22:207-10. tion with illicit drugs to increase the Care Med 2009;37(7 Suppl):S223-6. .ICHOLS 3$ -C#ARTHY -# %KEH !0 euphoric high. 57. Borgquist O, Friberg H. Therapeutic et al. Outcome of cervical near-hanging B. The intention is to produce cerebral hypothermia for comatose survivors after injuries. J Trauma 2009;66:174-8. hypoxia but not complete loss of con- near-hanging — a retrospective analysis. sciousness. Resuscitation 2009;80:210-2. C. Severe headache is a common symp- Physician CME Questions tom if the patient is brought to the 58. Jehle D, Meyer M, Gemme S. Beneficial emergency department. response to mild therapeutic hypothermia D. The activity can be done in groups. for comatose survivors of near-hanging. 31. Which of the following is the correct defi- Am J Emerg Med 2010;28:390.e1-3 nition of asphyxia? 39. Which imaging modality has the highest A. obstruction of the upper airway 59. Baldursdottir S, Sigvaldason K, Karason S, sensitivity for detecting soft-tissue injuries resulting in death et al. Induced hypothermia in comatose from strangulation? survivors of asphyxia: A case series of 14 B. loss of consciousness due to stoppage consecutive cases. Acta Anaesthesiol Scand of ventilation A. ultrasound 2010;54:821-6. C. absence of oxygen for a period of time B. fiberoptic laryngoscopy D. loss of consciousness due to inhalation C. computed tomography (CT) 60. Mohanty MK, Rastogi P, Kumar GP, et of a poisonous gas D. magnetic resonance imaging (MRI) al. Periligature injuries in hanging. J Clin Forensic Med 2003;10:255-8. 32. Which of the flowing is not one of the 40. Regarding blunt carotid injury, which of .IELSON !3 +ANG #3 )MAGES IN EMER- four categories of asphyxia? the following statements is false? gency medicine. Chokehold strangulation. A. strangulation A. Doppler ultrasound has a sensitivity Ann Emerg Med 2006;47:327, 343. B. apnea of about 80-90% when compared to 62. Lambe A, Püschel K, Anders S. Extensive C. drowning selective angiography. petechiae in attempted self-strangulation. D. suffocation B. A negative computed tomographic J Forensic Sci 2009;54:212-5.. angiography (CTA) study has about 100% predictive value for excluding 63. Miller PR, Fabian TC, Croce MA, et al. 33. When sufficient force is applied to impede subsequent neurologic events due to Prospective screening for blunt cerebro- respiration, how long will it take for the carotid artery injury. vascular injuries: Analysis of diagnostic typical adult to lose consciousness? C. The CTA is as sensitive as selective modalities and outcomes. Ann Surg A. 10-15 seconds angiography for detecting carotid 2002;236:386-93; discussion 393-5. B. 30 seconds injury. 64. Sliker CW, Shanmuganathan K, Mirvis C. 60 seconds D. Blunt carotid injury is generally SE. Diagnosis of blunt cerebrovascu- D. 5 minutes treated with an anticoagulant, such as lar injuries with 16-MDCT: Accuracy heparin. of whole-body MDCT compared with 34. In strangulation, all of the following con- neck MDCT angiography. AJR Am J tribute to the loss of consciousness except: Roentgenol 2008;190:790-9. A. obstruction of the carotid artery 65. Langner S, Fleck S, Kirsch M, et al. B. obstruction of the internal jugular Whole-body CT trauma imaging with vein CME Answer Key adapted and optimized CT angiography C. vagal nerve stimulation of the craniocervical vessels: Do we need D. sympathetic nerve stimulation 31. C; 32. B; 33. A; 34. D; 35. A; 36. C; 37. A; 38. A; 39. D; 40. C www.emreports.com Emergency Medicine Reports / Volume 31, Number 17 / August 2, 2010 203 Editors Michael L. Coates, MD, MS Southwestern Medical Center and Associate Dean, Graduate Medical Professor and Chair Parkland Hospital Education Sandra M. Schneider, MD Department of Family and Dallas, Texas University of New Mexico School of Professor Community Medicine Medicine Department of Emergency Medicine Wake Forest University School Charles V. Pollack, MA, MD, FACEP Albuquerque, New Mexico University of Rochester School of of Medicine Chairman, Department of Emergency Medicine Winston-Salem, North Carolina Medicine, Pennsylvania Hospital Charles E. Stewart, MD, FACEP Rochester, New York Associate Professor of Emergency Associate Professor of Emergency Alasdair K.T. Conn, MD Medicine Medicine, Director of Research J. Stephan Stapczynski, MD Chief of Emergency Services University of Pennsylvania School of Department of Emergency Medicine Chair Massachusetts General Hospital Medicine University of Oklahoma, Tulsa Emergency Medicine Department Boston, Massachusetts Philadelphia, Pennsylvania Maricopa Medical Center Gregory A. Volturo, MD, FACEP Phoenix, Arizona Charles L. Emerman, MD Robert Powers, MD, MPH Chairman, Department of Emergency Chairman Professor of Medicine and Medicine Department of Emergency Medicine Emergency Professor of Emergency Medicine Editorial Board MetroHealth Medical Center Medicine and Medicine Cleveland Clinic Foundation University of Virginia University of Massachusetts Medical Paul S. Auerbach, MD, MS, FACEP Cleveland, Ohio School of Medicine School Professor of Surgery Charlottesville, Virginia Worcester, Massachusetts Division of Emergency Medicine Kurt Kleinschmidt, MD, FACEP, Department of Surgery FACMT David J. Robinson, MD, MS, FACEP Albert C. 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Strangulation Injuries
Imaging Modalities Useful in Strangulation Injuries
Modality Advantages Disadvantages Readily available in the ED Cervical vertebral fractures rare in Plain radiography (bone technique) Visualization of cervical vertebral strangulation injuries fractures Readily available in the ED Visualization of laryngeal injuries Low sensitivity for detecting these Plain radiography (soft-tissue (subcutaneous emphysema, uncommon secondary signs of deep technique) tracheal deviation from edema and soft-tissue or laryngeal injuries in hemorrhage) survivors Visualization of hyoid bone fractures Routinely available in most U.S. EDs Intravenous contrast needed for Computed tomography (CT) Higher sensitivity for soft-tissue highest sensitivity injuries Routinely available in most U.S. EDs Computed tomographic angiography Visualization of carotid artery injury Need for intravenous contrast (CTA) and thrombosis Highest sensitivity for deep soft-tissue Magnetic resonance imaging (MRI) Less availability in U.S. EDs injury Visualization of intimal injury to Less availability in U.S. EDs carotid arteries and/or intraluminal Lower resolution and presumably less Doppler ultrasound thrombosis sensitive for carotid artery injury and Can be brought to the bedside of intraluminal thrombosis unstable patients Visualization of vocal cords and Not readily available in the emergency Fiberoptic laryngoscopy adjacent structures department
Imaging Recommendations for Strangulation Victims in the Emergency Department
Clinical Scenario Recommended Imaging Modality Alternative Imaging Modality Manual strangulation with no loss of consciousness and no physical None None evidence of force to the neck Manual strangulation with no loss of MRI with contrast Fiberoptic laryngoscopy consciousness but with voice changes Manual strangulation with loss of consciousness and/or physical MRI without contrast CT with intravenous contrast evidence of force to the neck Incomplete near-hanging with intact consciousness and bilateral MRI without contrast CT with intravenous contrast neurologic function Accidental strangulation with ligature caught in moving machinery but with MRI without contrast CT with intravenous contrast intact consciousness and bilateral neurologic function Any form of strangulation with 4-vessel cranial-cervical CT MRI without contrast persistent unconsciousness angiogram Any form of strangulation with intact Doppler ultrasound of the carotid 4-vessel cranial-cervical CT consciousness but with unilateral arteries or 4-vessel selective angiogram neurologic fi ndings angiography
Classification Suicidal Incomplete of Asphyxiation Hanging
Suffocation • Smothering • Choking • Confi ned space entrapment
Strangulation • Manual • Ligature • Hanging
Mechanical • Positional • Compressive or traumatic
Drowning Linear ecchymoses across the • Death due to immersion in neck liquid
Suicidal Incomplete Hanging
CT scan shows signifi cant pharyngeal edema, most marked in the palatine fossa. Structured Assessment and Documentation for Strangulation Victims
Method or Manner • Hands (manual strangulation) • Elbow and forearm (sleeper or “choke hold”) • Knee • Ligature • Other
Number of Episodes • Single • Multiple • Repeated with different methods
Other Circumstances • Was the victim also smothered? • Was the victim also shaken? • Was the victim knocked or pounded into a wall or the ground? • Was the victim also hit or physically assaulted? • Was the victim also sexually assaulted?
Symptoms • Did the victim lose consciousness? • Neck pain • Neck swelling • Diffi culty breathing • Voice changes: hoarse, raspy, unable to speak • Sore throat • Diffi culty swallowing • Pain with swallowing • Headache • Other symptoms: urinary and/or fecal incontinence
Signs • Redness or ecchymoses on the neck • Neck swelling • Neck tenderness • Laryngeal and subcutaneous crepitus • Facial or conjunctival petechiae • Ptosis, facial droop, unilateral weakness
Supplement to Emergency Medicine Reports, August 2, 2010: “Strangulation Injuries.” Author: J. Stephan Stapczynski, MD, FACEP, Chair, Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ. Emergency Medicine Reports’ “Rapid Access Guidelines.” Copyright © 2010 AHC Media LLC, Atlanta, GA. Editors: Sandra M. Schneider, MD, FACEP, and J. Stephan Stapczynski, MD. Executive Editor: Russ Underwood. Specialty Editor: Shelly Morrow Mark. For customer service, call: 1-800-688- 2421. This is an educational publication designed to present scientific information and opinion to health care professionals. It does not provide advice regarding medical diagnosis or treatment for any individual case. Not intended for use by the layman.