WISCONSIN MEDICAL JOURNAL Strangulation Injuries Maureen Funk, BS; Julie Schuppel, RN ABSTRACT daughter again.” She started crying, and he stopped Strangulation accounts for 10% of all violent deaths in strangling her. He left the house. She then started the United States. Many people who are strangled sur- walking towards the local women’s shelter. She en- vive. These survivors may have minimal visible external countered a police officer on patrol, and she reported findings. Because of the slowly compressive nature of the incident. She was brought immediately to the the forces involved in strangulation, clinicians should emergency department (ED). On assessment in the be aware of the potential for significant complications ED, she had numerous abrasions and contusions to including laryngeal fractures, upper airway edema, and her extremities and face. She had a 3 cm laceration/ vocal cord immobility. Survivors are most often as- human bite wound to the posterior area of her right saulted during an incident of intimate partner violence ear. When asked what she thought would happen or sexual assault, and need to be specifically asked if when she was being strangled, the patient stated, “I they were strangled. Many survivors of strangulation thought I would die.” will not volunteer this information. Accurate docu- On initial physical exam, her vital signs were BP mentation in the medical chart is essential to substanti- 141/54, pulse – 110, respirations –22, pulse oximetry – ate a survivor’s account of the incident. Medical pro- 99% on room air, fetal heart tones – 147. Tetanus status viders are a significant community resource with the was up to date. responsibility to provide expert information to patients Injuries that may have been strangulation related in- and other systems working with survivors of strangula- cluded right eye reddened, eyelid drooping with sub- tion. This case study reviews a strangulation victim conjunctival hemorrhage, petechaie right frontal re- who exhibited some classic findings. gion, 2 cm abrasion to right posterior neck region, ecchymosis to left clavicle region, 5 cm abrasion to left STRANGULATION CASE PRESENTATION lateral neck region. Her voice was slightly raspy. A 24-year-old woman presented to the emergency de- Her subjective symptoms pertaining to strangula- partment after being physically assaulted by her inti- tion included pain in the posterior neck region, com- mate partner 1 hour prior to arrival. The patient was 7 plaints of swelling in throat region, difficulty breathing months pregnant. He grabbed her and threw her to the and swallowing, feeling lightheaded, loss of conscious- ground. She reported being strangled, with both hands ness, sore throat, and headache. around her neck. Her face was buried/smothered into In the ED, x-rays were taken of her facial bones and the carpet. He also gouged her eyes with his fingers. left knee, which were negative for fracture. Her right She started screaming, and he put his hands over her ear was irrigated and sutured. She was placed on aug- mouth and strangled her again. The patient lost con- mentin prophylactically for her human bite wound. All sciousness. He stated, “Don’t think I won’t kill you.” injuries were documented on the “Physical Trauma He also punched her in the head with his fists. He bit Body Map.” The Strangulation Check List (Figure 1) her right ear, and stated “I won’t let go.” He then was completed. Photographs were taken of all injuries, strangled the patient for a third time and stated, including hand placement of perpetrator during stran- “You’re lucky I don’t kill you, you’ll never see your gulation. The ED social worker provided emotional support for the patient and did safety assessment. The patient was reassessed and observed for further compli- Ms Funk, a social worker, is coordinator of the Gundersen Lutheran cations from the strangulation attempts. She was dis- Medical Center Domestic Abuse/Sexual Assault Program, La Crosse, Wis. Ms Schuppel is a program coordinator for SANE, charged after a 2.5-hour emergency department stay. Gundersen Lutheran Medical Center, La Crosse, Wis. An ophthalmology appointment was arranged. A refer- Wisconsin Medical Journal 2003 • Volume 102, No. 3 41 WISCONSIN MEDICAL JOURNAL ral to the hospital-based domestic abuse/sexual assault appropriate workup, unless there are visible injuries to program was also made and follow-up was provided. the neck.1 She was taken to the Labor and Delivery department “Strangle” means to obstruct seriously or fatally the for fetal monitoring and was discharged after a 4-hour normal breathing of a person. “Choke” means having stay. the trachea blocked entirely or partly by some foreign object like food.2 When assessing a patient who may INTRODUCTION have been strangled, it is acceptable to ask whether they Services for patients experiencing domestic violence or were strangled or choked. When documenting, always sexual assault have expanded dramatically in the hospi- use the term “strangled.” tal setting. Medical providers have learned to routinely There are 4 types of strangulation: screen, document and refer patients who experience in- • Hanging timate partner violence. Many communities in Wiscon- • Manual (also called throttling)–The use of bare sin now offer collection of forensic evidence by Sexual hands Assault Nurse Examiners. This increase in care and knowledge about the needs of patients presenting with • Chokehold (also called sleeper hold)—Elbow bend these issues also increases the medical system’s respon- compression sibility in collaborating with other agencies. • Ligature (also known as garroting)—Use of a cord- Strangulation is an injury experienced in sexual as- like object, clothing, rope, or belt sault and intimate partner violence. It is imperative that When being strangled, the victim will first experience patients who experience this type of violence access severe pain, followed by loss of consciousness, then brain medical care as soon as possible. It is important for all death. The victim will lose consciousness by any one or service providers in a community to be trained about all of the following: pressure obstruction of the carotid the potential injuries and risks associated with strangu- arteries preventing blood flow to the brain, pressure on lation. Often victims do not present to an emergency the jugular veins preventing venous blood return from department identifying that they have been strangled in the brain, or pressure obstruction of the larynx, which an assault. They may present to various community re- cuts off air flow to the lungs, producing asphyxia.2,3 Only sources with a variety of physical complaints, none of 11 pounds of pressure placed on both carotid arteries for which may appear to be serious. Advocates, local 10 seconds is necessary to cause loss of consciousness. women’s shelter staff, law enforcement, district attor- However, if pressure is released immediately, conscious- neys, EMS personnel, human services, and particularly ness will be regained within 10 seconds. To completely ED and urgent care staff should be educated about close off the trachea, 33 pounds of pressure is required. If strangulation. strangulation persists, brain death will occur in 4 to 5 Service providers must ask a victim if they have been minutes.2 strangled during the assault. When patients present to an ED or urgent care with injuries from intimate part- ner violence or a sexual assault, they must be screened CLINICAL PRESENTATION for strangulation. Many patients do not remember Because of the slowly compressive nature of the forces being strangled, or will not offer that information, un- involved in strangulation, victims may present with de- less they are specifically asked. If law enforcement or ceivingly harmless signs and symptoms. There may be an advocate is the first community provider contacted no or minimal external symptoms of soft tissue injury. by the victim, they also need to screen for strangula- The upper airway also may appear normal beneath in- tion. If victims identify that they have been strangled, tact mucosa, despite hyoid bone or laryngeal fractures. they should be instructed to seek medical attention in Up to 36 hours after the strangulation attempt, the pa- the ED as soon as possible. tient can develop edema of the supraglottic and oropha- ryngeal soft tissue, leading to airway obstruction. BACKGROUND Delayed edema, hematoma, vocal cord immobility, Patients that seek medical care after a strangulation and displaced laryngeal fractures all may contribute to episode are often not thoroughly evaluated. This may an unstable airway following strangulation.4 If the vic- occur if the victim is intoxicated or hysterical. Their de- tim survives the initial assault and the injuries go unrec- scription of the strangulation attempt is often viewed as ognized and untreated, delayed life-threatening airway an exaggerated claim and not addressed with a clinically obstruction or long term vocal dysfunction may result.5 42 Wisconsin Medical Journal 2003 • Volume 102, No. 3 WISCONSIN MEDICAL JOURNAL Signs and Symptoms the natural folds of the neck. They may also be more The specific injury will depend on the method of stran- apparent, reflecting the type of ligature used. gulation, the force and duration of the strangulation Ligature marks are a clue that the hyoid bone may episode. be fractured. • Voice Changes—May occur in up to 50% of victims, • Petechiae—May be found under the eyelids, perior- may be as minimal as simple hoarseness (dysphonia) bital region, face, scalp, and on the neck. Petechiae or as severe as complete loss of voice (aphonia). may occur at and above the area of constriction. • Swallowing Changes—Due to injury of the larynx • Subconjunctival Hemorrhage—This may occur when and/or hyoid bone. Swallowing may be difficult but there is a particularly vigorous struggle between the not painful (dysphagia) or painful (odynophagia). victim and assailant.2 • Breathing Changes—May be due to hyperventila- • Neurological Findings—These may include ptosis, tion or may be secondary to underlying neck and facial droop, unilateral weakness, paralysis or loss of airway injury.