changes: Difficulty breathing (dyspnea), hyperventilation, inability to breathe (apnea)
—Evidence of hypoxia/anoxia and near-unconsciousness: Changes in vision (eg, tunnel vision, blurred, “curtain closing in,” spots, flashes of light), changes in hearing (eg, hearing loss, ringing), loss of control over body (eg, weakness, limpness)
—Evidence of anoxia and unconsciousness: Loss of memory, unexplained injuries, brain damage, involuntary urination or defecation
Figure 5. Terminology for indicators of direction when documenting findings.
—Mental status changes: Restlessness/combativeness, seizure activity, frank psychosis/amnesia
—Swallowing changes (larynx/hyoid bone injury): Difficult, but not painful, swallowing (dysphagia); painful swallowing (odynophagia); drooling
—Symptomatic voice changes: Hoarse or raspy voice (dysphonia), complete loss of voice (aphonia)
LETHALITY OF STRANGULATION
Lethality refers to capacity to cause death. Therefore, lethality of strangulation refers to one’s chances of dying as a result of strangulation.29
LETHALITY AS A RESULT OF EXTERNAL PRESSURE
—Anoxia: In cases of strangulation, the absence of oxygen depriving the brain of oxygenated blood. Characterized by tachycardia, hypertension, dizziness, mental confusion, and unconsciousness.
—Neck swelling: May present as soft tissue trauma/inflammation, internal bleeding (carotid dissection), laryngeal injury (subcutaneous emphysema). May progress slowly.
—Pneumonitis: Inflammation of the lung, resulting from inhaled emesis where the gastric juices begin to digest lung tissue.
—Post-anoxic encephalopathy: Decrease in blood flow to the brain by which some brain cells die immediately while others survive for days. Surviving brain cells eventually succumb to the cerebral anoxia. Surviving patients may incur lifelong brain damage and neurologic deficits. May be fatal: “brain death,” persistent vegetative coma, cerebral edema (ie, brain swelling), and herniation of the brain. The hippocampus (part of the limbic system) is the most sensitive part of the brain to anoxia and is the first area to experience damage with anoxia.
—Pulmonary edema: Accumulation of extravascular fluid in lung tissues and alveoli. Caused by excessive negative respiratory pressures resulting from victim’s attempts to breathe while external neck pressure impedes the airway.
LETHALITY OF INTERPERSONAL VIOLENCE WITH NONFATAL STRANGULATION: RISK FOR HOMICIDE*
—Nonfatal strangulation has been reported in 45% of attempted homicides.
—Nonfatal strangulation has been reported in 43% of completed homicides.
—With nonfatal strangulation, odds of attempted homicide increase sixfold.
—With nonfatal strangulation, odds of completed homicide increase sevenfold.
TESTS AND TREATMENT
—CT of the neck: Sensitive for bony, cartilaginous, and soft tissue injuries. Also identifies edema, hemorrhage, and subcutaneous emphysema. However, CT without angiography does not evaluate the carotid or vertebral arteries for vascular damage.
—CTA of the neck: Very sensitive test for the detection of vascular injuries in the carotid and vertebral arteries. CTA is also sensitive for the detection of bony and cartilaginous injuries. The CTA is the gold standard for the emergent radiologic evaluation of nonfatal or near-fatal strangulation patients (Appendix 7).
—Discharge planning: Considered safe if patient experienced no loss of consciousness, presents with no or minimal soft tissue neck injury, and no objective/subjective neurologic findings. Encourage the patient to stay with someone, or have someone stay with them, for the 24 hours after discharge to help monitor for any increase in symptoms. Patients with significant trauma can be safely discharged if the CTA is negative for injury or dissection.
—Fiberoptic laryngoscopy: Visually evaluates the soft tissues of the oropharynx; however, this approach does not offer evaluation of deep soft tissue injuries.
—MRI and MRA: MRI and MRA are used to produce 2- or 3-dimensional images of the structures inside your body, including your blood vessels. Both an MRI and MRA are noninvasive and painless diagnostic tools used to view tissues, bones, or organs inside the body. An MRI creates detailed images of organs and tissues. An MRA focuses more on the blood vessels than the tissue surrounding it. Usually, the MRA is done in conjunction with the MRI. MRAs evolved from MRIs to give doctors the ability to look at blood vessels more thoroughly.
—Plain radiographs: Images that identify bone and laryngotracheal injuries. Plain radiographs are not recommended for emergent evaluation of the vasculature in nonfatal strangulation (Appendix 7).
REFERENCES
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2.Ditton M, Gray L. The ABC’s - Anatomy, “Bunk” and the Courtroom of Sexual Assault. Fort Wayne, IN: Socratic Parenting, LLC; 2015.
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4.Herman Kabat. Acute arrest of cerebral circulation in man. Arch Neurol. 1943;50(5):510-528.
5.Matusz EC, Schaffer JT, Bachmeier BA, et al. Evaluation of nonfatal strangulation in alert adults. Ann Emerg Med. 2019;S0196-0644(19)30594-3.
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7.Stark P. Principles of computed tomography of the chest. UpToDate Web site. http://www.uptodate.com/contents/principles-of-computed-tomography-of-the-chest?source=preview&search=CAT+Scan&language=en-US&anchor=H1&selectedTitle=1~150#H1. Updated April 22, 2019. Accessed December 4, 2019.
8.Raby BA. Basic principles of genetic disease. UpToDate Web site. http://www.uptodate.com/contents/basic-principles-of-genetic-disease?-source=machineLearning&search=DNA&selectedTitle=1~150§ion-Rank=1&anchor=H5203404#H5203404. Updated May 31, 2019. Accessed December 4, 2019.
