ENT
Strangulation Injury
search
Strangulation Injury
, Strangulation, Asphyxia by Strangulation, Suffocation by Strangulation
See Also
Blunt Neck Trauma
Neck Vascular Injury in Blunt Force Trauma
Near-Hanging
Definitions
Strangulation
External neck compression affecting underlying large vessel perfusion or tracheal airflow
Suffocation or Asphyxiation
Impeded respiration with tissue
Hypoxia
In addition to Strangulation, other causes include
Drowning
, obstruction of mouth and nose
Choking
Internal tracheal obstruction
Epidemiology
Strangulation contributes to 10% of violent deaths
Nonfatal Strangulation is a common presentation in
Intimate Partner Violence
and
Sexual Assault
Reported by 7 to 22% of
Sexual Assault
victims
Nonfatal Strangulation is reported by women in 24 to 68% of
Intimate Partner Violence
cases
High risk for future homicide by the assailant (RR 7.5)
Voluntary Strangulation causes (high risk activities)
Choking
Game
Self-Strangulation or that by a partner to achieve brief euphoria
(2008) MMWR Morb Mortal Wkly Rep 57(6):141-4
Autoerotic asphyxia
Used to enhance sexual stimulation
Pathophysiology
Suffocation or Asphyxiation resulting from neck compression
Vascular
Occlusion
Jugular Vein
s are first to obstruct even with superficial compression (2 kg force)
Results in vascular engorgement and
Petechiae
Carotid arteries obstruct with anterior neck compression (3.5 kg force)
Loss of consciousness occurs within 5-15 seconds due to rapid drop in brain perfusion
Carotid Artery
intima injury may lead to thrombosis and
Cerebral Infarction
Carotid Artery Dissection
(with direct compression, neck hyperextension, violent movement)
Airway obstruction (e.g. trachea)
Trachea obstruction (10 kg of force)
Obstruction due to Compression from
Hemorrhage
and edema mass effect
Thyroid
cartilage or
Hyoid Bone
Trauma
Carotid Sinus baroreceptor stimulation
Prolonged stimulation may cause severe
Bradycardia
degenerating into
Cardiac Arrest
Injury may be compounded by other
Trauma
tic injuries
Violent head or neck movements
Recurrent neck injury (cummulative effects of repeated neck
Trauma
)
Types
Strangulation
Manual Strangulation (Throttling, 83% of Strangulation cases)
Direct neck pressure by assailant's hands or feet, elbows or knees
Ligature Strangulation
Tightening of rope, cord, wire, clothing, or jewelry to constrict the neck
Avoid cutting knots if possible when removing (to preserve evidence)
Common accidental asphyxia cause in young children due to entanglement
Postural Strangulation
Weight is applied to a victims neck, preventing respiration
Hanging
Combines ligature Strangulation and postural Strangulation (patient's own body weight)
Precautions
Strangulation delayed presentation even up to 4 days after injury may require emergent airway management
Altered Mental Status
is a red flag for anoxic brain injury related to Strangulation
Exercise
caution in attributing
Altered Mental Status
to
Intoxication
Exam findings of Strangulation may be subtle
No visible external neck injuries in up to 50% of nonfatal Strangulation (and 20% of fatal Strangulation)
Careful documentation is important (and may avert need for physician
Testim
ony)
Careful history in patient's own words
Method of Strangulation and details of the attack
Body maps and images of injuries
Assign appropriate serious associated diagnosis (e.g. Strangulation,
Trauma
tic asphyxia)
Symptoms
Severe pain from neck compression
Loss of consciousness may occur even within 5-15 seconds of severe neck compression
Other symptoms
Dizziness
Headache
Tinnitus
Neck Pain
Shortness of Breath
Loss of bowel or blader function with episode
Psychiatric
Anxiety
Depressed mood with
Suicidality
Insomnia
or
Nightmare
s
Signs
See
Intimate Partner Violence
Face
Facial
Petechiae
Eyes
Subconjunctival Hemorrhage
or
Sclera
l
Hemorrhage
Conjunctiva
l
Petechiae
Ears
Hemotympanum
Blood in ear canal
Post-auricular
Bruising
Mouth
Tongue
swelling
Buccal mucosa
Petechiae
Peri-oral
Bruising
Drooling
Neck
Dysphonia
(50% of manual Strangulation cases)
Dysphagia
Subcutaneous
Emphysema
Skin findings (Ligature mark,
Bruising
,
Petechiae
, scratches)
Thyroid Storm
(has been reported with Strangulation Injury)
Airway and respiratory tract
Pharyngeal, supraglottic or laryngeal edema (presentation may be delayed >36 hours)
Pulmonary Edema
(may be delayed onset up to 48 hours)
Pneumothorax
Neurologic
Loss of consciousness
Seizure
s
Encephalopathy
Carotid Artery Dissection
Evaluate for CVA Symptoms or Signs (
Ptosis
, facial palsy,
Anisocoria
, extremity weakness)
Skin Findings
Scratches
Found on chest, neck, face (often related to attempts to break free)
Bruise
s
Found post-auricular (sternocleidomastoid
Muscle
), mouth, neck, chest
Ligature mark may also be present on neck
Petechiae
Found on
Conjunctiva
, scalp, face,
Buccal mucosa
Pregnancy
Fetal Hypoxia
Imaging
Soft-Tissue Neck XRay Findings (if CTA Neck not performed)
Subcutaneous air
Tracheal deviation
Hyoid
Fracture
Chest XRay
Findings
Pulmonary Edema
Aspiration Pneumonia
CT Angiogram Neck (CTA neck) Indications (for
Carotid Artery Dissection
,
Laryngeal Fracture
,
Cervical Spine Fracture
,
Hemorrhage
)
Visible neck
Trauma
related to attack
Dyspnea
Dysphonia
Neurologic changes with the attack
Loss of consciousness
GCS <15
Incontinence
Vision
changes
References
Matusz (2020) Ann Emerg Med 75(3): 329-38 [PubMed]
Zuberi (2019) Emerg Radiol 26(5): 485-92 [PubMed]
MRA Neck
Consider as alternative to CTA Neck (e.g. pregnancy)
Less
Test Sensitivity
than CT angiogram for vascular injury, but more sensitive for
Soft Tissue Injury
MRI/MRA Brain and Neck
Anoxic brain injury
Stroke Symptoms
Management
ABC Management
See Blunt Neck Injury
See
Neck Vascular Injury in Blunt Force Trauma
Consultation
Consult Forensic Nurse Examiner
Documents history and exam and assists with disposition planning
Consult
Domestic Violence
advocate
Consult resources related to children who witnessed or may have been injured in the attack
Disposition: Observation Indications (for 12 to 24 hours)
Loss of consciousness
Visible signs of
Trauma
(e.g.
Petechiae
)
Intoxication
Unreliable for outpatient monitoring
Disposition: Home
Specific symptom and sign precautions for return (delayed, Strangulation-related red flags)
Discharge to environment safe from perpetrator
References
Riviello and Rozzi (2020) Crit Dec Emerg Med 34(12): 17-23
Stapczynski (2010) Emergency Med Rep 31(17): 193-204
Type your search phrase here