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STRANGULATION
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YWCA - Oklahoma City Created by LaRae Huycke, RN, MS, APRN-BC, DNP & Shannon Liew, RN, BSN, SANE-A
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Strangulation and Domestic Violence Strangulation is a lethality risk factor – ultimate form of power and control short of homicide 68% of women in abusive relationships report strangulation by partner as a component of DV – Average length of abuse prior to strangulation is 3.1 years – Children witness strangulation in 41% of cases
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10% of violent deaths per year in U.S. due to strangulation
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Strangulation Strangulation versus choking: Strangulation – lack of oxygen due to external pressure on the neck Choking – lack of oxygen due to airway blockage by a foreign object
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Implies pressure to the neck and as such has great forensic importance
It is a squeezing of the neck that is independent of the gravitational weight or suspension of the head; it may be circumferential or placed specifically Categories: manual strangulation – use of the hands or arms to apply pressure to neck ligature strangulation – use of a ligature to apply pressure to neck postural strangulation – neck placed over an object and the weight of the body applies pressure to the neck
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What does it take? On average: Ten pounds of pressure to the carotids for ten seconds causes loss of consciousness Once this pressure is released it takes ten seconds to regain consciousness Four pounds of pressure to the jugular veins for 30-60 seconds causes loss of consciousness Thirty-three pounds of pressure obstructs the trachea, in an adult, causing death in 4-5 minutes
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Asphyxia A condition in which an extreme decrease in the concentration of oxygen in the body accompanied by an increase in the concentration of carbon dioxide leads to loss of consciousness or death
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Asphyxia can be induced by choking, strangulation, drowning, electric shock, injury, or the inhalation of toxic gases Absence of oxygen to tissues
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Does not occur equally throughout the body, not even equally in the brain
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Etiology of Asphyxia Mechanical constriction of the jugular veins by squeezing the soft tissues of the neck This is the most common type of strangulation asphyxia Consists of: compression of the jugular veins very little pressure required < 4.5 lbs of pressure leads to reduced outflow of blood as the veins are occluded cerebral vessels quickly engorge blocking further blood inflow oxygen flow to the brain is halted and cerebral CO2 increases loss of consciousness occurs in 30–60 seconds if jugulars are blocked
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Etiology of Asphyxia Mechanical constriction of the carotid arteries by squeezing the soft tissues of the neck Consists of: compression of the carotid arteries more pressure required than with jugulars ~ 10 lbs of pressure leads to reduced blood flow to the brain cerebral tissues quickly expend all available oxygen cerebral CO2 increases dramatically causing vascular spasms spasms block even small amounts of blood inflow loss of consciousness occurs in 10 seconds after release of constriction…10 seconds to regain wakefulness
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Etiology of Asphyxia Airway obstruction due to external pressure applied to neck Consists of: pressure is applied to the neck C-clamp / both hands around neck / across front of neck with forearm from front with patient supine; or with patient standing and attacker from behind the hyoid bone and tongue are pushed upward and backward blocking the laryngo-pharynx painful and panic inducing tremendous air hunger victim may have multiple injuries from struggle
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Cardiac Arrest In rare cases, strangulation may cause immediate cardiac dysrhythmia and/or cardiac arrest
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Due to pressure applied to nerves in carotid arteries Force applied to specific, localized anatomic area in neck
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___________________________________ Immediate Signs and Symptoms Difficulty breathing, especially when talking, or walking/airway compromise “Sniffing position” - a posture where they stand and lean forward to maintain optimal airway
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Loss of consciousness/memory loss Change in their voice quality, tone, or volume (hoarseness) An inability to sing, even if they can speak Neck pain/swelling/sore throat
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Difficulty swallowing/feeling of a lump in their throat Dizziness
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Shaking
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Immediate Signs and Symptoms Headache Vision changes Ringing in ears Nose bleed Vomiting Loss of bowel/bladder function Miscarriage Neurological sxs: One-sided weakness, facial droop, paralysis
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Mental Status Changes Hypoxia / Asphyxia can lead to temporary or permanent mental status changes Often noted as a change in personality by family or the patient
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Typically increased irritability, combative, hostile, anxious, panic, restless
Psychosis can occur if oxygen deprivation is severe, includes: Hallucinations - auditory, visual, olfactory, tactile Delusions - paranoid, persecution Take comments seriously!
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Psychiatric Effects Psychosis
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Amnesia Depression
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Anxiety PTSD
Suicidal ideation
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Cognitive Stages Disbelief - “I can’t belief he is doing this!” Realization - “Yes, this IS happening!” pain and fear
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Survival - “I’ve got to make him stop!” terrible struggle to preserve airway and life Resignation - “This is how I will die.” “Who will take care of my children?”
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This stages evolve quickly as hypoxia worsens and CO 2 increases Important to document mental and emotional status of patient and their perceptions of what happened
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Long Term Health Risks At risk for developing serious health problems and/or fatal outcomes up to two weeks post strangulation: CVA/stroke – inflammatory process due to damaged blood vessels Aspiration pneumonia Pulmonary edema Progressive degeneration of brain function Progressive dementia
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Strangulation Injury 50% of strangulation victims have NO visible injury to the neck No external evidence of injury may be present on fatal strangulation victims – autopsy needed If injury present, most common site on head, neck and face Consists of: Bruising Ligature marks Petechiae to eyes, scalp, skin and ears Defensive injuries – fingernail marks from victim trying to escape
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Strangulation: Manual
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Strangulation fatality; note the extensive bruising, swelling, and petechiae
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A stab wound over the right clavicle is also noted, but was not the cause of death
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Strangulation: Manual Note scratches as patient tried to remove attacker’s hands
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This women did not survive
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___________________________________ Strangulation: Manual
___________________________________ Manual strangulation fatality; note extensive bruising when the C-Clamp technique was used; bleeding noted at the back of the neck represents dependent areas
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___________________________________ Strangulation: Ligature
___________________________________ Here the injury, along with the cord that was used, are shown; note the teardrop shape of the ligature mark around the neck
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___________________________________ Strangulation
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Petechiae Small pinpoint areas of bleeding caused when small capillaries rupture and bleed into the surrounding tissues
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These area are not raised; they rest flat against the skin Petechiae do not blanche The configuration will follow vessels - if you see petechiae on the face or neck track the vessel into the scalp
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They may also be present in and around the eyes, ears, and hairline Petechiae are located above (superior) to the constriction
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___________________________________ Petechiae Petechiae around eye and lid
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Strangulation: Other findings
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Note petechiae in the lower lid and on sclera
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Hard Palate Petechiae may also be seen on the hard palate. Remember what petechiae look like: small pinpoint highly red / blue spots
Caution this is NOT petechiae…this is a burn injury from smoking crack; it is painful to touch
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___________________________________ Areas of Bleeding
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Swelling, Bruising, Abrasion
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Note bruising has tracked along the fascial planes of the neck
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Areas of Bleeding
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As First Responders Victims often seen as unstable, drunk, drugged, hysterical and/or hyperventilating and may not receive the appropriate medical care and evaluation
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ALL STRANGULATION VICTIMS NEED IMMEDIATE MEDICAL ATTENTION
The Journal of Emergency Medicine recommends hospital admission for evaluation and observation for worsening signs and symptoms
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Refer to healthcare provider if strangulation within two weeks
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Total Picture… This child nearly died when he wrapped the cord of a blind around his neck
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He has the classic ligature mark around the neck Swelling of the neck is present Marks where he scratched at the cord are present at the front of his neck
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Note the petechiae ABOVE the ligature especially around the eyes and mouth His name is Gavin and his parents shared this picture
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Aftermath…
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References Hawley, D.A., McClane, G.E., & Strack, G.B. (2001). A review of 300 attempted strangulation cases Part III: Injuries in fatal cases. The Journal of Emergency Medicine, 21(3), 317-322. McClane, G.E., Strack, G.B., & Hawley, D. (2001). A review of 300 attempted strangulation cases Part II: Clinical evaluation of the surviving victim. The Journal of Emergency Medicine, 21(3), 311-315. Smith, Jr., D.J., Milles, T., & Taliaferro, E.H. (2001). Frequency and relationship of reported symptomology in victims of intimate partner violence: The effect of multiple strangulation attacks. The Journal of Emergency Medicine, 21(3), 323-329. Strack, G.B., McClane, G.E., & Hawley, D. (2001). A review of 300 attempted strangulation cases Part I: Criminal legal issues. The Journal of Emergency Medicine, 21(3), 303-309. Wilbur, L., Higley, M., Hatfield, J., Surprenant, Z., Taliaferro, E., Smith, Jr., D.J., & Paolo, A. (2001). Survey results of women who have been strangled while in an abusive relationship. The Journal of Emergency Medicine, 21(3), 297302.
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