Strangulation: Care of the Victim 3/3

I’m concluding my series on strangulation today. You can find Part I and Part II by clicking the links.

Victims of strangulation/hanging require emergent evaluation due to the structures in the neck that could have obtained injury (trachia, hyoid bone, vocal cords, blood vessels, and brain from lack of blood flow).

image by thetombstonesnake courtesy of Flickr via
If the victim was hanged, it is important to know the height from which they dropped. If if was equal to or greater than their height, there is a high probability of C-spine injury. Therefore, these patients need to be placed in a C-collar until such injury is ruled out.

Remember, there may few external signs of injury. This doesn’t rule out significant damage. However, there may be signs of bruising around the neck and petechia above the point of the ligature. There may also be bleeding in the eye, changes to the voice. Symptoms may range from general soreness to difficulty breathing.

Other signs and symptoms include:

1. Difficulty swallowing.
2. Mental Status Changes: may indicate a period where the brain has gone without oxygen.
3. Miscarriage
4. Swelling of the neck
5. Lung Injury: if the patient vomited during strangulation.
6. Chin Abrasions: from the victim trying to protect their neck.
7. Defensive wounds to the neck from the victim tryng to break free.

How do we care for this patient? History of the event will be paramount in helping the physician determine what tests to run. Hopefully the patient will be able to supply pertinant information.

1. Baseline vital signs including continuous monitoring of the patient’s oxygen level.

2. Assessment of neurological (did the patient lose consciousness, are they neurologically intact?), respiratory (are they having difficulty breathing) and cardiovascular systems.

3. If the patient was hanged– they will need X-rays of the spine to rule out fracture as well as soft tissue films of that area. If they were strangled, soft tissue films of the neck are still warranted.

4. Direct Laryngoscopy: Visualizing the vocal cords to look for damage.

5. CT of the brain: if the patient was unconcious at any point.

6. CT/MRI scan of the neck: to look for soft tissue/vascular injury.

7. Chest x-ray: aid in diagnosis of aspiration.

8. Carotid Doppler: Looking at the neck vessels with ultrasound to look for injury and clots as a result of the attack.

This patient, depending on their severity of injury, could be observed in the emergency department for several hours and sent home or intubated out of concern for further airway compromise and admitted into the ICU. There is a lot of lattitude for the writer here.


General Overview:

Wisconsin Medical Journal: Strangulation Injuries

Emergency Medicine Reports: Strangulation Injuries.

How to Improve Your Investigation and Prosecution of Strangulation Cases.

Strangulation: Facts 2/3

I’m continuing my series on strangulation injuries. Here is Part I.

I once worked with a physician who was having a baby. Her father handmade her a crib. Sadly, his grandchild was strangled in that crib.

Vintage crib where slats are too wide.

I often think about that family– how he must feel to have constructed the tool of this infant’s demise. How was the relationship of that woman with her father after that? Definitely enough conflict in just that scenario to carry a novel.

While researching this series of posts on strangulation for a reader, I came upon a lot of interesting facts I didn’t know myself. This is one reason why I’m such a research hound– I love learning these things to add extra detail for the reader.

There are four types of strangulation:

1. Hanging
2. Manual: The use of bare hands.
3. Chokehold: Elbow bend compression
4. Ligature

Strangulation injury is not as uncommon as I thought– it accounts for 10% of all violent deaths in the US. Perhaps because the hands are such a ready weapon– the criminal doesn’t have to think about bringing them to the crime scene.

Infants are likely to be strangled by falling between something (like slats in a crib that are too wide), or entangling themselves in something (like cords that dangle down from blinds).

Teens and pre-teens can suffer strangulation injury by playing the “choking” game or engaging in autoerotic hanging. These are not so uncommon activities in the pediatric population and we should discuss their danger with our children.

Women are increasingly using hanging as a means of suicide whereas in the past it was more common among men.

Prisoners will often kill themselves by hanging as it is the means of suicide that is most available to them.

When treating the victim of a hanging– it is important to know the height they dropped from. A height equal to or greater than their height brings forth large concerns for C-spine injury. When a prisoner is hanged, they essentially die from decapitation. The C-spine is fractured between C1-C2 and thus severs the spinal cord(also called a Hangman’s Fracture) so the head will free float. If done right, death is instantaneous.

When a person is strangled, there may be no signs of injury to the neck or very minimal signs. There may be only a single bruise present which is caused by the imprint of the thumb.


General Overview:

Wisconsin Medical Journal: Strangulation Injuries

Emergency Medicine Reports: Strangulation Injuries.

How to Improve Your Investigation and Prosecution of Strangulation Cases.

Strangulation: What Really Kills the Victim 1/3

I got a message from a new blog reader with this comment:

Finding this blog is so timely for me, as my protagonist witnesses a strangulation in the first scene of my WIP, and I haven’t been able to find out the precise observable symptoms.  I wanted to ask if you’d done a posting on strangulation.  I’ve looked back a bit in the blog archives, but haven’t seen that topic yet.

Well, let’s just fix that for Colleen.

I’m sure many of you, particularly if you’re an avid crime show TV watcher, have seen the scene with the medical examiner and the victim splayed open on the table talking about damage to the “hyoid” bone. Though this is true, damage to this bone or the trachea itself is not what ultimately kills a victim who is strangled to death, though it can complicate their care if they live.

For instance, there have been instances of individuals with tracheotomies hanging themselves and the ligatures were above the level of the trach– which means the person would still be able to breathe.

So the following theories are proposed as explanations for the cause of death related to strangling.

Venous obstruction, leading to cerebral stagnation, hypoxia, and unconsciousness, which, in turn, produces loss of muscle tone and final arterial and airway obstruction.

Arterial spasm due to carotid pressure, leading to low cerebral blood flow and collapse.

Vagal collapse, caused by pressure to the carotid sinuses and increased parasympathetic tone.

Which is a lot of scientific language to say “death ultimately occurs from cerebral hypoxia and ischemic neuronal death“.

Which means– when a person is strangled, they die because their brain is no longer getting blood flow from the carotid arteries, which leads to brain cells dying from lack of oxygen.
As you can see from this photo, the major blood vessels that drain blood from the brain but also, more importantly, feed it with oxygen– are in very close proximety to the trachea or windpipe.

It is the vital oxygen these vessels carry to the brain that upon slowing or stopping– is the biggest problem for the victim.

Next post we’ll discuss some strangulation facts. Third part of this series will include treatment of the strangulation victim.


Other Resources:

Wisconsin Medical Journal: Strangulation Injuries

Emergency Medicine Reports: Strangulation Injuries.

How to Improve Your Investigation and Prosecution of Strangulation Cases.