SIGNS AND SYMPTOMS STRANGULATION

S S IGNS AND YMPTOMS OF

STRANGULATION

(visible signs may not be present)

Loss of memory Loss of consciousness Behavioral changes Loss of sensation Extremity weakness Difficulty speaking

Fainting Urination Defecation Vomiting Dizziness Headaches

Petechiae (tiny red spots) Bald spots (from hair being pulled) Swelling on the head (from blunt force

trauma or falling to the ground)

Petechiae to eyeball Petechiae to eyelid Bloody red eyeball(s) Vision changes Droopy eyelid

Ringing in ears Petechiae on earlobe(s) Bruising behind the ear Bleeding in the ear

Petechiae Scratch marks Facial drooping Swelling

Bruising Swollen tongue Swollen lips Cuts/abrasions Internal Petechiae

Chest pain Redness Scratch marks Bruising Abrasions

Redness Scratch marks Finger nail impressions Bruising (thumb or fingers) Swelling Ligature or Clothing Marks

Raspy or hoarse voice Unable to speak Trouble swallowing Painful to swallow Clearing the throat

Coughing Nausea Drooling Sore throat Stridor

Illustration & Graphics by Yesenia Aceves

Difficulty breathing Respiratory distress Unable to breathe

Source: Strangulation in Intimate Partner Violence, Chapter 16, Intimate Partner Violence. Oxford University Press, Inc. 2009.



v 10.5.2017

Diana Faugno MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN

Diana Faugno graduated with a Bachelor of Science in Nursing-University of North Dakota and a Master of Science in Nursing-University of Phoenix. Ms. Faugno is a Founding Board Director for End Violence Against Women International (EVAWI) She is a member of the Board of Directors for the California American Professional Society on the Abuse of Children.She is the current president of the Acadmey of Forensic Nurses as well as a retired-fellow in the American Academy of Forensic Science and a Distinguished Fellow in the International Association of Forensic Nurses. She currently is the nurse examiner at the Barbara Sinatra Childrens Center and a nurse examiner for Eisenhower Medical Center's SART team. She is the co-author on numberous textbooks and papers on dealing with the forensic medical aspects of violence.

RECOMMENDATIONS for the MEDICAL/RADIOGRAPHIC

EVALUATION of ACUTE ADULT, NON-FATAL STRANGULATION

Prepared by Bill Smock, MD and Sally Sturgeon, DNP, SANE-A Office of the Police Surgeon, Louisville Metro Police Department Endorsed by the National Medical Advisory Committee: Bill Smock, MD, Chair; Cathy Baldwin, MD; William Green, MD; Dean Hawley, MD; Ralph Riviello, MD; Heather Rozzi, MD; Steve Stapczynski, MD; Ellen Tailiaferro, MD; Michael Weaver, MD

GOALS:

1. Evaluate carotid and vertebral arteries for injuries 2. Evaluate bony/cartilaginous and soft tissue neck structures 3. Evaluate brain for anoxic injury

Strangulation patient presents to the Emergency Department

History of and/or physical exam with ANY of the following:

? Loss of Consciousness (anoxic brain injury) ? Visual changes: "spots", "flashing light", "tunnel vision" ? Facial, intraoral or conjunctival petechial hemorrhage ? Ligature mark or neck contusions ? Soft tissue neck injury/swelling of the

neck/cartoid tenderness ? Incontinence (bladder and/or bowel from anoxic injury) ? Neurological signs or symptoms (LOC, seizures,

mental status changes, amnesia, visual changes, cortical blindness, movement disorders, stroke-like symtoms.) ? Dysphonia/Aphonia (hematoma, laryngeal fracture, soft tissue swelling, recurrent laryngeal nerve injury) ? Dyspnea (hematoma, laryngeal fractures, soft tissue swelling, phrenic nerve injury) ? Subcutaneous emphysema (tracheal/laryngeal rupture)

Recommended Radiographic Studies to Rule Out Life-Threatening Injuries*

(including delayed presentations of up to 6 months)

History of and/or physical exam with:

? ? No LOC (anoxic brain injury) ? No visual changes: "spots", "flashing light",

"tunnel vision" ? No petechial hemorrhage ? No soft tissue trauma to the neck ? No dyspnea, dysphonia or odynophagia ? No neurological signs or symptoms (i.e.

LOC, seizures, mental status changes, amnesia, visual changes, cortical blindness, movement disorder, stroke-like symtoms) ? And reliable home monitoring

Discharge home with detailed instructions to return to ED if:

neurological signs/symptoms, dyspnea, dysphonia or odynophagia develops or worsens

? CT Angio of carotid/vertebral arteries

(GOLD STANDARD for evaluation of vessels and bony/

cartilaginous structures, less sensitive for soft tissue

trauma) or ? CT neck with contrast (less sensitive than CT Angio

(-)

for vessels, good for bony/cartilaginous structures) or

? MRA of neck (less sensitive than CT Angio for vessels,

best for soft tissue trauma) or

? MRI of neck (less sensitive than CT Angio for vessels

and bony/cartilaginous structures, best study for soft

tissue trauma) or

? MRI/MRA of brain (most sensitive for anoxic brain

(+)

injury, stroke symptoms and intercerebral

petechial hemorrhage)

? Carotid Doppler Ultrasound (NOT RECOMMENDED: least

sensitive study, unable to adequately evaluate vertebral

arteries or proximal internal carotid)*References on page 2

Continued ED/Hospital Observation (based on severity of symptoms and reliable home monitoring)

? Consult Neurology Neurosurgery/Trauma Surgery for admission

? Consider ENT consult for laryngeal trauma with dysphonia

Brochure Design by Yesenia Aceves



Version 17.9 9/16 WSS

RECOMMENDATIONS for the MEDICAL/RADIOGRAPHIC EVALUATION of ACUTE ADULT, NON-FATAL STRANGULATION

REFERENCES

(Recommendations based upon case reports, case studies, and cited medical literature)

1. Christe A, Thoeny H, Ross S, et al. Life-threatening versus non-life-threatening manual strangulation: are there appropriate criteria for MR imaging of the neck?. Eur Radiol 2009;19: 1882-1889

2. Christe A, Oesterhelweg L, Ross S, et al. Can MRI of the Neck Compete with Clinical Findings in Assessing Danger to Life for Survivors of Manual Strangulation? A Statistical Analysis, Legal Med 2010;12:228-232

3. Yen K, Thali MJ, Aghayev E, et al. Strangulation Signs: Initial Correlation of MRI, MSCT, and Forensic Neck Findings, J Magn Reson Imaging 2005;22:501-510

4. Stapczynski JS, Strangulation Injuries, Emergency Medicine Reports 2010;31(17):193-203

5. Yen K, Vock P, Christe A, et al. Clinical Forensic Radiology in Strangulation Victims: Forensic expertise based on magnetic resonance imaging (MRI) findings, Int J Legal Med 2007;121:115-123

6. Malek AM, Higashida RT, Halback VV, et al. Patient Presentation Angiographic Features and Treatment of Strangulation-Induced Bilateral Dissection of the Cervical Carotid Artery: Report of three cases, J Neurosurg 2000;92(3):481-487

7. Di Paolo M, Guidi B, Bruschini L, et al. Unexpected delayed death after manual strangulation: need for care examination in the emergency room, Monaldi Arch Chest Dis 2009;Sep;71(3):132-4

8. Dayapala A, Samarasekera A and Jayasena A, An Uncommon Delayed Sequela After Pressure on the Neck: An autopsy case report, Am J Forensic Med Pathol 2012;33:80-82

9. Hori A, Hirose G, Kataoka, et al. Delayed Postanoxic Encephalopathy After Strangulation, Arch Neurol 1991;48:871-874

10. Iacovou E, Nayar M, Fleming J, Lew-Gor S, A pain in the neck: a rare case of isolated hyoid bone trauma, JSCR 2011;7(3)

11. Oh JH, Min HS, Park TU, Sang JL, Kim SE, Isolated Cricoid Fracture Associated with Blunt Neck Trauma; Emerg Med J 2007;24:505-506

12. Gill JR, Cavalli DP, Ely SF, Stahl-Herz J, Homicidal Neck Compression of Females: Autopsy and Sexual Assault Findings, Acad Forensic Path 2013;3(4):454-457

13. Sethi PK, Sethi NK, Torgovnick J, Arsura E, Delayed Left Anterior and Middle Cerebral Artery Hemorrhagic Infarctions After Attempted Strangulation, A case report; Am J Forensic Med Pathol 2012;33:105-106

14. Clarot F, Vaz E, Papin F, Proust B, Fatal and Non-fatal Bilateral Delayed Carotid Artery Dissection after Manual Strangulation, Forensic Sci Int 2005;149:143-150

15. Molack J, Baxa J, Ferda J, Treska V, Bilateral Post-Traumatic Carotid Dissection as a Result of a Strangulation Injury, Ann Vasc Surg 2010;24:1133e9-1133e11

16. Plattner T, Bollinger S, Zollinger U, Forensic Assessment of Survived Strangulation, Forensic Sci Int 2005;153:202-207

17. Miao J, Su C, Wang W, et al. Delayed Parkinsonism with Selective Symmetric Basal Ganglia Lesion after Manual Strangulation, J Clin Neurosci 2009;16:573-575

18. Purvin V, Unilateral Headache and Ptosis in a 30-Year-Old Woman, Surv Ophthalmol 1997;42(2):163-168

19. Nazzal M, Herial NA, MacNealy MW: Diagnostic Imaging in Carotid Artery Dissection: A case report and review of current modalities; Ann Vasc Surg 2014;28;739.e5-739.e9

20. Chokyu TT, Miyamoto T, Yamaga H, Terada T, Itakura T: Traumatic Bilateral Common Carotid Artery Dissection Due to Strangulation: A case report; Interventional Neuroradiology;12:149-154, 2006

Brochure Design by Yesenia Aceves



Version 17.9 9/16 WSS

PHYSIOLOGICAL CONSEQUENCES OF STRANGULATION Occlusion of Arterial Blood Flow: Seconds to Minutes Timeline

Created by: Ruth Carter; Bill Smock, MD; Gael Strack, JD; Yesenia Aceves, BA; Marisol Martinez, MA; and Ashley Peck

0

seconds

6.8 sec.

(5-10 sec. range)

14 sec.

(11-17 sec. range)

15 sec.

(minimum)

30 sec.

(minimum)

1

minute

62 sec.

152 sec.

Pressure APPlied

Occlusion of

carotid

arteries

Time To render unconscious

6.8 seconds Adult Male1

Anoxic seizure1,2

loss of BlAdder conTrol1

loss of Bowel conTrol1

deATh/resPirATion ceAses

Beginning Time2

(First patient, 1/14 dead at 62 seconds)

deATh/resPirATion ceAses

Ending Time2

(All patients, 14/14 dead between 62 and 152 seconds)

RefeRences and ResouRces

1 Acute Arrest of Cerebral Circulation in Man, Lieutenant Ralph Rossen (MC), U.S.N.R.; Herman Kabat, M.D., PH.D. Bethesda, MD.

and John P. Anderson Red Wing, Minn.; Archives of Neurology and Psychiatry, 1944, Volume 50, #5.

2 Anny Sauvagneau, MD, MSc; Romano LaHarpe, MD; David King, MD; Graeme Dowling, MD; Sam Andrews, MD; Sean Kelly, MD;

Corinne Ambrosi, MD; Jean-Pierre Guay, PhD; and Vernon J. Geberth, MS; MPS for the Working Group on Human Asphyxia, Forensic Med Pathol 2011;32: 104 ? 107.

3 Training Institute on Strangulation Prevention:



Ogle

County

This project is supported all or in part by Grant No. 2016-TA-AX-K067 awarded by the Office on Violence Against Women, U.S. Department of Justice.

The opinions, findings, conclusions, and recommendations expressed in this publication/program/exhibition are those of the author(s) and do not

necessarily reflect the views of the Department of Justice, Office on Violence Against Women.

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