Police and EMS are dispatched for a domestic dispute as reported by a neighbor who states he heard a disturbance. The crew responds for a female patient with a head injury. She’s seated in a chair speaking to a police officer as the crew enters the front of the home. Her husband is being interviewed by other police officers outside.
As she sees the EMS crew enter, she tells the police officers, “I told you I don’t want to go to the hospital. I’m fine. Why are you making such a big deal out of this? Married people are still allowed to argue, aren’t they?”
The patient has a small, red, swollen area about 1″ in diameter over the left brow. She says their toddler accidentally kicked her in the head while she was putting his shoes on. She has no other visible injuries, but appears to be about 7 months pregnant.
The crew calmly reassures her their concern is for her and her baby’s welfare. She reluctantly agrees to have her vitals taken and cooperates with a focused physical exam. Her respiratory rate is 22, heart rate is 128, blood pressure is 148/80 and SpO2 is 99%. She’s agitated and her hands are trembling.
Five minutes later, when she appears visibly calmer, her respiratory rate is 18, heart rate is 104, blood pressure is 126/74 and SpO2 is 98%.
The patient and her husband both insist there was no physical altercation—they simply had a disagreement. The furniture is in place and the police find no property damage. A detailed patient refusal is completed, signed by the patient and witnessed by a police officer.
The next day, 9-1-1 is called back to the residence by the patient’s sister, who requested a welfare check when her sister failed to show up at work. The EMS crew finds last night’s patient dead, lying supine in bed with rigor mortis and lividity. There’s no sign of a struggle and no obvious signs of external injuries.
The EMS providers are left wondering what went wrong. Did they miss any signs the patient was gravely injured? Could something have been done to convince the patient to cooperate?
Media outlets soon report the patient died unexpectedly from strangulation injuries. The crew is called to meet with investigators and the patient care report (PCR) is subpoenaed. Questioning of the crew throughout the investigation and court hearing is consistent: Did the patient have any red discoloration or spots on her face? Did they notice any subconjunctival hemorrhage? Was her voice muffled, harsh or raspy? Had they inspected her neck and shoulders for signs of soft tissue injury?
The PCR describes the patient as having no apparent injuries in addition to the small hematoma over her left brow. The crew learns it would’ve been more accurate to document that the patient denied additional injuries, and that a visual inspection of the patient revealed no obvious injuries, but that she was wearing jeans and a long sleeve shirt with a scarf around her neck. During the autopsy, injuries were documented that wouldn’t have been plainly visible to the crew.
Both crew members recall red spots on her face they assumed were due to a skin condition. Those marks were petechial hemorrhages due to strangulation injury. They did document subconjunctival hemorrhage in the right eye, which they were aware is often due to sneezing or coughing, and are minor and self-limiting. They were unaware these can also be an indication of strangulation injury.
It’s important to distinguish between strangulation, suffocation, choking and smothering. Strangulation is a form of asphyxia caused by mechanical obstruction of blood vessels or the airway.1 Suffocation occurs when a person has been inhibited from breathing.2 “Choking” means to mechanically obstruct the upper airway, and smothering is mechanical obstruction of airflow through the mouth and nose.1
Strangulation accounts for 10% of violent deaths in the United States, with most victims being female.3,4 It’s an extremely common and serious consequence of domestic violence: Up to 68% of domestic violence victims suffer strangulation by their male partner in their lifetime.1
The initial patient presentation isn’t reliably predictive of outcome, and is often subtle and underappreciated by everyone involved. Historically, limited detection, medical evaluation and treatment have led to subsequent deterioration and bad outcomes, and left persecutors without adequate proof to intervene.1
Strangulation can be a means of suicide and can also occur accidentally, despite the violent nature often associated with these injuries. “Choking games” and autoerotic behavior can lead to accidental strangulation, and are most common in teenagers and young adults.3 In children, strangulation sometimes occurs when a child’s body fits through a railing, but the head is too large to pass through the same opening. Children may also suffer accidental strangulation due to curtain cords or ties on hats and hoods.
The structures of the neck are poorly protected and extremely vulnerable to severe injury. Vascular injuries due to strangulation aren’t uncommon. Venous obstruction leads to cerebral stagnation and petechial hemorrhages develop due to lack of drainage of the deoxygenated blood. Continued obstruction of venous blood flow may cause ruptured blood vessels and hemorrhagic stroke. Carotid pressure causes low cerebral blood flow and cerebral hypoxia. A single blocked carotid artery can cause neurologic findings on the opposite side of the body due to cerebral hypoxia. Thrombosis can form in blocked vessels. Embolization of the clot to the brain can result in an ischemic cerebral vascular accident. Bradycardia and cardiovascular collapse occur from pressure on the carotid sinuses, overstimulating the vagal nerve and increasing parasympathetic tone.1 (See Table 1.)
Mechanical airway compromise plays a minimal role in the immediate death of victims of strangulation.2 Several reports exist of suicidal post-tracheostomy patients who successfully hung themselves with ligatures well above the tracheostomy, where death wasn’t related to spinal cord injury.3 In cases where death isn’t immediate, the risk of delayed airway obstruction is significant due to swelling. Strangulation injuries can also result in delayed death due to vascular injuries, stroke, dysrhythmias and hypoxic brain damage.
Victims of strangulation often trivialize their injuries and fail to report strangulation due to a misconception that if you survived the event, you’ll be OK. Victims will often try to protect their attacker, who’s often closely related to the victim. Sometimes the perpetrator prohibits the victim from seeking aid. In many states, strangulation is being given felony-level prosecution due to the lethality of strangulation injuries.4
An awareness of the signs and symptoms of strangulation injuries can help EMS responders to identify potential victims, provide needed treatment and make appropriate transport decisions, and properly document physical findings
Knowledge of the many potential complications of strangulation, including delayed death, will allow EMS providers to better educate their patients and possibly convince victims to seek care and crisis intervention before the situation become fatal. When an index of suspicion is raised due to historical information or physical exam findings, it’s appropriate to ask directly if the patient was grabbed, choked or strangled during an assault.2
If an unreported strangulation injury is suspected, every attempt to convince the patient to be evaluated and monitored at the hospital is essential for the patient’s physical and mental recovery.
1. Green W: Strangulation. In American College of Emergency Physicians (Eds.), Evaluation and management of sexually assaulted or sexually abused patient, 2nd edition. ACEP: Dallas, pp. 83–90, 2013.
2. Faungo D, Waszak D, Strack G, et al. Strangulation forensic examination: Best practice for health care providers. Adv Emerg Nurs J. 2013;35(4):314–327.
3. Ernoehazy W. (June 14, 2013.) Hanging injuries and strangulation.Medscape. Retrieved Aug. 24, 2015, from http://emedicine.medscape.com/article/826704-overview.
4. Schwartz A. (Nov. 19, 2010.) Strangulation and domestic violence: Important changes in New York criminal and domestic violence law. Empire Justice. Retrieved Aug. 24, 2015, from www.empirejustice.org/issue-areas/domestic-violence/caselaws-statues/criminal/strangulation-and-domestic.html.