Strangulation Victims: A Forensic Approach

Troy Brown, RN


January 11, 2019

Strangulation in the News

A quick Internet search for news on strangulation events returns pages and pages of tragic examples. The most recent cases to grab the nation's attention were the asphyxiation deaths of a pregnant Colorado woman and her two young daughters in August 2018.[1] Christopher Watts fatally strangled his pregnant wife Shanann and asphyxiated their daughters, Bella, aged 4 years, and Celeste, aged 3. Watts pleaded guilty to strangling Shanann and asphyxiating Bella and Celeste, and was sentenced to life in prison.

The typical victims of strangulation are women involved in domestic relationships, and the abuser is generally a woman's male partner. However, strangulation isn't limited to intimate relationships. In October, Colorado anesthesiologist Mark Randle Ryan, MD, was charged with felony assault after allegedly strangling a recovery room nurse until she was nearly unconscious.[2]

Leigh Vinocur, MD (spokesperson for the American College of Emergency Physicians), describes her own experience of being strangled by a patient in the emergency department (ED).

He was behind me grabbing my throat and started choking me as I was clawing my neck. I felt like I was about to pass out because I was biting my tongue. And then one of our brave ED or radiology techs grabbed him in a chokehold around the neck...and I could feel the man's grip on my neck loosen. I got away and his hands caught in my necklace—it was the last time I ever wore jewelry on a shift—ripped across my neck and then kind of cut into my neck. But I had the petechiae and thumbprints all over my neck. It's a pretty frightening experience when it's happening to you.

In the "choking game" (or "pass-out challenge"), a person purposely cuts off the oxygen supply to his or her brain to induce euphoria.[3] The game is often played in groups, but sometimes it is performed alone, upping the danger. The choking game differs from autoerotic asphyxia, which is intended to increase sexual arousal.[3]

Methods of Strangulation

Strangulation is a type of asphyxia that results from the application of constant pressure to the neck. The International Association of Forensic Nurses (IAFN) defines three types of strangulation:

  • Hanging: The person is suspended with a ligature around his or her neck, which constricts owing to the gravitational pull of the person's own body weight.

  • Ligature: Pressure is applied around the neck with a ligature (eg, a cord, rope, or wire) without hanging.

  • Manual: Pressure is applied to the neck with hands, arms, or legs.

Pressure applied to the neck can impede blood flow and/or the victim's airway. Occlusion of the jugular veins causes venous congestion and increased venous and intracranial pressure. Carotid artery obstruction disrupts the delivery of oxygen to the brain. Finally, pressure on the carotid sinus results in acute bradycardia and/or cardiac arrest.[4] Unconsciousness can occur within seconds, and death within minutes.[5]

Strangulation attempts are much more common than many people realize. More than two thirds (68%) of women at high risk for intimate partner violence will experience near-fatal strangulation at the hands of a partner.[6] The risk for homicide skyrockets after a nonfatal strangulation, which is associated with more than a seven-fold odds of a future completed homicide.[7] In fact, 70% of strangled women believed they were going to die during the attack.[6]

Children are particularly vulnerable to strangulation. "They are not merely little adults," noted Jennifer Pierce-Weeks, RN, SANE-A, SANE-P, chief executive officer of IAFN. She explained that, depending on age, the muscle development in the neck and head area of a child is incomplete. The edema that results from external pressure can more easily obstruct the smaller airway of a child.

Pregnancy is an underappreciated risk factor for strangulation. "It's an out-of-control time for abusers," Vinocur explained.

Documenting the Effects of Strangulation

Strangulation should be considered a medical emergency, according to Pierce-Weeks. Victims of strangulation should be monitored closely for potential life-threatening after-effects. Strangulation can injure the soft tissues of the neck; the larynx, trachea, esophagus, and cervical spine; and the laryngeal and facial nerves—injuries that may not be immediately apparent.[8] In a recent study, external physical signs were absent during the initial examination of women in nearly 50% of nonfatal strangulation cases.[9]

Likewise, such injuries as bruising and airway trauma can develop over time. "The findings can be subtle," Vinocur said. The consequences of airway edema—even death—can be delayed if the onset of swelling is gradual.

Strangulation victims should undergo a thorough physical examination, the documentation of which may include written observations, illustrations, and photographs. The IAFN has a strangulation documentation toolkit that provides resources for nurses and other healthcare providers.

Patients may hesitate to disclose assault or strangulation, so healthcare providers need to ask direct questions and be alert to clues that the patient has been strangled.

"If you are taking care of a victim of domestic violence, explain what strangulation is and ask outright whether that took place," advised Pierce-Weeks, adding that a direct inquiry about strangulation should be made whenever there is injury to a patient's neck—including a child's.

According to Pierce-Weeks, healthcare providers should be prepared to not only describe the injuries in text, body maps, and diagrams, but they also should use photography to document the injuries in the medical record. An expensive camera isn't required, says Pierce-Weeks. But, she added, owing to privacy and confidentiality issues, clinicians should never use their personal mobile phones to photograph patient injuries. Every facility should have a policy concerning who will photograph strangulation injuries, how the photographs will be taken, and how they will be stored and/or released. "Make sure your facility has a policy, and that you follow it," advised Pierce-Weeks. "Strangulation injuries can get worse before they improve, so it's important to document the appearance of the injury at the time of presentation."

In a position paper, the IAFN recommends the following:

We believe that globally, systems should be in place to support universal screening with detailed medical-forensic assessments of patients of any age who have experienced strangulation. First responders, including emergency medical services and ED providers, must be trained in screening, assessment, documentation, intervention, and follow-up services.

Pierce-Weeks recommends that whenever possible, victims should be connected to local community crisis centers. "Whether it's a sexual assault or a domestic violence crisis center, that connection should always be made, so patients know where they can follow up, where they can find support services," adding, "Crisis centers can help with safety planning if the patient is returning to the abusive situation. That's a critical component of care."

Healthcare providers should follow their jurisdictional laws with respect to reporting strangulation injuries. "These laws can vary pretty dramatically from state to state," Pierce-Weeks said. In fact, in some states, despite being potentially lethal, strangulation or "choking" in a domestic violence context is still only a misdemeanor.[10]

"There is an expectation of confidentiality when you enter a medical facility. The patient-provider relationship is confidential and privileged as far as communication goes," says Pierce-Weeks. "It's important that the healthcare provider lets the patient know up front the limits of that confidentiality, so that they're not completely surprised if a mandatory report takes place," she explained.


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