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The Case

A 26-year-old female presents to the emergency department, stating that her husband assaulted her. She complains of headache and sore throat. When directly questioned, she states, “He choked me so bad, I assumed I was going come die. I can have blacked the end for a minute. It really harms to swallow.”


Strangulation is a form of asphyxia, identified by closure the the blood vessels and also air passages of the neck as a result of outside pressure. There is a distinction between strangulation and choking, i m sorry is an internal obstruction of the airway. Over there is a misperception the strangulation is always fatal, and also patients will certainly often explain a “choking” episode following nonfatal strangulation.

Strangulation and also Domestic Violence

Strangulation has been established as one of the many lethal develops of residential violence. It is just one of the finest predictors for subsequent homicide. Former strangulation rises the odds that strangulation homicide by much more than 7 times.1 For perpetrators, strangulation is the ultimate kind of power and control. However, because there are regularly no visible injuries, patients, physicians, and also law enforcement regularly minimize the feasible health results of report strangulation.

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Pathophysiology

The vasculature the the neck is reasonably unprotected and vulnerable come injury and vascular occlusion. The applications of 4.4 pounds of pressure to the jugular veins reasons venous outflow obstruction native the mind and hence stagnant hypoxia. Eleven pounds of press to the carotid arteries can reason loss of awareness in about 10 seconds. Compression of the trachea needs significantly much more force: 33 pounds of pressure for occlusion and also 35 pounds come fracture tracheal cartilage.2

Strangulation deserve to be fatal in as tiny as four to 5 minutes. Instrument in addition to hypoxia as result of vascular occlusion have been proposed. Pressure on the carotid body may reason bradycardia and subsequent cardiac arrest. Delay mortality may be brought about by carotid artery dissection, aspiration, postobstructive pulmonary edema, acute respiratory distress syndrome, or tracheal injury.

In domestic violence and sexual attack cases, manual strangulation (with hand or various other body parts such as a knee) is most common. Ligature strangulation is substantially less typical but much more likely to result in clearly shows injuries.

Clinical Findings

Frequently, strangulation does not result in clearly shows physical findings.3 The lack of obvious injury, along with the distraught mental state of this patients, regularly results in underevaluation. It is essential to execute a thorough exam, together findings may be subtle and located in difficult to see locations such as the scalp, behind the ears, and also inside the mouth.

In the 50 percent of patient who have visible injuries, skin injuries room the most common. Faint bruises resulted in by the assailant’s fingertips, fingernail marks (sometimes self-inflicted), and also petechiae may be seen. Subconjunctival hemorrhage may also occur.

Patients may have actually dysphagia and also odynophagia. Voice transforms are current in about fifty percent of strangulation cases; questioning the patient if your voice sound normal. Pains with motion of the tongue may indicate injury to the epiglottis. Although uncommon, hyoid fracture or tracheal cartilage fractures may an outcome in crepitus followed by quick airway obstruction.

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Patients who have actually been strangled may current with pulmonary complaints, i m sorry are often mistakenly attributed to hyperventilation. Aspiration or postobstructive pulmonary edema may result in tachypnea and hypoxia.

Occlusion that or injury to one carotid artery may reason neurological deficits top top the contralateral side. This include transforms in vision, ptosis, facial droop, and also unilateral weakness.4 If strangulation results in hypoxia, patient may have actually mental standing changes and also incontinence. Death has resulted days after ~ strangulation because of hypoxic encephalopathy.