Strangulation

Background

An example of strangulation ("blood choke") from a rear naked choke.
Anatomy of neck arteries.
Midline neck anatomy on lateral view.
  • Strangulation
    • Hanging, ligature, manual or postural strangulation
    • Homicide, assault, suicide or execution
  • Mechanism of death/injury [1]
    • Spinal cord/brainstem injury
    • Mechanical compression
    • Bradycardia

Pathophysiology

Clinical Features

Strangulation marks sustained after scarf-related strangulation injury.

Differential Diagnosis

Neck Trauma

Evaluation

  • CBC
  • Chem 10
  • PT/PTT
  • Type and screen
  • Lactate
  • VBG/ABG
  • EtOH, Utox
  • CT brain
  • CT cervical spine
  • CTA neck criteria from Taming of the Sru Grand Rounds [2]directly quoted below:
    • Guidelines for imaging: GCS<8, audible neck bruit, expanding neck hematoma, focal neurologic deficit (including TIAs, Horner’s syndrome, vertebrobasilar syndrome), arterial bleeding from nose, mouth, neck
      • OR consider adding on if high C spine fracture, cervical vertebral body or fracture through foramen transversarium, subluxation or ligamentous injury at any level, significant thoracic/cardiac blunt force trauma, LeFort II or III fractures, skull base fracture, diffuse axonal injury
      • CTA neck AND head (can miss top of carotids with just CTA neck)
  • CXR

Denver screening criteria for blunt cerebrovascular injury

Algorithm for evaluation of BCVI with high risk criteria based on Memphis and Denver Screening Criteria

The Denver Screening Criteria are divided into risk factors and signs and symptoms

Signs and Symptoms

  • Arterial hemorrhage
  • Cervical bruit
  • Expanding neck hematoma
  • Focal neurologic deficit
  • Neuro exam inconsistent with head CT
  • Stroke on head CT

Management

  • ATLS
  • Secure airway if indicated
    • Stridor/hoarseness suggests upper airway obstruction
  • Cervical spine immobilization
  • Cardiac monitoring
  • Antibiotics if aspiration present
  • PEEP for hypoxia
  • Levophed for neurogenic shock

Disposition

  • Observation warranted if awake, alert, no stridor
  • ICU
  • Psychiatric assessment

See Also

References

  1. ↑ Iserson, K. V. (1984) ‘Strangulation: A review of ligature, manual, and postural neck compression injuries’, Annals of Emergency Medicine, 13(3), pp. 179–185.
  2. ↑ Taming of the Sru Grand Rounds Recap 11.6.19 accessed 11/25/2019. Copy permission given by CC BY-NC-SA 4.0 license Taming of the Sru Website
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