Strangulation Injuries

What is Strangulation Injuries?

Strangulation injuries are caused by external force being applied to the neck and surrounding areas. These injuries can prevent oxygen from reaching the brain either by blocking blood vessels in the neck or by preventing air flow through the windpipe. If the pressure is not relieved quickly, it can lead to death. If someone survives these initial injuries, it’s important to check for hidden damage as the visible injuries might not show the full extent of harm caused. The term “choking” is often used to describe these injuries, but medically, it’s mostly used to denote blockage within the upper airway.

Those who go through such injuries are at high risk of developing physical, psychological, and social complications. Domestic violence and other violent incidents unfortunately cause a big portion of these injuries yearly. They are also a common injury in suicide attempts. Furthermore, these injuries can occur in both consensual and non-consensual sexual activities, martial arts, combat sports, military training, and law enforcement actions.

Children are particularly at risk due to their physical differences and they may also face additional psychological issues making them more susceptible to serious health risks if they survive the initial injury. Additionally, social media and other external media sources have been linked to suicide attempts in teenagers.

Identifying, diagnosing, and treating these injuries take a team approach. Along with the doctors who are treating the injury, mental health experts, social workers, and law enforcement (depending on local laws) need to be involved. Also, there may be legal repercussions in cases where someone died due to a strangulation injury.

What Causes Strangulation Injuries?

Strangulation refers to anything that squeezes the neck structures to a point where it cuts off air supply or blood flow. This can cause a lack of oxygen and eventual brain damage or even death. There are many types of strangulation injuries, such as those caused by hanging, someone choking another person (manual strangulation), or an object tied around the neck (ligature injuries).

Hanging injuries can either be complete or incomplete. A complete hanging means the person’s entire body weight is supported by their neck. An incomplete hanging is when part of the person’s body touches another object like the floor or a piece of furniture. Hangings can sometimes cause damage to the bones in the spine and the blood vessels in the neck. Strangulation injuries can also happen due to various reasons, such as murder, suicide, accident, or erotic activities.

Children often get strangulated accidentally. Different age groups have their unique behaviors that can lead to potential risks. For example, younger kids can get injured from car windows, electrical cords or getting stuck between furniture. There is also a risk of suffocation, which is not the same as strangulation as it blocks the air from the mouth and nose. Some rare incidents happen in playgrounds or because of bicycle handlebars. Nowadays, social media influences play a crucial role among teenagers and can lead to instances of self-strangulation in moments of curiosity or arousal.

Strangulation can also happen during sexual activities – whether it’s intentional, accidental, or both. This poses a serious risk particularly in abusive relationships. Some adults willingly engage in activities where they strangle each other lightly for pleasure, but this can become dangerous if they are not careful. Certain practices such as auto-erotic asphyxiation, a form of sexual behavior where someone strangles themselves for pleasure, have been reported among adults.

In addition, martial art techniques or law enforcement methods sometimes use neck restraints to control an opponent. While these moves can be efficient, they might also cause serious, lifelong injuries or even death.

Risk Factors and Frequency for Strangulation Injuries

The exact number of people who get strangulation injuries or die from these injuries is not known. This is partly because different factors can lead to such injuries, and studies usually focus on specific causes or specific groups of people.

Hanging is the second most common method of suicide in the United States, followed by gunshot wounds. Men are more likely to commit suicide using these methods. Women who are in abusive relationships are the ones most at risk of strangulation injury. It’s also thought that the true number of these injuries is much higher than reported because many patients don’t report them when they seek medical help. The number of hanging injuries has been going up over the years. However, the number of people dying from homicides using hanging has not changed much between 2006 to 2013. The growing trend of ‘choking games’ among young people has also led to more of these injuries.

Hanging is the second most common cause of suicide in the US followed by gunshot wounds.
Men are more likely to commit suicide these ways.
Women in abusive relationships are at most risk of getting strangulated.
Many cases of strangulation injury may not be reported, so the true number is likely higher.
The number of hanging injuries is increasing among young people due to a trend in choking games.

In a study published in 2019, 98 patients who had almost died by hanging were examined over an 11-year period. They all had checks for injuries, and through 254 scans, only 8 injuries were found. These included injuries to neck blood vessels, fractures of the thyroid cartilage and hyoid bone, and back injuries. About 35.7% of these patients had a brain injury due to lack of oxygen, which was found in all 19 patients who died (19.5%). The injuries were more common in those who had a low score in the Glasgow Coma Scale test, which gauges the severity of brain injuries.

Out of 98 patients who almost died by hanging, only 8 injuries were found.
About 35.7% of these patients had a brain injury due to lack of oxygen.
The injuries were more common in patients who scored low in a brain injury severity test.

For children less than 1 year old, unintentional strangulation injuries are the fourth most common cause of accidental injury. The other top causes are car accidents, drowning, and burns. Out of 200,000 playground injuries in 1999, only 0.07% were fatal. Half of these were caused by strangulation. Eighty percent of victims were found to be under 10 years old.

For children under 1 year, unintentional strangulation is the fourth most common cause of accidental injury.
Out of 200,000 playground injuries in 1999, strangulation injuries caused half of the fatal cases.
80% of victims were under 10 years old.

Signs and Symptoms of Strangulation Injuries

When treating a patient who has suffered a strangulation injury, it’s important to get a detailed account of what happened. This could come from the patient, witnesses, first responders, friends or family, or a combination of these sources. It’s important to find out what type of strangulation happened – was it manual, with something like a rope or wire, or did the person hang themselves? For a hanging, was it complete or partial, and how high was the drop? Knowing the details can help determine the best treatment. Other injuries and any substance use should also be assessed, as well as how long ago the injury happened and its duration. Information about initial treatment efforts and changes in the patient’s condition can also be helpful.

When a physical examination is carried out, doctors will look for a number of physical signs that could indicate a strangulation injury. These are divided into three main categories:

Head, Eyes, Ears, Nose, and Throat signs: things like vision problems, small red spots on the face or eyes from burst blood vessels, swelling or wounds in the mouth or face, swelling or wounds in the neck, voice changes or difficulty breathing, and swelling or crepitus under the skin.
Cardiovascular signs: skin discoloration, irregular heartbeat, trouble breathing, abnormal lung sounds, or coughing.
Neurologic signs: changes in consciousness, seizures, stroke-symptoms, or loss of bladder or bowel control.

The first thing a doctor should check is the patient’s airway. If there’s something obstructing it like blood or vomit, it can make breathing difficult. Listening to the patient’s breathing and heartbeat can also reveal problems with the blood vessels in the neck. Checking the patient’s circulation is crucial too, and there can be signs of serious injury to the spinal cord.

A full neurological exam is also necessary. If the nerves in the brain or spinal cord are damaged, it could affect the patient’s muscle tone and reflexes. Looking for injuries to the skin and muscles is also part of the examination, especially if the injury is severe. In some cases, a quick mental health assessment may be needed, particularly if there are signs of depression, thoughts of suicide, altered thought content or symptoms of intoxication or head injury.

Testing for Strangulation Injuries

If you’ve suffered from strangulation injuries, there are several medical tests and procedures your doctor might use to understand how severe your injuries are. Initially, they may need to conduct some laboratory tests, such as complete blood count, comprehensive metabolic panel (CMP), clotting (coagulation) tests, beta-HCG (pregnancy hormone test), tests for drugs and toxins (toxicology panel), lactic acid test, and arterial blood gas test that measures oxygen and carbon dioxide levels in your blood.

After that, they may use computed tomography (CT), a sort of X-ray that takes cross-sectional images of your body. In the case of strangulation injuries, CT is often the first line of investigation, especially a specific type called CT Angiogram. This looks at the carotid and vertebral arteries—large blood vessels in the neck—and is the gold standard in care because it can evaluate blood vessels and bony structures of the neck.

A CT scan of the neck with a special dye (contrast) can also evaluate bony and blood vessel structures, but it’s less precise than a CT Angiogram. If there’s concern about a stroke, a non-contrast CT scan of the brain (no dye used) will be performed. This test is more accurate at detecting bleeding in the brain than smaller strokes that block blood flow. It can also identify large areas of dead (infarcted) tissue and can be used to evaluate for conditions like brain edema (brain swelling) in patients who’ve just arrived for treatment.

There are other imaging options, though. Magnetic Resonance Angiography (MRA) of the neck is another one. However, it’s typically less available, especially in smaller and rural areas, and takes longer to complete than a CT. Additionally, its ability to view blood vessels isn’t as good as a CT Angiogram. Similarly, MRI of the neck isn’t as readily available and isn’t as precise for viewing blood vessels, but it’s the best option for viewing the soft tissues of the neck. MRI or MRA of the brain is the most sensitive for evaluating brain injuries, including strokes and bleeding inside the brain. However, doctors have to consider whether you’re well enough for MRI-based studies.

Carotid Doppler isn’t often recommended. Although it checks blood flow in the carotid arteries—it’s not able to evaluate all the potentially affected vascular structures. If you’re having breathing difficulties or have needed a breathing tube (intubation), you might also need a chest X-ray. Additionally, bronchoscopy (checking the airways) and upper gastrointestinal endoscopy (checking the upper digestive tract) could be required later in your care, especially if there are signs of injury like coughing up or vomiting blood (hemoptysis and hematemesis).

Treatment Options for Strangulation Injuries

When treating any kind of traumatic injury, the first step should be to check the patient’s breathing and circulation, and make sure their airway is clear. It’s more important to start immediately addressing these critical needs than to perform scans or other tests. Medical clinicians who deal with cases of strangulation need significant experience in managing patient’s airways, which might include performing emergency procedures like tracheostomy (creating an opening in the neck to allow air to enter the windpipe).

If the patient shows “hard signs” or other physical symptoms of severe neck injury, a cervical collar or other device should be used to immobilize the neck immediately. It shouldn’t be removed unless tests have ruled out the risk of unstable bone fractures, blood vessel injuries, or other dangerous conditions. If there are no “hard signs” present, then scans might not be necessary. After an evaluation in the emergency department, the patient could potentially be sent home with clear instructions of when to return for a checkup. However, if there are “hard signs” of strangulation injury, lab and imaging tests should be performed.

If all the scan results come back clear, then what happens next depends on the patient’s condition. If the patient doesn’t have any symptoms, they can be sent home after their emergency department evaluation. There should be someone at home, like family or friends, to keep an eye on the patient, and there must be clear instructions on when to come back to the emergency department. On the other hand, if the patient does have symptoms but normal scan results, they should be either admitted to the hospital or an emergency department observation unit for further monitoring.

Patients who are admitted to the hospital will require a team of medical professionals providing specialized care, depending on their injuries. Possible complications that might arise later like fluid in the lungs or issues from related bone injuries should be watched out for, and these specialized professionals should be ready to provide organ-specific care.

There are several health conditions and situations which could be in need of medical attention. They include:

Anaphylaxis (a severe allergic reaction)
Angioedema (swelling beneath the skin)
Asthma (a respiratory condition)
COPD (Chronic Obstructive Pulmonary Disease)
Depression and Suicide
Domestic Violence
Epiglottitis (swelling of the part of the throat that keeps food from going into the windpipe)
Neck Trauma (any injury to the neck)
Sexual Assault
Spinal Cord injuries

What to expect with Strangulation Injuries

Generally, patients who display few or no external symptoms, and whose medical imaging results don’t show serious issues, usually have a good chance of getting better. In terms of conditions caused by an injury, delayed issues with blood vessels can be serious, but with today’s high-tech imaging, these instances are rare. So, the future health of these patients often relies on the reasons that led to the injury and whether they can avoid further exposure to such risks.

Patients who are seriously injured or have serious brain function problems usually do not fare so well. Their chances of improvement heavily depend on the degree and length of their brain injury due to a lack of oxygen, and their long term recovery depends on which specific areas of the brain are damaged. While patients scoring low on a scale measuring consciousness levels (Glasgow Coma Scale) generally have a hard time improving, an initially severe neurological condition doesn’t mean a good recovery is impossible. However, patients who are brought to the hospital in a state of cardiac arrest generally have a very low chance of improvement.

Frequently asked questions

Strangulation injuries are caused by external force being applied to the neck and surrounding areas, which can block blood vessels in the neck or prevent air flow through the windpipe. If not relieved quickly, it can lead to death.

Signs and symptoms of strangulation injuries can be categorized into three main categories: 1. Head, Eyes, Ears, Nose, and Throat signs: - Vision problems - Small red spots on the face or eyes from burst blood vessels - Swelling or wounds in the mouth or face - Swelling or wounds in the neck - Voice changes or difficulty breathing - Swelling or crepitus under the skin 2. Cardiovascular signs: - Skin discoloration - Irregular heartbeat - Trouble breathing - Abnormal lung sounds - Coughing 3. Neurologic signs: - Changes in consciousness - Seizures - Stroke symptoms - Loss of bladder or bowel control In addition to these specific signs and symptoms, it is important to check the patient's airway for any obstructions that may make breathing difficult. Listening to the patient's breathing and heartbeat can reveal problems with the blood vessels in the neck. Checking the patient's circulation is crucial, and there may be signs of serious injury to the spinal cord. A full neurological exam is also necessary to assess any damage to the nerves in the brain or spinal cord, which could affect muscle tone and reflexes. Injuries to the skin and muscles should also be examined, especially in cases of severe injury. In some cases, a quick mental health assessment may be needed if there are signs of depression, thoughts of suicide, altered thought content, or symptoms of intoxication or head injury.

Strangulation injuries can occur through various means, such as hanging, manual strangulation (someone choking another person), or an object tied around the neck (ligature injuries).

The other conditions that a doctor needs to rule out when diagnosing Strangulation Injuries are: 1. Anaphylaxis (a severe allergic reaction) 2. Angioedema (swelling beneath the skin) 3. Asthma (a respiratory condition) 4. COPD (Chronic Obstructive Pulmonary Disease) 5. Depression and Suicide 6. Domestic Violence 7. Epiglottitis (swelling of the part of the throat that keeps food from going into the windpipe) 8. Neck Trauma (any injury to the neck) 9. Sexual Assault 10. Spinal Cord injuries

The types of tests that a doctor might order to properly diagnose strangulation injuries include: - Laboratory tests: complete blood count, comprehensive metabolic panel (CMP), clotting (coagulation) tests, beta-HCG (pregnancy hormone test), tests for drugs and toxins (toxicology panel), lactic acid test, and arterial blood gas test. - Computed tomography (CT): including CT Angiogram to evaluate blood vessels and bony structures of the neck, CT scan of the neck with contrast to evaluate bony and blood vessel structures, and non-contrast CT scan of the brain to detect bleeding and evaluate for conditions like brain edema. - Magnetic Resonance Angiography (MRA) of the neck (less available and takes longer to complete) and MRI of the neck (best option for viewing soft tissues of the neck). - Carotid Doppler (checks blood flow in the carotid arteries). - Additional tests like chest X-ray, bronchoscopy, and upper gastrointestinal endoscopy may be required later in the care if there are signs of injury. - The first step in treating any traumatic injury is to check the patient's breathing and circulation and make sure their airway is clear. Scans and other tests should be performed after addressing these critical needs.

When treating strangulation injuries, the first step is to check the patient's breathing and circulation and ensure their airway is clear. Addressing these critical needs immediately is more important than performing scans or other tests. Medical clinicians with experience in managing airways may need to perform emergency procedures like tracheostomy. If the patient shows severe neck injury symptoms, a cervical collar or other device should be used to immobilize the neck. Scans may not be necessary if there are no "hard signs" present, but if there are, lab and imaging tests should be performed. Treatment after clear scan results depends on the patient's condition, with the option of being sent home with clear instructions or being admitted to the hospital or an emergency department observation unit for further monitoring. Specialized care will be provided to patients admitted to the hospital, with a focus on watching for complications and providing organ-specific care.

When treating strangulation injuries, there can be several side effects and complications that may arise. These include: - Unstable bone fractures - Blood vessel injuries - Dangerous conditions related to the neck injury - Potential complications such as fluid in the lungs or issues from related bone injuries - The need for specialized care from a team of medical professionals - Organ-specific care may be required for certain complications.

The prognosis for strangulation injuries depends on various factors, including the severity and duration of the brain injury due to lack of oxygen, the specific areas of the brain that are damaged, and the overall health of the patient. Generally, patients who display few or no external symptoms and have no serious issues on medical imaging have a good chance of recovery. However, patients who are seriously injured or have serious brain function problems may have a more difficult time improving, and those brought to the hospital in a state of cardiac arrest generally have a very low chance of improvement.

Doctors who specialize in treating strangulation injuries include emergency medicine physicians, trauma surgeons, otolaryngologists (ear, nose, and throat specialists), neurologists, and radiologists. Mental health experts, social workers, and law enforcement may also be involved in the treatment process.