This is a CE article for my service, very well received, looking at Strangulation trauma of the type seen in domestic VIolence. It covers patho-physiology, incidence, documentation, recognition, treatment, and much more.

1. ©Robert S. Cole, 8/2004 All rights reserved.
Strangulation Trauma in Assaults: An Overview for
Emergency Services Personnel
By
Robert S. Cole, CCEMT-P
Forward: I wish to thank the assistance of San Diego’s Gail B. Strack,
J.D. of the San Diego City Attorneys Office, and George McClane, M.D.,
for inspiring me to research and write this article for EMS providers.
Introduction
While domestic violence (DV) and sexual abuse (SA) in any form is horrible,
strangulation during sexual or domestic assault is a marker of a particularly dangerous
and potentially life-threatening situation. Strangulation is a relatively under-reported,
under-prosecuted, and under treated situation in both the law enforcement and medical
communities alike. Frequently, unless the victim sustained obvious visible (often non
life-threatening) injuries in addition to the strangulation, the incident is overlooked or
downplayed.
As a better understanding of the dangers of strangulation (both as an injury and marker
for future violence) filter down from above, more and more Law Enforcement Agencies
mandate a medical evaluation for victims. Frequently this is simply interpreted as
summoning EMS to “check the victim out”. Unfortunately what should be an opportunity
to see that a victim gets physical and social assistance often becomes another routine
“treat and release”. In addition, brief or sketchy documentation by EMS providers may
cast enough doubt in the legal system to prevent successful prosecution of aggravated
battery or more serious charges.
By the end of this article EMS providers should be able to:
1- Define domestic violence and sexual assault.
2- Recognize high-risk situations for victims of domestic violence.
3- Define 4 types of strangulation trauma.
4- Learn to identify the physical and subjective presentations of the victim.
5- Recognize the need for medical evaluation of all strangulation victims, as well as
those with especially high risk.
6- Screen victims and anticipate problems in acute medical care.
Prevalence and importance.
It is widely acknowledged that Domestic Violence and Sexual Assault in general (and by
default, strangulation) are under reported. However strangulation has recently been
recognized as one of the most severe forms of DV. Statistics show:

2. ©Robert S. Cole, 8/2004 All rights reserved.
• Mortality statistics that relate to method and demographics of homicidal
strangulation are uncommon, however the King County Coroner’s Office Report
that only 4% of all Homicides in 2002 were strangulations, but all of the victims
were female. Over the previous 10 years, approximately 2-6% of homicides were
strangulations(6).
• In the US as a whole, 10% of all violent non-accidental deaths are the result of
some form of strangulation. Females outnumber males as victims 6 to 1.(5)
• In a profile of 100 DV related strangulation cases in San Diego, 62 percent had no
reported visible injury and in only 3 instances did the victim seek medical
treatment. (5)
• Upwards to 40% of DV victims reported strangling as part of their DV, however
only about 10% actually report this to police at the time of the incident. (5, 7)
• The most dangerous time for a victim of DV is during pregnancy, during
separation, or after reporting abuse. (5)
In the past, strangulation in DV was not aggressively prosecuted. The general feeling was
that if it left no marks or did not immediately kill the victim, and then it was not a serious
incident. This combined with victims that recant their testimony (up to 70%), and failure
of medical personnel to recognize more subtle symptoms, simply resulted in a lack of
appreciation for the seriousness of the crime. As medical and forensic science has
progressed, this is fortunately changing.
Many prosecuting attorneys use not only the police reports, but also the reports of EMS
providers and ED staff to determine how aggressively to charge perpetrators of DV.
Medical documentation is considered “persuasive evidence” in the legal community. In
fact, anecdotal reports from prosecutors indicate that simple awareness of the severity of
strangulation, combined with better documentation by both law enforcement and medical
personnel (including EMS) dramatically increased not only the percentage of successful
prosecution, but the severity of the convictions as well.
Definitions
TDomestic Violence:T While legal definitions vary from state to state, it is generally
safe to say DV is the abuse (emotional, physical, sexual, and financial/exploitive) of one
party by an “intimate partner”.
• Emotional or psychological abuse includes intimidation, degradation, coercion,
false accusations, humiliation, ridicule and threats of physical harm. In same sex
relationships this may mean threatening to “out” (expose) the victims sexual
preference (or even past sexual acts/history) to family or friends. Often this
includes social isolation, forced dependence, and obsessive ridicule.
• Forms of physical violence include pushing, shoving, slapping, punching, kicking,
binding, holding, choking and assault with (or without) weapons.
• Sexual abuse may involve unprotected, nonconsensual or painful sexual acts. It
may involve participation in pornography, or sex with multiple partners.
Frequently this goes hand in hand with emotional abuse, as this is used to
“blackmail” the victim and force dependence. It is important to note that in most
states no “penetration” is required for the abuse to be sexual.
• Financial/Exploitive: The most common form of this is control over family assets
used in such a way to cause “forced dependence”.

3. ©Robert S. Cole, 8/2004 All rights reserved.
While typically thought of as a male verses female problem, DV may occur at least as
often, possibly even higher rates in some same sex couples. It is also important to know
that DV is as much about control as it is about anger. Many victims report being
strangled multiple times by the same assailant as means of control and submission.
TSexual Assault:T Sexual assault is defined as sexualized contact of any nature
(sometimes referred to as carnal knowledge) with another person without consent and by
force (compulsion). Some forms of sexual assault do not require the use of force, but
instead fear or drugs as a means of coercion, and are still considered criminal. Sexual
assault in DV is considered a marker for “high risk” cases, and strangulation is often seen
as well.
TStrangulation:T Strangulation is defined as a form of asphyxia where either the blood
vessels or the trachea is closed by external pressure on the neck. Commonly called
“throttling” in the United Kingdom, and “choking” in the United States, it is beneficial to
simply use the universally accepted term strangulation.
While domestic violence spans all social and gender barriers, it typically takes someone
of significantly larger mass and strength to strangle someone. While there are of course
exceptions, for this reason most (not all) victims are female and most perpetrators are
male.
There are 3 main types of strangulation methods:
• Manual: Simply put the use of one or both hands in the strangulation of the
victim. Variations include using forearms, knees, and similar methods.

4. ©Robert S. Cole, 8/2004 All rights reserved.
• Ligature: This consists of anything from telephone cord, clothing (in one case a
bikini top was used) or wire. This form is most likely to leave physical marks.
• Choke Holds: Such as those used by Law enforcement agencies (A.K.A. Lateral
Vascular Restraint, L.V.R.), often will leave little or no initial external signs, as
most occlusion of the carotid arteries is caused by indirect pressure distributed
over the muscular structures of the neck. Initial signs of bruising should be
considered.
• Other types: asphyxiation by occlusion of the airway with a plastic bag.
Physiology
The structures affected in the neck are the jugular veins, carotid arteries, and the cartilage
structures of the trachea. While the end result is the same (severe pain, followed by
cerebral hypoxia, unresponsiveness, seizure, and death), this is most likely the result of
damage to vascular structures of the neck, not occlusion of the airways. It takes just over
30 pounds of pressure to close the trachea, but only 11 pounds of pressure to occlude the
carotid arteries. Considering that a typical trigger pull on the Glock® 35 .40 Caliber
pistol is 4.5 pounds, one can see that it doesn’t take much pressure to successfully
strangle a person.
McClane, et al, reports that when the arteries are occluded, unresponsiveness can occur in
less than 10 seconds. It is also reported that for every 10 seconds of occlusion that the pt
will remain unresponsive for an additional 10 seconds. After a minute of complete
occlusion, the victim is frequently unresponsive, apniec, and will not recover with out
medical intervention. Strangulation or apnea in excess of 4-6 minutes will result in brain
damage or death. It is assumed that the victims survive because many perpetrators let go
shortly after the victim goes limp, soils them selves, or seizes. Many anecdotal reports
show that victims survived by “playing dead”.
Direct pressure over the carotid arteries may mimic carotid sinus massage used as a
treatment for certain tachycardic rhythms. As a result, all of the same complications may

5. ©Robert S. Cole, 8/2004 All rights reserved.
result, including severe bradycardia, thrombosis, and stroke. In addition the profound
catecholamine dump combined with the hypoxia typically present in these situations may
precipitate other cardiac emergencies such as myocardial infarction or lethal arrhythmia.
The Hyiod bone is a small structure that sits at the base of the tongue. It completely fuses
at about age 30 in humans. About 1/3 of victims of manual strangulation will have
suffered a fracture to the Hyiod bone. Loss of the structural integrity of the hyoid, as well
as resultant swelling, may cause severe airway issues, as well as make for difficult
intubations.
The Hyoid Bone and other structures
In pregnant patients, miscarriage has been anecdotally reported with in 24-48 hours post
strangulation.
Delayed death has been reported in some cases, sometimes up to 36 hours later, due to
cerebral swelling, hypoxic brain injury, respiratory decomposition (from aspiration), and
swelling/damage to the carotid bodies or airways. For this reason all victims should be
encouraged to seek medical evaluation by an MD.
Recognition
Strangulation cases are notoriously difficult to document. Many of the external bruising
of the neck will not show for many hours and days later. The San Diego Police
department reported that in 50% of Strangulation cases, there were no visible injuries; In
another 35% the injuries were too minor to photograph (the classic “redness” or
scratches). Thus only in 15%, were there obvious signs of injury. In the same review,
victims only sought care at a medical facility in 3% of cases, predominantly for
complaints due to pain, voice changes, and difficulty swallowing, thus stressing the fact
that EMS providers may be the only medical personnel these victims may see.
Common exam findings are:
• Petechiae: With particularly violent or vigorous struggle or strangling, and more
commonly with ligature strangling, petechiae may be seen. Sometimes this is
only seen in the conjunctiva. These are the rupture of small capillaries at or above
the level of strangulation. This may be commonly confused with benign rosacea.
A common variation on this is “Blood shot eyes”.
• Ligature Marks: While frequently more obvious, ligature marks may be hidden in
the folds of neck tissue. Sometimes the pattern can reflect the type used, such as
telephone cord. Occasionally assailants will try to mask ligature strangulation by
Hyoid
Cricoid
and
Thyroid
Tracheal
Rings

6. ©Robert S. Cole, 8/2004 All rights reserved.
Hanging the victim post mortem. Assessing the angle of ligature marks, or the
presence of multiple ligature marks, as well as other signs of assault is essential.
• Bruises: Round or oblong bruises may be from thumbs or fingers of the assailant
and indicate extreme pressure if they are acutely visible. Often these may be
hidden under the chin, in the folds of the neck, or in the hair behind the ears.
• Sustained pressure may cause congestion and blueness of the tongue, pharynx and
larynx
“He choked me…but there are no marks…”
With the lack of obvious physical evidence at the initial scene, it seems pointless to spend
a lot of energy on these calls. However, as the human body is predictable in its response
to injury, even minor clues may help win a case or show the need for ongoing medical
evaluation. The right assessments not only will help show a pattern of physiologic
response, but may encourage the pt to seek medical care when she would not normally.
While the act of strangulation may not leave much initial physical evidence, often the
victim’s struggles may. Scratches, gouges, and abrasions from the instinctual attempts at
defense may be noted. Sometimes the scratches may be from the assailant, but this will
be difficult to determine. These may be seen as self inflicted by the uniformed observer,
but may be defensive in nature. Common defensive marks are:
• Impressions: Impressions are semi-circular “gouges” from fingernails digging in
as the victim tries to work her hands around the assailant’s hands, arms, or
ligatures.
• Scratches: Just like they sound, these are long linear abrasions and vary in width
depending on the angle of the nail against the skin.
• Claw Marks: Simply long scratches running parallel to each other.
• Chin Abrasions: A common finding in manual strangulation, resulting from the
victim lowering her chin to protect her neck from the assailant, causing it to rub
against the assailant’s hands.
Good places to look for marks are the chin, behind the ears, back of the neck, and in folds
of skin. HAVE THE VICTIM LIFT UP ANY HAIR WHEN YOU INSPECT THE
VICTIM. Also look on the underside of the chin. Injuries may be hidden otherwise.
As with the rest of medicine, the subjective assessment is the most difficult part of the art
we practice. The main difficulty in documenting strangulation cases is not that we aren’t
looking for physical signs; it is that we are not asking the right questions. Common key
questions should assess for:
• What was the victim strangled with (one or both hands, bar hold, wire, etc). How
many times?
• What time did this occur or how long ago did it occur?
• Has this happened before?
• How long and how many times did the assailant strangle the victim?
• Rate the pain on a 1-10 scale. Rate the pressure used.
• Where else did the assailant grab or hurt the victim?
While we should always try to get the victim to an MD for evaluation, the following are
especially worrisome signs indicative of medical need.

7. ©Robert S. Cole, 8/2004 All rights reserved.
• Was the victim shaken while strangled? (Consider possible spinal injury)
• Was the victim’s head thrown or beat against the ground, wall, or other object?
(Consider possible closed head injury)
• Is there any difficulty swallowing (dysphagia) or moving the tongue? (Consider
airway swelling or nerve damage)
• Is the victim short of breath?
• Did the victim bite their tongue, lose consciousness, have any memory loss, seize,
or pass out?
• Was the victim incontinent?
• Any sign of vomit on the pt or clothes?
• Was an object used (ligature)?
• Presence of visible injuries, petechiae, or vocal changes (dysphonia).
• Statements of suicidal thoughts.
The main difficulty in documenting strangulation cases is
not that we aren’t looking for physical signs; it is that we
are not asking the right questions.
Treatment
In mild to moderate cases, care is simply palliative, with a strong emphasis on getting the
pt to ongoing medical and mental help. Simply being a patient advocate, a good listener,
and showing compassion and respect to the traumatized victim is essential.
In severe cases, most care will result around airway management. As discussed above,
some patients may develop severe respiratory compromise either due to airway swelling,
aspiration, or hypoxia. Providers should be prepared for a difficult airway, or possibly
surgical cricothyrotomy. Most strangulation is a rather physically violent episode, and as
such should be evaluated for need of spinal immobilization. Certainly not always
required, but documentation should reflect a thorough evaluation in this regard. This is
especially true when the victim suffers other injuries, as well.
Documentation
EMS personnel are in the unique position of being the only health professionals who have
actual eyewitness exposure to the domestic abuse home environment. In addition, since
only about 3% of victims will seek medical evaluation by a physician, EMS providers
may be the ONLY medical evaluation the victim receives. They may find evidence that
would otherwise be unsuspected and unreported. They may be the only health
professionals able to recognize, report, or suggest intervention.
Some sources (predominately non EMS) suggest there is a reluctance to get involved or
collect data by EMS providers. In my experience, this is not the case. Many medics will
thoroughly document cases like drunk driving, child abuse, and battery, with the hopes it

8. ©Robert S. Cole, 8/2004 All rights reserved.
will help in the prosecution of the perpetrators of such crimes. However, if this is true
(which the author hopes is not the case), then this must be addressed through education.
Paramedics must understand that detailed and correct evaluation and documentation can
save lives, even if the pt never presents to the hospital.
Simply put, since we know that victims will often suffer multiple attacks over the course
or a relationship (and often after it ends), and that the pattern of violence is typically one
of escalation, honest and thorough medical evaluation and documentation may prevent
future abuse, possibly even homicide, by supporting the prosecutor’s efforts to
incarcerate the perpetrator.
Simply put, since we know that victims will often suffer multiple attacks
over the course or a relationship (and often after it ends), and that the
pattern of violence is typically one of escalation, then honest and
thorough medical evaluation and documentation may prevent future
abuse, possibly even homicide, by supporting the prosecutor’s efforts to
incarcerate the perpetrator.
Summary
A better understanding of the physiological, as well as the psychological and legal
aspects of strangulation trauma, will enable EMS providers to be not only better and
more vigilant care providers, but better patient advocates as well. This is especially
important, as EMS providers will likely be the only medical provider the victim sees after
an incident.
Bibliography
1- Analysis of Data on Crimes by Current or Former Spouses, Boyfriends,
and Girlfriends, U.S. Department of Justice, March, 1998
2- Tjaden P, Thoennes N. Full report of the prevalence, incidence, and
consequences of violence against women. Washington, DC: National
Institute of Justice and CDC, 2000 (NCJ183781).
3- Uniform Crime Reports of the U.S. 1996, Federal Bureau of Investigation,
1996.
4- Sex Differences in Violent Victimization, 1994, U.S. Department of Justice
5- Strangulation and Domestic Violence Presentation for Nampa Police
Department, Nampa Idaho, 2003, Strack and McClane.
6- 2002 Annual Report, 2002, King County Medical Examiners Office.
7- Know the Law: resource Material on Strangulation, 2000,
HTUwww.correctionhistory.orgUTH