Strangulation: Death Without a Mark Diane Burkart RN, SANE-A, SANE-P, CFN and Beth Roach RN, SANE-A, SANE-P

Inova Ewing Forensic Assessment and Consultation Teams Department, Falls Church, Virginia

Strangulation can be the last violent act before homicide. A woman who is strangled is 7X more likely to be a victim of homicide compared to women who have never been strangled. Sadly, it is one of the most commonly minimized forms of violence. With increased awareness, better interviewing and documentation by all of us, we can improve

victim outcomes, safety and potentially save a life.

911/EMS- First responders are more focused on obvious

injuries and victim may have no visible neck injuries. Have little training in S/S of strangulation and the dynamics of domestic violence. Lack of protocols for

dispatch and EMS related to domestic violence and

strangulation.

Law Enforcement-

Difficult to discern the dominant aggressor-may identify the

victim as the primary aggressor due to the abuser’s visible injury from victim’s defensive reflexes.

Not trained to ask about strangulation.

Prosecutor- not familiar with the new laws

associated with strangulation and how best to prosecute these

cases. If there are no visible marks on the neck, might think

it will be difficult to prove beyond a reasonable doubt.

Doesn’t obtain expert witness’ to educate the jury and judge.

Advocate - Focused on safety planning and psychosocial

issues. Not aware of the immediate and long term health consequences of strangulation as well as its lethal place in the continuum of violence.

Abuser- uses strangulation as a tool for power and control. He

often doesn’t consider it as serious as hitting and punching, “I didn’t hit her – all I did was choke

her- I’m the one with all the injury.” Their intention may not be to kill but to show that he can kill

– Even the abuser may not understand the consequences of

his actions.

How we minimize the

seriousness of strangulation

What will we see?

How much pressure is required?

Questions to ask: 1. “Did he put his hands or anything else around or

on your neck?” * many do not understand the terms choke and strangle

2. “How did you feel when being strangled?” * feelings of impending death, dizziness

3. “Did you experience loss of consciousness?” * Can’t remember everything that happened or doesn’t recall being moved from one position or room to another *probably lost consciousness – caused by lack of blood flow to the brain

4. “Was it or is it difficult to breathe?” *Coughing, hyperventilating, shortness of breath, all show impairment of respiration.

5. “Is this your normal voice?” * Pressure to trachea causes hoarseness in 50% of victims, raspy voice, inability to speak and coughing all show impairment in respiration.

6. “Did you have vision changes or hearing changes?” Seeing stars, tunnel vision, blurred vision, loss of vision, sounds of rushing air, sea shell noise, ringing in ears * all show impairment of blood to essential nerves in brain.

7. “Do you have difficulty swallowing?” *Painful swallowing, drooling, sore throat, clearing throat, nausea, vomiting show impairment of respiration.

8. “Did you lose control of your urine or stool?” * Many will not offer this info and may have

changed clothing out of embarrassment. Shows lack of circulation causing relaxation of sphincters. 9. “How do you feel?” * Headache, weakness, difficulty concentrating, seizure, behavior changes, combativeness and agitation shows lack of circulation to the brain. 10. “Do you have red marks on your face, in your eyes?” * Caused by pressure of backed up blood in head. 11. “Does HE have marks on his face?” * Caused by her primal instincts to survive and release the pressure on her neck.

0.0 20.0 40.0 60.0 80.0 100.0

Jugular Occlusion

Carotid Occlusion

Tracheal Occlusion

Trigger of a gun

Open a soda can

Adult Handshake

PSI Requirements

Because this force is slow and compressive, victim may present with few, if any marks on the neck or with seemingly harmless signs and symptoms of their strangulation.

Patient/ Victim-

Starts to deny what happened due to the

cycle of violence –”everything is good now”

May fear intimidation or Retaliation; may be dependent upon

abuser for support-financial and emotional; doesn’t understand the serious

medical dangers and long term effects; May have passed out and have no recollection of

the assault and doesn’t understand how likely it is that she will can be killed by her abuser or that her children will be victims.

Medical- Circulation and

respiration seem to be normal-more focus on obvious injuries. May mistake hypoxic

symptoms as hysterical behavior related to domestic argument.” No visible neck injuries and if patient is not asked or

doesn’t reveal strangulation, patient may be misdiagnosed or under

diagnosed. Lack of understanding of long term consequences such as stroke, PTSD

and short term effects of an impaired airway.

50% with no visible injury 35% with injuries to minor to photograph 15% with injuries sufficient to photograph

38 states have strangulation laws that define it as an impairment of circulation or respiration Asking the patient proper questions and

performing a complete medical evaluation can prevent the legal definition from interfering with effective prosecution.

10 seconds to unconsciousness

20 seconds should bounce back on own

30 seconds need to medically revive

50 seconds is point of no return-rarely recover even with CPR

Time is Life

Strack GB, McClane G, Hawley DA: A review of 300 attempted strangulation cases

Dr. Luis Pena

Smock, William S.