1. Strangulation

2. Objectives Understand the definition of strangulation
Know the different types of strangulation
Understand some basic facts concerning strangulation
Know presentations of victims of strangulation
Phases of strangulation
Knowledge of basic anatomy of the neck.

3. Mary 1
25 year old female. Domestic dispute with boyfriend. No previous reports of abuse.
Says he put his arm around her neck and squeezed tight. She got dizzy and saw black spots.
She is agitated and her neck hurts. There are no visible injuries. No respiratory distress, difficulty swallowing, or loss of consciousness.
Where else would you look for injuries?
Would you photograph Mary’s neck and call EMS? Why, Why not?

4. Mary 2
42 year old female. Fight with husband. Not the first time. PD called to house numerous times before. She always refuses to file complaint.
Two young children present at time of incident. Crying and clinging to Mother.
Says he slapped her, kicked her in stomach, sat on her chest and choked her.
Passed out, hoarse, ashamed to admit but she urinated on self, hurts to swallow.
Patterned injury to both sides of her neck consistent with fingers pads. Two lunar indentations noticed on each side of anterior neck midline. Linear abrasions noticed over the two lunar indentations. Chest hurts.
Told her that she was going to $5#&*% die!
Would you photograph her injuries? Would you ask her to change her clothes so that you could photograph her chest? Would you call EMS and insist that she go to the Hospital?
Where else would you want to look for injuries?

5. Definition
Strangulation: A form of asphyxia (lack of oxygen) that is an intentional act and causes closure of the blood vessels and / or air passage of the neck thereby decreasing blood flow to the brain.
Choking: Is an accidental obstruction of the trachea (windpipe) thereby blocking flow of oxygen to the brain.
Smothering: Requires a soft, flexible object that can be molded over the irregular contours of the face, occluding the nostrils and mouth. May be accidental or intentional.
1. Suffocation
2. Burking
3. Natural

6. Types of Strangulation
Manual : hands apply external force. “choke hold” , “sleeper hold”
Ligature: “garrote” or “garroting”. Placing loop of rope or string around neck, then placing stick or rod in the loop and twisting to cause external pressure. ( Thuggee )
Gravity : pressure caused by individuals weight. Portion of body may remains on floor . ( Erotic asphyxiation).
All cause brain cells to be deprived of oxygen and blood.

7. Did You Know ?
Most strangulation cases produce minor or no visible injury.
Many victims suffer internal injuries and have documental symptoms
Is a gendered crime-virtually all perpetrators are men.
Most abusers do not strangle to kill, but to show that they can kill. Is the ultimate form of power and control.
Victims often suffer major long term emotional and physical impacts
Victims of prior attempted strangulations are 7 times more likely to become homicide victims.
Is one of the most lethal forms of domestic violence.
Accounts for 2.5% of traumatic deaths worldwide and up to 10% of violent deaths in the United States.

8. Presentation
Vary according to method of strangulation and may not show up for hrs or weeks afterwards.
Voice changes: seen in 50% of victims ( hoarse, raspy or loss of voice)
Difficulty swallowing : seen in 44% of victims ( painful or difficult )
Breathing difficulties : seen in 85% of victims ( short of breath that may be due to edema or fractures , usually hyoid bone )
Pain: Common post strangulation. May be localized or diffuse depending on method.
Neurological symptoms : visual changes, eyelid droop, facial droop, ringing in ears, unilateral weakness

9. Mental Status changes: confusion, loss of memory, loss of body functions. Severe headache.
Soft Tissue injuries: edema ( swelling), abrasions, contusions , scratches or claw marks, hyperemia ( redness), bruises to one side ( thumb print ) or grouped bruises ( finger pads ), crescent shaped marks on one side ( due to nails ), ligature or clothing marks.
Petechiae : reddish spots ( pinpoint hemorrhages ) that are seen in conjunctiva, eye lids, deep internal organs and /or face. Due to increased pressure from occlusion of vessels. Usually denotes vigorous struggle between victim and assailant. Does not prove or disprove strangulation.
Laryngeal changes : subcutaneous emphysema ( air in tissue ) due to laryngeal fractures.
Spontaneous abortions have occurred immediately or days afterwards.

10. Phases of Strangulation
Denial : Cannot believe what is happening to her. Unable to respond and defend self. Anxiety begins to set in.
Panic : Has sensation that cannot breath. Starts clawing at her neck to get his hands off. He presses harder.
Realization : Aware that he may kill her. Becomes dizzy and looses consciousness in 10 to 15 sec. During this phase, pressure on carotid artery causes bradycardia, or possible cardiac arrest. Clots begin to form in the blood vessels due to obstruction and may cause stroke. ( May happen 12 – 24 hours post). Petechia form.
Resolution : She accepts her fate and stops fighting. She is going to die. Brain death will occur in 4 to 5 minutes.
It takes less pressure to occlude the blood vessels than it does to pull the trigger of a gun.

11. Help….
When do you call EMS ? As soon as they say the word “CHOKED”. Need MRI to show deep tissue injuries.
Many have no visible injuries. Passed off as “nothing” but may die later due to swelling, hemorrhage, or brain injury. As skin dries some of injuries become transparent and dry and no longer visible.
Call in your forensic nurses. Accustomed to assessing, taking photographs, documenting and testifying
TAKE PICTURES regardless of no visible injuries.
How were they strangled?
How many times?
Did the assailant wear jewelry?
Use diagrams and document carefully.
Talk to the victim. Encourage them to report the incident. Ups the ante to felony.

23. Questions ???????
No Math and No Science Questions Please !!!

24. Break

25. Court Room Presentation