Strangulation: Difference between revisions

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==Background==
==Background==
[[File:MCMAP Rear choke - Defense Visual Information Center 2006.jpg|thumb|An example of strangulation ("blood choke") from a rear naked choke.]]
[[File:Gray513.png|thumb|Anatomy of neck arteries.]]
[[File:Human anatomy, including structure and development and practical considerations (1911) (14594049867).jpg|thumb|Midline neck anatomy on lateral view.]]
*Strangulation
*Strangulation
**Hanging, ligature, manual or postural strangulation
**Hanging, ligature, manual or postural strangulation
**Homicide, assault, suicide or execution
**Homicide, assault, [[suicide]] or execution
*Mechanism of death/injury <ref>Iserson, K. V. (1984) ‘Strangulation: A review of ligature, manual, and postural neck compression injuries’, Annals of Emergency Medicine, 13(3), pp. 179–185.</ref>  
*Mechanism of death/injury <ref>Iserson, K. V. (1984) ‘Strangulation: A review of ligature, manual, and postural neck compression injuries’, Annals of Emergency Medicine, 13(3), pp. 179–185.</ref>  
**Spinal cord/brainstem injury
**Spinal cord/brainstem injury
**Mechanical compression
**Mechanical compression
**Bradycardia
**[[Bradycardia]]


==Pathophysiology==
===Pathophysiology===
*Upper C-spine fractures
*Upper [[cervical Spine Injuries|C-spine fractures]]
**Hanging, greater heights
**Judicial hanging, greater heights
*Jugular venous obstruction
*Jugular venous obstruction
**Cerebral congestion
**Cerebral congestion
**Loss of consciousness
**[[syncope|Loss of consciousness]]
*Arterial compression
*Arterial compression
**Cerebral ischemia
**Cerebral ischemia
*Airway compression
*Airway compression
**Hypoxia
**[[Hypoxia]]
*Carotid baroreceptor reflex
*Carotid baroreceptor reflex
**Bradycardic arrest
**[[bradycardia|Bradycardic]] [[cardiac arrest|arrest]]


==Clinical Features==
==Clinical Features==
*Facial petechiae
[[File:PMC5392724 gr1.png|thumb|Strangulation marks sustained after scarf-related strangulation injury.]]
*Facial [[petechiae]]
*Ecchymoses
*Ecchymoses
*Airway
*Airway
**Hoarseness
**[[dysphonia|Hoarseness]]
**Stridor
**[[Stridor]]
**Fracture of larynx, hyoid, thyroid cartilage
**Fracture of larynx, hyoid, thyroid cartilage
**Laryngeal edema
**Laryngeal edema
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**Aspiration [[pneumonia]]
**Aspiration [[pneumonia]]
**[[Cardiac arrest]]
**[[Cardiac arrest]]
**Bradycardia
**[[Bradycardia]]
**Neurogenic pulmonary edema
**[[Negative-pressure pulmonary edema (NPPE)]]
*Neurologic
*Neurologic
**[[Spinal cord trauma]]
**[[Spinal cord trauma]]
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**Cerebral anoxia
**Cerebral anoxia
**Cerebral edema
**Cerebral edema
**Delayed dementia, amnesia, psychosis
**Delayed [[dementia]], amnesia, [[psychosis]]


==Work up==
==Differential Diagnosis==
{{Blunt neck trauma DDX}}
 
==Evaluation==
*CBC
*CBC
*Chem 10
*Chem 10
*PT/PTT
*PT/PTT
*Type and screen
*Type and screen
*Lactate
*[[Lactate]]
*VBG/ABG
*[[VBG]]/[[ABG]]
*EtOH, UTox
*EtOH, [[Utox]]
*CT brain
*[[CT brain]]
*CT cervical spine
*CT cervical spine
*CTA neck
*CTA neck criteria from Taming of the Sru Grand Rounds <ref>[http://www.tamingthesru.com/blog/grand-rounds/recap-110619 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]</ref>directly quoted below:
*CXR
**''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]]


==Treatment==
{{Denver Screening Criteria}}
 
==Management==
*[[ATLS]]
*[[ATLS]]
*Secure airway if indicated
*Secure airway if indicated
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*Cervical spine immobilization
*Cervical spine immobilization
*Cardiac monitoring
*Cardiac monitoring
*ABX if aspiration present
*[[Antibiotics]] if aspiration present
*PEEP for hypoxia
*PEEP for hypoxia
*Levophed for neurogenic shock
*[[Levophed]] for neurogenic shock
 


==Disposition==
==Disposition==
*Observation warranted if awake, alert, no stridor
*Observation warranted if awake, alert, no stridor
*ICU
*ICU
*Psychiatric assessment
==See Also==
*[[Denver screening criteria]]
==References==
<references/>
[[category:Trauma]][[category:ENT]]

Latest revision as of 22:17, 13 November 2024

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

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

Risk Factors

  • Midface Fractures (Le Fort II or III)
  • Basilar Skull Fracture with carotid canal involvement
  • Diffuse axonal injury with GCS<6
  • Cervical spine fracture
  • Hanging with anoxic brain injury
  • Seat belt abrasion or other soft tissue injury of the anterior neck resulting in significant swelling or altered mental status
    • Isolated seatbelt sign without other neurologic symptoms has not been identified as a risk factor[3][4][5]

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
  3. ↑ DiPerna CA, Rowe VL, Terramani TT, et al. Clinical importance of the “seat belt sign” in blunt trauma to the neck. Am Surg. 2002;68:441–445
  4. ↑ Rozycki GS, Tremblay L, Feliciano DV, et al. A prospective study for the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs. J Trauma. 2002;52:618–623; discussion 623–624
  5. ↑ Sherbaf FG, Chen B, Pomeranz T, et al. Value of emergent neurovascular imaging for “Seat belt injury”: A multi-institutional study. American Journal of Neuroradiology. 2021;42(4):743-748
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