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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.
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