GEMC- Hanging and Strangulation, Asphyxiation & AeA "The Choking Game"- Resident Training
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GEMC- Hanging and Strangulation, Asphyxiation & AeA "The Choking Game"- Resident Training

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This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, ...

This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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    GEMC- Hanging and Strangulation, Asphyxiation & AeA "The Choking Game"- Resident Training GEMC- Hanging and Strangulation, Asphyxiation & AeA "The Choking Game"- Resident Training Presentation Transcript

    • Project: Ghana Emergency Medicine Collaborative Document Title: Hanging & Strangulation, Asphyxiation & AeA “The Choking Game” Author(s): Joe Lex, MD, FACEP, FAAEM, MAAEM (Temple University) 2013 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
    • Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
    • Hanging & Strangulation Asphyxiation & AeA “The Choking Game” Joseph R Lex Jr, FACEP, MAAEM Temple University School of Medicine Philadelphia, PA USA
    • Objectives • Describe causes of death in judicial and suicidal hangings • Discuss how initial Glasgow Score is not predictive of outcome in hanging victims • Explain how ARDS develops after hanging
    • Objectives • Discuss the mechanism of death in traumatic asphyxia • List tell-tale signs that an adolescent is playing “The Choking Game”
    • Judicial Hanging Suicidal Hanging Wikimedia Commons Wikimedia Commons
    • Homicidal Lynching Wikimedia Commons
    • Judicial Hanging • Short drop: from ladder, cart, stool • Suspension hanging • Standard drop: 4 – 6 feet • break neck & paralyze
    • Judicial Hanging • Long drop: ~10 feet  can decapitate –1260 lbf = 5600 newtons = 572 kgf • Upright jerker: weights and pulleys jerk up & snap neck
    • Judicial Hanging • “Typical” midline under occiput • “Atypical” other placement • Force enough for C2 vertebral body to sublux from C3 and crush cord –Usually between C3 vertebral body and posterior elements C1 and C2
    • Judicial Hanging • When studied: judicial hangings produced fractures of cervical spine in 6/34 • Only half (3/34) were classic “hangman's fracture” James R, Nasmyth-Jones R., The occurrence of cervical fractures in victims of judicial hanging, Forensic Science International, 1992 Apr;54(1):81–91.
    • Judicial Hanging • C2  ~20% of all spinal fracture • C2  >50% of cervical fractures • Hangman’s fracture ~20-25% of C2 fractures –Dens fracture ~55% • So Hangman’s ~4-5% of all cervical fractures
    • Hangman’s Fracture • Mechanism: forcible head hyperextension, usually with neck distraction • Cause of death: compression / distraction spinal cord • Traditionally when noose placed below condemned subject’s chin
    • Hangman’s Fracture • Now seen in falls (~60%), especially age 65 and up • Metropolitan areas (94%). • Also seen: sports injuries, road traffic accidents (~20%)
    • Hangman’s Fracture Rockycpp, Wikimedia Commons Rockycpp, Wikimedia Commons
    • Hangman’s Fracture Source Undetermined
    • Hangman’s Fracture Source Undetermined
    • Hangman’s Fracture Source Undetermined
    • Hangman’s Fracture Source Undetermined
    • Suicidal Hanging Source Undetermined
    • Source Undetermined
    • Suicidal Hanging • Great Britain: most common among men, 2nd most common among women • Canada: most common method • US: 2nd most common (firearms)
    • Famous Hanging Suicides • Cheyenne Brando, daughter of Marlon Brando • Ian Curtis, lead singer of Joy Division • Buster Edwards, Great Train Robber • Frederick Fleet, lookout on Titanic who first spotted the iceberg • Pete Ham, guitarist and singer of Badfinger
    • Famous Hanging Suicides • Rudolf Hess, Hitler’s Deputy Fuhrer • Michael Hutchence, singer INXS • Richard Manuel, member The Band • Phil Ochs, political folksinger • Harold Shipman, “doctor” • David Foster Wallace, author of Infinite Jest • Aaron Swartz: internet guru
    • More Epidemiology • Materials readily available: popular among prisoners • Full suspension not mandatory • Cervical fractures rare (~0.6%) • In absence of fracture, vessel occlusion is cause of death rather than asphyxiation
    • Direct carotid bulb pressure OR Valsalva Parasympathetic discharge Bradycardic cardiac arrest Pericarotid stimulation Sympathetic discharge Dysrhythmic cardiac arrest Low neck pressure (2 kg) Venous obstruction Stagnant hypoxia Ischemia LOC ↑ ICP Neck muscle relaxation Carotid obstruction (3.5 kg) Vertebral vessel obstruction (16 kg) Brain glucose / ATP exhaustion (3-5 minutes) Cytotoxic edema Vasogenic edema Brain death
    • Direct carotid bulb pressure OR Valsalva Parasympathetic discharge Bradycardic cardiac arrest Pericarotid stimulation Sympathetic discharge Dysrhythmic cardiac arrest Low neck pressure (2 kg) Venous obstruction Stagnant hypoxia Ischemia LOC ↑ ICP Neck muscle relaxation Carotid obstruction (3.5 kg) Vertebral vessel obstruction (16 kg) Brain glucose / ATP exhaustion (3-5 minutes) Cytotoxic edema Vasogenic edema Brain death Upward displacement of tongue & epiglottis Airway obstruction Respiratory arrest
    • Low neck pressure (2 kg) Venous obstruction Stagnant hypoxia Ischemia LOC ↑ ICP Neck muscle relaxation Carotid obstruction (3.5 kg) Vertebral vessel obstruction (16 kg) Brain glucose / ATP exhaustion (3-5 minutes) Cytotoxic edema Vasogenic edema Brain death Pericarotid stimulation Sympathetic discharge Dysrhythmic cardiac arrest Direct carotid bulb pressure OR Valsalva Parasympathetic discharge Bradycardic cardiac arrest
    • Sequence of Events • Internal jugular vein occlusion  cerebral edema, ischemia, coma • Muscles loosen  carotids compressed •  vagal reflex  dysrhythmias •  sympathetic tone  dysrhythmias
    • Sequence of Events • 31 newtons = 7 lbf = 3.5 kgf  constricts carotid arteries • Face engorged and cyanotic • Tongue may protrude • Airway compression not involved –Cases of patients with functioning tracheostomy committing suicide by hanging
    • How Long to Die • Filmed hangings by the Working Group on Human Asphyxia (WGHA) • Rapid loss of consciousness: 10 ± 3 seconds Sauvageau A, et al. Agonal sequences in eight filmed hangings: analysis of respiratory and movement responses to asphyxia. J Forensic Sci. 2010; 55: 1278.
    • How Long to Die • Mild generalized convulsions: 14 ± 3 seconds • Decerebrate rigidity: 19 ± 5 seconds • Multiple phases of decorticate rigidity: 38 ± 15 seconds Sauvageau A, et al. Agonal sequences in eight filmed hangings: analysis of respiratory and movement responses to asphyxia. J Forensic Sci. 2010; 55: 1278.
    • How Long to Die • Loss of muscle tone: 1 minute 17 ± 25 seconds • Isolated muscular movements ending in 4 minutes 12 seconds ± 2 minutes 29 seconds Sauvageau A, et al. Agonal sequences in eight filmed hangings: analysis of respiratory and movement responses to asphyxia. J Forensic Sci. 2010; 55: 1278.
    • How Long to Die • Respiratory response: deep rhythmic abdominal respiratory movements described, starting at 19 ± 5 seconds and ending at 1 minute 51 ± 30 seconds Sauvageau A, et al. Agonal sequences in eight filmed hangings: analysis of respiratory and movement responses to asphyxia. J Forensic Sci. 2010; 55: 1278.
    • Time to Irreversibility • Hanging <5 minutes: survived by all patients • No patient survives hanging >30 minutes Matsuyama T, Okuchi K, Seki T, et al. Prognostic factors in hanging injuries. Am J Emerg Med. 2004; 22: 207–210.
    • What Injuries to Expect? Nikolic S, et al. Analysis of neck injuries in hanging. Am J Forensic Med Pathol. 2003 Jun;24(2):179-82.
    • Tardieu’s Spots Source Undetermined
    • Tardieu’s Spots Source Undetermined
    • Treatment • Aggressive resuscitation warranted • GCS not predictive of outcome • Assume ICP, treat accordingly • Late carotid dissection, thrombus formation reported (but rare)
    • Treatment • Pulmonary sequelae common –Neurogenic pulmonary edema: massive sympathetic discharge  poor prognosis • Thyroid cartilage fracture: ~50% • Hyoid bone fracture: ~20%
    • A R D S • Postobstructive edema: forceful inspiration against extrathoracic obstruction  negative intrapleural pressure • Pressure removed  rapid pulmonary edema  ARDS
    • Ligature Strangulation Source Undetermined
    • Ligature Strangulation • Manual strangulation = throttling –Usually man vs. woman • Ligature strangulation  loss of consciousness in 15 seconds, neuronal death in 5 minutes –Man vs. woman, child, elderly
    • Manual Strangulation Source Undetermined
    • Manual Strangulation • Disc-like finger-tip bruises • Linear finger-nail scratches: from assailant or victim • Tongue congestion and cyanosis • Damage to larynx –Superior horns of thyroid cartilage and greater horns of hyoid bone
    • Chokehold • AKA stranglehold –Judo  shime-waza • Grappling hold that critically reduces or prevents either air (choking) or blood (strangling) from passing through neck
    • Sleeper Hold United States Marine Corps, Wikimedia Commons
    • Sleeper Hold • Lateral vascular neck restraint • Used in law enforcement • From behind suspect or from front when the officer is on top • Arm around neck of suspect with crook of elbow over neck midline • Pinch arm  compress carotid arteries and jugular veins
    • Positional Asphyxia Source Undetermined
    • Positional Asphyxia Source Undetermined
    • Positional Asphyxia Source Undetermined
    • Positional Asphyxia – Hogtie Jbc01, Wikimedia Commons
    • Positional Asphyxia • Body position prevents adequate breathing • People die suddenly and without apparent reason during restraint by police, prison officers, and health care staff
    • Positional Asphyxia • Risk factors increasing chance of death: obesity, prior cardiac or respiratory problems, use of illicit drugs such as cocaine or methamphetamine Byard RW, et al. Conditions and circumstances predisposing to death from positional asphyxia in adults. J Forensic Leg Med. 2008 Oct;15(7):415-9.
    • United States Army, Wikimedia Commons
    • Traumatic Asphyxia United States Navy, Wikimedia Commons
    • Traumatic Asphyxia • Cause: compression of upper abdomen or thorax • First report in Paris riots: 1837 –“Masque ecchymotique” Ollivier DA: Relation médicale des événements survenus au Champs-de-Mars le 14 Juin, 1837. Ann Hyg 1837; 18:485-494
    • Traumatic Asphyxia • Usually diagnosed postmortem • Prognosis good if patient survives until hospital admission
    • Common Causes • Jack slippage • Landslide • Toppling of heavy machinery • Garage door • Crowd surges James Cridland, Flickr
    • Hillsborough Disaster • 15 April 1989 • Football stadium in Sheffield • 96 people crushed to death –All fans of Liverpool Football Club • Deadliest stadium-related disaster in British history
    • Hillsborough Disaster nicksarebi, flickr
    • Hillsborough Disaster Superbfc, Wikimedia Commons
    • Pathophysiology 1.Sudden  intrathoracic pressure 2.Massive object falls on chest  prolonged chest compression 3.Massive  thoracic venous pressure  cephalad venous blood ejection  capillary rupture  ecchymosis
    • The Fear Factor • Sudden  intrathoracic pressure • Sense of impending doom when realizes about to be crushed • Deep breath, hold, brace for impact • Closed epiglottis  intrathoracic pressure during compression Lee M, et al. Ann Thorac Surg 1991;51:86-88
    • Experimental Model • Early dog experiments unsuccessful • Only worked after occluding endotracheal tubes
    • Cause of Death • Chest wall constriction, hypoxia, and apnea • No animal can survive more than five times its body weight for longer than 10 minutes Furuya Y, et al. Igaku Kenkyu 1981;51:117-119
    • Concomitant Injuries • Lower extremities spared: abdominal pressure partially obstructs inferior vena cava • Hematuria common • Common: rib, clavicle fracture • Blunt cardiac injury: rare • CNS impair: rarely long-term
    • Concomitant Injuries • Subconjunctival hemorrhages • Proptosis, diplopia • Transient blindness • Retinal vessel leakage Purdy RH, et al. J Emerg Med 1988; 6:373-376. Macnab AJ, et al. AEM 1987;16:1289-1290 Baldwin GA, et al. J Trauma 1988;28:557-558.
    • Treatment Supportive • Elevate head of bed to 30o • Give high-flow oxygen • Monitor cardiac status • Treat associated injuries • Evaluate for crush syndromes: rhabdomyolysis, renal failure Stewart CE. Emerg Med Rep 1993;14:227-235.
    • Prognosis • Dismal or excellent: no middle ground • Large series: survivors extricated within 15 minutes of entrapment • If survive for more than an hour, more than 90% survival without sequelae or complications Gorenstein L. J Pediatr Surg 1986;21:753-756.
    • Erotic (Sexual) Asphyxia • Intentionally cutting off oxygen to the brain for sexual arousal • Also called asphyxiophilia, autoerotic asphyxia, scarfing, kotzwarraism, breath control play • Person engaging in activity is called a gasper
    • Erotic (Sexual) Asphyxia • Classified as paraphilia in DSM- IV (Diagnostic and Statistical Manual of the American Psychiatric Association) • Estimated 250 – 1000 deaths / year in US Hazelwood, R., Dietz, P, and Burgess, A., Autoerotic Fatalities, Lexington, MA, Heath, 1983.
    • Estragon: What about hanging ourselves? Vladimir: Hmm. It’d give us an erection. Estragon: An erection! Vladimir: With all that follows. Where it falls mandrakes grow. That’s why they shriek when you pull them up. Did you not know that? Estragon: Let’s hang ourselves immediately!
    • Erotic (Sexual) Asphyxia 1. Evidence of a physiological mechanism for obtaining or enhancing sexual arousal that provides self-rescue mechanism or allows victim to voluntarily discontinue its effect 2. Reasonable expectation of privacy
    • Erotic (Sexual) Asphyxia 3. Evidence of solo sexual activity 4. Evidence of sexual fantasy aid 5. Evidence of prior dangerous autoerotic practice 6. No apparent suicidal intent
    • Erotic (Sexual) Asphyxia • Not against the law (except in Missouri and Mississippi) • If found to be accidental, police back off and insurance must pay
    • G.A.S.P Games Adolescents Shouldn’t Play
    • The Choking Game • Airplaning • America Dream • Black Boxing • Black Out Game • Breath Play • Breathing the Zoo • Bum Rushing • Catching Some Zs • California Blackout • California Choke • California Dreaming • California Headrush • California High • California Knockout • Choking Game • Cloud Nine
    • The Choking Game • Cobra Clutch • Crank • Dream Game • Dreaming Game • Dying game • Fall Out Game • Flat Liner • Flatline Game • Flatliner Game • Funky Chicken • Getting Passed Out • Grandma's Boy • Groobling • Halloween • Harvey Wall Banger • High Riser
    • The Choking Game • Hoola Hooping • Hyperventilation Game • Indian Headrush • Knockout Game • Pass-out Game • Purple Dragon • Natural High • Neckies • P.J. Carlesimo's Revenge • Redline • Rising Sun • Rocket Ride • Sandboxing • Sleeper Hold
    • The Choking Game • Sleepers • Space Monkey • Speed Dreaming • Suffocation Game • Suffocation Roulette • The Game • The Mysto World • Tingling Game • Trip to Heaven
    • OnLine Survey Male Female Have you heard of the choking game? 77% 75% Did you know it by any other name? 39% 34% Do you know someone who has played? 64% 57% Do you know someone who still plays? 22% 13% Have you played? 37% 34% Do you still play? 12% 4% Have you played alone? 15% 8% Have you shown or told anyone how to play? 27% 17%
    • Source Undetermined
    • Source Undetermined
    • The Choking Game • Usually NOT sexual gratification • On a “dare” for peer acceptance • During school, to get out of class • Curiosity: copycatting Flatliners • Brief sense of euphoria • Intoxication at no financial cost
    • Telltale Signs • Suspicious marks on neck –May be hidden by turtleneck, scarf, turned-up collar • Changes in personality: overtly aggressive, agitated • Strap, rope or belt lying around –Attempts to elude questions
    • Telltale Signs • Headaches (sometimes very bad), loss of concentration, flushed face • “Bloodshot” eyes • Thud in bedroom or against wall –Fall in cases of solitary practice
    • Telltale Signs • Questions about effect, danger, or sensation of strangulation • Use of symbols or emoticons indicating self-asphyxiation: : ) llll : p
    • Conclusions
    • 10 Conclusions 1. In victims of hanging and strangulation, initial GCS does not predict outcome 2. Neurogenic pulmonary edema from massive sympathetic discharge has poor prognosis 3. Ligature strangulation can cause loss of consciousness in <15 sec
    • Conclusions 4. Cervical fractures rare in suicidal hangings 5. No animal can survive more than five times its body weight for longer than 10 minutes 6. If survive traumatic asphyxia for more than an hour, >90% w/o sequelae or complications
    • Conclusions 7. Death from erotic asphyxia is accidental 8. “The Choking Game” common in adolescents, boy and girls 9. Not for sexual stimulation 10.Even Kiefer Sutherland and Julia Roberts take bad roles