EMS- Strangulation Trauma in Domestic Violence


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This is a CE article for my service, very well received, looking at Strangulation trauma of the type seen in domestic VIolence. It covers patho-physiology, incidence, documentation, recognition, treatment, and much more.

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EMS- Strangulation Trauma in Domestic Violence

  1. 1. ©Robert S. Cole, 8/2004 All rights reserved. Strangulation Trauma in Assaults: An Overview for Emergency Services Personnel By Robert S. Cole, CCEMT-P Forward: I wish to thank the assistance of San Diego’s Gail B. Strack, J.D. of the San Diego City Attorneys Office, and George McClane, M.D., for inspiring me to research and write this article for EMS providers. Introduction While domestic violence (DV) and sexual abuse (SA) in any form is horrible, strangulation during sexual or domestic assault is a marker of a particularly dangerous and potentially life-threatening situation. Strangulation is a relatively under-reported, under-prosecuted, and under treated situation in both the law enforcement and medical communities alike. Frequently, unless the victim sustained obvious visible (often non life-threatening) injuries in addition to the strangulation, the incident is overlooked or downplayed. As a better understanding of the dangers of strangulation (both as an injury and marker for future violence) filter down from above, more and more Law Enforcement Agencies mandate a medical evaluation for victims. Frequently this is simply interpreted as summoning EMS to “check the victim out”. Unfortunately what should be an opportunity to see that a victim gets physical and social assistance often becomes another routine “treat and release”. In addition, brief or sketchy documentation by EMS providers may cast enough doubt in the legal system to prevent successful prosecution of aggravated battery or more serious charges. By the end of this article EMS providers should be able to: 1- Define domestic violence and sexual assault. 2- Recognize high-risk situations for victims of domestic violence. 3- Define 4 types of strangulation trauma. 4- Learn to identify the physical and subjective presentations of the victim. 5- Recognize the need for medical evaluation of all strangulation victims, as well as those with especially high risk. 6- Screen victims and anticipate problems in acute medical care. Prevalence and importance. It is widely acknowledged that Domestic Violence and Sexual Assault in general (and by default, strangulation) are under reported. However strangulation has recently been recognized as one of the most severe forms of DV. Statistics show:
  2. 2. ©Robert S. Cole, 8/2004 All rights reserved. • Mortality statistics that relate to method and demographics of homicidal strangulation are uncommon, however the King County Coroner’s Office Report that only 4% of all Homicides in 2002 were strangulations, but all of the victims were female. Over the previous 10 years, approximately 2-6% of homicides were strangulations(6). • In the US as a whole, 10% of all violent non-accidental deaths are the result of some form of strangulation. Females outnumber males as victims 6 to 1.(5) • In a profile of 100 DV related strangulation cases in San Diego, 62 percent had no reported visible injury and in only 3 instances did the victim seek medical treatment. (5) • Upwards to 40% of DV victims reported strangling as part of their DV, however only about 10% actually report this to police at the time of the incident. (5, 7) • The most dangerous time for a victim of DV is during pregnancy, during separation, or after reporting abuse. (5) In the past, strangulation in DV was not aggressively prosecuted. The general feeling was that if it left no marks or did not immediately kill the victim, and then it was not a serious incident. This combined with victims that recant their testimony (up to 70%), and failure of medical personnel to recognize more subtle symptoms, simply resulted in a lack of appreciation for the seriousness of the crime. As medical and forensic science has progressed, this is fortunately changing. Many prosecuting attorneys use not only the police reports, but also the reports of EMS providers and ED staff to determine how aggressively to charge perpetrators of DV. Medical documentation is considered “persuasive evidence” in the legal community. In fact, anecdotal reports from prosecutors indicate that simple awareness of the severity of strangulation, combined with better documentation by both law enforcement and medical personnel (including EMS) dramatically increased not only the percentage of successful prosecution, but the severity of the convictions as well. Definitions TDomestic Violence:T While legal definitions vary from state to state, it is generally safe to say DV is the abuse (emotional, physical, sexual, and financial/exploitive) of one party by an “intimate partner”. • Emotional or psychological abuse includes intimidation, degradation, coercion, false accusations, humiliation, ridicule and threats of physical harm. In same sex relationships this may mean threatening to “out” (expose) the victims sexual preference (or even past sexual acts/history) to family or friends. Often this includes social isolation, forced dependence, and obsessive ridicule. • Forms of physical violence include pushing, shoving, slapping, punching, kicking, binding, holding, choking and assault with (or without) weapons. • Sexual abuse may involve unprotected, nonconsensual or painful sexual acts. It may involve participation in pornography, or sex with multiple partners. Frequently this goes hand in hand with emotional abuse, as this is used to “blackmail” the victim and force dependence. It is important to note that in most states no “penetration” is required for the abuse to be sexual. • Financial/Exploitive: The most common form of this is control over family assets used in such a way to cause “forced dependence”.
  3. 3. ©Robert S. Cole, 8/2004 All rights reserved. While typically thought of as a male verses female problem, DV may occur at least as often, possibly even higher rates in some same sex couples. It is also important to know that DV is as much about control as it is about anger. Many victims report being strangled multiple times by the same assailant as means of control and submission. TSexual Assault:T Sexual assault is defined as sexualized contact of any nature (sometimes referred to as carnal knowledge) with another person without consent and by force (compulsion). Some forms of sexual assault do not require the use of force, but instead fear or drugs as a means of coercion, and are still considered criminal. Sexual assault in DV is considered a marker for “high risk” cases, and strangulation is often seen as well. TStrangulation:T Strangulation is defined as a form of asphyxia where either the blood vessels or the trachea is closed by external pressure on the neck. Commonly called “throttling” in the United Kingdom, and “choking” in the United States, it is beneficial to simply use the universally accepted term strangulation. While domestic violence spans all social and gender barriers, it typically takes someone of significantly larger mass and strength to strangle someone. While there are of course exceptions, for this reason most (not all) victims are female and most perpetrators are male. There are 3 main types of strangulation methods: • Manual: Simply put the use of one or both hands in the strangulation of the victim. Variations include using forearms, knees, and similar methods.
  4. 4. ©Robert S. Cole, 8/2004 All rights reserved. • Ligature: This consists of anything from telephone cord, clothing (in one case a bikini top was used) or wire. This form is most likely to leave physical marks. • Choke Holds: Such as those used by Law enforcement agencies (A.K.A. Lateral Vascular Restraint, L.V.R.), often will leave little or no initial external signs, as most occlusion of the carotid arteries is caused by indirect pressure distributed over the muscular structures of the neck. Initial signs of bruising should be considered. • Other types: asphyxiation by occlusion of the airway with a plastic bag. Physiology The structures affected in the neck are the jugular veins, carotid arteries, and the cartilage structures of the trachea. While the end result is the same (severe pain, followed by cerebral hypoxia, unresponsiveness, seizure, and death), this is most likely the result of damage to vascular structures of the neck, not occlusion of the airways. It takes just over 30 pounds of pressure to close the trachea, but only 11 pounds of pressure to occlude the carotid arteries. Considering that a typical trigger pull on the Glock® 35 .40 Caliber pistol is 4.5 pounds, one can see that it doesn’t take much pressure to successfully strangle a person. McClane, et al, reports that when the arteries are occluded, unresponsiveness can occur in less than 10 seconds. It is also reported that for every 10 seconds of occlusion that the pt will remain unresponsive for an additional 10 seconds. After a minute of complete occlusion, the victim is frequently unresponsive, apniec, and will not recover with out medical intervention. Strangulation or apnea in excess of 4-6 minutes will result in brain damage or death. It is assumed that the victims survive because many perpetrators let go shortly after the victim goes limp, soils them selves, or seizes. Many anecdotal reports show that victims survived by “playing dead”. Direct pressure over the carotid arteries may mimic carotid sinus massage used as a treatment for certain tachycardic rhythms. As a result, all of the same complications may
  5. 5. ©Robert S. Cole, 8/2004 All rights reserved. result, including severe bradycardia, thrombosis, and stroke. In addition the profound catecholamine dump combined with the hypoxia typically present in these situations may precipitate other cardiac emergencies such as myocardial infarction or lethal arrhythmia. The Hyiod bone is a small structure that sits at the base of the tongue. It completely fuses at about age 30 in humans. About 1/3 of victims of manual strangulation will have suffered a fracture to the Hyiod bone. Loss of the structural integrity of the hyoid, as well as resultant swelling, may cause severe airway issues, as well as make for difficult intubations. The Hyoid Bone and other structures In pregnant patients, miscarriage has been anecdotally reported with in 24-48 hours post strangulation. Delayed death has been reported in some cases, sometimes up to 36 hours later, due to cerebral swelling, hypoxic brain injury, respiratory decomposition (from aspiration), and swelling/damage to the carotid bodies or airways. For this reason all victims should be encouraged to seek medical evaluation by an MD. Recognition Strangulation cases are notoriously difficult to document. Many of the external bruising of the neck will not show for many hours and days later. The San Diego Police department reported that in 50% of Strangulation cases, there were no visible injuries; In another 35% the injuries were too minor to photograph (the classic “redness” or scratches). Thus only in 15%, were there obvious signs of injury. In the same review, victims only sought care at a medical facility in 3% of cases, predominantly for complaints due to pain, voice changes, and difficulty swallowing, thus stressing the fact that EMS providers may be the only medical personnel these victims may see. Common exam findings are: • Petechiae: With particularly violent or vigorous struggle or strangling, and more commonly with ligature strangling, petechiae may be seen. Sometimes this is only seen in the conjunctiva. These are the rupture of small capillaries at or above the level of strangulation. This may be commonly confused with benign rosacea. A common variation on this is “Blood shot eyes”. • Ligature Marks: While frequently more obvious, ligature marks may be hidden in the folds of neck tissue. Sometimes the pattern can reflect the type used, such as telephone cord. Occasionally assailants will try to mask ligature strangulation by Hyoid Cricoid and Thyroid Tracheal Rings
  6. 6. ©Robert S. Cole, 8/2004 All rights reserved. Hanging the victim post mortem. Assessing the angle of ligature marks, or the presence of multiple ligature marks, as well as other signs of assault is essential. • Bruises: Round or oblong bruises may be from thumbs or fingers of the assailant and indicate extreme pressure if they are acutely visible. Often these may be hidden under the chin, in the folds of the neck, or in the hair behind the ears. • Sustained pressure may cause congestion and blueness of the tongue, pharynx and larynx “He choked me…but there are no marks…” With the lack of obvious physical evidence at the initial scene, it seems pointless to spend a lot of energy on these calls. However, as the human body is predictable in its response to injury, even minor clues may help win a case or show the need for ongoing medical evaluation. The right assessments not only will help show a pattern of physiologic response, but may encourage the pt to seek medical care when she would not normally. While the act of strangulation may not leave much initial physical evidence, often the victim’s struggles may. Scratches, gouges, and abrasions from the instinctual attempts at defense may be noted. Sometimes the scratches may be from the assailant, but this will be difficult to determine. These may be seen as self inflicted by the uniformed observer, but may be defensive in nature. Common defensive marks are: • Impressions: Impressions are semi-circular “gouges” from fingernails digging in as the victim tries to work her hands around the assailant’s hands, arms, or ligatures. • Scratches: Just like they sound, these are long linear abrasions and vary in width depending on the angle of the nail against the skin. • Claw Marks: Simply long scratches running parallel to each other. • Chin Abrasions: A common finding in manual strangulation, resulting from the victim lowering her chin to protect her neck from the assailant, causing it to rub against the assailant’s hands. Good places to look for marks are the chin, behind the ears, back of the neck, and in folds of skin. HAVE THE VICTIM LIFT UP ANY HAIR WHEN YOU INSPECT THE VICTIM. Also look on the underside of the chin. Injuries may be hidden otherwise. As with the rest of medicine, the subjective assessment is the most difficult part of the art we practice. The main difficulty in documenting strangulation cases is not that we aren’t looking for physical signs; it is that we are not asking the right questions. Common key questions should assess for: • What was the victim strangled with (one or both hands, bar hold, wire, etc). How many times? • What time did this occur or how long ago did it occur? • Has this happened before? • How long and how many times did the assailant strangle the victim? • Rate the pain on a 1-10 scale. Rate the pressure used. • Where else did the assailant grab or hurt the victim? While we should always try to get the victim to an MD for evaluation, the following are especially worrisome signs indicative of medical need.
  7. 7. ©Robert S. Cole, 8/2004 All rights reserved. • Was the victim shaken while strangled? (Consider possible spinal injury) • Was the victim’s head thrown or beat against the ground, wall, or other object? (Consider possible closed head injury) • Is there any difficulty swallowing (dysphagia) or moving the tongue? (Consider airway swelling or nerve damage) • Is the victim short of breath? • Did the victim bite their tongue, lose consciousness, have any memory loss, seize, or pass out? • Was the victim incontinent? • Any sign of vomit on the pt or clothes? • Was an object used (ligature)? • Presence of visible injuries, petechiae, or vocal changes (dysphonia). • Statements of suicidal thoughts. The main difficulty in documenting strangulation cases is not that we aren’t looking for physical signs; it is that we are not asking the right questions. Treatment In mild to moderate cases, care is simply palliative, with a strong emphasis on getting the pt to ongoing medical and mental help. Simply being a patient advocate, a good listener, and showing compassion and respect to the traumatized victim is essential. In severe cases, most care will result around airway management. As discussed above, some patients may develop severe respiratory compromise either due to airway swelling, aspiration, or hypoxia. Providers should be prepared for a difficult airway, or possibly surgical cricothyrotomy. Most strangulation is a rather physically violent episode, and as such should be evaluated for need of spinal immobilization. Certainly not always required, but documentation should reflect a thorough evaluation in this regard. This is especially true when the victim suffers other injuries, as well. Documentation EMS personnel are in the unique position of being the only health professionals who have actual eyewitness exposure to the domestic abuse home environment. In addition, since only about 3% of victims will seek medical evaluation by a physician, EMS providers may be the ONLY medical evaluation the victim receives. They may find evidence that would otherwise be unsuspected and unreported. They may be the only health professionals able to recognize, report, or suggest intervention. Some sources (predominately non EMS) suggest there is a reluctance to get involved or collect data by EMS providers. In my experience, this is not the case. Many medics will thoroughly document cases like drunk driving, child abuse, and battery, with the hopes it
  8. 8. ©Robert S. Cole, 8/2004 All rights reserved. will help in the prosecution of the perpetrators of such crimes. However, if this is true (which the author hopes is not the case), then this must be addressed through education. Paramedics must understand that detailed and correct evaluation and documentation can save lives, even if the pt never presents to the hospital. Simply put, since we know that victims will often suffer multiple attacks over the course or a relationship (and often after it ends), and that the pattern of violence is typically one of escalation, honest and thorough medical evaluation and documentation may prevent future abuse, possibly even homicide, by supporting the prosecutor’s efforts to incarcerate the perpetrator. Simply put, since we know that victims will often suffer multiple attacks over the course or a relationship (and often after it ends), and that the pattern of violence is typically one of escalation, then honest and thorough medical evaluation and documentation may prevent future abuse, possibly even homicide, by supporting the prosecutor’s efforts to incarcerate the perpetrator. Summary A better understanding of the physiological, as well as the psychological and legal aspects of strangulation trauma, will enable EMS providers to be not only better and more vigilant care providers, but better patient advocates as well. This is especially important, as EMS providers will likely be the only medical provider the victim sees after an incident. Bibliography 1- Analysis of Data on Crimes by Current or Former Spouses, Boyfriends, and Girlfriends, U.S. Department of Justice, March, 1998 2- Tjaden P, Thoennes N. Full report of the prevalence, incidence, and consequences of violence against women. Washington, DC: National Institute of Justice and CDC, 2000 (NCJ183781). 3- Uniform Crime Reports of the U.S. 1996, Federal Bureau of Investigation, 1996. 4- Sex Differences in Violent Victimization, 1994, U.S. Department of Justice 5- Strangulation and Domestic Violence Presentation for Nampa Police Department, Nampa Idaho, 2003, Strack and McClane. 6- 2002 Annual Report, 2002, King County Medical Examiners Office. 7- Know the Law: resource Material on Strangulation, 2000, HTUwww.correctionhistory.orgUTH