RUNNING HEADER: STRANGULATION

EXAMINATION

Introduction

Strangulation, one of the best predictors of homicide, is present in 10% of traumatic

deaths (Strack & Gwinn, 2011). It is estimated only 11 pounds of pressure applied to both carotid

arteries for ten seconds leads to unconsciousness. Brain death can result if this pressure is

sustained for four to five minutes (McCance & Heuther, 2010; Strack & McClane, 1999). More

than half of states have a statute specific to strangulation; yet, it can be minimized or not reported

at all by victims (Turkel, 2010). Even though strangulation can occur with a small amount

ofwith minimal pressure to the neck, it can be easily missed by a health care provider because

there may be no physical findings. Lack of visible injury or delayed or vague signs and

symptoms contribute to the lack of reporting and make evaluation difficult and challenging

(Clarot, Vaz, Papin, & Proust, 2005; Taliaferro, Hawley, McClane, & Strack, 2009). Despite

this, the victim may have serious internal injuries, such as respiratory or neurologic disorders that

require medical observation or treatment. In fact, victims of strangulation may die several days

or even weeks after the event. (Gwinn, McClane, Shanel-Hogan, Strack, 2008).

More expertise is needed to properly identify and examine victims of non-fatal

strangulation. It is vital for the health care provider to understand the severity of strangulation

and be prepared to examine the patient and collect evidence. The purpose of this article is to

provide an overview of strangulation for health care providers, especially those who may care for

victims of IPV, and to present best practice guidelines for performing an evidentiary examination

on victims of non-fatal strangulation.

Prevalence
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There are about 1.5 million women violently assaulted each year in the United States by

an intimate partner (Shields, Corey, Weakley-Jones & Stewart, 2010). A study published by

Moyer (2013) indicates 31% of women report some IPV in their lifetime. Females are almost

always the gender of victims of strangulation cases, and their intimate partners are most

commonly the assailant (Plattner, Bolliger, & Zollinger, 2005; Shields et al., 2010). A review of

300 strangulation cases randomly selected over a five-year period by Strack et al. (2001) showed

there was history of IPV in 89% of the strangulation cases.

Strangulation often occurs late in a relationship, over 5 years in (Wilbur, Hugley,

Hatfield, Surprenant, Taliaferro, Smith & Paolo, 2001). By the time strangulation occurs, the

victim is a very ominous situation. A study by Wilbur et al. (2001) shows 87% of those strangled

reported they had been threatened with death by their abuser. In a recent study of protection

orders at the San Diego Family Justice Center, 60% of the women seeking protection orders

reported being strangled (National Strangulation Training Institute, 2012). The odds of

becoming an attempted homicide victim increased by seven 7 times for women who had been

strangled by their partner (Glass, Laughon, Campbell, Block, Hanson, Sharps, & Taliaferro,

2008).

Definition of Strangulation

An important distinction for health care providers is the difference between strangulation,

suffocation, and choking. These terms are often confused, yet all lead to asphyxia – a lack of

oxygen to the brain (Taliaferro et al., 2009). Strangulation occurs when external pressure is

applied to the neck compromising the blood vessels or potentially also the air passages (it takes

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33 lbs of pressure to close the trachea) (McCance & Heuther, 2010; Strack & McClane, 1999).

Suffocation results from obstruction of the airway at the nose or mouth and can also occur

accidentally or intentionally (Taliaferro et al., 2009). Choking, on the other hand, may be used in

reference to strangulation and can also be used in reference to obstruction of airways internally,

such as with food or an object (McCance & Heuther, 2010).

When patients give their history of eventsdisclose the details of the assault, they may

refer to strangulation as choking. Use of the term strangulation or non-fatal strangulation is more

specific than choking and should be used in place of choking. However, when interviewing

victims of non-fatal strangulation cases, professionals should use terminology the victim

understands and is comfortable with and document what the patient says in direct quotes. The

victim would likely prefer to be referred to as a patient instead of a victim. In this article, both

terms are used, as appropriate.

Types of Strangulation

Manual

Manual is the most common type of strangulation and is used when the assailant’s hands are

used to compress the victim’s neck. Manual strangulation occurs in 83% of strangulation cases

(Shields et al., 2010).

Choke Hold

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A choke hold is used when the assailant’s arm is bent at the elbow and comes from behind the

victim to apply pressure to both sides of the neck at the same time. This may leave no external

marks (Dix & Calaluce, 1998).

Ligature

A ligature type of strangulation is when an object, such as a rope, is used to compress the neck.

Postural

In a postural strangulation, the victim is unable to breathe because of the position of the chest

(for example, assailant is sitting on victim’s chest; victim states they couldn’t breathe).

Hanging

A hanging involves the use of a noose around the victim’s neck and the weight of the

victim’s body to cause compression on the neck.

Figure 1. Terminology

Mechanism of Injury

Compression of the neck or applying pressure to the neck can cause significant injury in

the following ways:

Venous congestion

The jugular veins are the vessels in the neck that carry deoxygenated blood from the

brain back to the heart. Only a minimal amount of pressure, 4.5 lbs, is needed to close the jugular

veins. Closure of the jugular veins causes stasis of the blood within the vessels of the brain

leading to unconsciousness and cerebral hypoxemia (McCance & Heuther, 2010). Petechial

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hemorrhages may develop due to the increased negative intracranial pressure in the head due to

lack of drainage of the deoxygenated blood.

Figure 2. Anatomy illustration of the neck. Used with permission, National Strangulation

Training Institute

Arterial obstruction

The carotid arteries are the vessels in the neck that carry oxygenated blood to the brain. A

little more pressure, 11 lbs for 10 seconds, is needed to close occlude the carotid arteries. If this

pressure is immediately released, blood flow should be restored and consciousness may be

regained, but if this pressure continues for four to five minutes, death will result. Closure of the

carotid arteries stops this vital blood supply to the brain leading to unconsciousness and cerebral

hypoxemia (McCance & Heuther, 2010). Petechial hemorrhages will not necessarily occur

because blood can escape through the jugular veins (for example, lack of negative negative

intracranial pressure in the head).

Airway Obstruction

This is uncommon as 33 lbs of pressure is needed to close the trachea. Closure of the

trachea prevents oxygen from entering the lung causing asphyxia (McCance & Heuther, 2010).

Carotid Sinus Pressure

With strangulation, there is the possibility of pressure being placed on the carotid sinus

leading to cardiac dysrhythmias and arrest. However, this is not likely since force must be

applied to a specific area for at least 3-4 minutes (Clarot et al., 2005).

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Regardless of the mechanism, the victim of strangulation will endure severe pain before

unconsciousness, and subsequent death will follow (McClane, Strack & Hawley, 2001). As

described above, strangulation can be a quick way for the assailant to gain control over the

victim. The amount of time pressure was applied to the neck and the amount of how much

pressure was applied likely reflects the intent of the assailant’s intent. This is why it is essential

to have excellent documentation of the patient’s history of events and examination findings.

Screening for Strangulation

The U.S. Preventive Task Force recommends screening all women of childbearing age

for IPV – regardless of presence of abuse in their history (Moyer, 2013). For those with positive

IPV screenings, keep in mind strangulation often leaves no visible injuries. In a review of 300

attempted strangulation cases, 35% of strangulation cases, injuries were found to be very minor

in 35% of caseswere characterized as “very minor” (Funk & Schuppel, 2003; Strack et al., 2001;

McClane et al., 2001). This may help explain why, in a study by Strack et al. (2001), in this

study, only five percent of of 300 victims sought medical attention for strangulation injuries.

With such a small percent of victims coming forward to report strangulation, the only chance of

identifying such cases may be when the victim is being treated for other IPV related injuries or

sexual assault. These victims should be directly asked if they were grabbed, choked, strangled,

or if during the assault they felt like they couldn’t breathe due to pressure on their neck from the

assailant’s hands or arm. If the victim reports that they were strangled, but has no visible injuries,

a complete assessment and forensic examination should still be completed.

Physical Findings

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In a review of 134 strangulation cases in Switzerland in which the victims survived,

Plattner et al. (2005) created categories based on severity of injuries for choke-hold and ligature

strangulations. The study found that even mild injuries physical findings may be lacking in these

cases. Light strangulation injuries included findings, such as: superficial skin lesions, (abrasions

and redness of neck); moderate strangulation injuries included findings, such as: signs of

bleeding or bruising of neck or soft tissue, pharynx or larynx lesions (for example, hoarseness,

sore throat, hyoid bone fracture); and severe strangulation injuries included signs of venous

congestion or cerebral hypoxia, such as: loss of consciousness and loss of urine. More research is

needed on traumatic brain injury and association of IPV and strangulation in women (Kwako,

Glass, Campbell, Melvin, Barr & Gill, 2011).

In a separate study of 172 strangulation patients at Mercy Medical Center in Baltimore,

the use of alternative light sources (ALSs), more traditionally used for evidence collection, were

found to be very effective in identifying soft tissue injury. The study found 93% of the victims

had no visible evidence of external injuries upon examination without the ALS. Once the ALS

was used, 98% of those patients had intradermal injuries found (Holbrook & Jackson, 2013).

Delayed Sequelae

Some medical complications can occur after strangulation and may initially appear as

mild symptoms, becoming more severe hours or days later. The health care provider should

consider admitting the patient for up to 24-36 hours of observation for long term effectsdelayed

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manifestations, which may include (Taliaferro et al., 2009; McClane et al., 2001; Funk &

Schuppel, 2003):

 Pneumonia or aspiration pneumonitis can result from gasping of air during the attack and

subsequent vomiting (McClane et al., 2001).

 Edematous internal tissue of airway (Funk & Schuppel, 2003).

 Progressive, irreversible encephalopathy (McClane et al., 2001).

 Neurological problems can present themselves secondary to a cerebral artery infarct

(Sethi, Sethi, Torgovnick & Arsura, 2012).

 Miscarriage Spontaneous abortion can result from lack of oxygen to the embryo or fetus

(Strack et al., 2001)

 Carotid dissection or cerebral infarction when the main arteries supplying blood to the

brain are damaged and begin leaking blood. This is one of the most lethal and often

overlooked outcomes of strangulation (Clarot et al., 2011; Vilke & Chan, 2011).

Assessment

The following diagnostic tools can be helpful to evaluate the victim (McClane et al.,

2001):

 Pulse oximetry

 CT Scan or MRI of neck

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 X-Ray of chest to detect pulmonary edema, pneumonia or aspiration

 X-Ray of cervical spine x-ray as lateral view may reveal hyoid bone fracture

 X-Ray of nose to detect nasal fracture, if presenting with hemoptysis

 X-Ray of neck to detect tracheal deviation or fractured larynx

 Pharyngoscopy to view pharyngeal petechiae, edema or other findings

 Fiberoptic Laryngobronchoscopy to evaluate vocal cord and trachea

 Carotid doppler ultrasound to evaluate signs of cerebral vascular accident

 Otoscopic exam to evaluate ear pain or bleeding (Duband, Timioshenko, Morrison, Prades,

Debout, & Peoc’h, 2009)

Once the victim is initially assessed and cleared of the need for immediate treatment, the

health care provider should contact law enforcement, and if possible, a forensic nurse to conduct

the forensic examination.

Forensic examination

Skin

Faint circular bruises may be caused by fingertips or an isolated bruise at the front of the

neck may be caused by the assailant’s thumb (McClane et al., 2001). Fingernail marks may

appear on the victim’s neck from assailant or from victim trying to get away. This may appear

like curved or linear scratches (McClane et al., 2001). Also, chin injuries may result when the

victim presses their head down to protect their neck (McClane et al., 2001; Funk & Schuppel,

2003). Petechiae may also be present on the skin on the victim’s neck, head, face, forehead,

around eyes and ears, conjunctivae and buccal mucosa (Clarot et al., 2005; Plattner, et al., 2005;

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Dix & Calaluce, 1998). Physical findings on the skin may be more difficult to identify in darker

skinned patients; this is an area for further research (Sommers, Fargo, Baker, Fisher, Buschur &

Zink, 2009). A study by Sommers et al.A 2009 (2009) examined women after consensual

intercourse and determined it was harder to find external anogential injuries in those with darker

skin compared to those with lighter skin. This is an area for further consideration and research as

it relates to injuries to the skin after strangulation (Sommers, et al., 2009).

action items.

Image 1. Multiple scratches and marks to the neck and under the chin.

Image 2. The same picture but with a negative filter to show more of the injury. The red marks

are more visible.

Respiratory

Hoarseness in the victim should not be assumed to be related to smoking or yelling

during the assault. Approximately half of manual strangulation cases result in voice changes

(Stapczynski, 2010). The hyoid bone may not fracture during strangulation as children and

young adults have especially pliable hyoid bones (Hawley, McClane, & Strack, 2001). Older

individuals may have age-related changes to the hyoid bone or thyroid cartilage making them

more brittle and susceptible to fracture from strangulation (Stapczynski, 2010).

Eyes/Ears

Duband et al. (2009) reported hemotympanom (blood in tympanic cavity of ear) and

otorrhagia (ear hemorrhage) in two cases of strangulation.

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Image 3. Multiple pathetical hemorrhages around the eye and sub conjunctive or sclera.

Neurologic/Psychologic

The mental status of the victim can be affected both neurologically and psychologically.

The victim may have lost consciousness and may have even lost control of urine and bowels due

to cerebral hypoxia. When interviewing the victim of strangulation it is important to directly ask

whether or not they lost control of their urine and bowel because they likely will not volunteer

this information or realize it is important. Neurological deficits can also result; these symptoms

are frequently reported in the victim of strangulation and include changes in vision, tinnitus,

eyelid droop, facial droop or unilateral weakness (Stapczynski, 2010).

Due to the emotional trauma of the attack, the victim may experience memory loss,

nausea and vomiting or behavioral changes (Plattner et al., 2005; McClane et al., 2001). Even

mental status changes may occur and be delayed in survivors of strangulation. (Taliaferro et al.,

2009) These changes can be related to cerebral hypoxia, intracranial injury or ingestion of

alcohol or drugs (Stapczynski, 2010).

Pain

For strangulation patients, pain is often the only physical symptom.

Forensic Examination Pearls

Skin

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 Assess skin on the victim’s neck, head, face, chin, shoulders, and chest for signs of blunt force

trauma, such as: abrasions, bruises, swelling, redness, and pain. The BALD STEP by Carter-

Snell (2009) is a useful mnemonic for identification of injuries in a forensic examination:

o B = bleeding, bruise, burn, bitemark

o A = Abrasion, avulsion

o L= Laceration

o D = deformity

o S = Stain (+ if fluorescent), swelling

o T = tenderness to palpation, trace evidence

o E = erythema

o P = patterned (injury), petechiae, and penetrating

 Swab the victim’s neck as there is a possibility the assailant’s epithelial cells were left on skin

(de Bruin, Verhiij, Veenhoven, & Sijen, 2010). Swab the area to collect the cells twice: first with

a swab moistened with sterile water, then with a dry swab. Once the swabs have dried, place

them in a labeled container and seal it.

 Measure the circumference of the neck and document this in the patient record. Mark the

vertical point on the neck where the circumference was initially measured and re-measure the

circumference every 10-12 hours. Notify a medical doctor if the neck swelling is increasing.

 Collect debris or foreign material from the victim, if applicable. All swabs or other evidence

collected must be labeled, sealed and monitored until it is transferred appropriately over to law

enforcement.
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Respiratory

 Assess the respiratory system for dyspnea, shortness of breath, difficulty swallowing, stridor,

sore throat, tongue swelling and hemoptysis.

 Check the patient’s ability to speak (dysphonia/aphonia).

Eyes/Ears

 Assess eyes for petechiae or redness (subconjunctival hemorrhage) (Plattner et al., 2005).

 If the patient reports ear pain or other ear symptoms, ensure an otoscopic examination is

performed to check for injury.

Neurologic

 Describe the patient’s mental status, appearance, and behavior objectively. For example, the

health care provider could record that the “Patient is constantly rolling back and forth on the

gurney. Patient is frequently grabbing her throat and complaining that it hurts.”

 Document the presence, location, quality and severity of pain.

Discharge Instructions

Discharge Instructions should include the components as show in Figure 2.

Documentation

Comprehensive documentation is integral to a strangulation forensic examination. It leads

to quicker disposition of cases in court without requiring a health care provider to testify in court.

(Gwinn et al., 2004). All visible physical findings should be documented by charting (narrative),

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using body maps (diagrammatic), and obtaining photos (photo-documentation). If possible, tape

record the victim to provide a baseline capture of voice strength and status (Taliaferro et al.,

2009). Here are some important documentation instructions:

 Document everything thoroughly, including the victim’s verbatim recount of what

happened, their demeanor, mental and emotional status (McClane et al., 2001).

 Document the shape, color and location of all injuries. Minor injuries may not

photograph well, so written documentation must be accurate and thorough. Include

subjective findings, such as: nausea, pain, loss of memory, difficulty swallowing, and

complaints of throat hurting. Document these accounts in the patient’s own words.

Include objective findings, such as descriptive notations of bruising, swelling, and

abrasions and neck circumference measurements.

 Take photographs of all observed findings: distance, close and follow-up.

 Measure the circumference of the victim’s neck every 12 hours to identify swelling. Mark

the neck with a marker so that next nurse will use same vertical location to measure the

circumference of the victim’s neck. Document this in the record.

 Document the severity of the strangulation by taking a MRI of the neck (Christe, Thoeny,

Ross, Spendlove, Tshering, Bolliger, Grabherr, Thali, Vock & Oesterhelwig, 2009).

 Document all findings on a strangulation form, such as the one below. This form is an

excellent tool to assist the provider in covering all complaints and findings in

strangulation.

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Figure 4. Strangulation Form

Here are two other form examples to assist with comprehensive documentation of

strangulation:

o The State of California Office of Emergency Services has produced a Forensic

Medical Report: IPV Examination, form OES 502. This form also has detailed

documentation of history and physical examination of victims of IPV and was

created through a consensus process including health professionals, forensic

experts, prosecuting attorneys and IPV advocates (Taliaferro et al., 2009).

o The Abuse and Assessment Screen (AAS) is another widely used instrument for

screening and documenting IPV, which includes strangulation (Laughon, Renker,

Glass & Parker, 2008; McFarlane, Hughes, Nosek, Groff, Swedlend, & Dolan

Mullen, 2001).

Key Points for Healthcare Providers

1. Use the terms strangulation and choking appropriately and know that patients have

different meanings for these terms.

2. Particularly for victims of IPV, be cognizant of the prevalence of strangulation and its

lack of reporting. Ask the patient directly if they have been strangled or choked. Many

patients will show you how it was done if you ask.

3. Don’t assume the patient is not being truthful. The most important factor is the patient’s

history; screen for strangulation. Don’t fail to perform a forensic examination if no injury

is visible.

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4. Ask the patient directly about loss of urine or bowel movement during assault as they

may not volunteer this information.

5. Document all findings carefully and thoroughly with both written and photographic

methods.

6. Observe and educate patients of strangulation for delayed signs and symptoms.

7. Contact law enforcement (some states are mandated to report; other states will report if

patient agrees), and use the forensic nurse to assist in the history gathering and forensic

examination if possible.

8. Ensure chain of evidence is maintained for evidence collected.

Case Vignette # 1

Background

A 17 year-old Hispanic American female approximately five feet five inches tall and

weighing 125 lbs, was single and living with her boyfriend. She presented to the emergency

department with complaints of neck pain and problems breathing because her boyfriend was

angry with her for going out with her friends. She was initially evaluated by the midnight staff,

who did a cursory evaluation and then transferred her care to the day shift nurse practitioner.

Forensic Examination/History of Events

The forensic nurse examiner was consulted after obtaining the history the patient had

been “choked” by her boyfriend. Upon further evaluation, the patient revealed her throat was

sore and a little swollen. She had multiple linear patterned abrasions to her neck and her left eye

had a beefy red sclera. Additionally, she had petechiae along her hairline and underneath both
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eyes. She had multiple circular blue bruises measuring 1cm x 1cm to the posterior aspect of both

forearms. She also had several circular bruises on her left upper thigh and right lower leg; she

stated “he bit me there,” when asked about the injuries. The patient reported passing out several

times while her boyfriend was choking her with his hands. She tried to pull his hands off her

neck but was unsuccessful. Her boyfriend, who had choked her before, was twice her size; she

stated several times, “I thought he was going to kill me.”

Image 5. Photograph of fingernail-shaped scratches and patterned abrasions on the neck - taken

during examination of case vignette No. 1.

Diagnosis and Treatment Plan

A CT scan of the patient’s neck was ordered and revealed soft tissue swelling. Steroids

were given to the patient, and admission for observation was initiated. Pulse oximetery oxygen

saturations were also monitored as well as Q12 hour neck measurements. Documentation

including photographs was completed. The domestic violence response team and child protective

services were notified to provide community resources and development of a safety plan for the

patient and her 6-month-old baby. The patient was discharged 24 hours later from the hospital to

the local domestic violence shelter.   

Case Successes:

1. Forensic nurse examiner documented injuries and directly quoted the patient, when

needed, to document history of events.

2. Forensic nurse examiner measured the neck every 12 hours.

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3. Forensic nurse examiner communicated the observations and examination findings to law

enforcement and discharged the patient to a local domestic violence shelter.

Case Vignette # 2

Background

An 89-year-old, widowed African American female, approximately 5 feet in height,

weighing 105 lbs., was found in her apartment by emergency medical services (EMS) after

neighbors had reported to the police a domestic disturbance. EMS found the patient underneath

a sofa unresponsive, naked from the waist down with a Glascow Coma Scale (GCS) of 3. The

apartment was noted to be disarranged, and Pepto-Bismol was scattered throughout the

apartment walls.

The patient was stabilized and transferred to a level one trauma center, placed on a

ventilator and admitted to the intensive care unit (ICU). The CT scan revealed blood filling the

Circle of Willis with increasing intracranial pressures. The patient also continued to have high

ventilator peak pressures without lung issues.

A 40 year-old male suspect, six ft in. tall and weighing 250 lbs, was living in another

apartment and was identified by witnesses. The detective interviewed him; he was on parole for a

previous sex offense and openly admitted to knowing the victim. The forensic lab identified a

fingerprint lifted from the Pepto-Bismol bottle in the apartment as his. Additionally, hair and

skin from the patient were taken from a door in her apartment. When questioned, the suspect

admitted he had broken into the patient’s apartment, surprising her. He strangulated her with his

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right hand, slamming her head on the door because she would not disclose the location of an

insurance check. He then admitted to throwing her down pulling her clothes off and anally

penetrating her with his penis. He heard the police coming and ran off.

Forensic Examination

A law enforcement officer arrived in the ICU with a warrant for collection of a sexual

assault kit and photographs of all injuries. A forensic nurse examiner was notified and arrived at

the unit. The patient assessment revealed the following findings: oral endotracheal tube in place

with an oral pharyngeal airway, nasogasteric, nasogasteric tube in right nare, intracranial

pressure monitor in place, foley catheter draining clear yellow urine and a cervical collar was

still in place because the patient’s cervical x-rays had not been reviewed by the trauma service.

Bilateral bruising and swelling of both eyes with extravagation of blood under the lower eye lids,

the right eye had greater swelling than the left, the left eye had conjunctiva and sclera were beefy

red, the right eye had no redness to the conjunctiva or sclera. Her GCS continued at three and she

had no reaction to painful stimulus. Her neck was exposed by holding cervical spine alignment

and upon removal of cervical collar, significant swelling was noted on the patient’s neck in the

left side. Her neck circumference measured 19 inches. On anal exam, the patient had a three in.

laceration to the anal folds at the six o’clock position. A sexual assault kit was collected and

photographs taken of her injuries. The detective was informed of the examination findings.

Outcome

The patient died six days later. The assailant accepted a plea agreement which included

multiple years in prison for second degree murder to avoid possible rape charges.

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Case Successes:

1. Forensic nurse examiner documented the patient’s examination findings and detailed

observations, including neck swelling and trauma to the facial area.

2. Forensic nurse examiner noted anal lacerations, collected swabs and provided

documentation both photographic and in the written report.

3. Forensic nurse examiner communicated the observations and examination findings to law

enforcement.

Conclusion

Over the recent years, many strangulation cases are now being elevated for felony-level

prosecution due to professionals’ understanding of the lethality of strangulation. Police and

prosecutors are using existing statutes or working with legislators to create new felony

legislation. Specialized forms have been developed to help legal and medical professionals

document patient injuries and identify strangulation symptoms. Doctors, forensic nurses and

detectives are being utilized as experts and are testifying in court about strangulation.

Strangulation training is also being provided at many conferences and included at some regional

police training academies, often aided by strangulation training videos produced in San Diego

(Strack & Gwinn, 2011).

Despite the work that has been accomplished, much more needs to be done in the

handling of non-fatal strangulation cases. There is a need for more training, trainers and experts.

Most recently, the National Family Justice Alliance was awarded a grant by Department of

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Justice through the Office on the Violence Against Women to launch the National Strangulation

Training Institute. The goal of the Institute is to assist IPV and sexual assault forensic

professionals in the handling of non-fatal strangulation cases by providing more resources and

technical assistance, including developing two new courses for “Train the Trainers” and

“Developing Your Expert.” Every professional who works with victims of strangulation should

receive training in how to examine, manage, and document such assaults. Thousands of women

in communities across America continue to suffer from strangulation assaults without ready

access to effective prevention strategies and intervention efforts. The research is now clear:

when a victim is strangled, they are at the edge of a homicide. We are all responsible for

becoming educated and applying the best practices for forensic examination of the strangled

patient. Responsible professionals can ultimately help prevent major injuries to victims of abuse

and facilitate needed treatment. They can save lives.

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References

Carter-Snell, C. (2009). Forensic Injury Assessment & Documentation Using BALD STEP.

Forensic Nurses’ Society of Canada Website. Retrieved from

http://www.forensicnurse.ca/articles/cartersnell-BALDSTEP-instructions.pdf

Christe, A., Thoeny, H., Ross, S., Spendlove, D., Tshering, D., Bolliger, S., Grabherr, S., Thali,

M., Vock, P., & Oesterhelwig, L. (2009). Life-Threatening Versus Non-Life-Threatening

Manual Strangulation: Are There Appropriate Criteria For MR Imaging of the Neck.

European Radiology, 19(8), 1882-1889.

Clarot, F., Vaz, E., Papin, F., & Proust, B. (2005). Fatal and Non-Fatal Bilateral Delayed Carotid

Artery Dissection After Manual Strangulation. Forensic Science International, 149, 143-

150.

de Bruin, K.G., Verhiij, S.M., Veenhoven, M., & Sijen, T. (2010). Comparison of Stubbing and

the Double Swab Method for Collecting Offender Epithelial Material From a Victim’s

Skin. Forensic Science International Genet, 31(4), 320-325.

Dix, J. & Calaluce, R. (1998). Guide to Forensic Pathology. USA: Jay Dix, MD.

Duband, S., Timioshenko, A., Morrison, A., Prades, J., Debout, M., & Peoc’h, M. (2009). Ear

Bleeding: A Sign Not to be Underestimated in Cases of Strangulation. American Journal

of Forensic Medicine and Pathology, 30(2), 175-176.

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