How should a patient presenting after strangulation be managed?

Management of Strangulation Injuries

All patients presenting after strangulation require immediate airway assessment, continuous monitoring in an intensive care setting for at least 24 hours, and advanced imaging (CT or MRI of the neck) even in the absence of visible external injuries, as life-threatening complications can develop in a delayed fashion up to 36 hours post-injury. 1, 2

Immediate Assessment and Stabilization

Airway Management Priority

• Secure the airway immediately if any signs of respiratory distress are present, including stridor, hoarseness, dysphagia, or altered mental status (GCS <15). 1, 2
• Perform fiberoptic laryngoscopy in all cases to identify airway petechiae, edema, or structural injury that may not be visible externally. 3
• Maintain a low threshold for prophylactic intubation, as delayed airway obstruction can occur up to 36 hours post-injury and may necessitate emergency tracheotomy. 1

Critical Initial Evaluation

• Obtain baseline neurologic assessment using GCS, as any score <15 significantly increases risk of serious injury including cervical artery dissection. 2
• Directly assess for dysphagia, as this finding predicts clinically important injuries requiring intervention. 2
• Document all visible injuries including neck marks, facial or conjunctival petechiae, neck swelling, and any respiratory abnormalities. 3, 4

Diagnostic Imaging Strategy

Mandatory Advanced Imaging

• Obtain CT angiography of the neck in all patients with GCS <15, dysphagia, persistent neck pain, or any neurologic symptoms, as these findings predict cervical artery dissection (0.6% incidence in alert patients). 2
• MRI of the neck is the most sensitive test for subtle strangulation injuries and should be considered when CT is negative but clinical suspicion remains high. 3
• Chest radiography is indicated to evaluate for postobstructive pulmonary edema. 3

Risk Stratification for Imaging

While alert patients (GCS 15) without dysphagia or neurologic deficits have low injury rates (1.7%), the delayed presentation of life-threatening complications mandates a cautious approach:

• Any patient with concerning findings beyond isolated neck pain requires advanced imaging. 2
• The absence of visible external injury does not exclude serious internal damage, as 97% of manual strangulations leave minimal external marks. 3

Intensive Care Monitoring Protocol

Admission Criteria

• Admit all strangulation patients to an intensive care unit for continuous airway monitoring for a minimum of 24 hours, regardless of initial presentation severity. 1
• Extend monitoring beyond 24 hours if any abnormal findings on imaging, laryngoscopy, or physical examination are present. 1

Monitoring Parameters

• Continuous pulse oximetry and cardiac monitoring. 1
• Serial neurologic assessments every 2-4 hours to detect delayed cerebrovascular complications. 2, 3
• Repeated airway assessments for development of stridor, voice changes, or dysphagia. 1

Management of Identified Injuries

Cervical Artery Dissection

• Initiate antiplatelet therapy (aspirin) for cervical artery dissections without neurologic deficits. 2
• Neurology and vascular surgery consultation for all arterial injuries. 2

Airway Injuries

• Perform immediate tracheotomy for acute upper airway obstruction that cannot be managed with intubation. 1
• Neck exploration and drainage may be required for developing neck abscess or hematoma. 1
• Otolaryngology consultation for all patients with laryngeal injury or persistent voice changes. 3

Critical Pitfalls to Avoid

• Never discharge a strangulation patient from the emergency department without a period of observation, as symptoms can be deceptively benign initially with life-threatening complications developing hours later. 1
• Do not rely on absence of external neck injuries to rule out serious internal damage—most manual strangulations (97%) leave minimal visible marks. 3
• Avoid using single hemoglobin measurements as markers for bleeding severity in the acute setting. 5
• Do not delay imaging or airway intervention for "optimization" in patients with concerning symptoms. 2

Special Forensic Considerations

Documentation Requirements

• Photograph all visible injuries with and without a measurement scale. 4
• Document the exact mechanism (manual strangulation, ligature, hanging attempt) and duration if known. 6, 4
• Record all subjective complaints including sensation of inability to breathe, loss of consciousness, or memory gaps. 4
• Use structured forensic examination forms to ensure comprehensive assessment and legal documentation. 4

Intimate Partner Violence Screening

• Directly ask all patients whether they were choked or felt unable to breathe due to neck pressure, as strangulation is often underreported and represents one of the most dangerous forms of interpersonal violence. 4
• Recognize that 94% of strangulation survivors are women strangled by male household members. 3
• Provide resources for domestic violence support and safety planning before discharge. 3, 4

Discharge Criteria and Follow-Up

Safe Discharge Requirements

• Minimum 24 hours of observation without development of new symptoms. 1
• Normal advanced imaging (CT or MRI). 2, 3
• Normal fiberoptic laryngoscopy. 3
• GCS 15 with no neurologic deficits. 2
• No dysphagia or respiratory symptoms. 2

Mandatory Follow-Up

• Otolaryngology follow-up within 7 days for repeat laryngoscopy. 3
• Neurology follow-up within 30 days if any vascular imaging abnormalities. 2
• Return precautions for development of voice changes, difficulty breathing, difficulty swallowing, or neurologic symptoms. 1, 2