Domestic Violence and Nonfatal Strangulation Assessment. Patricia M. Speck, DNSc, ARNP, APN, FNP-BC, DF-IAFN, FAAFS, DF-AFN, FAAN
—Crus of helix: The continuation of the anteroinferior ascending helix, which extends in a posteroinferior direction into the cavity of the concha above the external auditory meatus. The average crus helix extends about one-half to two-thirds the distance across the concha.
—Antihelix: A Y-shaped curved cartilaginous ridge arising from the antitragus and separating the concha, triangular fossa, and scapha. The antihelix represents a folding of the conchal cartilage, and it usually has similar prominence to a well-developed helix. The stem (the part below the bifurcation) of the normal antihelix is gently curved and branches about two-thirds of the way along its course to form the broad fold of the superior (posterior) antihelical crus and the more sharply folded inferior (anterior) crus. The inferior and superior crura of the antihelix can vary both in volume and degree of folding.
—Tragus: A posterior, slightly inferior, protrusion of skin-covered cartilage, anterior to the auditory meatus. The inferoposterior margin of the tragus forms the anterior wall of the incisura.
—Intertragic notch: The space that separates the tragus from the antitragus in the outer ear.
—Antitragus: The anterosuperior cartilaginous protrusion lying between the incisura and the origin of the antihelix. The anterosuperior margin of the antitragus forms the posterior wall of the incisura.
—Concha: The fossa bounded by the tragus, incisura, antitragus, antihelix, inferior crus of the antihelix, and root of the helix, into which opens the external auditory canal. It is usually bisected by the crus helix into the cymba superiorly and cavum inferiorly.
—Cavum concha: The inferior portion of the cavity of the auricle of the ear. It leads to the external acoustic meatus.
—Cymba concha: The narrowest end of the concha.
—Lobe: The soft, fleshy lower part of the external ear.
STRANGULATION-RELATED INJURIES AND CONDITIONS
The learner may find reviewing the following definitions useful in completing the activities within this book. Terminology for indicators of direction when documenting findings in a medical forensic examination include anterior (nearer the front), posterior (nearer the back), inferior (nearer the bottom), superior (nearer the top), medial (to the middle), lateral (to the side), proximal (nearer the center of the body), and distal (away from the center of the body) (Figure 5).
SIGNS AND SYMPTOMS OF STRANGULATION
—Breathing changes: Difficulty breathing (dyspnea), hyperventilation, inability to breathe (apnea)
—Evidence of hypoxia/anoxia and near-unconsciousness: Changes in vision (eg, tunnel vision, blurred, “curtain closing in,” spots, flashes of light), changes in hearing (eg, hearing loss, ringing), loss of control over body (eg, weakness, limpness)
—Evidence of anoxia and unconsciousness: Loss of memory, unexplained injuries, brain damage, involuntary urination or defecation
Figure 5. Terminology for indicators of direction when documenting findings.
—Mental status changes: Restlessness/combativeness, seizure activity, frank psychosis/amnesia
—Swallowing changes (larynx/hyoid bone injury): Difficult, but not painful, swallowing (dysphagia); painful swallowing (odynophagia); drooling
—Symptomatic voice changes: Hoarse or raspy voice (dysphonia), complete loss of voice (aphonia)
LETHALITY OF STRANGULATION
Lethality refers to capacity to cause death. Therefore, lethality of strangulation refers to one’s chances of dying as a result of strangulation.29
LETHALITY AS A RESULT OF EXTERNAL PRESSURE
—Anoxia: In cases of strangulation, the absence of oxygen depriving the brain of oxygenated blood. Characterized by tachycardia, hypertension, dizziness, mental confusion, and unconsciousness.
—Neck swelling: May present as soft tissue trauma/inflammation, internal bleeding (carotid dissection), laryngeal injury (subcutaneous emphysema). May progress slowly.
—Pneumonitis: Inflammation of the lung, resulting from inhaled emesis where the gastric juices begin to digest lung tissue.
—Post-anoxic encephalopathy: Decrease in blood flow to the brain by which some brain cells die immediately while others survive for days. Surviving brain cells eventually succumb to the cerebral anoxia. Surviving patients may incur lifelong brain damage and neurologic deficits. May be fatal: “brain death,” persistent vegetative coma, cerebral edema (ie, brain swelling), and herniation of the brain. The hippocampus (part of the limbic system) is the most sensitive part of the brain to anoxia and is the first area to experience damage with anoxia.
—Pulmonary edema: Accumulation of extravascular fluid in lung tissues and alveoli. Caused by excessive negative respiratory pressures resulting from victim’s attempts to breathe while external neck pressure impedes the airway.
LETHALITY OF INTERPERSONAL VIOLENCE WITH NONFATAL STRANGULATION: RISK FOR HOMICIDE*
—Nonfatal strangulation has been reported in 45% of attempted homicides.
—Nonfatal strangulation has been reported in 43% of completed homicides.
—With nonfatal strangulation, odds of attempted homicide increase sixfold.
—With nonfatal strangulation, odds of completed homicide increase sevenfold.
TESTS AND TREATMENT
—CT of the neck: Sensitive for bony, cartilaginous, and soft tissue injuries. Also identifies edema, hemorrhage, and subcutaneous emphysema. However, CT without angiography does not evaluate the carotid or vertebral arteries for vascular damage.
—CTA of the neck: Very sensitive test for the detection of vascular injuries in the carotid and vertebral arteries. CTA is also sensitive for the detection of bony and cartilaginous injuries. The CTA is the gold standard for the emergent radiologic evaluation of nonfatal or near-fatal strangulation patients (Appendix 7).
—Discharge planning: Considered safe if patient experienced no loss of consciousness, presents with no or minimal soft tissue neck injury, and no objective/subjective neurologic findings. Encourage the patient to stay with someone, or have someone stay with them, for the 24 hours after discharge to help monitor for any increase in symptoms. Patients with significant trauma can be safely discharged if the CTA is negative for injury or dissection.
—Fiberoptic laryngoscopy: Visually evaluates the soft tissues of the oropharynx; however, this approach does not offer evaluation of deep soft tissue injuries.
—MRI and MRA: MRI and MRA are used to produce 2- or 3-dimensional images of the structures inside your body, including your blood vessels. Both an MRI and MRA are noninvasive and painless diagnostic tools used to view tissues, bones,