non fatal strangulation

Non-fatal strangulation

Background

Non-fatal strangulation (NFS) is a significant clinical and societal issue, particularly within the contexts of domestic abuse, sexual violence, and suicide attempts. Strangulation involves asphyxia due to the closure of blood vessels or air passages in the neck because of external pressure. The clinical management of non-fatal strangulation is an important EM clinical topic as carotid artery dissection, stroke, and acquired brain injury may result. In addition, it has significant psychosocial implications, as we discuss below. It is estimated that there are 20,000 victims annually in the UK, but there has been a lack of comprehensive guidelines for its management in acute and emergency care settings until now. This week, we are reviewing a relatively new document that is essential for emergency care clinicians who deal with victims of NFS.

Where has this new guideline come from?

The document is a set of clinical guidelines developed by an intercollegiate group, including members from various professional bodies, including the Royal College of Emergency Medicine, the Faculty of Forensic & Legal Medicine, and the Institute for Addressing Strangulation. The guidelines aim to standardise the approach to non-fatal strangulation in acute and emergency care, providing clear pathways for assessment, management, and follow-up of patients who have experienced NFS. Although we have sumarised the main recommendations below we strongly recommend you read the document yourself. Click here to download the document.

Guidelines for clinical management of non fatal strangulation

Which patients should we consider non-fatal strangulation in?

Non-fatal strangulation can occur in various social contexts, including domestic abuse, sexual violence, self-harm, or as part of consensual activities. It is probably more common than we think, and the estimate of 20,000 episodes in the UK alone is quite shocking. In my practice, this almost certainly means that we are missing episodes presenting to emergency care, and that’s something that we can change. It is worth noting that the guidelines focus on adult and adolescent patients who have experienced NFS within the last four weeks or those presenting with symptoms beyond this period. So it’s not just about the acute injury that we may see ‘on the day’ but also in the assessment and diligence of past injury that may present to emergency care later. It requires clinicians to be vigilant as patients may not readily disclose incidents of strangulation and the threat may continue. We must enquire sensitively in a way that protects the patient. The guidelines emphasise the need for a trauma-informed approach, ensuring patient safety and confidentiality during assessment and management.

Also, remember that although non-fatal strangulation statistics indicate that women in different-sex relationships account for the majority of cases, there are occurrences against men and between same-sex couples.

Trauma-informed practice is an approach to health and care interventions which is grounded in the understanding that trauma exposure can impact an individual’s neurological, biological, psychological and social development.

https://www.gov.uk/government/publications/working-definition-of-trauma-informed-practice/working-definition-of-trauma-informed-practice

Initial assessment and management

There are five main decision points in this approach to NFS

  1. Is this non-fatal strangulation?
  2. Immediate Management
  3. Red Flags Identification: Recognising symptoms and signs that indicate severe injury or complications.
  4. Safeguarding and Referral: Recognising and offering support and protection to cases of domestic or sexual abuse and referring to appropriate support services.
  5. Follow-up Care: Including potential neuropsychological assessment and ongoing monitoring for vascular complications.

1. Is this non-fatal strangulation?

This may be harder than initially thought. Patients may not offer the information spontaneously, and you may have to gently question this when patients present with a history that may be associated with it. Notably, this would be in all cases where sexual or domestic violence is suspected. If you suspect domestic or sexual abuse, you may have to creatively find a way to talk to the person in a confidential setting.

The guideline highlights that NFS can occur as part of consensual sexual practice. Maintain a non-judgmental approach and ensure that patients are aware of the potential harm and the law regarding consent (explore whether it really was consensual?). Listen for language that may suggest the actions of NFS, such as ‘grabbed by the throat, choked, pinned, etc.’ The term ‘breath play’ may be used.

A key point is that there may be no external signs of injury, and in 50% of cases, this will be the case. A lack of external injury should not influence imaging decisions.

As with all aspects of our practice. If in doubt, phone a friend and get a second opinion.

2. Immediate Management of non-fatal strangulation

This relates to the immediate management of the patient and follows our usual resuscitation guidelines

Red Flags Related to Strangulation

Airway Compromise
  • History of significant pressure applied to the neck
  • Dyspnoea (objective signs/symptoms of difficulty breathing) / voice changes
  • Dysphagia or odynophagia (difficulty or pain on swallowing)
  • Neck swelling or tenderness of larynx/trachea
Cervical Spine Concerns
  • Mechanism concerning for, or radiological evidence identified of, cervical spine injury
Dyspnoea (Breathing Difficulties)
  • Subcutaneous emphysema
Petechial Haemorrhages
  • Petechial haemorrhages on the face, neck, oral, or conjunctival areas
  • Any degree of bruising to neck or ligature marks (Note: absence of bruising is not reassuring)
Carotid Bruits or Tenderness
  • Carotid bruits (absence is not reassuring)
  • Carotid tenderness
Neurological Symptoms or Signs
  • Loss or near loss of consciousness
  • Amnesia or altered mental state (e.g., dizziness, confusion, memory loss)
  • Incontinence (bladder and/or bowels)
  • Seizure
  • Stroke-like symptoms
  • Severe headache
  • Tinnitus (ringing in ears)
  • Hearing loss
  • Paraesthesia (tingling or prickling sensation)
  • Visual symptoms (e.g., flashing lights, spots, stars, tunnel vision)
Previous Head Injury or Stroke
  • History of significant blunt force/pressure to the neck or head
  • Previous head injury or stroke
Additional Considerations
  • Subcutaneous emphysema
  • Any concerning blunt trauma to the chest

These red flags guide clinicians in identifying patients at high risk of severe injury or complications, and therefore the need to consider immediate imaging.

The point of the red flags is to identify those patients who may be at risk of neurological injury, airway injury and vascular injury as a result of NFS. The imaging modality of choice is CT angiography of the neck with an arterial phased and bone reconstruction. Ultrasound and plain films are NOT recommended as they will miss significant pathology. Once diagnosed the management of the patient will follow normal clinical practice depending on the pathology. Obviously, the involvement of specialist surgery may be necessary for some injuries.

4. Safeguarding Advice Summary

The guidelines provide comprehensive safeguarding advice for managing patients who have experienced non-fatal strangulation (NFS).

Assessment of Patient Safety:
  • Ensure the patient is safe to go home (considering all social contexts)
  • Evaluate the safety of the patient’s living environment (e.g. in the case of suspected abuse, is the potential perpetrator living with the patient or transporting the patient?).
Safeguarding Referrals
  • Make relevant safeguarding referrals for children, young people, or vulnerable adults who may be at risk.
  • Consider referring to specialist support services, such as Independent Domestic Violence Advisors (IDVAs) or Sexual Assault Referral Centres (SARCs).
Reporting to Police:
  • Discuss with the patient the option of reporting the incident to the police, taking into account the patient’s capacity, confidentiality, and best interests. The GMC has good guidance on this (see links below)
Suicide Risk and Self-Harm Assessment:
  • Conduct a thorough assessment for suicide risk or self-harm, as self-harm by hanging/strangulation often indicates a high suicide intent.
Domestic Abuse and Sexual Violence:
  • In the UK, we should complete a Domestic Abuse, Stalking, and Honour-Based Violence (DASH) risk assessment. Non-fatal strangulation itself warrants a Multi-Agency Risk Assessment Conference (MARAC) referral, regardless of the overall DASH score. This latter point is key: non-fatal strangulation is in itself a reason to complete MARAC (please don’t forget this).
  • Refer to or seek advice from local SARCs (links below) for cases involving sexual assault or rape, including those in the context of domestic abuse. Note that in Virchester you cannot refer to SARC from the ED, it has to be done either by the police or by the patient themselves. It is really important to discuss this with patients and to offer support in verbal and written format for those considering self referral.
  • Consider forensic medical examination and support from Independent Sexual Violence Advisors (ISVAs).
  • Assess the need for emergency contraception, HIV, and Hepatitis B post-exposure prophylaxis in cases of sexual assault.
  • Provide information about the law related to consent and serious harm, especially relevant in cases involving consensual sexual practices.
Discharge Planning and Follow-up:
  • Provide safety netting information to the patient or carer, outlining signs and symptoms that would require urgent medical assessment.
  • Arrange outpatient imaging for patients not seen within four weeks of strangulation but who screen positive for any red flags, considering antiplatelet treatment.
  • Organise an acquired brain injury assessment by a clinical neuropsychologist three months post-strangulation, if needed.
Communication with General Practitioners (GPs):
  • Follow standard local consent processes to share information with the patient’s GP.
  • Include details of the strangulation and requested GP actions in a timely manner, considering confidentiality and risk issues.

Anything else?

The guidelines are comprehensive and reflect a multidisciplinary consensus, which is a significant strength. I would like to see more about the assessment of patients in resource-poor environments, as not everyone has access to CT angiography (thinking internationally and remote/rural here). However, I suspect that, given the strength of the recommendations, the authors would stick to their guns of CT or nothing. The neuropsychological assessment recommendation is crucial, but the guidelines could elaborate on the referral criteria and timing.

I think it is always important to approach these very sensitive and often complex issues of abuse with compassion and sensitivity. If patients feel judged, they may not disclose their information and will be more likely to tale their own discharge against medical advice or without critical referrals or support.

Lastly, with regards to patient confidentiality, the balance between patient confidentiality and the need for safeguarding interventions could be discussed in more depth. These are always difficult areas of practice, and I wonder whether some case presentations and examples to explore would be helpful. As a wider point I think that guidelines that produce a series of clinical vignettes/stories work really well as they help clinicians such as myself understand the real practicalities of using them. There is some guidance from the GMC here.

Should We Change Practice Based on This Guideline?

The guidelines represent a significant step forward in standardising the management of NFS in acute and emergency settings. They provide clear, actionable steps for clinicians, which can improve patient outcomes through timely and appropriate interventions. This is guidance that we should disseminate to our emergency care providers and integrate these guidelines into their practice.

Final thoughts

Non-fatal strangulation is a potentially life-threatening event, either as a result of the episode that precipitated their contact with emergency services and/or as a precursor to a future severe or fatal injury. Emergency clinicians need to be vigilant of the diagnosis and use their expert clinical and communication skills to compassionately and sensitively identify it, investigate it, treat it and follow up/signpost the patient for further support.

vb

S

@EMManchester

With thanks to Liz Crowe for the review and excellent suggestions on compassion, communication skills and more.

References and Further Reading

Relevant Websites

These references and websites provide additional context and detailed information on the management and implications of non-fatal strangulation, supporting the guidelines’ recommendations and offering further reading for interested healthcare professionals.

Cite this article as: Simon Carley, "Non-fatal strangulation," in St.Emlyn's, July 11, 2024, https://www.stemlynsblog.org/non-fatal-strangulation/.

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