By Gael Strack, J.D.

Strangulation is Prevalent: High risk domestic violence victims are experiencing high rates of non-fatal strangulation, between 68% to 80% (Wilbur, 2001; Campbell, 2017).  Because most victims suffer minimal or no visible external injuries with few symptoms, there is a tendency to minimize non-fatal strangulation. Untrained medical professionals often underestimate the risk of internal injuries and have traditionally been reluctant to order imaging for the alert patient who looks relatively fine. Yet, case reports and research articles have proven that victims of strangulation and suffocation may experience a wide range of internal injuries including injuries to the arteries and veins, fractures, swelling and other injuries that may result in delayed stroke and death.

New Research: Today, new research suggests strangulation victims are at risk of suffering an arterial dissection in 1 out 75 (Matusz, et al, 2019) or 1 out of 47 cases (Zuberi, et al, 2019). This is critical new information, especially when you consider that the risk of a carotid dissection was previously estimated to be 1 out 1,000. (Vilke, 2010).

New Laws: With 48 states now passing some form of a felony law on non-fatal strangulation, there is a growing awareness of the risks. There are more professionals encouraging victims to seek medical attention. In California, it is the law under Penal Code Section 13701(I). Hospitals will see more strangled patients. Clear protocols should be in place to guide medical professionals.The first protocol for screening the strangled patient was published in 2001 in the Journal of Emergency Medicine, “Clinical Evaluation of the Surviving Victim” authored by Dr. George McClane and Dr. Dean Hawley. In 2016, Imaging recommendations for the acute adult strangled patient were developed by Drs. Smock, Baldwin-Johnson, Green, Hawley, Riviello, Rozzi, Stapczynski, Taliaferro and Weaver.

Significant Finding, Reasonable Conclusion: The authors from the Matusz, et al, 2019 article urge physicians and hospitals to adopt the Institute’s imaging recommendations of 2016 developed by the leading forensic physicians in the field from the Institute. The Institute’s recommendations were a product of a thoughtful process that involved a lengthy peer discussion and expert consensus based on a literature review and review of published and unpublished case studies. One particular case study is noteworthy. In 2016, the medical advisors reviewed the case of Tanika Lee. The case review included a review of her medical records and an in-person interview with Tanika. Tanika, a nurse, was manually strangled by her husband who applied pressure to Tanika’s neck using a chokehold from behind. Tanika was also threatened with death. She reported that it felt like he was trying to pull her neck off her body. Tanika called the police and was referred to the San Diego Family Justice Center for services. There she met with a detective, Sylvia Vella, who was trained in the handling of near and non-fatal strangulation assaults. Detective Vella recommended she seek medical attention. Tanika, as a nurse, believed she was fine and did not need medical attention nor imaging. Six days after the strangulation assault, Tanika relented and sought medical attention at the Detective’s insistence.  When she arrived at our Level 1 trauma center in San Diego, she had no visible injuries to her neck and no symptoms. She did, however, have a small bruise behind her ear. The treating physician ordered a CTA. When the results came back, they discovered bilateral carotid dissections (CD) – six days after being strangled. Given the risk of a CD without visible injury or symptoms, the physicians were unanimous in developing our Imaging Recommendations.

Significant Finding, Unreasonable Conclusion: Unfortunately, the authors from the Zuberi, et al, 2019, did not recommend adopting the imaging recommendations of 2016 for reasons that have eluded the Institute and has resulted in a letter to the Editor with our concerns. We simply hope and pray that physicians do not follow the Zuberi recommendations in light of current understanding and evidence. Following these recommendations invites potential harm to strangled victims, catastrophic health consequences, increased risk of stroke and death, and profound malpractice liability for doctors and hospitals. Medical professionals cannot wait for the strangled victim to return with a stroke before they perform a CTA. Victims of domestic violence are already reluctant to seek medical attention for their injuries. When they do, they deserve the best standard of care possible.

We can’t afford to miss even one: For years, emergency room physicians have routinely ordered CT scans for blunt trauma patients, including head, neck, check and abdominal scans – out of an abundance of caution and despite the risk of radiation of exposure which we now know is 1/13,699. Aggressive screening protocols in the stroke literature have proven to be cost effective. (Nazzal, 2014). It generally results in early diagnosis and better outcomes. The risk of missing even one important finding may have a catastrophic outcome such as a  stroke which could lead to brain damage or death.