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Strangulation

Evaluating Strangulation Evidence from a Medical Perspective

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Merriam Young MS RN CCRN TCRN

Certified Forensic Nurse
Bachelors Degree in Nursing, 1998
University of Pittsburgh

Masters Degree in Nursing, 2005

San Jose State University

Forensic Experience
Certificate in Forensic Nursing, 2021
UC Riverside
Clinical Experience:
Stanford University Medical Center (8 yrs/ongoing)
Surgical/Trauma ICU

Testimony Experience:
–Blunt Force Trauma/Concussion
–Medical Record Interpretation
–Medically Acceptable Blood Draws
–Strangulation
–Blunt vs Sharp force trauma

Testified for both Prosecution and Defense

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Founder of GMFI: Tara’s Story

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Dr. Judy Melinek

PathologyExpert, Inc.
Forensic Pathologist
San Francisco
www.pathologyexpert.com

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***TRIGGER WARNING***

Disclaimer :

• Disturbing Content is used during the presentation.

• The information presented is for mature individuals

• Be respectful while learning this information

• Some topics, videos, images or other content may be triggering.

• Feel free to leave the room or exit the webinar if the subject
triggers you.

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What I will discuss today…

• Anatomy

• Choking, strangulation, suffocation, asphyxia

• HYPOXIA

• Statistics and studies

• How to strangle someone

• Petechiae

• Timing

• Common signs and symptoms of strangulation

• Fatal strangulation

• Lethality risk and case development

• How a strangulation expert can help

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Anatomy

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Choking??
Choking
• Obstruction of the airway from internal forces, such as a foreign object.

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Strangulation vs Suffocation

Strangulation Suffocation
• Pressure on the neck causing the • Obstruction or restriction of breathing
temporary obstruction of the carotid
arteries or jugular veins and
occasionally the airway.

Examples of Suffocation
• Smothering - Hand over mouth
• Entrapment - Bag over head/buried
• Mechanical Asphyxia - Sitting on chest
• Positional asphyxia – intoxication,
restraints
• Choking - food

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Strangulation vs Suffocation

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Asphyxiation vs Hypoxia

Asphyxiation Hypoxia

• An interruption in • Below normal level of

oxygenation. oxygen in the blood or
body tissues

• Oxygen doesn’t get into the • The body doesn’t have enough
body oxygen

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Symptoms of Hypoxia

Mild Moderate Severe

• disorientation, • visual disturbances, • delirium,

• restlessness, • anxiety, • loss of consciousness,
• headache, • agitation • paralysis,
• vomiting,
• nausea, • elevated blood • decreased and irregular
• increased respiratory pressure, respirations,
rate, • breathing pauses, • abrupt drop in blood
• increased heart rate, • slow or irregular heart pressure,
rate, • incontinence,
• slight increase in blood
pressure, • convulsions, • Faint/irregular heart rate,
• deeply blue skin color.
• bluish skin color. • deeper blue skin color

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Ischemia vs Infarction

Ischemia Infarction

• Temporary and reversible cell • Permanent cell death

damage

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Deterioration Path

Strangulation OR Suffocation

Asphyxiation
Hypoxia
Ischemia

Infarction

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Question: What is the biggest issue

related to lethality in strangulation
cases?

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HYPOXIA!!!! HYPOXIA!!!!!!!

HYPOXIA!!!!!!!!!!

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Statistics

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San Diego Studies

• A review of 300 attempted strangulation cases. Part I: Criminal legal issues.
- Out of 300 300-69-36=195

- 50% of cases had visible injuries (n=149)

- 15% cases injuries visible in photographs (n=45) 45/195 = 23% have injuries
seen in photographs
- 35% had injuries too minor to photograph

• Problems with the study Not the same as injuries too

- Lobbying for felony charges minor to photograph!

- Really old (2001)

• 35% didn’t have photos or usable photos
- 69 cases (23%) had unusable photographs (injuries too minor OR poor quality)
- 36 cases (12%) the injuries weren’t even photographed

A review of 300 attempted strangulation cases. Part I: Criminal legal issues. J Emerg Med. 2001 Oct;21(3):303-9. Strack GB, McClane GE, Hawley D.

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Other Studies

• Shields, et. al,

2010
- 85% do have
injuries

Shields, L. B., Corey, T. S., Weakley-Jones, B., & Stewart, D. (2010, Dec). Living
Victims of Strangulation: A 10-Year Review of Cases in a Metropolitan
Community. American Journal of Forensic Medicine and Pathology, 31(4), 320-
325. doi:10.1097/PAF.0b013e3181d3dc02

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• Matusz, et. al, 2020

Matusz, E. C., Schaffer, J. T., Bachmeier, B. A.,

Kirschner, J. M., Musey, P. I., Roumpf, S. K., . . .
Hunter, B. R. (2020). Evaluation of Nonfatal
Strangulation in Alert Adults. Annals of Emergency
Medicine, 75(3), 329-338.

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Carotid hold

Reiner, R. (1987). The Princess Bride. Twentieth Century Fox.

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How to Strangle Someone

Vascular Airway
- aka “Carotid sleeper hold” - aka “bar arm” or “choke hold”
- Blood Vessels compressed - Airway compressed
- Airway open - Blood vessels open

Spitz, W. U. (2006). Spitz & Fisher's MedicoLegal Investigation of Death. Springfield, IL: Charles C Thomas, Publisher, Ltd.

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How to Strangle Someone

Manual
- Blood Vessels and/or Airway
- Depends on position of hands

- Fractures of the larynx

- hyoid, thyroid and cricoid cartilages

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How to Strangle Someone

Ligature Hanging
- Blood Vessels and/or - Usually vessels, but
Airway airway may also be
- Petechiae may be compromised
found with an obvious
line above ligature

Spitz, W. U. (2006). Spitz & Fisher's MedicoLegal

Investigation of Death. Springfield, IL: Charles C Thomas,
Publisher, Ltd.

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Strangulation
• Hanging/ Ligature/Manual
• Manual: 70-90% have fractures
• Ligature: ~33% have fractures

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Manual Strangulation

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Hanging
Hanging
• Compression and occlusion of vessels and trachea
• Angled impression on neck
• Facial pallor
• Almost always suicide
• Jugular veins: 4.4 lbs
• Carotid arteries: 11 lbs.
• Trachea: 33 lbs.
• Vertebral arteries: 66 lbs.

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Hanging

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Judicial Hanging
• Intension- death by fracture of spinal cord
• Fall insufficient distance
• Strangles, person jerks around

• Fall too far

• Decapitation

• Fall just right

• Quick jerk of head, spinal cord snaps
• Better for the audience!!!

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Ligature marks

Canders, C., Nguyen, A., & Como, E. (2022, Jan 1).

Strangulation and Related Injuries. Emergency Medicine
Reports. Retrieved Mar 9, 2022, from
https://www.reliasmedia.com/articles/148916-
strangulation-and-related-injuries

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Ligature marks

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Who’s a petechiae expert?

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Petechiae – Test your knowledge

What are petechiae?

Small hemorrhages in the skin

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Petechiae or Petechial Hemorrhage

Small hemorrhages in the

skin (or mucous
membranes).

Bhupesh, K. (2015). Chapter-14 An Approach to a Case of Near-

hanging/Attempted Strangulation. In G. Biswas (Ed.), Recent
Advances in Forensic Medicine & Toxicology (Volume 1)

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Petechiae – Test your knowledge

What is the medical process that causes

petechiae?

An increase in vascular
pressure causes capillaries to
burst.

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Petechiae or Petechial
Hemorrhage
Small hemorrhages in
the skin.

Venous return is
impaired, causing
capillaries to burst due
to increased vascular
pressure.

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Petechiae – Test your knowledge

Can you see petechiae in survivors of

strangulation?

Yes!

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Petechiae – Test your knowledge

Do you see petechiae in both suffocation

and strangulation?

Strangulation and Suffocation

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Type of assault Location of Petechiae

Carotid Sleeper • Head/neck

Bar arm • Whole body

Manual • Head/neck, or whole body

Ligature/hanging • Clear Linear mark

Suffocation • Whole body possible

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Petechiae – Test your knowledge

Is petechiae only seen in

strangulation/suffocation assaults?

No!

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Other causes of Petechaie

Prolonged
Straining Medications Medical Conditions
• Crying • Anticoagulants • Infectious Diseases
• Mono, Rocky Mtn Spotted
• Coughing • warfarin, heparin Fever, Strep Throat
• Vomiting • Naproxen • Blood Disorders
• Aleve, Naprosyn • Thrombocytopenia
• Childbirth • Scurvy (Vit C Deficiency)
• Penicillin • Vitamin K Deficiency
• Weightlifting

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Petechiae – Test your knowledge

How long does it take for petechiae to

form?

Give a number!

20-30 seconds

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Timing

Carotid • LOC: 5-10 seconds

Occlusion • Death: 15-20 seconds

Jugular • Petechiae: 20-30 seconds

• LOC: 2 minutes
Occlusion • Death: 4 minutes

Airway • LOC: 2+ minutes

Occlusion • Death: 3-5 minutes

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Timing

Reiner, R. (1987). The Princess Bride. Twentieth Century Fox.

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Godoy Medical Forensics gratefully acknowledges Alliance for HOPE International and Dr. William Smock, for allowing us to
reproduce, in part or in whole, the Physiological Consequences of Strangulation Seconds to Minute Timeline.a

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Timing

Abstract
The Working Group on Human Asphyxia has analyzed 14 filmed hangings:
9 autoerotic accidents, 4 suicides, and 1 homicide.

The following sequence of agonal responses was observed: rapid loss of consciousness in 10 ± 3
seconds, mild generalized convulsions in 14 ± 3 seconds, decerebrate rigidity in 19 ± 5 seconds, beginning
of deep rhythmic abdominal respiratory movements in 19 ± 5 seconds, decorticate rigidity in 38 ± 15
seconds, loss of muscle tone in 1 minute 17 seconds ± 25 seconds, end of deep abdominal respiratory
movements in 1 minute 51 seconds ± 30 seconds, and last muscle movement in 4 minutes 12 seconds ± 2
minutes 29 seconds. The type of suspension and ethanol intoxication does not seem to influence the
timing of the agonal responses, whereas ischemic habituation in autoerotic practitioner might decelerate
the late responses to hanging.

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Timing Medical Expert Witness Services

Death doesn’t occur for 4+ minutes (2-6 min),

and could occur after the assailant releases the hold.

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Time to Unconsciousness
• Kabat, Rosen and Anderson. Archives of Neurology and
Psychiatry, 50, 510-28, 1943
• Experiments demonstrated unconsciousness in 5-6 seconds using an inflatable neck cuff.

• DiMaio:
• Carotid arteries: 10-15 sec max
• V fib: 5-10 sec

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Most Common Symptoms - During

• Changes in vision
• Stars, tunnel vision, etc.

• Changes in breathing
• Shortness of breath, inability to breathe
• Other
• Vomiting, dizziness, feeling like they’re going to black out

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Question: What are all those symptoms

related to?

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HYPOXIA!!!! HYPOXIA!!!!!!!

HYPOXIA!!!!!!!!!!

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Most Common Symptoms - After

• Changes in speech
• Sore throat, raspy, scratchy voice

• Changes in swallowing
• Pain on swallowing
• Other
• Vomiting, tearful, anxious, dizziness, pain, coughing

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Signs

Common signs Serious Signs

• Abrasions/scratch/fingernail marks • Loss of Consciousness

• Petechiae • watch for amnesia

• Abrasions over nostrils/under chin • Loss of control of bodily

functions (urination/defecation)
• Ligature marks
• Associated with loss of consciousness

• Redness/Bruising

• Cuts inside mouth where gums are

pushed against teeth

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Other possible Signs/Symptoms

• Neck swelling

• Rope burns

• Thumb print/patterned bruising

• Bloodshot eyes

• Subconjunctival hemorrhages

• Pain to neck/throat

• Ears ringing

• Head rush

• Miscarriage

• Nothing

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Important Notes about Signs/Symptoms

• “I was telling him to stop” or other speech during strangulation

• Indicates airway was not occluded, no loss of consciousness (at that time)

• Look for signs of Hypoxia

• Indicated by visual changes, incontinence, loss of consciousness, headache, inability to breath
• If no indication of hypoxia, then risk of lethality is reduced.

• Petechiae
• Face: Indicates Jugular vein occlusion
• Body: Indicates Suffocation

• Skin injuries
• Usually non-specific

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Autopsy Findings
• Heart
• Heart may continue to beat for as long as 10 minutes after respiratory arrest
• Carotid Body Stimulation – no autopsy findings, instant/rapid death

• Brain
• Microscopic signs of hypoxia/anoxia show up as early as 30 minutes after oxygen deprivation

• Neck
• Injuries to strap muscles, and thyroid cartilage/hyoid bone fractures rare in hanging, more common in manual strangulation
• Hyoid bone may also be fractured from a fall or blow to the neck – cause of death will most likely be obvious (major MVC or
positional asphyxia)

• Petechiae
• Can be due to a terminal face down collapse, with passive congestion occurring in the face, bursting the delicate blood
vessels.

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Complications
• Brain
• Anoxic/hypoxic brain cell death (can be delayed)
• Stroke
• Delayed Cryptogenic Strokes (months to years later – due to anoxic damage)
• Anoxic Encephalopathy – cytotoxic brain edema (can be delayed)
• Anoxic Convulsions (Seizures)

• Neck
• Cervical Spine injury
• Carotid Artery Dissection/Hematoma
• Airway swelling/respiratory failure
• Vocal Cord Paralysis
• Hyoid bone /Thyroid or Cricoid Cartilage fracture

• Other
• Tinnitus (ringing in the ears)
• PTSD

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Get a clear picture

Have the victim describe very clearly the following:

1. In what manner did he/she attack (i.e. one hand, two hands, ligature)?

2. Where were the defendant’s hands/where was the ligature?

• BE VERY SPECIFIC, fingers, thumbs, etc.

3. Was he/she in front of you or behind you?

4. Where did you feel the pressure?

5. How long did it last?

6. When did you feel xx symptoms - how long after it started?

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GBI/SBI
Related to

Hypoxia!!!
and subsequent brain/cell damage
• Cognitive deficit from anoxic encephalopathy and intra-cerebral petechial hemorrhage.

• Other Medical Complications

• Aspiration pneumonia
• Fracture of trachea or larynx
• Swelling with airway obstruction (can be complicated by intoxication)
• Carotid artery dissection or thrombosis with stroke
• Dehydration

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Risk for lethality

Duration

Location Lethality Force

Surface
Area

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Question: The four factors all come

together to cause what?

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HYPOXIA!!!! HYPOXIA!!!!!!!

HYPOXIA!!!!!!!!!!

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Risk for lethality

Not just related to
Hypoxia

WHAT?!?!

• History of strangulation attempt causes:

• 6x increase risk for attempted homicide

• 7x increase risk for homicide

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Any Questions?

Request an estimate for

your case now!

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Recommended Resources

• Spitz, W. U. (2006). Spitz & Fisher's MedicoLegal Investigation of

Death. Springfield, IL: Charles C Thomas, Publisher, Ltd.

• Training Institute on Strangulation Prevention and the California

District Attorneys Association. (2020). The Investigation and
Prosecution of Strangulation Cases.

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