Strangling or compressing the neck can be very dangerous and potentially life threatening. The neck contains several vital structures including the airway, arteries that supply blood to the brain, and the spinal cord. Compression of these structures can lead to asphyxia (inadequate oxygen), cerebral hypoxia (inadequate oxygen to the brain), stroke, neurological damage, cardiac arrest, and death. Strangulation that does not result in death still causes injury and requires prompt medical attention.
Mechanism of injury
There are several mechanisms by which strangling the neck causes injury and death:
Asphyxia
The neck contains the upper airway structures including the larynx, trachea and bronchi that allow air to reach the lungs. Compression of these structures restricts airflow leading to asphyxia (lack of oxygen). It only takes minutes of airway compression to cause unconsciousness and brain injury. Prolonged compression leads to cardiorespiratory arrest and death.
Cerebral hypoxia
The neck also contains the carotid arteries and the vertebral arteries that are responsible for supplying oxygenated blood to the brain. Compression of these blood vessels reduces blood flow to the brain leading to cerebral hypoxia (lack of oxygen to the brain tissue). Cerebral hypoxia causes neurological dysfunction, stroke, seizures, coma and brain death within minutes if blood flow is not restored.
Spinal cord injury
The cervical vertebrae that surround and protect the spinal cord are also located in the neck. Forcible compression or traction of the neck can cause fractures or misalignment of the cervical vertebrae damaging the spinal cord. This can lead to paralysis below the level of injury. Damage to the spinal cord itself, without radiographic evidence of vertebral injury can also occur.
Cardiac arrest
The vagus nerves, which help regulate heart rate and blood pressure pass through the neck. Stimulation of the vagus nerves by compression of the neck causes profound bradycardia (slow heart rate) and hypotension which can lead to cardiac arrest. Arrhythmias like ventricular tachycardia and ventricular fibrillation can also occur.
Jugular venous obstruction
Strangulation can obstruct the jugular veins which drain deoxygenated blood from the brain back to the heart. This causes intracranial hypertension (increased pressure around the brain). The subsequent reduction in blood flow to the brain adds to the effects of arterial compression leading to cerebral hypoxia.
Signs and symptoms
The signs and symptoms that can occur immediately during strangulation include:
- Difficulty breathing
- Hoarseness or coughing due to laryngeal injury
- Confusion, dizziness, fainting or loss of consciousness
- Facial and conjunctival petechiae (small hemorrhages)
- Pain and swelling in the neck
- Cyanosis (bluish discoloration of skin due to lack of oxygen)
After the strangulation, symptoms may include:
- Difficulty swallowing
- Neck pain
- Coughing or spitting up blood
- Voice changes like raspy voice or hoarseness
- Breathing changes
- Neurological symptoms like headache, seizures, vision changes, vertigo, loss of memory
- PTSD and emotional distress
Immediate complications
Some of the acute, immediately life-threatening complications of neck strangulation include:
Cardiac arrest
Lack of blood flow and oxygen to the heart muscle can cause lethal cardiac arrhythmias leading to cardiac arrest.
Respiratory arrest
Compression of the airway rapidly leads to lack of airflow into the lungs causing respiratory arrest. This prevents oxygenation of blood leading to hypoxemia, organ damage and death.
Cerebral vascular accidents
Reduced blood flow to the brain causes ischemic strokes leading to permanent neurological damage or death. Hemorrhagic strokes from arterial dissections or ruptures are also possible.
| Type of Stroke | Mechanism | Effects |
|---|---|---|
| Ischemic stroke | Blockage of blood supply | Loss of brain function in blocked area |
| Hemorrhagic stroke | Bleeding into brain | Brain damage and increased intracranial pressure |
Spinal cord injury
Compression, hyperextension or flexion injuries to the cervical spine can sever or damage the spinal cord. This can lead to tetraplegia or partial loss of motor function.
Delayed complications
Delayed consequences of strangulation include:
Brain damage
Prolonged loss of oxygen supply causes permanent brain damage affecting cognitive, sensory and motor functions. This manifests as disabilities like dementia, seizures, paralysis etc.
Neuropsychiatric disorders
Survivors can develop PTSD, depression, anxiety disorders and sleep disturbances requiring long term psychiatric treatment and therapy.
Laryngeal injuries
Fractures of the larynx and tracheal rings can occur. This leads to airway obstruction manifesting as voice changes, breathing difficulties and cough.
Esophageal injury
Tears in the esophagus allow food contents and fluids to leak into surrounding tissues leading to infections like mediastinitis, abscess formation and sepsis.
Pneumonitis and pneumonia
Aspiration of oral and gastric contents into the lungs during strangulation causes chemical pneumonitis and bacterial pneumonia.
Diagnosis
The diagnosis of neck strangulation is made clinically based on:
- History of compression of the neck
- Signs and symptoms like petechiae, swallowing difficulties, voice changes etc.
- Hypoxia, respiratory distress, arrhythmias or neurological deficits on evaluation
- Imaging like CT angiography, MRI, flexible laryngoscopy
Investigations
The following additional investigations aid in evaluating complications:
- Blood tests: Cell counts, metabolic panel, coagulation studies
- Cardiac enzymes: Troponin, CPK
- Carotid doppler ultrasound
- CT scan and CT angiography of the neck and brain
- MRI of the brain and cervical spine
- Flexible nasolaryngoscopy
- Pulmonary function tests
- Neuropsychological testing
Treatment
Management involves:
Airway management
Securing the airway is the most urgent priority. Endotracheal intubation or emergency cricothyrotomy may be required.
Cardiopulmonary resuscitation
CPR with chest compressions must be initiated in cardiac arrest. Defibrillation may be needed for ventricular arrhythmias.
Neuroprotective measures
Head elevation, hyperventilation, osmotherapy using mannitol and induced hypothermia help prevent secondary cerebral injury.
ICU monitoring
Admission to ICU for cardiorespiratory monitoring allows for early detection and management of complications.
Surgical repair
This includes fracture fixation, hemorrhage control, debridement of necrotic tissues, esophageal repairs, tracheostomy etc.
Rehabilitation
Physical therapy, speech therapy, occupational therapy and neuro-cognitive therapy are critical to help regain function after neurological deficits.
Psychotherapy and counseling
PTSD and other mental health disorders require psychotherapy, counseling, cognitive behavioral techniques and psychiatric medications.
Prognosis and outcomes
With severe and prolonged strangulation, rates of death can approach 10-20%. Hypoxic brain injury causes significant morbidity in survivors. However, the prognosis depends on:
- Duration of strangulation
- Timeliness of resuscitation
- Patient age
- Presence of comorbidities
- Extent of injuries
Early intervention limits long term neurological deficits. But deficits like motor disabilities, dysphagia, dysarthria, cognitive impairment and psychiatric disorders may still occur requiring prolonged rehabilitation.
Prevention
Preventing strangulation injuries involves:
- Public education about dangers of strangulation and asphyxial games
- Teaching safe sex practices like avoiding erotic asphyxiation
- Addressing alcohol and substance abuse
- Anger management counseling
- Treating underlying mental health conditions
- Improving social support systems
- Domestic violence prevention programs
Conclusion
Strangulation or compression of the neck is extremely dangerous and life threatening. It causes hypoxic brain injury, airway compromise, cardiovascular collapse and spinal cord damage which can lead to permanent neurological deficits and death. Rapid resuscitation, airway management, ICU monitoring and prompt surgical intervention provide the best outcomes. Public health measures focusing on education, responsible sexual practices, substance abuse treatment and domestic violence prevention are key to reducing these catastrophic but preventable injuries.