GEMC- Hanging and Strangulation, Asphyxiation & AeA "The Choking Game"- Resident Training

Project: Ghana Emergency Medicine Collaborative

Document Title: Hanging & Strangulation, Asphyxiation & AeA “The

Choking Game”

Author(s): Joe Lex, MD, FACEP, FAAEM, MAAEM (Temple University)

2013

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Hanging & Strangulation

Asphyxiation & AeA

“The Choking Game”

Joseph R Lex Jr, FACEP, MAAEM

Temple University School of Medicine

Philadelphia, PA USA

Objectives

• Describe causes of death in

judicial and suicidal hangings

• Discuss how initial Glasgow

Score is not predictive of

outcome in hanging victims

• Explain how ARDS develops

after hanging

Objectives

• Discuss the mechanism of death

in traumatic asphyxia

• List tell-tale signs that an

adolescent is playing “The

Choking Game”

Judicial Hanging Suicidal Hanging

Wikimedia Commons Wikimedia Commons

http://en.wikipedia.org/wiki/File:Hanged,_drawn_and_quartered.jpg

http://en.wikipedia.org/wiki/File:Giotto_-_Scrovegni_-_-47-_-_Desperation.jpg

Homicidal

Lynching

Wikimedia Commons

https://commons.wikimedia.org/wiki/File:Lynching_of_Redmond,_Roberson_and_Addison.jpg

Judicial Hanging

• Short drop: from ladder, cart,

stool

• Suspension hanging

• Standard drop: 4 – 6 feet

• break neck & paralyze

Judicial Hanging

• Long drop: ~10 feet can

decapitate

– 1260 lbf = 5600 newtons = 572 kgf

• Upright jerker: weights and

pulleys jerk up & snap neck

Judicial Hanging

• “Typical” midline under

occiput

• “Atypical” other placement

• Force enough for C2 vertebral

body to sublux from C3 and

crush cord

– Usually between C3 vertebral body

and posterior elements C1 and C2

Judicial Hanging

• When studied: judicial hangings

produced fractures of cervical

spine in 6/34

• Only half (3/34) were classic

“hangman's fracture”

James R, Nasmyth-Jones R., The occurrence of

cervical fractures in victims of judicial hanging, Forensic

Science International, 1992 Apr;54(1):81–91.

Judicial Hanging

• C2 ~20% of all spinal fracture

• C2 >50% of cervical fractures

• Hangman’s fracture ~20-25% of

C2 fractures

– Dens fracture ~55%

• So Hangman’s ~4-5% of all

cervical fractures

Hangman’s Fracture

• Mechanism: forcible head

hyperextension, usually with

neck distraction

• Cause of death: compression /

distraction spinal cord

• Traditionally when noose placed

below condemned subject’s chin


• Now seen in falls (~60%),

especially age 65 and up

• Metropolitan areas (94%).

• Also seen: sports injuries, road

traffic accidents (~20%)


Rockycpp, Wikimedia Commons Rockycpp, Wikimedia Commons

http://en.wikipedia.org/wiki/File:Hangman's_fracture.jpg

http://en.wikipedia.org/wiki/File:Hangman's_fracture.jpg


Source Undetermined

Suicidal Hanging

Source Undetermined

Source Undetermined

Suicidal Hanging

• Great Britain: most common

among men, 2nd most common

among women

• Canada: most common method

• US: 2nd most common (firearms)

Famous Hanging Suicides

• Cheyenne Brando, daughter of

Marlon Brando

• Ian Curtis, lead singer of Joy Division

• Buster Edwards, Great Train Robber

• Frederick Fleet, lookout on Titanic

who first spotted the iceberg

• Pete Ham, guitarist and singer of

Badfinger

Famous Hanging Suicides

• Rudolf Hess, Hitler’s Deputy Fuhrer

• Michael Hutchence, singer INXS

• Richard Manuel, member The Band

• Phil Ochs, political folksinger

• Harold Shipman, “doctor”

• David Foster Wallace, author of

Infinite Jest

• Aaron Swartz: internet guru

More Epidemiology

• Materials readily available:

popular among prisoners

• Full suspension not mandatory

• Cervical fractures rare (~0.6%)

• In absence of fracture, vessel

occlusion is cause of death

rather than asphyxiation

Direct carotid bulb

pressure OR Valsalva

Parasympathetic

discharge

Bradycardic cardiac arrest

Pericarotid stimulation

Sympathetic discharge

Dysrhythmic cardiac arrest

Low neck pressure (2 kg)

Venous obstruction

Stagnant hypoxia Ischemia

LOC ↑ ICP

Neck muscle relaxation

Carotid obstruction (3.5 kg)

Vertebral vessel obstruction (16 kg)

Brain glucose / ATP exhaustion (3-5 minutes)

Cytotoxic edema

Vasogenic edema

Brain death

Direct carotid bulb


Parasympathetic

discharge






Venous obstruction


LOC ↑ ICP





Cytotoxic edema

Vasogenic edema

Brain death

Upward displacement of

tongue & epiglottis

Airway obstruction

Respiratory arrest


Venous obstruction


LOC ↑ ICP





Cytotoxic edema

Vasogenic edema

Brain death




Direct carotid bulb


Parasympathetic

discharge


Sequence of Events

• Internal jugular vein occlusion

cerebral edema, ischemia, coma

• Muscles loosen carotids

compressed

• vagal reflex dysrhythmias

• sympathetic tone

dysrhythmias

Sequence of Events

• 31 newtons = 7 lbf = 3.5 kgf

constricts carotid arteries

• Face engorged and cyanotic

• Tongue may protrude

• Airway compression not involved

– Cases of patients with functioning

tracheostomy committing suicide

by hanging

How Long to Die

• Filmed hangings by the Working

Group on Human Asphyxia

(WGHA)

• Rapid loss of consciousness: 10

± 3 seconds

Sauvageau A, et al. Agonal sequences in eight filmed

hangings: analysis of respiratory and movement

responses to asphyxia. J Forensic Sci. 2010; 55: 1278.

How Long to Die

• Mild generalized convulsions: 14

± 3 seconds

• Decerebrate rigidity: 19 ± 5

seconds

• Multiple phases of decorticate

rigidity: 38 ± 15 seconds




How Long to Die

• Loss of muscle tone: 1 minute 17

± 25 seconds

• Isolated muscular movements

ending in 4 minutes 12 seconds

± 2 minutes 29 seconds




How Long to Die

• Respiratory response: deep

rhythmic abdominal respiratory

movements described, starting

at 19 ± 5 seconds and ending at

1 minute 51 ± 30 seconds




Time to Irreversibility

• Hanging <5 minutes: survived by

all patients

• No patient survives hanging >30

minutes

Matsuyama T, Okuchi K, Seki T, et al. Prognostic

factors in hanging injuries. Am J Emerg Med. 2004; 22:

207–210.

What Injuries to Expect?

Nikolic S, et al. Analysis of neck injuries in hanging.

Am J Forensic Med Pathol. 2003 Jun;24(2):179-82.

Tardieu’s Spots

Source Undetermined

Treatment

• Aggressive resuscitation

warranted

• GCS not predictive of outcome

• Assume ICP, treat accordingly

• Late carotid dissection, thrombus

formation reported (but rare)

Treatment

• Pulmonary sequelae common

– Neurogenic pulmonary edema:

massive sympathetic discharge

poor prognosis

• Thyroid cartilage fracture: ~50%

• Hyoid bone fracture: ~20%

A R D S

• Postobstructive edema: forceful

inspiration against extrathoracic

obstruction negative

intrapleural pressure

• Pressure removed rapid

pulmonary edema ARDS

Ligature

Strangulation

Source Undetermined

Ligature Strangulation

• Manual strangulation = throttling

– Usually man vs. woman

• Ligature strangulation loss of

consciousness in 15 seconds,

neuronal death in 5 minutes

– Man vs. woman, child, elderly

Manual

Strangulation

Source Undetermined

Manual Strangulation

• Disc-like finger-tip bruises

• Linear finger-nail scratches: from

assailant or victim

• Tongue congestion and cyanosis

• Damage to larynx

– Superior horns of thyroid cartilage

and greater horns of hyoid bone

Chokehold

• AKA stranglehold

–Judo shime-waza

• Grappling hold that critically

reduces or prevents either air

(choking) or blood (strangling)

from passing through neck

Sleeper Hold

United States Marine Corps, Wikimedia

Commons

http://en.wikipedia.org/wiki/File:Maldives25a-rear_choke.jpg

http://en.wikipedia.org/wiki/File:Maldives25a-rear_choke.jpg

Sleeper Hold

• Lateral vascular neck restraint

• Used in law enforcement

• From behind suspect or from

front when the officer is on top

• Arm around neck of suspect with

crook of elbow over neck midline

• Pinch arm compress carotid

arteries and jugular veins

Positional

Asphyxia

Source Undetermined

Positional

Asphyxia – Hogtie

Jbc01, Wikimedia Commons

https://commons.wikimedia.org/wiki/File:Model_in_classic_Hogtie.jpg

Positional Asphyxia

• Body position prevents adequate

breathing

• People die suddenly and without

apparent reason during restraint

by police, prison officers, and

health care staff

Positional Asphyxia

• Risk factors increasing chance of

death: obesity, prior cardiac or

respiratory problems, use of illicit

drugs such as cocaine or

methamphetamine

Byard RW, et al. Conditions and circumstances

predisposing to death from positional asphyxia in

adults. J Forensic Leg Med. 2008 Oct;15(7):415-9.

United States Army, Wikimedia Commons

https://commons.wikimedia.org/wiki/File:Combatives_knee_mount.tif

Traumatic

Asphyxia

United States Navy, Wikimedia Commons

https://commons.wikimedia.org/wiki/File:US_Navy_030423-N-6967M-060_Lt._j.g._John_Gore_checks_on_a_patient_who_is_recovering_from_a_stomach_wound.jpg

Traumatic Asphyxia

• Cause: compression of upper

abdomen or thorax

• First report in Paris riots: 1837

–“Masque ecchymotique”

Ollivier DA: Relation médicale des événements

survenus au Champs-de-Mars le 14 Juin, 1837.

Ann Hyg 1837; 18:485-494

Traumatic Asphyxia

• Usually diagnosed postmortem

• Prognosis good if patient

survives until hospital admission

Common Causes

• Jack slippage • Landslide • Toppling of

heavy

machinery • Garage door • Crowd surges

James Cridland, Flickr

http://www.flickr.com/photos/jamescridland/613445810/

Hillsborough Disaster

• 15 April 1989

• Football stadium in Sheffield

• 96 people crushed to death

– All fans of Liverpool Football Club

• Deadliest stadium-related

disaster in British history


nicksarebi, flickr

http://www.flickr.com/photos/34517490@N00/6921136772/in/photolist-bxACQm-eVLgqT-ecGwwC


Superbfc, Wikimedia Commons

http://en.wikipedia.org/wiki/File:Hillsborough_Memorial.jpg

Pathophysiology

1.Sudden intrathoracic pressure

2.Massive object falls on chest

prolonged chest compression

3.Massive thoracic venous

pressure cephalad venous

blood ejection capillary

rupture ecchymosis

The Fear Factor

• Sudden intrathoracic pressure

• Sense of impending doom when

realizes about to be crushed

• Deep breath, hold, brace for

impact

• Closed epiglottis intrathoracic

pressure during compression

Lee M, et al. Ann Thorac Surg 1991;51:86-88

Experimental Model

• Early dog experiments

unsuccessful

• Only worked after occluding

endotracheal tubes

Cause of Death

• Chest wall constriction, hypoxia,

and apnea

• No animal can survive more

than five times its body weight

for longer than 10 minutes

Furuya Y, et al. Igaku Kenkyu 1981;51:117-119

Concomitant Injuries

• Lower extremities spared:

abdominal pressure partially

obstructs inferior vena cava

• Hematuria common

• Common: rib, clavicle fracture

• Blunt cardiac injury: rare

• CNS impair: rarely long-term

Concomitant Injuries

• Subconjunctival

hemorrhages

• Proptosis,

diplopia

• Transient

blindness

• Retinal vessel

leakage

Purdy RH, et al. J Emerg

Med 1988; 6:373-376.

Macnab AJ, et al. AEM

1987;16:1289-1290

Baldwin GA, et al. J

Trauma 1988;28:557-558.

Treatment

Supportive

• Elevate head of bed to 30o

• Give high-flow oxygen

• Monitor cardiac status

• Treat associated injuries

• Evaluate for crush syndromes:

rhabdomyolysis, renal failure

Stewart CE. Emerg Med Rep 1993;14:227-235.

Prognosis

• Dismal or excellent: no middle

ground

• Large series: survivors extricated

within 15 minutes of entrapment

• If survive for more than an hour,

more than 90% survival without

sequelae or complications

Gorenstein L. J Pediatr Surg 1986;21:753-756.

Erotic (Sexual) Asphyxia

• Intentionally cutting off oxygen to

the brain for sexual arousal

• Also called asphyxiophilia,

autoerotic asphyxia, scarfing,

kotzwarraism, breath control play

• Person engaging in activity is

called a gasper


• Classified as paraphilia in DSM-

IV (Diagnostic and Statistical

Manual of the American

Psychiatric Association)

• Estimated 250 – 1000 deaths /

year in US

Hazelwood, R., Dietz, P, and Burgess, A.,

Autoerotic Fatalities, Lexington, MA, Heath, 1983.

Estragon: What about hanging ourselves?

Vladimir: Hmm. It’d give us an erection.

Estragon: An erection!

Vladimir: With all that follows. Where it

falls mandrakes grow. That’s why they

shriek when you pull them up. Did you

not know that?

Estragon: Let’s hang ourselves

immediately!


1. Evidence of a physiological

mechanism for obtaining or

enhancing sexual arousal that

provides self-rescue

mechanism or allows victim to

voluntarily discontinue its effect

2. Reasonable expectation of

privacy


3. Evidence of solo sexual activity

4. Evidence of sexual fantasy aid

5. Evidence of prior dangerous

autoerotic practice

6. No apparent suicidal intent


• Not against the law (except in

Missouri and Mississippi)

• If found to be accidental, police

back off and insurance must pay

G.A.S.P

Games

Adolescents

Shouldn’t Play

The Choking Game

• Airplaning

• America Dream

• Black Boxing

• Black Out Game

• Breath Play

• Breathing the Zoo

• Bum Rushing

• Catching Some Zs

• California Blackout

• California Choke

• California Dreaming

• California Headrush

• California High

• California Knockout

• Choking Game

• Cloud Nine

The Choking Game

• Cobra Clutch

• Crank

• Dream Game

• Dreaming Game

• Dying game

• Fall Out Game

• Flat Liner

• Flatline Game

• Flatliner Game

• Funky Chicken

• Getting Passed Out

• Grandma's Boy

• Groobling

• Halloween

• Harvey Wall Banger

• High Riser

The Choking Game

• Hoola Hooping

• Hyperventilation

Game

• Indian Headrush

• Knockout Game

• Pass-out Game

• Purple Dragon

• Natural High

• Neckies

• P.J. Carlesimo's

Revenge

• Redline

• Rising Sun

• Rocket Ride

• Sandboxing

• Sleeper Hold

The Choking Game

• Sleepers

• Space Monkey

• Speed Dreaming

• Suffocation Game

• Suffocation

Roulette

• The Game

• The Mysto World

• Tingling Game

• Trip to Heaven

OnLine Survey Male Female

Have you heard of the choking

game? 77% 75%

Did you know it by any other name? 39% 34%

Do you know someone who has

played? 64% 57%

Do you know someone who still

plays? 22% 13%

Have you played? 37% 34%

Do you still play? 12% 4%

Have you played alone? 15% 8%

Have you shown or told anyone how

to play? 27% 17%

Source Undetermined

The Choking Game

• Usually NOT sexual gratification

• On a “dare” for peer acceptance

• During school, to get out of class

• Curiosity: copycatting Flatliners

• Brief sense of euphoria

• Intoxication at no financial cost

Telltale Signs

• Suspicious marks on neck

– May be hidden by turtleneck, scarf,

turned-up collar

• Changes in personality: overtly

aggressive, agitated

• Strap, rope or belt lying around

– Attempts to elude questions

Telltale Signs

• Headaches (sometimes very

bad), loss of concentration,

flushed face

• “Bloodshot” eyes

• Thud in bedroom or against wall

– Fall in cases of solitary practice

Telltale Signs

• Questions about effect, danger,

or sensation of strangulation

• Use of symbols or emoticons

indicating self-asphyxiation:

: ) llll : p \\\\

Conclusions

10 Conclusions

1. In victims of hanging and strangulation, initial GCS does not predict outcome

2. Neurogenic pulmonary edema from massive sympathetic discharge has poor prognosis

3. Ligature strangulation can cause loss of consciousness in <15 sec

Conclusions

4. Cervical fractures rare in suicidal hangings

5. No animal can survive more than five times its body weight for longer than 10 minutes

6. If survive traumatic asphyxia for more than an hour, >90% w/o sequelae or complications

Conclusions

7. Death from erotic asphyxia is

accidental

8. “The Choking Game” common

in adolescents, boy and girls

9. Not for sexual stimulation

10.Even Kiefer Sutherland and

Julia Roberts take bad roles

GEMC- Hanging and Strangulation, Asphyxiation & AeA "The Choking Game"- Resident Training

Education

Transcript of GEMC- Hanging and Strangulation, Asphyxiation & AeA "The Choking Game"- Resident Training