This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
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GEMC- Hanging and Strangulation, Asphyxiation & AeA "The Choking Game"- Resident Training
1. 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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3. Hanging & Strangulation
Asphyxiation & AeA
“The Choking Game”
Joseph R Lex Jr, FACEP, MAAEM
Temple University School of Medicine
Philadelphia, PA USA
4. 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
5. Objectives
• Discuss the mechanism of death
in traumatic asphyxia
• List tell-tale signs that an
adolescent is playing “The
Choking Game”
8. Judicial Hanging
• Short drop: from ladder, cart,
stool
• Suspension hanging
• Standard drop: 4 – 6 feet
• break neck & paralyze
9. Judicial Hanging
• Long drop: ~10 feet can
decapitate
–1260 lbf = 5600 newtons = 572 kgf
• Upright jerker: weights and
pulleys jerk up & snap neck
10. 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
11. 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.
12. 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
13. 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
14. Hangman’s Fracture
• Now seen in falls (~60%),
especially age 65 and up
• Metropolitan areas (94%).
• Also seen: sports injuries, road
traffic accidents (~20%)
22. Suicidal Hanging
• Great Britain: most common
among men, 2nd most common
among women
• Canada: most common method
• US: 2nd most common (firearms)
23. 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
24. 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
25. 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
26. 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
27. 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
Upward displacement of
tongue & epiglottis
Airway obstruction
Respiratory arrest
28. 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
Pericarotid stimulation
Sympathetic discharge
Dysrhythmic cardiac arrest
Direct carotid bulb
pressure OR Valsalva
Parasympathetic
discharge
Bradycardic cardiac arrest
30. 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
31. 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.
32. How Long to Die
• Mild generalized convulsions: 14
± 3 seconds
• Decerebrate rigidity: 19 ± 5
seconds
• Multiple phases of decorticate
rigidity: 38 ± 15 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.
33. 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
Sauvageau A, et al. Agonal sequences in eight filmed
hangings: analysis of respiratory and movement
responses to asphyxia. J Forensic Sci. 2010; 55: 1278.
34. 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
Sauvageau A, et al. Agonal sequences in eight filmed
hangings: analysis of respiratory and movement
responses to asphyxia. J Forensic Sci. 2010; 55: 1278.
35. 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.
36. 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.
43. 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
45. 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
46. Chokehold
• AKA stranglehold
–Judo shime-waza
• Grappling hold that critically
reduces or prevents either air
(choking) or blood (strangling)
from passing through neck
48. 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
53. Positional Asphyxia
• Body position prevents adequate
breathing
• People die suddenly and without
apparent reason during restraint
by police, prison officers, and
health care staff
54. 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.
57. 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
59. Common Causes
• Jack slippage
• Landslide
• Toppling of
heavy
machinery
• Garage door
• Crowd surges
James Cridland, Flickr
60. 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
64. 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
65. Experimental Model
• Early dog experiments
unsuccessful
• Only worked after occluding
endotracheal tubes
66. 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
68. 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.
69. 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.
70. 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.
71. 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
72. Erotic (Sexual) Asphyxia
• 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.
73. 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!
74. Erotic (Sexual) Asphyxia
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
75. Erotic (Sexual) Asphyxia
3. Evidence of solo sexual activity
4. Evidence of sexual fantasy aid
5. Evidence of prior dangerous
autoerotic practice
6. No apparent suicidal intent
76. Erotic (Sexual) Asphyxia
• Not against the law (except in
Missouri and Mississippi)
• If found to be accidental, police
back off and insurance must pay
78. 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
79. 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
80. 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
81. The Choking Game
• Sleepers
• Space Monkey
• Speed Dreaming
• Suffocation Game
• Suffocation
Roulette
• The Game
• The Mysto World
• Tingling Game
• Trip to Heaven
82. 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%
85. 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
86. 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
87. 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
88. Telltale Signs
• Questions about effect, danger,
or sensation of strangulation
• Use of symbols or emoticons
indicating self-asphyxiation:
: ) llll : p
90. 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
91. 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
92. 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