Stapczynski, J. Stephan. Plain radiographs may show signs suggestive of laryngotracheal injury, such as subcutaneous emphysema, tracheal deviation from edema/hemorrhage, or hyoid bone fracture. A common method for suicide, hanging presents EPs with the question of whether imaging is necessary. Pulmonary complications are frequently responsible for delayed mortality in survivors of near-hanging and strangulation. J Emerg Med 2011;40:355-58. . He had recently been on suicide watch and reports initially suggested he had hung himself by his bed sheet. I don’t know what I am doing wrong….I guess I just have too much neck muscle for this to be a feasible method of suicide…which is a shame since I don’t own a gun and I don’t have a suitable place to do a full on suspension hanging in my apartment. In ligature strangulation, in contrast to hangings, the ligature mark usually encircles the neck in a horizontal plane often overlying the larynx or upper trachea (Figure 8.22). As seen above, a “hangman’s fracture” is seen with hyperextension injuries where the pars interarticularis on the pedicle of the C2 vertebrae becomes fractured. CT Angiography is considered by most to be the test of choice when evaluating for blunt vascular injury. In Berlin (3.5 million inhabitants; ca. 2,4,5. The Dr. Daliah Show , is nationally syndicated M-F from 11:00 am - 2:00 pm and Saturday from Noon-1:00 pm (all central times) at GCN. Chapter 16:217-35. However, it is still recommended that precautions be taken to stabilize the cervical spine until such injury can be appropriately excluded. He had recently been on suicide watch and reports initially suggested he had hung himself by his bed sheet. Someone with no signs of trauma and no neurologic symptoms should just require a period of observation, if anything, following initial evaluation. He was unconscious when he was cut down and had been hanging for an unknown amount of time. Patients may also exhibit dysphonia, aphonia, dyspnea, stridor, hemoptysis, neck tenderness over the larynx, or loss of landmarks of the anterior neck secondary to swelling or overlying hematoma. Given the potential for delayed and rapid airway obstruction, earlier intubation often leads to easier intubation in this patient population. United States Census Bureau; Statistical Abstract of the United States; 2012. Forensic Sci Int 2005;149:143-50. So injuries incurred can be similar in both strangulation and hanging, especially if the latter is done improperly and ineffectively severs the spinal cord. Ligature strangulation: the ligature mark on the neck is usually horizontal ; If homicidal (most common), may … If they do strangulate ...they asphyxiate (lose air flow), or lose blood flow from their carotid arteries being compromised. 7. Jeffrey Epstein's cause of death has been ruled a suicide by hanging; however, there a series of conspiracy theories that suggest he was strangled. Strangulation: A review of ligature, manual, and postural neck compression injuries. The ligature material can be any household substance. Am J Forensic Med Pathol. “Strangulation Injuries.” Emergency Medicine Reports. 9. This is frequently the cause of accidental asphyxiation in children. 1). Three states still have this form of execution as an option if lethal injection is not available (DE, NH, WA). Int J Care Injured 2006;37:435-39. Strangulation is a type of mechanical asphyxia produced by constriction of the neck by ligature material, without suspending the body . Hangings and strangulations can all be accidental, self-inflicted (e.g. Other patients encountered in the ED may be survivors of manual or ligature strangulation with the forces applied to the neck being independent of the victim’s body weight. Such fractures are rare in children and infants, since the hyoid components are not fully ossified and are more flexible than in adults. A very busy Level I trauma center reviewed their registry for adult near-hangings over a 19 year period. In the ED, his physical exam is notable for ligature marks on his neck (image 1). Dr. Sherly Vasu on Postmortem Findings in Cases of Hanging and Ligature Strangulation The official YouTube channel for Manorama News. There was no sign of forced entry to the door of the house. However, since hanging causes a blood pressure drop and strangulation causes a backup of pressure into the head due to vessel constrictions, on autopsy one may find more signs of hemorrhage (retinal hemorrhages) and swelling (brain edema) during strangulation than accurate hanging. Other Strangulation Injuries Patients that require imaging who are stable enough for CT scan or MRI will get little to no benefit from a pre CT/MRI Plain Film. Hanging—Suspension from a cord wound around the neck; Ligature strangulation—Strangulation without suspension using some form of cord-like object called a garrote; Manual strangulation—Strangulation using the fingers or other extremity Management and Disposition MRI seems to give the most information regarding the direct injury to the soft tissues and vessels and further information regarding neurologic injury to the central nervous system. For this reason, hangings in the past were broadly categorized as judicial or non-judicial. Imaging Weight of the body has nothing to do with strangulation. In many cases, physical findings are completely absent in non-fatal strangulation. It’s worrying to know how many things can go wrong when something gets fractured around the neck area due to strangulation. From a capital punishment standpoint, hanging is one of the most common and barbaric ways to execute. in suicide) or intentional (e.g. He was unconscious when he was cut down and had been hanging for an unknown amount of time. Depending upon the method used to constrict the neck, strangulation can be divided into: STRANGULATION Strangulation is the form of asphlxia caused by constriction of neck by ligature or some other method, but without suspension of the body. The pattern of these injuries allows us to recognize strangulation as a mechanism, and to distinguish strangulation from other blunt injuries including hanging, traumatic blows to the neck, and artifacts of decomposition. Clarot F, Vaz E, Papin F, Proust B. process of strangulation, whether by hand (manual), or by ligature, results in blunt force injury of the tissues of the neck. Taliaferro E, Hawley D, McClane G, Strack G. “Strangulation in Intimate Partner Violence”. Vander Krol L, Wolfe R. The emergency department management of near-hanging victims. Cervical spine fractures are well-documented in judicial hangings but are thought to be exceedingly rare or non-existent in non-judicial hangings. 6. It’s shocking to learn that hanging is the most common type of suicide in the united states. It boasts sensitivities up to 100% (for clinically significant injuries). First you have the patients who show little to no evidence of trauma and or vascular congestion, who are and have remained conscious and have no neurologic deficits. When done properly, this resulted in forceful distraction of the head and neck from the body, high cervical fracture, complete cord transection, and death. Plutonium “smuggled” into site near Las Vegas…..What are the health impacts? This should be a consideration if the patient will be leaving the department for imaging studies or prior to transfer to another facility if necessary. In patients not requiring emergent or early intubation, serial exams are crucial. Here, we present the main findings of 19 cases investigated between 1978 and 1998, compared to 47 cases of homicidal ligature strangulation. July 2003. Often hanging can have the same marking on the body as ligature strangulation as they are technically the same thing, but with different processes. The majority of hanging victims are males. More than half were aged 15-44 years1. Salim A, Martin M, Sangthong B, Brown C, Rhee P, Demetriades D. Near-hanging injuries: A 10-year experience. Most of the strangulation deaths are homicidal in nature. When the fa… Obstruction can be delayed, rapid, and life-threatening, making close airway monitoring a must. 3. Two mechanisms have been proposed as causes for pulmonary edema. Differentiation from hanging Ligature strangulation mark usually not mimic hanging, except strangle with ligature and then pull along the ground from the free end of the ligature resulting an inverted V appearance at the knot mark. He was found hanging from a tow rope in the back yard by his brother who immediately cut him down. Carotid Doppler ultrasound is an alternative method for diagnosis of carotid injury and it has the advantage of being readily available, portable, and does not require radiation or IV contrast. Attempted to in past. In postmortem hanging, the corpse has to be moved and placed in the position of strangulation. 66 year-old Jeffrey Epstein, who recently pleaded not guilty of sex trafficking charges, was found dead in his jail cell on August 10. The direction of the furrow on the decedent's neck can help the examining physician determine whether the cause of death was a hanging or a strangulation -- but it … However, one retrospective case review of near-hangings over a 10-year period at LA County and University of Southern California Medical Center found a cervical spine fracture incidence of nearly 5%9. 5. Regardless of the manner of death, ligature strangulation occurs when an external object is placed around the neck and provides compression. A 31-year-old male was brought in by ambulance after attempting to hang himself. Now-a-days hanging is a very serious injury in our society, most of the people hang for the suicide. These are referred to as Tardieu’s spots and occur when the venous pressure rises as the ligature tightens resulting in congestion and capillary rupture. MRI is the best imaging modality for deep soft tissue injury and edema. 2. This can help us identify patients who may need further imaging or observation. Imaging should be ordered based on clinical suspicion. Pulmonary sequelae are frequently seen in survivors of near-hanging and strangulation as well. The inside of the house was neat and undisturbed. Intimate Partner Violence: A Health-Based Perspective. Perimortem hyoid fracture frequently indicates manual strangulation, although ligature strangulation, hanging, and other forms of trauma to the neck cannot be ruled out without additional evidence. These injuries may present with subcutaneous air or bony crepitus over the larynx. Ligature strangulation is a violent form of death, which results from constricting the neck by means of a ligature or by any other means without suspending the body. It could be executed using a ligature (scarf, sheet, cord) or by one’s hands. 1. Dominic Gascho, Jakob Heimer, Carlo Tappero, Sarah Schaerli, Relevant findings on postmortem CT and postmortem MRI in hanging, ligature strangulation and manual strangulation and their additional value compared to autopsy – a systematic review, Forensic Science, Medicine and Pathology, 10.1007/s12024-018-0070-z, (2019). By William Sullivan, DO, JD & Andrew F. Kalnow, DO, “I was entranced by an essay in Emergency Physicians Monthly . Strangulation. He was found hanging from a tow rope in the back yard by his brother who immediately cut him down. 5. The most extensive review of imaging modalities for strangulation victims by Stapczynski in 2010 gives recommendations based on clinical scenarios in terms of which type of imaging to pursue. It is important to re-evaluate frequently for evidence of progressive airway or vascular compromise, such as dyspnea, dysphonia, stridor, drooling, bruits, and focal neurologic deficits. This may be as subtle as hyperemia or as obvious as ecchymosis or abrasions. Women are much more likely to be victims of strangulation assaults than men. Copyright © 2019 EPMonthly.com | Web Design by Transfuture, Clinical Focus: Strangulation and Hanging Injuries, Spanish Influenza – Looking at a Pandemic From 100 Years ago, EPM Talk Ep. The difference is that the force used to exert this pressure is something other than the individual’s body weight. Daliah Wachs is a guest contributor to GCN news, her views and opinions, medical or otherwise, are her own. Injury is thought to occur from compression of the common carotid artery against the transverse processes of the fourth to sixth vertebrae leading to hemorrhage within the media or intimal disruption. of sex trafficking charges, was found dead in his jail cell on August 10. Suicide by Strangulation („Suspension hanging“) Suspension hanging will kill its victims in three ways: compression of the carotid arteries , the jugular veins , or the airway . Testosterone Therapy: New guidelines released, Cervical cancer awareness: The simple scoop on pap smears, Easy and practical New Year’s Resolutions. Incidences reported in the literature range from 10-68% for non-fatal strangulation in intimate partner violence3. EPM is the independent voice for emergency medicine, bringing together commentary from the top opinion leaders, clinical reviews from leading educators and quick-hit departments covering everything from ultrasound to toxicology. Background 286 it was also stated of the distinction between suffocation and strangulation that conditions associated with mechanical asphyxia include suffocation where the interference with the process of breathing is at the level of the nose or mouth; strangulation where there is compression of the neck, either by (a) the human hand (manual strangulation or throttling); (b) a ligature. It sometimes is called throttling. The disadvantage of this method is that ultrasound has a lower resolution than CT and thus, lower sensitivity. 36 – When Minutes Matter: Dr. Este O’Daniell on Syndromic Infectious Disease Testing for Meningitis, EM Quiz: Ill-appearing, minimally responsive patient. A 31-year-old male was brought in by ambulance after attempting to hang himself. I also never knew that2.4% of murders are due to strangulation or asphyxiation. The resultant decrease in muscle tone allows the external force to tighten further and leads to complete arterial occlusion, brain injury, and death. Strangulation causes asphyxia. Judicial Hanging. It is the best modality for assessing the deep soft tissues, larynx, and vessels; however, it is not as readily available from the ED and its cost and time requirements make it less appealing for routine use. The distance of the drop is crucial in determining the success of the execution. Some cases of suicidal hanging, however, do show the furrow at the level of the thyroid cartilage (134). Three states still have this form of execution as an option if lethal injection is not available (DE, NH, WA). The Marrot! Recommendations for group two the most severely injured are ABCD stabilization and admission to the appropriate level of care. Strangulation is when external pressure is applied to the neck obstructing airflow and blood flow. Diagnostic Considerations . Hangings are in fact a type of strangulation, along with ligature strangulation and manual strangulation. Group 3 will be the group that requires that the provider decide imaging (CTA vs. MRI vs. observation), and if observation is decided then 12 hour vs. 24 hour. External compression of the airway structures requires significantly more force than the vascular structures and this is not thought to play a significant role. Hanging is the most common method of suicide in Malaysia. Pathophysiology Obstruction of venous outflow from the brain leads to stagnant hypoxia and loss of consciousness in as little as 15 seconds. Medical crew treating me snapped a phone picture of me. Overhanging these recommendations is the understanding that “There is not enough experience to present an evidence-based approach for the use of the CTA.” The author then goes on to recommend CTA for patients who remain unconscious after ED arrival or exhibit unilateral neurologic signs9. The furrow is typically at or above the thyroid cartilage prominence (notch, Adam's apple) in contrast to ligature strangulation, in which the furrow is typically on or below the thyroid cartilage (refs. There was no issue with his airway, vascular or neurologic systems and the patient was cleared by Psychiatry the next day and discharged home. Fiber optic laryngoscopy is useful to evaluate the soft tissues of the oropharynx but tells us little about the deeper soft tissue injuries. Hanging is the second most common form of suicide in the United States after firearms, accounting for 23% of the over 34,500 suicides that occurred in the year 2007. The role of the carotid sinus reflex in strangulation and near hanging is disputed and believed to be relatively uncommon. The circle was constricted by rotating the bar, thus placing pressure on the neck. Diagnosis requires a high index of suspicion, as patients are frequently asymptomatic immediately after the injury. Postural strangulation is the term applied to compression of the anterior neck against a firm object and also involves the victim’s body weight. There is inadequate experience or data to recommend an evidence-based approach to imaging in strangulation or near-hanging victims. A severe blood pressure drop can ensue and the victim may die within minutes. Definition: external pressure on neck resulting in compression of blood vessels and occasionally airway ; Strangulation: neck compression due to something other than the victim's body weight, such as manual compression or ligature tightened by assailant; usually homicidal . 4. Non-judicial hangings are those that occur in homes and jails. Ann Emerg Med 1984;13:179-85. People that remain unconscious or have signs of neurologic injury will need further imaging be it MRI or CTA. From a capital punishment standpoint, hanging is one of the most common and barbaric ways to execute. The body is heavy, and characteristic findings are therefore usually present at the scene and on the body [ 24 , 32 ] (e.g., variable excoriations of the … Hand prints or remnants of an object will most likely be visible on the neck. Doctor Wachs is an MD, FAAFP and a Board Certified Family Physician. Moreover, it can occur if a hanging drop is improperly calculated. Several paragraphs later the author discusses MRI stating “There is not enough experience with MRI to present an evidence-based decision tool for its use in strangulation victims.” His recommendation is that MRI be done in patients who are awake but report a loss of consciousness during the strangulation episode or have facial or conjunctival petechiae. This number is on the rise compared with prior years. A history of drug or alcohol abuse is seen frequently among hanging victims, as is psychiatric illness2. 500 suicides per year) approximately one case per year occurs. J Emerg Med 1994;12:285-92. Neck Trauma: Don’t Put Your Neck On The Line. Drop is at least as long as the height of the victim, hanging is complete; Head hyperextends => Fracture of upper cervical spine, most commonly traumatic spondylolisthesis of C2, “hangman’s fracture” Transection of the spinal cord . Once the obstruction is removed, pulmonary edema develops and can rapidly lead to ARDS. The compression is usually applied to the neck by using the decedent's own body weight in what would generally be described as either a partial or complete hanging. Ligature strangulation, also called garroting, is the wrapping of a pliable object such as a rope, wire, or shoelaces partially or fully around the neck and pulling it tightly across the throat. Hanging was strictly defined as a ligature around the neck with only the body weight for suspension. Our patient underwent a 6-hour observation period and was deemed medically stable for a psychiatric evaluation. 8. 12). Presenting signs and symptoms vary depending on mechanism. One of my friends is considering to file a divorce soon due to a few instances of domestic abuse. ”, -David Brooks, New York Times Op/Ed Editor. Defensive marks may also appear on the neck in the form of abrasions/fingernail scratches. Daliah Wachs is a guest contributor to GCN news, her views and opinions, medical or otherwise, are her own. The true incidence of manual strangulation is unknown. These type of things created so many problems for the people and the society also, in this situation so many people got dead and many people admit in the hospital and treatment for the curing. However, hanging in combination with suicidal ligature strangulation is uncommon. Fatal and non-fatal bilateral delayed carotid artery dissection after manual strangulation. The first group can be assessed and discharged without imaging or observation period. They are usually not associated with any significant drop and frequently lead to incomplete suspension, with part of the victim’s body still in contact with the ground. A drop to long could cause beheading, a drop too short could cause strangulation. The third and the final group include patients with voice changes, petechial and or evidence of trauma from the strangulation. The relatively superficial and unprotected jugular veins in the neck are quite vulnerable to compression by external forces. Accidental and self-strangulation death are very rare to meet in practice. Manual strangulation occurs when one person uses their hands, another extremity, or an object of some sort to block airflow in another person. About 5 kg of pressure is required to compress the carotid artery; 2 kg for the jugular veins; and at least 15 kg for the airway. Other frequently reported symptoms include voice changes (from hoarseness to aphonia), odynophagia, dysphagia, dyspnea, neck or throat pain, altered mental status and neurologic symptoms. How do forensic experts tell the difference? Classically, a judicial hanging involved a ligature with careful knot placement directly below the occiput and a drop equivalent to the victim’s height with abrupt tightening of the ligature and complete suspension of the entirety of the victim’s body weight. A total of 125 patients were analyzed, and were grouped into patients presenting with a normal GCS (15), and those who were abnormal (<15). Other, more common injuries are hyoid bone fractures and laryngeal fractures and contusions. Petechial hemorrhages on conjunctiva, mucous membranes, and skin cephalad to ligature are another common feature (as shown in image 2). Dr. Peter Pryor is an Attending Physician at Denver Health and Assistant Professor of EM at the University of Colorado School of Medicine. More than half were aged 15-44 years1. A2A Manual strangulation, aka throttling, is with the bare hands or an object such as a pipe or a baseball bat. The victim was lying on his back on the bed and there was a 5 cm-wide, thick fabric belt around his neck (Fig. There are some distinct physical findings that would differentiate the two. 6. Iserson KV. Hanging was historically used as a method for execution. Doctor Wachs is an MD, FAAFP and a Board Certified Family Physician. Many times the hyoid bone is fractured (1/3 of all homicides) as its think U-shape is vulnerable to the forces of strangulation. Pain with movements of the tongue or with swallowing may imply injury to the epiglottis, hyoid bone, or laryngeal cartilage. Fractures of bony and cartilaginous structures in the neck are common, reported in both near-hanging and strangulation victims. If you want to know what professional craftsmanship looks like, this is it. Case Conclusion Fuck this. Strangulation occurs when one compresses the structures of the neck causing decrease air and blood flow. A 68-year-old man was found dead in his hut-like home in the autumn of 2000. For this reason, near-hangings are associated with very different pathophysiology and injuries than complete, judicial hangings. Strangulation occurs when one compresses the structures of the neck causing decrease air and blood flow. Fracture of non-calcified cartilages may not be readily apparent on plain film and further imaging should be pursued if this is suspected. Strangulation vs. Choking (02:00) Choking is when an object gets in the airway internally. Definition-Strangulation is defined as the compression of the neck by a force other than hanging. Children and individuals who practice autoerotic asphyxiation are the most common victims of accidental hanging (1). Garroting or ligature strangulation involves pressure being applied to the neck by a ligature just as in hanging. The majority of hanging victims are males. However, the results of the financier’s autopsy suggest he sustained trauma consistent with hanging (after preliminary reports suggested strangulation). Cervical spine fractures are also uncommon in manual strangulation. Two … Injury to any of these structures puts patients at risk for airway obstruction from edema. Victims of judicial hanging are not patients who survive and present to the ED. Both thrombosis and thromboembolism can lead to delayed neurologic signs and symptoms. When a wire or cord is used, it often completely encircles the neck. The most severely injured and the least severely injured are the two groups that you can decide imaging most easily. Written by Dr. Daliah Wachs, 66 year-old Jeffrey Epstein, who recently pleaded. The factor of suspension differentiates hanging from strangulation by ligature; the latter being caused by application of a ligature of the neck in such a way that the force acting upon it is other than the weight of the body . At page No. With hanging, one drops from a height and suspends, incurring a fracture of a neck bone which in turn may sever the spinal cord. It has been reported in both near-hanging and strangulation victims. If I were a lawyer or an investigator that handle this type of case, I’ll make sure to work with a service that specializes in strangulations because they’ll be able to help me present evidence that can be used in the court. As with any ED patient, airway management is the initial priority. These include pulmonary edema, aspiration pneumonitis/pneumonia, and adult respiratory distress syndrome (ARDS). Emergency Medicine Practice. Post-obstructive pulmonary edema results from excessive negative inspiratory pressures generated by the victim’s attempts to forcefully inspire against an airway obstruction. Schaider J, Bailitz J. judicial hangings) 3. Neurogenic pulmonary edema results from a centrally-mediated, massive sympathetic discharge after anoxic brain injury. In 2009, 2.4% of murders were secondary to “strangulation” or “asphyxiation”1. Its sensitivity is reported as 80-90%. Dr. Ashley Menne is a 4th year EM Resident at the Denver Health Emergency Medicine Residency Program. Cricoid fractures are touted as the most serious of laryngotracheal injuries; being the only complete ring, fracture of this structure can rapidly lead to complete airway obstruction. On EMS arrival he was noted to be groggy but awake and alert, breathing spontaneously with normal breath sounds. You wonder if you should get a CT angiogram or if he needs just observation, or if he can be safely discharged soon. Clinically these patients can be divided into 3 main groups. Epidemiology People with no neurologic injury but with evidence of trauma and or petechial or subconjunctival hemorrhage seem to merit some sort of imaging although exact recommendations are not available at this time. Non-fatal manual strangulation is likely underestimated and under reported, especially in the setting of intimate partner violence. Ultimately it seems as though there are several modalities available to us when evaluating strangled patients. So the force constricting the neck is external force (not the weight of the body as occurs in hanging). Blunt vascular injury is rare but is thought to be one of the most underdiagnosed injuries and may have devastating delayed complications. Plain films utility in determining life threats or helping the physician disposition their patient is limited. The same mechanism leads to subconjunctival hemorrhages. In 2009, 2.4% of murders were secondary to “strangulation” or “asphyxiation”1. Maybe backing up her claims with medical records that prove instances of strangulation will help make the process faster for her. His voice sounds normal to you and to the patient. These findings supported suspicions that the dry ligature mark had been caused by hanging after her death, and that the light ligature mark with slight subcutaneous haemorrhages on the left side and back of the neck had been caused by strangulation, which had brought on the victim's death. A type of hanging comparable to full suspension hanging may be obtained by self-strangulation using a ligature around the neck and the partial weight of the body (partial suspension) to tighten the ligature. 7, 8, 15, 16, and 50 and Fig. Vilke G, Chan T. Evaluation and Management for carotid dissection in patients presenting after choking or strangulation. Fortunately cricoid injuries are rare. « This year’s predictions for upcoming hurricane season, Weird News: The Impossible Burger vs. 2 Aug 2010. CT is much more sensitive for bony, cartilaginous, and soft tissue injuries, subcutaneous emphysema, edema, and hemorrhage. The ligature mark completely encircles the neck in strangulation, while in hanging it is absent near the point of suspension. The occurrence of a narrow zone of engorgement or bruising immediately above and below the groove, confirms that the victim was alive at the time when the ligature … Key Words: Hanging, Ligature strangulation, Hyoid Bone, Thyroid Cartilage, Compression of neck Introduction: Violent asphyxial deaths is one of the most important cause for unnatural deaths among which hanging and ligature strangulation are commonly encountered in the professional life of forensic expert during day to day autopsy. Self-strangulation by ligature is uncommon . Clinical Features Common features include evidence of external pressure on the skin of the neck by the ligature, assailant’s hands, or other object causing strangulation. The best and safest technique for intubation is controversial but oral intubation, if necessary, is safe in most. Second, there are the patients that had an episode of unconsciousness or continue to be unconscious requiring intubation or have neurologic deficits. Volume 5, Number 7. Is this a violation of hippa? 2012 Dec. 33(4):339-40. . ». A history of drug or alcohol abuse is seen frequently among hanging victims, as is psychiatric illness2. A wooden bar passed through the circle created by the belt on the right side of the neck (ie, the tourniquet method). When a suicidal hanging involves partial suspension the deceased is found to have both feet touching the ground, e.g., they are kneeling, crouching or standing. Suicides by ligature strangulation are rare events. Another proposed mechanism for the cause of death relates to vagal reflexes resulting from external pressure on the carotid body, which can lead to extreme bradycardia and cardiac arrest. The true incidence of manual strangulation is unknown. Sauvageau A, Ambrosi C, Kelly S. Three nonlethal ligature strangulations filmed by an autoerotic practitioner: comparison of early agonal responses in strangulation by ligature, hanging, and manual strangulation.
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