—Clustering bruises: Usually located on the sides of the neck and on the jawline. May extend onto the chin and collar bones. Consistent with fingers in a hand-grasp strangulation.
—Fingertip bruises: Circular, oval-shaped bruises consistent with the assailant’s grasp.
—Single bruise on neck: Most frequently caused by the assailant’s thumb. Because the thumb generates more pressure than any other finger, this bruise is found more often than fingertip bruises in a hand-grasp strangulation.
—Buccal swabs: Cotton swabs used to collect cheek cells for DNA samples from the inside of the mouth.2
—Choking: Blockage of respiratory passage(s) with a foreign body. Choking results from materials such as food or other objects obstructing the airway and preventing the exchange of oxygen and carbon dioxide.
—Computed tomographic angiography or angiogram (CTA): CTA is used to evaluate the arterial vessels. CTA is the gold standard for the evaluation of the carotid and vertebral arteries for a strangulation-induced dissection. CTA is sensitive for bony, cartilaginous, and soft tissue trauma as well as vascular injuries (Appendix 7).
—Computed tomography (CT): CT is an imaging technique which is fast and provides a detailed view of the internal organs and structures. CT imaging will identify injuries to neck structures (bones and cartilage); however it fails to evaluate injuries to the vasculature of the neck. A CT is not recommended to determine if there are injuries to the carotid or vertebral arteries (Appendix 7).
—Deoxyribonucleic acid (DNA): A valuable piece of biologic forensic evidence. DNA can be transferred between the assailant and the victim during an assault. Swabbing of the victim’s neck, the suspect’s injuries, and other locations is an important component of a strangulation examination.
—Dysphonia: Involves difficulty in speaking because of a physical disorder of the mouth, tongue, throat, or vocal cords.9,10 Spastic dysphonia is a condition of the voice box or larynx, causing the voice to “break.” It is a lifelong condition thought to begin after an upper respiratory infection, injury to the larynx, voice overuse, or stress.11,12
—Dyspnea: Shortness of breath or difficulty breathing.9,13
—ENT: Acronym for “ears, nose, and throat.”14
—Examiner: The term refers to a health care provider conducting a medical forensic examination after trauma. Titles for the role are determined by license, education, and job description in the institution or organization. The term “examiner” has roots in English law and Scotland Yard and is not used by most state licensing boards or educational institutions. For the purposes of this document, the term “examiner” is used for the health care provider. Additional terms used in this document include the “medical forensic provider,” the “sexual assault forensic examiner” (SAFE), the “sexual assault examiner” (SAE), the “forensic nurse,” and the “forensic nurse examiner” (FNE). Many communities refer to the SAE by more specific acronyms and have justification in the specific license, practitioner role, or achievement of specialized education and clinical experiences.15
—Forensic nurse: A registered nurse or advanced practice nurse who has received specific education and training. Forensic nurses provide specialized care for patients who are experiencing acute and long-term health consequences associated with victimization or violence and have unmet evidentiary needs related to being victimized. Forensic nurses also provide consultation and testimony for civil and criminal proceedings. Forensic nursing care is not separate and distinct from other forms of medical care. It is integrated into the overall care needs of individual patients.
—Hypoxia: The deficiency of sufficient oxygen in the blood, tissues, or cells to maintain normal physiological function.
—Magnetic resonance with angiography (MRA): MRA is used to evaluate the carotid and vertebral arteries for a possible dissection after strangulation. MRA is equally as sensitive as CTA for arterial dissection and does not involve ionizing radiation (Appendix 7).
—Magnetic resonance imaging (MRI): MRI is a technique that uses a magnetic field and radio waves to create detailed images of the organs and tissues within the body. An MRI machine also produces 3D images that can be viewed from many different angles.16
—Odynophagia: Pain when swallowing.9
—OLDCARTS: Acronym (Onset, Location, Duration, Character, Aggravating/relieving, Radiation, Timing, Severity) used by health care providers when completing a comprehensive symptom history in the great subjective history provided by the patient.
—Petechial hemorrhages: Small, pinhead-sized hemorrhages caused by increased venous pressure in the capillary bed. Capillaries may be singular or multiple in appearance and may occur in any part of the body. The development of petechial hemorrhages in strangulation requires venous obstruction without obstruction of arterial flow. May be found under the eyelids (conjunctive), around the eyes, scalp, or anywhere on the face and neck in and above the area of constriction. Petechial hemorrhages can also result from nontraumatic causes, including forceful vomiting, coughing, childbirth, infection, and bleeding disorders.5
—Positional asphyxia (postural asphyxia): A form of asphyxia occurring when the position of a person’s body or external pressure prevents the person from breathing adequately.17 External pressure on the chest, neck, or abdomen restricts respiration and the exchange of oxygen and carbon dioxide resulting in hypoxia and elevated levels of carbon dioxide.
—Pulse oximetry: A device that measures the oxygen saturation of arterial blood in a subject. A sensor is usually attached to a finger, toe, or ear to determine the percentage of oxyhemoglobin in the blood pulsating through a network of capillaries.18
—Sexual assault forensic examiner (SAFE): Advanced practice providers, including nurse practitioners, physician assistants, and physicians with specialized education in the forensic aspects of health care for sexual assault patients.1,15
—Sexual assault nurse examiner (SANE): A registered nurse who has specialized education in the forensic aspects of health care for sexual assault patients.1,15
—Sexual assault response or resource team (SART): Coalitions of agencies that serve sexual assault victims. Core membership for SARTs typically includes victim advocates, law enforcement officers, medical forensic providers, forensic scientists, and prosecutors. Multidisciplinary SARTs work together to formalize interagency guidelines that prioritize victims’ needs, hold offenders accountable, and promote public safety.19,20
—Strangulation: A form of asphyxiation characterized by closure of the air passage and/or blood vessels of the neck from the application of external pressure to the neck.
—Subconjunctival hemorrhage: Capillary rupture and bleeding into the white portion of the eye (ie, sclera).
—Suffocation: Obstruction or restriction of breathing by external mechanical forces. Suffocation does not require blunt force.9
—Swelling (edema) of the neck: Notable puffiness or tight appearance of the neck caused by tissue trauma, bleeding, or subcutaneous emphysema; may also be slight visible puffiness with more significant swelling inside, compromising the airway. Patient may