A 28-year-old woman is brought to the ED 45 minutes after being found with a scarf tightly wound around her neck by her partner during a domestic dispute. She is conscious, alert, with hoarseness, dysphagia, and mild stridor. Vitals are stable: BP 128/82 mmHg, HR 92/min, RR 18/min, SpO₂ 97% on room air. Neck examination shows ligature marks, mild soft tissue swelling, no obvious tracheal deviation. What is the most appropriate next step in management?

Explanation

## Clinical Context: Strangulation Injury Assessment This patient presents with **strangulation**—compression of the neck by an external ligature (scarf) applied by another person. Unlike hanging (which involves suspension), strangulation is a form of asphyxia caused by direct neck compression. ## Key Distinction: Hanging vs. Strangulation | Feature | Hanging | Strangulation | |---------|---------|---------------| | Mechanism | Suspension + neck compression | Direct neck compression (no suspension) | | Ligature | Noose, rope, cord | Hands, scarf, cord, wire | | Pressure distribution | Concentrated at one point | May be diffuse | | Asphyxia onset | Rapid (seconds to minutes) | Variable (depends on force) | | Delayed complications | Less common | **More common** (laryngeal edema, tracheal stenosis, vascular thrombosis) | **High-Yield:** Strangulation survivors are at HIGH RISK for **delayed airway compromise** and **internal neck injuries** even when initially stable. ## Why This Patient Needs Admission and Laryngoscopy **Clinical Pearl:** The presence of hoarseness and mild stridor indicates laryngeal involvement. These symptoms may worsen over hours as edema progresses, potentially leading to complete airway obstruction. **Key Point:** Strangulation survivors who are initially stable can deteriorate suddenly within 24–48 hours due to: 1. Progressive laryngeal edema 2. Tracheal stenosis 3. Hematoma formation 4. Vascular injury (carotid artery dissection, jugular vein thrombosis) ## Management Algorithm ```mermaid flowchart TD A[Strangulation survivor]:::outcome --> B{Airway symptoms?}:::decision B -->|Stridor, hoarseness, dysphagia| C[Admit for observation]:::action B -->|No symptoms| D{High-risk features?}:::decision C --> E[Keep NPO]:::action C --> F[Flexible laryngoscopy]:::action F --> G{Laryngeal injury?}:::decision G -->|Yes| H[ICU monitoring, consider intubation]:::urgent G -->|No| I[Continue observation, serial exams]:::action D -->|Loss of consciousness, severe trauma| C D -->|Minimal trauma, no symptoms| J[Admit for 24-48 hr observation]:::action ``` ## Rationale for Flexible Laryngoscopy **Action:** Flexible laryngoscopy allows direct visualization of: - Vocal cord position and mobility - Laryngeal edema severity - Mucosal lacerations or hematomas - Subglottic stenosis risk This assessment guides decisions on: - Need for intubation (if edema is severe) - Duration of observation - Steroid therapy (controversial but sometimes used for significant edema) ## Why NPO Status? **Tip:** Patients are kept NPO because: 1. Risk of aspiration if airway suddenly compromises 2. May need emergent intubation 3. Dysphagia is present, increasing aspiration risk ## Supportive Care During Admission - Continuous pulse oximetry and cardiac monitoring - Serial neck examinations (every 2–4 hours) - Humidified oxygen if stridor worsens - Prepare for emergency airway (difficult intubation kit at bedside) - Analgesia (avoid oversedation that masks deterioration) - Psychological support (victim of assault)