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Northwest Hospital develops protocol to detect strangulation, provide appropriate care

Monday November 5, 2012
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Rosalyn Berkowitz, RN
Strangulation often shows no visible signs. But undetected injuries to the neck or brain that might result from strangulation can be deadly.

The ED Physician Strangulation Response Protocol, used at a Maryland hospital to diagnose and provide appropriate care to patients who might have been strangled, could serve as a template for other hospitals. Developed at Northwest Hospital in Randallstown, Md., the protocol has contributed to more consistent treatment and documentation on the part of physicians and nurses. None of the strangulation victims had CT scans with IV contrast in 2006. Now, 70% receive CT scans with contrast, a best practice that allows for assessment of all structures of the neck, including the vessels, said Audrey Bergin, manager of the hospitalís domestic abuse program.

Often, victims did not realize they had been strangled, Bergin said.

"We realized a lot of people thought strangulation meant [immediate] death and they werenít saying anything," said Bergin, who developed the protocol with Rosalyn Berkowitz, RN, BSN, CHEP, clinical leader in the ED at Northwest. "Someone could come in walking, talking and looking fine, but then hours, days or even weeks later die as a result of the strangulation." Other serious outcomes include miscarriage and stroke, which can occur up to a year later, according to research, Bergin said.


Gael B. Strack
Bergin and Berkowitz, who also is a forensic nurse, decided to act after reading research in The Journal of Emergency Medicine that focused on 300 cases of strangulation victims who survived. Half of the victims had no visible injuries, so police and emergency room physicians downplayed their injuries, Berkowitz said. Subsequent studies found some of the victims had serious health repercussions.

They met with the medical director of the ED to talk about the need for more follow-up and better documentation of domestic violence victims. In 2009, they developed the protocol "which guided the physician in what to ask, what to document and what to do, what tests to order," Berkowitz said.

Some of the protocol questions include: How were you strangled? One hand or two, with a forearm, knee or object? Were you shaken, thrown to the floor or against the wall? Have you been strangled before? Did you urinate, defecate or vomit?

The protocol calls for an examination that includes checking the neck, eyelids, chin and behind the ears. Physicians look for subconjunctival hemorrhage, bruising and facial petechiae, among other possible symptoms.


Audrey Bergin
Research found strangulation assaults might place victims at greater risk for being murdered, said Gael B. Strack, CEO and co-founder of the national organization Family Justice Center Alliance. "This is a serious issue, we need to pay attention to it."

Strack oversees the Strangulation Training Institute and co-authored the series of strangulation articles that Bergin and Berkowitz credited for inspiring them to act.

To date, about 30 states consider strangulation assaults a felony, Strack said. Strangulation occurs more frequently than previously recognized and is common in women seeking medical help, a restraining order or shelter, she said.

"We are trying to create an army of professionals that know this," Strack said. "Weíve been working to understand this issue, and itís nice it is at a turning point, with the attention and awareness and the angels around us like the nurses in Maryland who got it and did something about it. They are probably the first ones to develop the emergency room protocol."

Robin Farmer is a freelance writer.


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