Hoarse Voice, No Marks: Strangulation at 26 Weeks' Gestation
A 29-year-old woman at 26 weeks' gestation presents to the ED at 09:00, roughly 18 hours after her partner placed both hands around her neck for an estimated 20 seconds during an argument. She did not lose consciousness. She reports a hoarse voice since last night, pain with swallowing, and one episode of vomiting. Vital signs: BP 118/74, HR 96, SpO2 98% on room air, RR 20. There are no visible external neck marks and no petechiae. She is tearful but declines to be examined by a male physician and asks whether she "really needs all these tests" because she "feels fine now." The nearest CT scanner is in the main ED; the SANE unit is in an adjacent building.
1. Which findings drive your sense of urgency, and what does the absence of external marks mean for your decision-making?
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Urgency is driven by mechanism plus symptoms, not by appearance.
- Mechanism: bilateral hand compression for ~20 seconds is a substantial carotid/jugular and airway load.
- Red-flag symptoms present: dysphonia (hoarse voice), odynophagia, and vomiting. Voice change and swallowing pain suggest laryngeal edema or injury; vomiting after neck compression is a recognized warning sign.
- Absence of marks is expected, not reassuring: a large share of strangulation victims have no visible external injury, and petechiae are frequently absent. "No marks" therefore cannot downgrade the triage level.
What this means practically: she needs evaluation for laryngeal injury and for carotid/vertebral dissection (CTA of the neck, with the ED physician deciding on additional vascular imaging). Screen and document neuro symptoms, neck pain, difficulty breathing, voice quality, and ability to swallow, and reassess airway serially because edema can progress over hours.
Pregnancy does not make imaging optional: a neck CTA delivers negligible fetal dose and the study is remote from the uterus; untreated maternal airway or vascular injury is the larger risk to both patients. Coordinate with the ED physician and obstetrics.
2. How do you sequence the forensic examination relative to medical imaging and transfer between buildings?
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Medical stability first; forensics second; neither is a reason to delay the other indefinitely.
Sequence that preserves both goals:
- Airway/vascular assessment and imaging are ordered by the ED physician immediately. The forensic exam does not require imaging to be complete.
- Collect time-sensitive, non-invasive evidence before she is moved or given food/drink if that can be done in minutes (e.g., neck swabs if she reports contact, fingernail swabs, clothing). Do not turn this into a full exam in an unstable patient.
- Complete the full head-to-toe and genital exam after imaging, in the SANE suite, with an escort so she is not walking between buildings alone.
- Document the order of events with times: arrival, imaging, exam start/finish, kit sealing. If the kit is sealed before imaging, note that no additional evidence was collected afterward.
Reasoning: strangulation injuries are time-critical and can decompensate; evidence on skin persists on the order of days, not minutes. The sequencing error to avoid is holding a patient with airway symptoms in the SANE room for a 90-minute exam while imaging waits.
3. She is declining "all these tests." How do you respond in a trauma-informed way while protecting her safety?
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Treat the refusal as information, not obstruction.
- Name the request: she has been examined by strangers, has had her neck handled, and is pregnant - control over her body is the exact thing that was taken from her.
- Offer concrete choices rather than a single package: female clinician and chaperone (her stated preference), the option to pause at any point, the option of imaging first and exam later, and a support person.
- Explain the "why" in plain language: "Your voice and swallowing changes can be signs of swelling inside your throat that isn't visible from the outside. That can worsen over hours. The scan checks for that."
- Do not coerce or imply she must consent to keep her child safe or to be believed.
If she still declines imaging: escalate to the ED physician for a capacity-and-risks discussion, document the specific risks explained (airway compromise, missed vascular injury), her stated reasons, and a safety plan - who is with her tonight, a safe place to go, a follow-up contact, and clear return precautions for breathing difficulty, voice loss, or neck swelling. Document the refusal on the chart, not in the forensic kit narrative alone.