You are at the front desk sorting walk-in patients as "sick, not sick" when you hear the door open for the first time in about 20 minutes. Jane and her son John Jr. walk in. Both present to your emergency department frequently with complaints that are typically low acuity, yet something about Jane looks different today. In a husky, hoarse voice, Jane says, “I need to be seen for my sore throat.” As the nurse responsible for making prioritization decisions, Jane's clinical presentation with her frequent visits could impact your acuity determination. What you do not know and what you cannot know but must suspect is that Jane may be a patient who has survived intimate partner violence. What you may find out if you ask the right questions is that Jane is a strangulation survivor. Strangulation is the act of pressure around the neck with enough force to impede respiration or circulation. Manual strangulation, with the hands, is more common than ligature strangulation using a rope or cordlike object.1Training Institute on Strangulation Prevention California District Attorneys Association The Investigation and Prosecution of Strangulation Cases. Training Institute on Strangulation Prevention, San Diego, CA2013Google Scholar True choking is an obstruction in the upper airway, although patients may describe their strangulation experience using the word choking or choked. Suffocation occurs from a lack of oxygen due to choking or smothering. Persons who have experienced intimate partner violence can be either gender, although strangulation survivors are more likely to be women.1Training Institute on Strangulation Prevention California District Attorneys Association The Investigation and Prosecution of Strangulation Cases. Training Institute on Strangulation Prevention, San Diego, CA2013Google Scholar Studies of women living in domestic violence shelters suggest that up to three fourths of residents report strangulation as part of the violence they survived.2Joshi M Thomas KA Sorenson SB “I didn’t know I could turn colors”: health problems and health care experiences reported by women who were strangled by an intimate partner.Soc Work Health Care. 2012; 51: 798-814Crossref PubMed Scopus (40) Google Scholar In almost half of deaths involving intimate partner violence, persons have experienced at least one episode of strangulation before the fatal violent incident.3Glass N Laughon K Campbell J et al.Non-fatal strangulation is an important risk factor for homicide in women.J Emerg Med. 2008; 35: 329-335Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar One episode of strangulation makes the person 700 times more likely to be strangled again by the same aggressor and 800 times more likely to die at the hands of the same aggressor.3Glass N Laughon K Campbell J et al.Non-fatal strangulation is an important risk factor for homicide in women.J Emerg Med. 2008; 35: 329-335Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar Only 37 states have specifically mentioned strangulation in statute, with penalties ranging from misdemeanor to felony.1Training Institute on Strangulation Prevention California District Attorneys Association The Investigation and Prosecution of Strangulation Cases. Training Institute on Strangulation Prevention, San Diego, CA2013Google Scholar Health care workers, law enforcement, prosecutors, and survivors themselves are only now starting to use language illustrating the potential of death from strangulation. A survivor of strangulation has not survived an attempted strangulation; rather, this person has survived attempted murder and was strangled. Moreover, even if the patient diminishes the personal risk, the emergency nurse must be aware of symptoms associated with strangulation because many patients do not have visible external signs of injury.1Training Institute on Strangulation Prevention California District Attorneys Association The Investigation and Prosecution of Strangulation Cases. Training Institute on Strangulation Prevention, San Diego, CA2013Google Scholar Researchers estimate as many as 50% of persons experiencing fatal and nonfatal strangulation will have no visible external signs.1Training Institute on Strangulation Prevention California District Attorneys Association The Investigation and Prosecution of Strangulation Cases. Training Institute on Strangulation Prevention, San Diego, CA2013Google Scholar Although the emergency nurse may see bruising, scratches, redness, or petechia, the absence of visible signs is just as likely, requiring the emergency nurse to be aware of symptoms associated with strangulation and familiar with screening questions to ask the strangulation patient.4McLean M The identification, care and advocacy of strangulation victims.http://www.von.ca/pdf/special_projects/STRANGULATION_PROTOCOL_Final_May_2012.pdfGoogle Scholar Jane complained of a sore throat and exhibited a husky, hoarse voice compared with her known baseline. A sore throat is reported in 60% to 70% of strangulation cases, and voice changes are reported by 50% of strangulation survivors.1Training Institute on Strangulation Prevention California District Attorneys Association The Investigation and Prosecution of Strangulation Cases. Training Institute on Strangulation Prevention, San Diego, CA2013Google Scholar Trouble swallowing may also be reported. Breathing changes, such as hyperventilation, complaints of shortness of breath, or exacerbations of existing asthma, are even more commonly reported symptoms, seen in 85% of nonfatal strangulation survivors.1Training Institute on Strangulation Prevention California District Attorneys Association The Investigation and Prosecution of Strangulation Cases. Training Institute on Strangulation Prevention, San Diego, CA2013Google Scholar Following a strangulation episode, behavioral signs may also be present. Patients may report anxiety or appear restless. Patients may report or exhibit a decreased ability to concentrate or focus. Weeks, months, or years later, patients may report sleeplessness and may exhibit depression or anxiety. Symptoms associated with neurovascular compromise, such as headache, dizziness, blurred or decreased vision, or memory loss, may be reported. Loss of consciousness and loss of bowel or bladder control may be reported, even within as short as 5 to 10 seconds of strangulation force being applied.1Training Institute on Strangulation Prevention California District Attorneys Association The Investigation and Prosecution of Strangulation Cases. Training Institute on Strangulation Prevention, San Diego, CA2013Google Scholar Case studies and anecdotal reports indicate strangulation survivors are also at risk of carotid dissection and pulmonary edema, as well as hemorrhagic and ischemic stroke, hours to years after a single episode of strangulation, with risk increasing with each strangulation event.1Training Institute on Strangulation Prevention California District Attorneys Association The Investigation and Prosecution of Strangulation Cases. Training Institute on Strangulation Prevention, San Diego, CA2013Google Scholar, 5Sethi PK Sethi NK Torgovnick J Arsura E Delayed left anterior and middle cerebral artery hemorrhagic infarctions after attempted strangulation: a case report.Am J Forensic Med Pathol. 2012; 33: 105-106Crossref PubMed Scopus (9) Google Scholar, 6Neto HS Neville IS Beer-Furlan A et al.Hemodynamic stroke caused by strangulation.Int J Clin Exp Med. 2014; 7: 2932-2935PubMed Google Scholar, 7Gwinn C Strack G Better and stronger together: Developing your multi-disciplinary team (MDT) response. Paper presented at: Advanced Strangulation Course.August 2014Google Scholar Signs and symptoms related to strangulation will vary from patient to patient, and the preceding list is not intended to be all encompassing. Recognition of potential strangulation injuries leads to assessment of the patient, including screening. Many tools for intimate partner violence screening exist that may include a strangulation component. For an individual seeking a short screening assessment, a Canadian strangulation protocol includes 6 brief questions, starting with whether the current strangulation event was the individual’s first strangulation.4McLean M The identification, care and advocacy of strangulation victims.http://www.von.ca/pdf/special_projects/STRANGULATION_PROTOCOL_Final_May_2012.pdfGoogle Scholar Assessment questions ask specifically about breathing difficulties, presence of a cough or voice changes, loss of consciousness, and loss of bowel or bladder control. The assessment concludes by asking, “Did you think you were going to die?” Determining the intent of the aggressor is out of scope for the health care team, but determining the patient’s perception of victimization may help the patient understand the danger and may provide support needed by law enforcement and prosecutors. Surviving strangulation is surviving attempted murder. The aggressor has demonstrated power and control over Jane, illustrating that the aggressor could kill Jane if he chose to. The instilled fear leading Jane to the emergency department may be the same fear pulling her back to the aggressor. Supportive, nonjudgmental care with an explanation of symptoms and long-term risks may be all Jane is willing to take away from the ED visit. Some patients, however, will be more ready. Are you ready?“I need to be seen for my sore throat. He choked me and I’m so scared he may really hurt John Jr. Can you help me?” Andi Foley, Member, Washington State Council Chapter, is Clinical Nurse Specialist, Emergency Services, CHI Franciscan St Francis Hospital, Federal Way, WA.