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Deaths Occurring Following the Application of Choke or Carotid Holds

Deaths Occurring Following the Application of Choke or Carotid Holds

In: Forensic Pathology. Dominick J. Di Maio, Vincent J. M. Di Maio, New York 1989
(Slightly abridged version without the references)

Rarely, one will encounter a death alleged to have occurred due to application of either a choke (bar arm control) or a carotid sleeper hold. These terms are often used interchangeably, but, in fact, refer to two different types of hold whose purpose is to produce transient cerebral ischemia and unconsciousness. Neither involves use of a mechanical implement. Rather, the arm and forearm are used to compress the neck, producing the cerebral ischemia and unconsciousness. Occasionally, a baton, large metal flashlight, or some other device will be used to compress the neck. The authors have seen a number of deaths with such instruments with fractures of the hyoid bone or the larynx. Since a device is used rather than the arm, they are not really deaths due to choke holds.

With choke (bar arm control) holds, compression of the neck by the forearm is used to occlude the upper airway. Incapacitation is due to collapse of the airway and the carotid arteries with a resultant decrease in oxygen to the brain. The forearm is placed straight across the front of the neck. The free hand grips the wrist, pulls it back, collapsing the airway. If too much force is used, there may be fracture of the larynx or hyoid bone. In the two cases reported in the literature by Reay and Eisele and in a recent case seen by the authors, there were unilateral fractures of the greater cornu of the thyroid cartilage. The authors' case also had a fracture of the hyoid bone on the same side. In the two cases reported by Reay and Eisele, both fractures are on the left side of the neck. These were produced using the right forearm across the neck and the left hand to pull it backward. Thus, pressure was eccentrically transferred to the neck, predominantly to the left side. In the case seen by the authors, the left forearm was used and the fractures were on the right side of the neck.

Choke holds can also cause death by another mechanism. In a choke hold, incapacitation is produced by lack of oxygen to the brain. This hypoxia is generalized, however, due to compression of the airway. Hypoxia sensitizes the heart to arrhythmia. The carotid sinus is a structure located in the internal carotid artery, just above the bifurcation of the common carotid artery. Stimulation of this structure by pressure to the neck can cause bradykardia and/or a fall in arterial blood pressure. Thus, we have two factors working on the heart predisposing to arrhythmias: the hypoxia from occlusion of the airway and the bradykardia from stimulation of the carotid sinus. There is, in addition, a third factor: release of catecholamines. Choke holds are used to restrain an individual who is struggling. On placement of the hold, the individual usually continues to struggle. This results in release of catecholamines, specifically, norepinephirene and epinephrine. These have an arrythmogenic action on the heart. Thus, the combined actions of hypoxia and catecholamines, which are both arrhytmogenic, plus the bradykardia produced by the carotid sinus stimulation, may result in a fatal cardiac arrhythmia.

In the carotid sleeper hold, symmetrical force is applied by the forearm and upper arm to the sides of the neck such that there is compression of only the carotid arteries and jugular veins and not the trachea. The arm is placed about the neck with the antecubital fossa or crook of the arm centered at the midline of the neck. The free hand grips the wrist of the other arm and pulls it backward, creating a pincher effect. This produces transient cerebral ischemia. The carotid sleeper hold impedes blood flow of the carotid arteries by pressure exerted on both sides of the neck by pincher effect of the arm and forearm. If properly applied, the compression of the carotid arteries will cause loss of consciousness in approximately 10-15 s. On relaxation of the hold, cerebral blood flow will be restored and consciousness will return in approximately 10-20 s, without any serious side effects. Maintenance of the pressure is essentially manual strangulation, and if continued long enough will, of course, cause death.


In theory, the carotid sleeper hold will cause rapid unconsciousness without injury to the individual. Unfortunately, in violently struggling individuals, a carotid sleeper hold can easily and unintentionally be converted into a choke hold as the individual twists and turns to break the hold.

A properly applied carotid sleeper can also cause death. One would not expect any trauma to the structures of the neck, however. The compression of the carotid arteries, with resultant decreased cerebral blood flow, can theoretically precipitate a stroke in an individual with atherosclerotic disease of the carotid and/or cerebral vasculature. The pressure may cause dislodgement of atherosclerotic material with a stroke due to an embolus. Blood flow to the brain is from both the carotid and the vertebral arteries. If the vertebral arteries have impaired blood flow due to atherosclerosis then occlusion of the carotid arteries may compromise an already compromised circulation with resultant thrombosis and/or stroke.

Compression of the neck by a carotid sleeper hold may also cause stimulation of the carotid sinus with bradycardia. Application of the hold to an individual who is agitated and struggling may increase the struggling, with increased release of catecholamines. The catecholamines working with the carotid sinus stimulation may produce a cardiac arrest. In addition, if the individual has intrinsic heart disease, he may be even more sensitive to bradycardia and the arrhythmogenic activity of the catecholamines


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