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The Dangers of Strangulation – The Hotline

By Heather, a Hotline Advocate

At The Hotline, we often speak with people who don’t think they are being abused because they aren’t being hit, aren’t being hit with a closed fist or aren’t being physically abused on a regular or daily basis. While abuse can include frequent, violent attacks, abuse can also include monitoring your phone, restricting access to finances, controlling who you spend time with and many other behaviors that aren’t physical at all. However, one of the most serious and deadly forms of abuse is physical, but many survivors are still hesitant to label strangulation or “choking” as abusive.

The information in this article is not meant to scare you, but you deserve to know the facts so you can make the best plan to keep yourself safe.

If your partner has ever put their hands around your neck, put you in a “sleeper hold” or used anything else to strangle you like a scarf, necklace, belt, rope, etc., keep reading.

Because strangulation can be very serious, symptoms of strangulation can include:

• a sore throat
• difficulty swallowing
• neck pain
• hoarseness
• bruising on the neck or behind your ears
• discoloration on your tongue
• ringing in your ears
• bloodshot eyes
• dizziness
• memory loss
• drooling
• nausea or vomiting
• difficulty breathing
• incontinence
• a seizure
• a miscarriage
• changes in mood or personality, like agitation or aggression
• changes in sleep patterns
• changes in vision, such as blurriness or seeing double
• fainted or lost consciousness

It’s possible to experience strangulation and show no symptoms at first but die weeks later because of brain damage due to lack of oxygen and other internal injuries. For this reason, and for a safe way to document the abuse, we strongly recommend you consider seeing a doctor if your partner has strangled or choked you. Also know that you always have the right to file a police report, press charges for an assault or seek a restraining order against someone who is choosing to be abusive towards you.

Facts You Deserve to Know

Filling out the lethality assessment, especially with an advocate at your local domestic violence agency, can help you learn more about your personal risk from your partner. This survivor’s story talks about how long-term memories can be affected by traumatic brain injuries caused by strangulation and concussion. We know that the details of abuse can get fuzzy, sometimes from gaslighting or from the abuse itself, so if it’s safe to do so we recommend documenting as much of the abuse you’re experiencing as possible. If you need to call the doctor, The Hotline or your local domestic violence agency but making calls is dangerous for you, here are some helpful tips that might work for you.

To find a domestic violence agency near you, or for help making a plan to stay safe, please call our advocates 24/7/365.

Taking your breath away – why strangulation in domestic violence is a huge red flag

As a part of Domestic Violence Awareness Month, we explain the common signs and symptoms of strangulation in the hopes of helping clinicians recognize, treat, and safety plan with victims to prevent future violence.

When conducting assessments or forensic exams with a victim of domestic violence (DV), any reported history of strangulation places the person at a higher risk for more serious violence or homicide by the hands of their intimate partner. By recognizing signs of strangulation, healthcare providers can help to mitigate long-term damage, properly document any evidence of abuse, and provide referrals for seeking safety assistance.

The Training Institute on Strangulation Prevention defines strangulation as “the obstruction of blood vessels and/or airflow in the neck resulting in asphyxia. ” This type of assault can have serious, permanent, or even fatal damage to the victim’s throat or brain. 

Data on strangulation reveals a glaring picture of the severity of this type of assault. One in four women will experience intimate partner violence (IPV) in their lifetime, and of those, up to 68 percent will suffer near-fatal strangulation at the hands of their partner. 

Of the victims, 97 percent are strangled by hands; 38 percent reported losing consciousness; 35 percent are strangled during sexual assault/abuse; 9 percent are also pregnant, and 70 percent of strangled women believed they were going to die. 

Why reported strangulation is a big warning sign for professionals

Not to be confused with “choking”, strangulation refers to when pressure is applied from the outside, cutting off airflow and/or blood vessels in the neck, preventing oxygen from reaching the brain. Choking, meanwhile, refers to a blockage inside the throat which makes it hard to breathe.

During an incidence of strangulation, closing off the airway makes breathing impossible, and a victim may lose consciousness due to the blocking of blood flow to and from the brain. Strangulation may obstruct the carotid arteries in the neck, depriving the brain of oxygen. Unconsciousness may also occur due to the blocking of the jugular veins which prevents deoxygenated blood from exiting the brain. 

The perpetrator strangles as a form of power and control over their intimate partner by controlling their breathing. This pressure can lead to a loss of consciousness within five to ten seconds and cause death within a few minutes.

Because such a thin line exists between unconsciousness and death, strangulation sits just before homicide on the continuum of domestic violence risk assessment.

Over the past 20 years, prosecutors and physicians have paid closer attention to the serious danger caused by strangulation, and strangulation is now recognized as one of the most lethal forms of violence. Since 2010, criminal laws reflecting the severity of strangulation have passed in at least 45 states in the US.

Depending on state law, strangulation can be charged as a misdemeanor or felony, but can also be coupled with attempted homicide charges based on the severity.  Current laws focus on the cutting off of another person’s blood flow or breathing, making it easier to prosecute even without visible injury. Professionals should also consider other high-risk factors such as the patient and/or perpetrator’s access to firearms, if the patient is suicidal, sexual violence, and injury to animals.

How to identify signs and symptoms of strangulation

Strangulation can lead to serious physical and psychological health problems. Common visible signs of strangulation include petechiae (red spots) in the eyes, blood-red eyes, swollen lips, and cord, rope burns, scratches, and bruising (particularly on the neck). 

When someone is being strangled, they will often try to regain control of their airway, by trying to pry the hands of the perpetrator off of them which can leave injuries on their neck and also leave the assailant with scratch marks or injuries on their face and hands. Strangulation may also coincide with other forms of domestic violence that leave bruising due to kicking, hitting, or pushing down the stairs. 

Physically, the victim may have difficulty breathing, speaking, and swallowing or experience nausea, vomiting, lightheadedness, headache, involuntary urination and/or defecation (common in pregnant victims). In these cases, conducting an immediate medical exam could prove necessary in saving the victim’s life. 

Signs of strangulation are not always visible

Just because a victim lacks any external signs of strangulation does not mean that they are not injured. Penny Clute, former Clinton County District Attorney and Plattsburgh City Court judge, recalls, “Whether death resulted or not, only half of strangulation victims had marks on their necks, and only 15 percent of those marks were clear enough to photograph.” 

A victim may suffer from internal injuries that do not appear on the outside. Immediately after the attack, the person may experience intense pain, vision changes, ringing in the ears, a swollen tongue, cuts in the mouth, swelling of the neck, difficulty swallowing, trouble breathing, or voice and throat changes. 

The victim may also experience neurological damage due to a lack of oxygen flow to the brain. These symptoms can include memory loss, dizziness, headaches, vomiting, and extreme weakness. 

Strangulation may cause long-term health consequences. A person’s behavior may become more combative. The victim may also suffer from PTSD, depression, suicidal ideations, memory problems, nightmares, anxiety, severe stress reaction, amnesia, and psychosis.

Death can also occur days or weeks subsequent to the attack due to carotid artery dissection and respiratory complications such as pneumonia, acute respiratory distress syndrome (ARDS), and the risk of blood clots traveling to the brain (embolization). 

According to forensic nursing expert, Diana Faugno MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN, DF-AFN, Computed Tomography Angiography (CTA) to scan the soft tissues and vascular structures of the neck should be assessed as appropriate to prevent further injury and possible death to the strangulation victim.

“Carotid artery dissections are the number one cause of stroke in people under the age of 45. Medical literature reports that the time period between neck trauma with an arterial injury and the patient’s presentation with an acute stroke can be hours to years,” states Faugno. 

Medical experts say that the lack of blood flow and oxygen to the brain during strangulation can cause memory loss, and the person may not remember what happened. In some cases, the victim may dismiss the incident as choking and seem fine after the attack, thinking the danger has passed. Nurses, therefore, must learn to recognize the signs and symptoms of strangulation to prevent any further damage or death.

What to do after identifying a victim of strangulation

Addressing strangulation effectively can prevent serious permanent side effects and death. Forensic nurses should know how to recognize and handle strangulation to help victims get appropriate medical care and emotional support, even after memory loss.

Sexual Assault Response Teams should ensure that professionals understand how to conduct a non-fatal strangulation exam including: 

• How to recognize visible symptoms and signs of strangulation and how to document them
• The physics of strangulation – how much pressure is needed to occlude the jugular and carotid artery
• Best practices for improving treatment and care provided to strangulation patients

Documentation aids are critical in the effective criminal prosecution of strangulation cases. When able, professionals should document changes in the victim using photographs sequentially for a period of days following the assault to establish a journal of physical evidence. Forensic nurses should also take detailed accounts in their forensic exam notes with the exact date and time to monitor the progression of signs and symptoms.

When in doubt, medical professionals can consult with experts during a forensic exam for guidance on recognizing strangulation. EVA for sexual assault examinations can help track information collected and share patient records with physicians, law enforcement, and legal teams for expert advice. The EVA System’s filters can help to highlight any bruising that may be less visible to the naked eye. 

Alliance for HOPE International, the leading domestic violence and sexual assault prevention organization in the United States, also provides information on strangulation, including training for police, prosecutors, medical clinicians, and domestic violence advocates to help recognize the signs and symptoms.

As a history of strangulation is a high-risk factor for intimate partner homicide, be sure to provide your patients with resources for safety planning if they are ready to leave their abusive partner. A safety plan essentially outlines the resources available to domestic violence victims and what to do in specific situations whether they decide to stay with or leave their abuser. 

Collaborate with local domestic violence service providers, shelters, and members of law enforcement to build a base of referrals. You can always refer patients to the national domestic violence hotline at 1-800-799-7233. 

How Risky Is it to be Choked During Sex?

This story appears in the March issue of VICE magazine. Click HERE to subscribe. 

Ah, friends. They’re like family but cooler. Fully customizable. Fall and one of them will be right there to pick you back up. But as great as friends can be, they also do a lot of really stupid stuff. Stuff that blows your mind. Like, sometimes it seems crazy that you even hang out with people who make such crappy decisions. Stuff that, were it to get out, would be mortifying for anyone with even a shred of self-respect. Lucky for your friends, they’ve got you to ask their deepest, darkest questions for them. And lucky for you, we started this column to answer those most embarrassing of queries.

The scenario: Your friend is into BDSM stuff and likes to have his mouth and nose covered during sex. He’s alluded to a curiosity about choking too. What? It gets him off.

What you’re afraid of: That your buddy will die happy, but way too early, in the throes of kinky sex.
A little background: Choking and breath play are “are possibly the single largest causes of permanent harm and death within the BDSM scene,” says Barak*, co-owner of adventuresinsexuality.org, and an ER Nurse. (*We’ve omitted Barak’s last name at the request of the medical institution he works for.)

What’s likely to happen: There aren’t solid statistics for how many people partake in this type of BDSM, or suffer the consequences of it. The main takeaway here is that anyone who tries it can have an experience that goes awry.

Research shows that healthy adults are unlikely to sustain permanent damage if the person being choked is released quickly and before losing consciousness, but Barak cautions that “this is not to say there will not be side effects and possible long term damage” from such a thing. Frequently, the stress that choking places on the body can cause “difficulty breathing, hoarse voice or cough, difficulty swallowing, headaches, and lightheadedness,” Barak says. Other injuries your friend could potentially expect to sustain are small red dots mainly on the face, and broken blood vessels in the eye.

The worst that could happen: Death. That’s especially a risk if things devolve into violent strangulation, aka squeezing or constricting of the neck. Also if they have certain pre-existing medical conditions—including high blood pressure, high cholesterol, cerebral aneurysms, and carotid fatty deposits—they’re particularly vulnerable to dangerous, even fatal, results.

What to do: In his seminal sadism and masochism book, SM 101, sex educator and activist David Wiseman writes, “I know of no way whatsoever that suffocation or strangulation can be done that does not intrinsically put the recipient at risk of cardiac arrest… I know of no reliable way to determine when such a cardiac arrest becomes imminent. If the recipient does arrest, the probability of resuscitating them, even with optimal CPR, is small.” Read that aloud to your friend and hope they lose their boner.

Choking: Signs, Choking Hazards and When to Visit the A&E

Last updated on 1 February 2021

Choking hazards are all around us. Most people choke at some point in their lives but it is usually quickly resolved and doesn’t pose a danger. There are, however, times when it can go wrong, leading to life-threatening complications. Here are some things to know that might just save a life.

Signs of choking

The following behaviours might indicate that a person is choking:

• Coughing or gagging
• Panic and hand signals for help
• Inability to speak, make noise or breathe
• Turning blue around the lips, face and nails due to a lack of oxygen
• Clutching the throat
• Infants who are choking may show signs of breathing difficulty, weak crying and/or coughing

If choking occurs, head to the A&E department where a doctor can remove the obstruction.

Choking may occur when food gets stuck in your trachea (windpipe). Food can also get stuck in your oesophagus (food pipe).

When food gets stuck in your windpipe

Symptoms

Partial choking may cause 

• Coughing
• Wheezing
• Breathlessness

Dangers

• Partial choking may result in chest infection
• Full choking may cause brain damage or death

Full choking is a medical emergency and requires immediate treatment to remove the blockage.

The brain will begin to die after 5 mins of suffocation.

What should you do if you see someone choking?

Do the Heimlich manoeuvre (Rescuer)

The Heimlich manoeuvre (also known as abdominal thrust) is performed on a person who is choking is unable to cough, speak or breathe. These are the steps to follow:

• Step 1: Help the person to stand up.
• Step 2: Position yourself behind the person.
• Step 3: Lean the person forward slightly and give 5 blows to their back with the heel of your hand.
• Step 4: Place your arms around their waist.
• Step 5: Make a fist and place it just above their navel, thumb side in.
• Step 6: Grab your fist with your other hand and make a quick push inward and upward at the same time. Do this 5 times.
• Step 7: Repeat until the object in expelled and the person can breathe or cough on their own.

If the person can’t stand up, straddle (kneel with one knee on either side) their waist, facing their head. Push your fist inwards and upward in the same way described above.

Head to the A&E department where a doctor can remove the obstruction.

When food gets stuck in your food pipe

What happens when a foreign object gets stuck in your throat or food pipe?

Symptoms

• Pain when swallowing
• Difficulty swallowing (including saliva)
• Discomfort
• Breathing difficulties

Dangers

• Throat injuries from bones and hard objects

What should you do?

• Drink water to try moving it down (if not bones or hard objects)
• Do not attempt to remove bones and hard objects by yourself as they may injure the throat
• Head to the A&E department where a doctor can remove the obstruction
• Specialised equipment may be needed to remove food stuck deep in the throat

How to tell if it is an emergency

When choking is severe, the person won’t be able to speak, cry, cough or breathe as most of their airway is blocked. Without help, they will eventually lose consciousness.

If this happens, quickly perform the Heimlich manoeuvre on them and get help immediately by calling emergency services or visiting the A&E.

If the person loses consciousness, begin cardiopulmonary resuscitation (CPR) with chest compressions.

Choking foods

Some items that may get stuck in the throat (potentially everything!) include:

• Small fish bones
• Plant fibres
• Chicken bones

Other less common items include:

• Hot dog
• Hard candy
• Chewing gum
• Nuts and seeds
• Chunks of meat or cheese
• Whole grapes
• Popcorn
• Chunks of peanut butter
• Raw vegetables
• Raisins

Common reasons why people choke

• Talking or laughing while chewing and swallowing
• Eating while running (mostly kids) = food may be inhaled with deep breaths
• Alcohol impairs the swallowing mechanism and gag reflex
• Big bites and improper swallowing
• Small foods like nuts can go into the windpipe by mistake
• Advanced age may weaken the gag reflex
• Diseases like Parkinson’s may disrupt the swallowing mechanism

During a medical emergency in Singapore, you can also call +65 6473 2222 for an ambulance that will transport you to the nearest hospital or a hospital of your choice. Learn more about Parkway Emergency services.

Reviewed by
Dr Dennis Chua, ear, nose and throat specialist at Mount Elizabeth Hospital
Dr Steve Tan, head of A&E department at Parkway Hospitals, Singapore

Infographic brought to you by Health Plus

References

Choking (2019, September 10) Retrieved December 04, 2020, from https://www.emedicinehealth.com/choking/article_em.htm

Heimlich Maneuver (2017, August 04) Retrieved December 04, 2020, from https://www.healthline.com/health/heimlich-maneuver

What Should I Do if Someone is Choking? (2018, August 21) Retrieved December 04, 2020, from https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/what-should-i-do-if-someone-is-choking/

Strangulation Injuries – StatPearls – NCBI Bookshelf

Continuing Education Activity

Strangulation injuries occur when external forces are applied to the neck leading to a variety of traumatic pathology. If the injury is severe enough cerebral perfusion and oxygen delivery is threatened and can lead to asphyxia and rapid neuronal death. These injuries can be encountered in various clinical scenarios and may be present in suicide attempts, sports injuries, motor vehicular trauma, and may have implications in the fields of criminology and forensic pathology. This activity describes the etiology, pathophysiology, and management of strangulation injuries, and stresses the role of the interprofessional team approach to the care of affected patients.

Objectives:

• Identify the causes of strangulation injuries.

• Describe the pathophysiology of strangulation injuries.

• Summarize the treatment options for strangulation injuries.

• Explain a well-coordinated interprofessional team approach to provide effective care to patients affected by strangulation injuries.

Access free multiple choice questions on this topic.

Introduction

Strangulation injuries are a heterogeneous set of traumatic pathology that occurs as a result of mechanical force applied externally to the neck and surrounding structures. As a type of asphyxia, these injuries may result in decreased cerebral oxygen delivery either by compression of cervical blood vessels, or tracheal occlusion. Death rapidly ensues without the removal of compressing forces. Should a patient survive the initial injury, care must be taken to evaluate for occult injury. External signs of injury, or lack thereof, may underrepresent the extent of deeper damage. The term “choking” is colloquially used to describe these injuries, however more accurately this term when used medically suggests an internal occlusion or partial occlusion of the proximal airway.

Patients who suffer from these injuries also represent a high-risk population in regards to a variety of biopsychosocial sequelae. Domestic and other types of violence unfortunately represent a significant percentage of these injuries year-over-year.[1][2] Additionally, it is a common injury pattern seen in completed suicide and suicide attempts. History and toxicological analysis of these patients sometimes reveal various substances, either intentionally ingested or otherwise. [3] Strangulation injuries can also occur as a result of both consensual and non-consensual sexual activity.[4] Martial arts, combat sports, military training, and law enforcement action are implicated as well – certain holds and detainment maneuvers may call for external neck compression.[4]

Pediatric populations are particularly vulnerable not only because of anatomic differences but because of downstream psychosocial issues that put them at high risk for morbidity and mortality should they survive the initial injury.[5][6] Additionally, social media and other outside media influences have been reported as a social stressor leading to suicide attempts in adolescent populations.[7][8]

Identification, diagnosis, and treatment require a multi-disciplinary approach. Once medical evaluation and treatment are underway, simultaneous mobilization of mental health experts, social workers, and law enforcement (depending on the clinician’s jurisdiction) must occur. Other personnel and approaches may be required as well depending on the individual injury pattern and psychosocial milieu. Criminal implications exist on the autopsy of patients who have succumbed to these injuries as well.

Etiology

Strangulation is defined as the compression of blood or air-filled structures which impedes circulation or function. In this summary, strangulation will refer to compression of anatomical neck structures leading to asphyxia and neuronal death. Strangulation injuries can be divided into several categories. These include hanging injuries, manual strangulation, and ligature injuries.[9][10][11][12]

Hanging injuries can be further divided into specific categories. Complete hanging is defined by the full weight of the patient being suspended by the neck. Incomplete hanging injuries encompass all injuries in which the patient is supported partially by another object such as the ground or furniture. For centuries hanging has been used in the penal systems as a form of punishment. The term “well-hung” referred to the erection a male experienced after a proper hanging was performed. This method of execution usually involved dropping the person from a height equal to or greater than their height, which often resulted in spinal fractures, spinal trauma, and spinal shock causing priapism.[13] Classically, hanging injuries have also been associated with vascular pathology ranging from carotid intimal tears to complete rupture.[14]

Ligature and manual strangulation injuries occur when a force that is independent of the patient’s body is applied to the neck. Strangulation injuries can also be divided into categories of intent. These include homicidal, suicidal, accidental, and auto-erotic.[2][15] The material involved in a ligature or hanging may also have implications on pathology and subsequent forensics.[16]

A significant number of pediatric strangulation injuries are accidental.[6] The unique behavioral characteristics of different ages highlight the mechanisms among these injuries and deaths. Younger children may suffer from injuries related to car windows, electrical cords, and becoming trapped between furniture (including high-chairs designed for children).[17][18] Accidental or intentional suffocation injuries, a mechanism distinct from strangulation via which asphyxia occurs due to oral-nasal obstruction, may also be part of the presenting situation.[16] Playground and handle-bar strangulation injuries, while rare, are important etiologic factors to consider in polytrauma pediatric patients with supporting histories.[19] As mentioned earlier, social media influences play a critical and more contemporary role in teenage and adolescent populations. The literature describes auto-erotic asphyxiation as a more common mechanism in this population as well and constitutes a mechanism of injury that can be considered both intentional and accidental. 

Strangulation injuries can occur during partnered sexual activity – either intentionally, accidentally, or both. It is a dangerous form of intimate partner violence, and survivors are at high risk for becoming victims of homicide.[20] Conversely, consenting adults engaging in low-force activity to enhance pleasure may sustain devastating injuries if care is not taken. Additionally, auto-erotic asphyxiation is seen in the adult population of strangulation injuries and is described as a paraphilia.[21]   

Many “submission holds” within the world of martial arts are known to place direct pressure on cervical structures and can result in strangulation injuries. Along similar lines, police and military combatants are given training on “vascular neck restraint.” This effective, but controversial, approach to subduing a target can result in permanent and debilitating injuries or even death.[22]

Epidemiology

The true prevalence and incidence of all-cause strangulation injuries and mortality is unknown. Because of the diversity of etiologies that lead to the common injury pathway, epidemiological studies, and case series within the literature tend to be etiology and population specific. 

Hanging injuries are the second most common cause of suicide in the United States; whereas, gunshot wounds are the leading cause. Males are more likely to commit suicide in both of these manners.[23] Women in abusive relationships are at the greatest risk of strangulation injury. Epidemiological studies and medical literature may underrepresent the true incidence and prevalence due to patient underreporting when medical attention is sought.[2] The incidence of hanging injuries has been increasing in the United States over the past several years, though as a cause of death in homicide cases it has remained fairly unchanged from 2006-2013.[3] The popularity of “choking games” amongst pre-teens and teens has also affected the escalation of these injuries.[24]

In a retrospective case series published by Berke et al (2019), 98 near-hanging patients were identified over an 11-year period. All patients underwent trauma evaluation, and 254 CT and MRI scans were performed, which discovered only 8 traumatic injuries. Two patients demonstrated injuries to the cervical vasculature, three patients showed signs of thyroid cartilage and hyoid bone fractures, and three patients had vertebral injuries. A total of 35.7% of patients had clinically diagnosed anoxic brain injury, which was deemed present in all 19 patients who expired (19.5%). Injuries were more common in patients with a low Glasgow Coma Scale (GCS) compared with those exhibiting a normal GCS.[25] 

Pediatric patients less than 1 year of age unintentional strangulation injuries ranks fourth among all causes of unintentional injury. Motor vehicle accidents, drownings, and burns are all more common. Of over 200,000 playground injuries recorded in 1999, only 0.07% were fatal, and of these 50% were determined to be caused by asphyxia from strangulation injuries. Eighty percent of victims were found to be under 10 years of age.[6]

Pathophysiology

The common pathway through which strangulation injuries cause morbidity and mortality is via cerebral hypoxemia and resultant cerebral ischemia. Four specific pathways are described in the literature.[26]

1. External pressure to the jugular veins prevents adequate venous return from the cerebral circulation. Backpressure prevents eventual arterial inflow and results in elevated intracranial pressures. This ultimately results in unconsciousness, depressed brainstem functions, and ultimately asphyxia and death.

2. External pressure to the carotid arteries directly prevents oxygenated blood flow to the cerebral vasculature which leads to asphyxia and death.

3. Pressure obstruction of the larynx primarily results in the inability to oxygenate the pulmonary vasculature. Systemic hypoxia quickly ensues of which the most pronounced effects are rapid loss of consciousness followed by death.

4. Though rare, cardiac dysrhythmias may occur with pressure directed towards the carotid bodies bilaterally. This has the potential to evoke cardiac arrest, and subsequent death if not promptly recognized

Acute sequelae of rapid (or slow) loss of perfusion include various forms of anoxic brain injury. Watershed infarcts can occur in patients with chronic cerebrovascular disease. Ultimately, with a significant initial injury, diffuse cerebral edema can result which may lead to various forms of brain herniation and death. Diffuse axonal injury has also been described in the autopsy literature.

Pathophysiologic phenomenon can also be grouped in relation to the aforementioned three categories of strangulation – hanging, manual strangulation, and ligature-based injuries.

The nature of the hanging injury informs the type of pathophysiology. Judicial hangings from height can result in rapid deceleration mechanisms. Mechanical forces transmitted in this manner can result in what is described as “internal decapitation” – spinal cord transection, cervical vascular transection, and various types of spinal fractures. Classically, the “hangman’s” fracture is described when deceleration causes forceful extension of the neck resulting in bilateral C2 pedicle fractures. If the force is severe enough C2 can become severely subluxated from C3, thus threatening the spinal cord. Associated hematomas may also result in neurological compromise. These fractures have been described in motor vehicle accidents where the top of the steering wheel immediately halts the forward movement of a patient’s neck (should an airbag not be present) resulting in a similar hyperextension injury. Manual strangulation or hanging without a significant height drop implies less deceleration force, and fractures are not typically common in this population. Many types of cervical spine injuries in these patients are described as unstable.[26][27]

Compression of the jugular veins results in acute death by causing cerebral hypoxia followed by loss of muscle tone. Once muscle tone is compromised, increased pressure is applied to both the carotid arteries and the trachea. Direct compression of the carotid arteries also leads to a decrease or loss of cerebral blood flow and brain death. The direct pressure on the carotid sinuses causes a systemic drop in blood pressure, bradycardia, and other arrhythmias. Consequences are anoxic and hypoxic brain injury death.

Ligature-based injuries can include focused force trauma to certain structures. Force applied over a smaller surface area may result in more pointed injuries rather than extensive and broader crush-type injuries. The type of ligature may also be important – barbed ligatures may cause penetrating trauma to various neck zones, and may even injure deep structures. All types of aerodigestive injuries must be considered in these patients. Fractures of the hyoid bones and thyroid cartilage result from a force directed towards these structures.[26]

A variety of spinal cord injuries are associated with strangulation and pathophysiology is directly related to the specific mechanism. Complete cord transection might be a sign of rapid deceleration injuries. Alternatively, injury to surrounding structures may threaten nearby neurological anatomy. Hematomas and injury-related edema have all been described as mechanisms that result in spinal cord trauma. Spinal cord ischemia may result from the disruption of vessels necessary to maintain perfusion. Care must be taken in the evaluation as mechanical forces and displaced surrounding structures may injure or disrupt spinal tendons and ligaments. The pathophysiology of these injuries is diverse and if severe can lead to paralysis and ultimately death.   

Facial and cervical petechiae and ecchymoses are a common injury pattern found in strangulation injuries. Pressure transmitted via compressed vasculature can result in capillary, venule, and arteriole injuries resulting in these skin findings. Facial plethora or swelling can occur due to the externally-applied pressure. Similar mechanisms result in ocular findings such as subconjunctival hemorrhages. Epistaxis from pressure has been described as well and is thought to be due to pressure-related vascular injury.[28]

Vascular trauma may include transection and intimal tears. These injuries can lead to chronic issues and possibly pseudoaneurysms and other vascular complications. Lower pressures are needed to occlude cervical veins, and higher pressure is required for cervical artery deformation. Thrombotic events may result, which can cause acute occlusion and/or embolic phenomenon.[3][26][28]

Histopathology

Histopathological implications of strangulation injuries are as diverse as the pathophysiology that underlies each specific type and the conditions present at the time of injury. Typical findings of anoxic brain injury can be expected. Cell damage can appear in as little as four hours and is dependent on the extent and duration of anoxia/hypoxia. Ischemic cell damage may result in primary necrosis of neurological structures, or a delayed fashion via apoptosis if the patient survives the initial insult. A “cloudy swelling” pattern of nuclear regions and a reduction in basophilic character to the nucleus have been described. Cytoplasmic shrinking and pyknotic nuclei are also potential injury patterns. At the 8-12-hour mark classic “red neurons” begin to appear.[29]

Higher metabolic rate and oxygen demand underscore the areas of the brain that are most easily affected by strangulation injuries. Watershed regions are at a particular risk as well. CA1 pyramidal neurons within the hippocampus are implicated in memory deficits seen in patients who survive. Within the cerebellum, the Purkinje cells are at higher risk of anoxic injury, which explains gait abnormalities sometimes seen in survivors. Arterial border zones in various areas of the brain may demonstrate “wedge-shaped” lesions, which may be seen on detailed neuroimaging as well.[29]

There are multiple forensic pathology considerations in this patient population as well. Excoriation marks on the face and various body surfaces may signal struggle either by the patient to remove a ligature or other object causing strangulation. They may also signify injury caused by a potential assailant. Burns and musculoskeletal trauma may be present on autopsy as well depending on the circumstances. The cause of death can be difficult to assess due to the multiple pathways that lead to the common pathophysiology of death in strangulation. For example, homicide victims who suffer strangulation injuries that were also found submerged in bodies of water might have signs of both strangulation and submersion injury. Both lead to hypoxia and eventually death, and thus determining a sequence of events might be difficult.[3]

Toxicokinetics

Strangulation injuries, whether accidental or intentional may also be compounded by toxicological pathology. Many times alcohol and/or prescription and non-prescription drugs may have been ingested by the patient at or around the time of injury. Many of these substances may also cause central nervous depression and contribute to altered mental status. Underlying life-threatening overdoses with acetaminophen, aspirin, tricyclic antidepressants, and other substances can cause severe metabolic disturbances and complicate strangulation injuries.[3]

History and Physical

The history of a strangulation injury may be obtained from the patient, witnesses, family or friends, first responder personnel, or a combination of the above. Proper history will facilitate proper management. If possible, determine whether the strangulation was a manual, ligature, or hanging injury. When a history of ligature or hanging is elicited, the clinician should further clarify the type of material used. Incomplete versus complete hanging injuries should also be differentiated. If the injury is a complete hanging, the height of the drop should be assessed as this may help prognosticate as well as. Associated injuries and ingestions need to be evaluated. Obtaining an approximate time of injury is also essential, along with a potential duration of the sustained injury. The patient’s initial on-scene presentation, resuscitative efforts initiated, and patient stability or decompensation en route will also aid the practitioner to initiate proper management.

Physical examination may include one or more of the following “hard signs” of strangulation:

Head, Eyes, Ears, Nose, and Throat

• Visual disturbances

• Conjunctival or facial petechial hemorrhages

• Swollen tongue or oropharynx

• Foreign body (blood, vomit, tissue) in the oropharynx

• Facial edema, lacerations, abrasions, ecchymosis

• Neck abrasions, edema, lacerations, or ligature marks

• Tenderness to palpation over the larynx

• Hoarseness or stridor

• Subcutaneous edema or crepitus

Cardiovascular

• Cyanosis or hypoxia

• Arrhythmias

• Respiratory distress

• Crackles or wheezes

• Cough

Neurologic

• Altered mental status

• Seizures

• Stroke-like symptoms

• Incontinence

As with all traumatic injuries, the physical exam must first start with an examination of the airway. Blood, vomitus, sputum, and other foreign bodies may be involved. Audible stridor can result from a threatened upper airway. Auscultation of cervical structures is helpful not only to assess airway patency, but to listen for bruits, thrills, and other signs of vascular injury. The patient’s breathing pattern should be noted. Bradypnea and other abnormal breathing patterns may result from Cushing’s triad if the patient is showing clinical signs of grave elevations in intracranial pressure. An assessment of the patient’s circulatory status is vital. Blood pressure monitoring, capillary refill, and extremity warmth can suggest to the clinician if the patient has signs of spinal shock.[5][25][28][30]

To this end a thorough neurological assessment is vital. Neurological tone, reflexes, and many eponymous findings may suggest upper motor neuron injury or cerebrovascular injury. Care should be taken to assess lateralizing signs as well which may help localize a certain level of spinal cord lesions.

Skin and musculoskeletal findings are likely to be present in severe injuries. Depending on the nature of the trauma a full head to toe assessment should be done for these organ systems. Polytrauma patients may have other injuries that go unrecognized when focused on the immediate needs of the strangulation injury.[28]

In patients where it is appropriate to do so, a rapid psychiatric assessment is necessary. Signs of depression (e.g. depressed mood, suicidal ideations, altered thought content, and many others) may be present. Assessment of the patient’s sensorium, concentration, memory, and other features may point towards concomitant intoxication or concussive head injury.

Evaluation

Once the patient is stabilized, laboratory and radiologic studies can aid in determining the severity of the injury. Laboratory studies may include complete blood count (CBC), CMP, coagulation studies, beta-HCG, toxicology panel (alcohol, drug, aspirin, and acetaminophen levels), lactic acid, and arterial blood gasses. CT is widely available and is the first line of radiologic evaluation of strangulation injuries. CT Angiogram of the carotid and vertebral arteries is the gold standard in care. This allows for the evaluation of vascular and bony structures.[31]

CT of the neck with contrast is less specific than CT Angiogram but will evaluate bony structures and vascular structures to a degree. Non-contrast CT of the brain will evaluate for stroke but is more sensitive for intracranial hemorrhage than for smaller ischemic strokes. A non-contrast CT scan of the brain may identify large areas of infarcted tissue. Non-contrast CT is also the study of choice to evaluate for cerebral edema in the acutely presenting patient.[31]

MRA of the neck is another imaging modality option, although it is less available in smaller and rural centers, and it is also more time-consuming than CT to complete. It is also less sensitive than CTA of the neck in evaluating vessels. MRI of the neck poses similar availability issues. It has less sensitivity than CTA in evaluating vascular structures; however, it is the most accurate study to evaluate the soft tissues of the neck. MRI/MRA of the brain is the most sensitive modality in evaluating both global and anoxic brain injury, ischemic stroke, and, intracranial hemorrhage. Consideration must be given to the patient’s clinical stability before pursuing magnetic resonance-based studies.

Carotid doppler is not recommended for the evaluation of strangulation injuries due to its inability to completely evaluate all of the possibly affected vascular structures. Plain chest radiography is also recommended in patients who have required intubation or are in respiratory distress. Bronchoscopy and upper gastrointestinal endoscopy may be indicated later on in the patient’s care. Indications include various signs of aerodigestive injury including hemoptysis and hematemesis.[32]

Treatment / Management

The primary survey, as in any traumatic injury, should begin with an evaluation of the patient’s airway, breathing, and circulation. Immediate resuscitative interventions should take priority over radiologic studies. Clinicians who practice in settings where they are responsible for acute management of patients suffering from strangulation must have extensive experience in airway management, including surgical techniques (emergent tracheostomy and cricothyrotomy).[30]

Patients with “hard signs” or other physical exam findings of extensive cervical injury should immediately have a cervical collar or other immobilization device placed. Removal can only occur once appropriate clinical and radiographic approaches have ruled out unstable fractures, vascular injury, and other threatening pathology. If none of the “hard signs” are present, radiologic studies are not always necessary. After evaluation in the emergency department, the patient may be discharged with strict return precautions. If the patient presents with any of the “hard signs” of strangulation injury, laboratory and radiologic evaluation must be performed.[4][33]

If the radiologic studies are completely negative, disposition should be based on the patient’s clinical condition. Asymptomatic patients may be discharged after Emergency Department evaluation with strict return precautions and in-home monitoring by family or friends. Symptomatic patients with normal radiologic studies should either be admitted to the hospital or the emergency department observation unit, if available, for further monitoring.

Admitted patients require a multidisciplinary approach depending on the extent of their injuries. Delayed pulmonary edema and complications from concomitant musculoskeletal trauma may become of particular importance and thus specialty and organ-specific care must be sought.[34]

Prognosis

Generally, the prognosis for patients who have minimal to no external signs and with unremarkable radiologic workups is favorable. In terms of traumatic sequelae delayed vascular findings are of importance, however with current imaging technology these cases are rare. The prognosis for these patients then becomes a matter of the psychosocial reasons that may have resulted in the injury, and depend on mitigation of exposure.[31]

Severely injured patients, and those with particularly devastating signs of neurological injury, tend to do much worse. Prognosis depends heavily on the extent and duration of anoxic brain injury, and long term recovery depends upon the specific areas of the brain involved. While patients with a low Glasgow Coma Scale tend to do worse, initial neurological conditions do not exclude a favorable recovery. Patients presenting in cardiac arrest tend to have a very grave prognosis.[3][14]

Consultations

Various specialty services may be required to manage strangulation injuries. Cerebral edema with impending herniation and cases involving spinal cord compromise (or other neurological injuries) may require neurosurgical intervention. Orthopedic surgeons with spine surgery fellowship training may be required for certain injuries. Vascular compromise, depending on the type and extent, may require a vascular surgeon or interventional radiologist. Tracheal injuries can be repaired by otolaryngology. Critically ill patients will require the care of a trained intensivist – skilled ventilator management is crucial for optimal recovery in this patient population. Once recovered, or if initial injuries are minimal, mental health experts and psychiatric care should be considered depending on case specifics. Long term neurological sequelae are best handled in conjunction with a trained neurologist.

Pearls and Other Issues

Given that strangulation injuries may be a result of a suicide attempt, patients may necessitate being placed on a psychiatric hold or need immediate emergency department psychiatric evaluation. These patients also require that suicide precautions be taken if admitted to the hospital. Strangulation injuries may also be a result of a criminal act. When these patients present to the emergency department, notification of the appropriate law enforcement agencies should also occur per local laws, policies, and procedures.

Enhancing Healthcare Team Outcomes

The care of a patient who has suffered from a strangulation injury requires a dedicated multidisciplinary approach. Patients with abnormal radiologic studies should be admitted to the hospital to the appropriate level of nursing care. The patient may require various levels of care depending on the nature of the injury – telemetry, step-down units, or the intensive care units may all play a part in management. Specialists should also be consulted based on specific injuries. This may include trauma surgery, neurosurgery, neurology, otolaryngology, and psychiatry. Any overdoses or metabolic disturbances warrant their specific and appropriate antidotes or symptomatic therapeutic interventions. Wound care specialists may be critical for the long term management of various injuries. Additionally, social workers and law enforcement may play an important role. Religious and spiritual preferences of the patient and involved families may require a versatile chaplain or other spiritual and religious leaders.

References

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Sep D, Thies KC. Strangulation injuries in children. Resuscitation. 2007 Aug;74(2):386-91. [PubMed: 17367911]

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Ambalavan AK, Moulahi B, Azé J, Bringay S. Unveiling Online Suicide Behavior: What Can We Learn About Mental Health from Suicide Survivors of Reddit? Stud Health Technol Inform. 2019 Aug 21;264:50-54. [PubMed: 31437883]

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De Boos J. Review article: Non-fatal strangulation: Hidden injuries, hidden risks. Emerg Med Australas. 2019 Jun;31(3):302-308. [PubMed: 30784203]

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Randall B, Thompson P, Wilson A. Racial differences within subsets of Sudden Unexpected Infant Death (SUID) with an emphasis on asphyxia. J Forensic Leg Med. 2019 Feb;62:52-55. [PubMed: 30658266]

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Wang L, Gao Y, Yin P, Cheng P, Liu Y, Schwebel DC, Liu J, Qi J, Zhou M, Hu G. Under-five mortality from unintentional suffocation in China, 2006-2016. J Glob Health. 2019 Jun;9(1):010602. [PMC free article: PMC6368940] [PubMed: 30774944]

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Gascho D, Heimer J, Tappero C, Schaerli S. Relevant findings on postmortem CT and postmortem MRI in hanging, ligature strangulation and manual strangulation and their additional value compared to autopsy – a systematic review. Forensic Sci Med Pathol. 2019 Mar;15(1):84-92. [PubMed: 30627977]

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Todd NV. Priapism in acute spinal cord injury. Spinal Cord. 2011 Oct;49(10):1033-5. [PubMed: 21647168]

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Kaki A, Crosby ET, Lui AC. Airway and respiratory management following non-lethal hanging. Can J Anaesth. 1997 Apr;44(4):445-50. [PubMed: 9104530]

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Radeloff K, Schraven SP, Radeloff D, Kraus F. [Functional rehabilitation of severe laryngopharyngeal injuries after near-lethal suicide attempt by hanging]. HNO. 2019 Feb;67(2):110-117. [PubMed: 30406269]

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Tumram NK, Ambade VN, Bardale RV, Dixit PG. Injuries over neck in hanging deaths and its relation with ligature material: is it vital? J Forensic Leg Med. 2014 Feb;22:80-3. [PubMed: 24485428]

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Sabo RA, Hanigan WC, Flessner K, Rose J, Aaland M. Strangulation injuries in children. Part 1. Clinical analysis. J Trauma. 1996 Jan;40(1):68-72. [PubMed: 8577002]

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Myers WC, Bukhanovskiy A, Justen E, Morton RJ, Tilley J, Adams K, Vandagriff VL, Hazelwood RR. The relationship between serial sexual murder and autoerotic asphyxiation. Forensic Sci Int. 2008 Apr 07;176(2-3):187-95. [PubMed: 17980531]

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Stellpflug SJ, Menton TR, Corry JJ, Schneir AB. There is more to the mechanism of unconsciousness from vascular neck restraint than simply carotid compression. Int J Neurosci. 2020 Jan;130(1):103-106. [PubMed: 31487214]

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Hostettler-Blunier S, Raoussi A, Johann S, Ricklin M, Klukowska-Rötzler J, Utiger S, Exadaktylos A, Brodmann Maeder M. [Domestic Violence at the University Emergency Department Bern: A Retrospective Analysis from 2006 to 2016]. Praxis (Bern 1994). 2018 Aug;107(16):886-892. [PubMed: 30086689]

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Spotting the signs of strangulation could save a life. But they’re not always obvious

It’s been described as a “last warning shot” before death.

Women who survive strangulation are up to seven times more likely to go on to die at the hands of their partner, according to recent studies in the US.

And there are side effects that aren’t always obvious to treating doctors, paramedics or police officers — everything from voice changes to blood clots, strokes and paralysis.

Survivors and medical professionals are now pushing for increased training and awareness around non-lethal strangulation — something they say could help save lives.

Family and domestic violence support services:

Sue* was strangled by her partner about a year ago in Queensland, and knows too well that the side-effects can be delayed, and severe.

“I have PTSD. I have vocal cord dysfunction,” she says.

“I’ll get halfway through a sentence and have to stop because I can’t swallow properly and I can’t breathe properly because the neck just spasms because of the damage done to the vocal cords.

“I have a dent in the back of my arm, which will be there forever, from trying to protect myself.

“I have ongoing back issues. I tore my major stomach muscle, which has never repaired, so that means I have a weak leg now.

“It’s not just about the instant that it happened, it’s all the after-effects and the aftermath that it leaves you with.”

Law professor Heather Douglas has also heard of cases involving memory loss, loss of consciousness, anxiety, paralysis and miscarriage.

“Gael Strack, who is an educator in the US around strangulation and prevention, describes it as the ‘last warning shot’,” she says.

Spotting the hidden signs

When somebody has been choked, it’s not always obvious to first responders.

Dr Vanita Parekh, the head of Clinical Forensic Medical Services at Canberra Hospital, says 50 per cent of people who report an attack will have no marks on their neck.

“About 35 per cent will have very minor marks, and 15 per cent will have enough injury to be photographed,” she says.

Without appropriate training, she says, it can be “very difficult” to spot other signs of non-lethal strangulation — like memory loss and increased anxiety.

Strangulation may lead to side effects that aren’t always obvious to first responders.(ABC News: Margaret Burin)

So she engaged members of Canberra’s professional community — including doctors, nurses, paramedics, police, counsellors, crisis centres, judges and magistrates — to work together on a training model.

“We needed everybody to be on board and [to] understand how important and how serious strangulation was and how we need to deal with it,” she says.

“And we had some fantastic outcomes in terms of CT angiography.”

A CT angiogram can be used to see if there is injury within the vessels in the neck.

Dr Parekh convinced radiologists in Canberra to provide the test free of charge, specifically for patients affected by domestic or sexual violence, as well as those who have a refugee status.

As a result of the training, she says, an ambulance officer attending a domestic violence incident referred a patient who said she had been choked.

The test found the woman had a clot and she was given drugs to dissolve it.

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Dr Parekh says it potentially saved the woman’s life.

“Not just her life … but also [avoiding] having that devastating consequence of having a major stroke at a very young age,” she says.

Sue didn’t have a CT angiogram until eight months after the strangulation event.

“I have no blood clots, for which I am eternally grateful for,” she says,

“I have been left with [symptoms that are] life-altering, [but] I’m here. I’m still upright and vertical.”

Training goes national

The ACT is a small, urbanised and well-resourced place but similar programs are being introduced in other states.

The Red Rose Foundation is a Queensland-based organisation which works to end domestic violence-related death and to support survivors.

The Red Rose Foundation is focusing on training Queensland Ambulance officers.(ABC News: Giulio Saggin)

Chief executive Betty Taylor is hopeful the state can follow the ACT’s lead in providing free angiograms to anyone identified as having been strangled.

“We want to pilot two strangulation trauma centres, where we hope to employ forensic nurses [who can] monitor and support women for up to six months post the strangulation episode,” she says.

She also hopes to have a statewide phoneline to give women ongoing support, and help them look out for dangerous symptoms.

Ms Taylor says her organisation across Australia has trained approximately 600 police officers, magistrates and prosecutors, and is now focusing its efforts on frontline health services.

“Where we are just embarking on it is with Queensland Ambulance because often they are the first on the scene and they need to know how to read the signs,” she says.

What is the law doing?

As understanding of the dangers of strangulation has increased, various jurisdictions have been updating their laws.

In NSW, a quarter of all murder victims have, at some point, been subject to strangulation.

Until recent changes to the law, prosecutors had to prove a victim had been rendered unconscious or unable to resist, or that the strangulation occurred in the course of an indictable offence.

But a new offence now only requires proof of intentional choking, strangulation or suffocating without consent.

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In 2016, Queensland also introduced a new strangulation offence: Choking, Suffocation or Strangulation in a Domestic Setting.

Professor Douglas says it “doesn’t require that the person has any specific intent to cause injury or cause death”.

“It’s simply the case that if a person chokes or suffocates or strangles a person unlawfully, they could be found guilty of that offence,” she says.

Ms Taylor says there have been around 1,900 charges brought since the act came in and roughly 450 people have been imprisoned.

But she says “legislation as written and legislation as implemented are two different things”, and many offences get “plea-bargained down”, partly because of a lack of solid definition around strangulation.

She says it is, “a huge issue that is missing within the Act”.

“Sometimes, I think it comes down to … police and prosecutors, defence barristers [who] would all have their own interpretation of strangulation rather than be guided by a solid definition in law.”

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However, Professor Douglas says the new laws have been successful in that they are leading to prosecutions for non-fatal strangulations, which might have otherwise not been prosecuted at all.

Sue’s attacker was convicted of assault, fined and subject to a five-year order preventing him from approaching her. But he avoided jail time.

Sue believes the way in which she described what happened to her to police had an impact on the legal outcome of the case.

“I kept saying, ‘He tried to strangle me’,” Sue says.

“What I learnt since that is because I put the word ‘tried’ in there it meant that he attempted to do it but didn’t actually make good enough contact to do it.

“If I had my time over I’d never say the word ‘tried’.”

*Name has been changed for privacy reasons.

Chlorine damage: symptoms, consequences and first aid

At high chlorine concentrations, the victim may die after a few minutes (lightning-fast form): persistent laryngospasm occurs (narrowing of the glottis, leading to respiratory arrest), loss of consciousness, convulsions, cyanosis, swelling of the veins on the face and neck, involuntary urination and defecation.

In a severe form of poisoning, a short-term cessation of breathing occurs, then breathing is restored, but not normal, but superficial, convulsive.The person loses consciousness. Death occurs within 5-25 minutes.

In case of moderate chlorine poisoning, the consciousness of the victims is preserved; reflex cessation of breathing is short-lived, but attacks of suffocation may recur during the first two hours. There is a burning sensation and pain in the eyes, lacrimation, pain behind the sternum, bouts of painful dry cough, and after 2-4 hours toxic pulmonary edema develops. In a mild form of acute chlorine poisoning, only signs of irritation of the upper respiratory tract are expressed, which persist for several days.

Long-term consequences of acute chlorine poisoning are manifested as chronic pharyngitis, laryngitis, tracheitis, tracheobronchitis, pneumosclerosis, pulmonary emphysema, broncho-ectatic disease, pulmonary heart failure. The same changes in the body occur during prolonged stay in conditions when the air constantly contains gaseous chlorine in low concentrations (chronic chlorine poisoning). Exposure to unprotected skin of chlorine-containing compounds causes acne, dermatitis, pyoderma.

First aid to victims includes:

– washing eyes, nose, mouth with 2% baking soda solution;

– instillation of vaseline or olive oil into the eyes, and for pain in the eyes – 2-3 drops of a 0.5% solution of dicaine;

– the application of eye ointment for the prevention of infection (0.5% syntomycin, 10% sulfacyl) or 2-3 drops of 30% albucide, 0.1% zinc sulfate solution and 1% boric acid solution – 2 times a day;

– administration of hydrocortisone 125 mg i / m, prednisolone 60 mg i / v or i / m.

It is necessary to treat and hospitalize the victims as early as possible.

All inquiries >>

90,000 Here’s how to relieve a child of a severe suffocating cough

People’s life hack, which will eliminate a strong cough and at the same time has no side effects.

Photo from Pixabay.com

The season of colds is in full swing, literally at every step you can catch ARVI and flu, the consequences of which are a strong cough.This is the body’s defensive reaction to irritating factors. With the help of a cough, phlegm and mucus are removed from the airways. Long-term coughing can damage the bronchial mucosa, which aggravates the cough.

A dry, irritating cough can be very uncomfortable, interfere with sleep and affect quality of life. If it is difficult for an adult to cope with it, then even more so for children. Fortunately, in folk medicine there are effective ways to alleviate the condition of the child. One of these methods is a potato wrap.Our grandmothers also used it. The compress soothes cough, has a warming effect. However, the recipe has been tested over the years and several generations.

How to prepare a compress? Boil five potatoes in their uniform, crush together with the peel. Add 4 teaspoons of baking soda and two tablespoons of natural honey. Stir the mixture thoroughly and form two cakes. We wrap them in gauze and put them on the back between the shoulder blades and on the chest. They should not be very hot.We wrap the child, leave the compress for one hour. Then we wipe the child’s body dry and put him to bed.

If a child suffers from bronchitis, then add 1 tablespoon of vegetable oil and 2-3 drops of iodine to mashed potatoes. We also form cakes and make a compress.

It is advisable to carry out these procedures at night, so that the child immediately lies down in a warm bed. Usually a few procedures are enough and the annoying cough will begin to recede.

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This document, provided by Lexicomp ^® , contains all the information you need to know about the drug, including the indications, route of administration, side effects and when you should contact your healthcare provider.

Trade names: Canada

Suprefact; Suprefact Depot 2 Months; Suprefact Depot 3 Months

What is this drug used for?

• Used to treat prostate cancer.
• It is used to treat the endometrium.
• This medicinal product may be used for other indications. Consult your doctor.

What do I need to tell my doctor BEFORE taking this drug?

All forms of issue:

• In case of an individual allergic reaction to buserelin or any other component of this medication.
• If you are allergic to this drug, any of its ingredients, other drugs, foods or substances. Tell your doctor about your allergy and how it manifested itself.
• If you have had your testicles removed or have had non-hormone-induced prostate cancer.
• If you have unexplained vaginal bleeding.
• With prolongation of the QT interval on the ECG.
• If you are or may become pregnant. Do not take this drug if you are pregnant.
• if you are breastfeeding. Do not breast-feed while taking this drug.

Injection:

• If the patient is a newborn or infant. This drug contains benzyl alcohol. Benzyl alcohol can cause severe and sometimes deadly side effects in newborns or babies. Do not give this drug to newborns or babies.

This list of drugs and diseases that may be adversely associated with this drug is not exhaustive.

Tell your doctor and pharmacist about all the medicines you take (both prescription and over-the-counter, natural products and vitamins) and your health problems. You need to make sure that this drug is safe for your medical conditions and in combination with other drugs you are already taking. Do not start or stop taking any drug or change the dosage without your doctor’s approval.

What do I need to know or do while taking this drug?

For all patients taking this drug:

• Tell all healthcare providers that you are taking this drug. These are doctors, nurses, pharmacists and dentists.
• Avoid driving or other activities that require increased attention until you see how this drug affects you.
• Be careful if you have risk factors for heart disease (high blood pressure, high cholesterol, being overweight, high blood sugar or diabetes, cigarette smoking, male and over 40 years of age, early heart disease in other members families, postmenopausal women).Consult your doctor.
• During the first few weeks of taking this drug may increase the level of some hormones in the body. Symptoms may get worse at first. Talk to your doctor if your symptoms worsen or new symptoms appear several weeks after you start taking this drug.
• Perform blood tests as directed by your healthcare practitioner. Please consult your doctor.
• This drug may cause increased bone fragility.This phenomenon is observed more often with prolonged use of the drug. This may increase the likelihood of bone fractures. If you develop bone pain, contact your doctor immediately.
• Get a bone density test as directed by your doctor. Consult your doctor.
• High blood sugar has happened with this drug. This includes the development or worsening of pre-existing diabetes mellitus.
• Check your blood sugar as directed by your doctor.
• High blood pressure has happened with this drug. Monitor your blood pressure as directed by your doctor.
• This drug may interfere with some laboratory tests. Tell all healthcare providers and laboratory staff that you are taking this drug.

Men:

• People with a blocked bladder may be at increased likelihood of serious and sometimes fatal problems.The risk may also be increased in people with growths on or near the spine or spinal cord. If you have any questions, consult your doctor.
• A decrease in the level of male sex hormones in the body may increase the risk of an irregular heart rhythm called prolonged QT interval. Please consult your doctor.

Women:

• While taking this drug, use a non-hormonal birth control to prevent pregnancy, such as a condom.Do not use birth control pills or other hormonal birth control while taking this drug.
• Intermenstrual bleeding may occur if you do not take your dose of this drug on time. Also, if you miss taking this drug, you may be more likely to become pregnant. Consult your doctor.
• If used during pregnancy, the drug may have a harmful effect on the fetus.
• Before you start taking this drug, you will have a pregnancy test to confirm that you are NOT pregnant.If you become pregnant while taking this drug, call your doctor right away.

What side effects should I report to my doctor immediately?

WARNING. In rare cases, some people with this drug can cause serious and sometimes deadly side effects. Call your doctor or get medical help right away if you have any of the following signs or symptoms, which may be associated with serious side effects:

• Signs of an allergic reaction such as rash, hives, itching, reddened and swollen skin with blistering or scaling, possibly associated with fever, wheezing or wheezing, tightness in the chest or throat, difficulty breathing, swallowing or speaking, unusual hoarseness, swelling in the mouth, face, lips, tongue, or throat.
• Signs of high blood sugar, such as confusion, drowsiness, increased thirst and hunger, increased urination, facial flushing, rapid breathing, and fruity breath.
• Signs of high blood pressure, such as very severe headache, or dizziness, or loss of consciousness, or blurred vision.
• Signs of infection such as fever, chills, very bad sore throat, ear, or sinuses, cough, increased or discolored phlegm, pain when urinating, mouth ulcers, or an open wound.
• Unusual burning, numbness, or tingling sensations.
• Severe back pain.
• Blood in the urine.
• Inability to move.
• Obstruction of the urinary tract.
• Feeling of an abnormal heartbeat.
• Severe dizziness or fainting.
• Feeling extremely tired or weak.
• Shortness of breath.
• Inflammation.
• When pain occurs or worsens.
• The appearance or aggravation of mental disorders, mood swings, or changes in behavior.

What are some other side effects of this drug?

Any medicine can have side effects. However, many people have little or no side effects. Call your doctor or get medical help if these or any other side effects bother you or do not go away:

All forms of issue:

• Tides.
• Decreased sex drive.
• Lack of ability to achieve or maintain an erection.

Injection and nasal spray:

• Dizziness.
• Gas.
• Enlarged breasts.
• Headache.
• Feeling tired or weak.
• Diarrhea.
• Nausea.
• Vaginal dryness.
• Menstrual irregularities.

Nasal spray:

• Nose irritation.
• Dry nose.
• Acne.

Implant and all injectables:

• Injection site irritation.

This list of potential side effects is not exhaustive. If you have any questions about side effects, please contact your doctor. Talk to your doctor about side effects.

You can report side effects to the National Health Office.

You can report side effects to the FDA at 1-800-332-1088. You can also report side effects at https://www.fda.gov/medwatch.

What is the best way to take this drug?

Use this drug as directed by your healthcare practitioner. Read all the information provided to you. Follow all instructions strictly.

Nasal spray:

• Not for oral administration. For nasal use only.Avoid contact with mouth and eyes (possible burns).
• If you are likely to get pregnant and are having your period, start this drug on the second or third day of your regular menstrual cycle.
• Wash hands before use.
• Prepare the inhaler before first use. Preparation of the inhaler is also necessary if it has not been used for some time. You need to know when and how to prepare your inhaler. If you have any questions, ask your doctor or pharmacist.

Implant:

• Inserted as an implant under the skin.
• Your doctor will give you this drug.

Injection:

• For subcutaneous injection.
• If you give yourself injections, your doctor or nurse will teach you how to inject.
• If you are likely to get pregnant and are having your period, start this drug on the second or third day of your regular menstrual cycle.
• Wash hands before and after use.
• Do not use if solution is cloudy, leaking, or contains particles.
• Do not use if solution changes color.
• Change the injection site each time.
• Dispose of needles in the sharps / needles container. Needles and other items cannot be reused. When the container is full, dispose of it according to local regulations. If you have questions, ask your doctor or pharmacist.

What should I do if a dose of a drug is missed?

Injection and nasal spray:

• Take the missed dose as soon as you can.
• If it is time for your next dose, do not take the missed dose and then return to your normal dose.
• Do not use 2 doses at the same time or an additional dose.

Implant:

• Call your doctor for further instructions.

How do I store and / or discard this drug?

Injection and nasal spray:

• Store at room temperature. Do not freeze.
• Store in primary container.
• Do not expose to heat and light.

Nasal spray:

• Store upright with the cap closed.
• Throw away all unused portions of the drug 5 weeks after opening the package.

Injection:

• Throw away all unused portions of the drug 2 weeks after the first use.

Implant:

• If you need to store this drug at home, ask your doctor, nurse, or pharmacist for information about how it is stored.

All forms of issue:

• Store all medicines in a safe place. Keep all medicines out of the reach of children and pets.
• Dispose of unused or expired drugs. Do not empty into toilet or drain unless directed to do so. If you have any questions about the disposal of your medicinal products, consult your pharmacist. Your area may have drug recycling programs.

General information on medicinal products

• If your health does not improve or even worsens, see your doctor.
• You should not give your medicine to anyone and take other people’s medicines.
• Some medicines may come with other patient information sheets. If you have questions about this drug, talk with your doctor, nurse, pharmacist, or other healthcare professional.
• Some medicines may come with other patient information sheets. Check with your pharmacist. If you have questions about this drug, talk with your doctor, nurse, pharmacist, or other healthcare professional.
• If you think an overdose has occurred, call a Poison Control Center immediately or seek medical attention. Be prepared to tell or show which drug you took, how much and when it happened.

Use of information by consumer and limitation of liability

This information should not be used to make decisions about taking this or any other drug. Only the attending physician has the necessary knowledge and experience to make decisions about which drugs are appropriate for a particular patient.This information does not guarantee that the drug is safe, effective, or approved for the treatment of any disease or specific patient. Here are only brief general information about this drug. It does NOT contain all available information on the possible use of the drug with instructions for use, warnings, precautions, information about interactions, side effects and risks that may be associated with this drug. This information should not be construed as a treatment guide and does not replace information provided to you by your healthcare professional.For complete information on the possible risks and benefits of taking this drug, consult your doctor. Use of this information is governed by the Lexicomp End User License Agreement available at https://www.wolterskluwer.com/en/solutions/lexicomp/about/eula.

Copyright

© UpToDate, Inc. and its affiliates and / or licensors, 2021. All rights reserved.

90,000 Heroes of the Storm Patch Notes – January 10, 2018- Heroes of the Storm – Blizzard News

We’ve released another update to Heroes of the Storm, adding Blaze, the veteran flamethrower, to the game.

Note: All changes added between the start of testing on the PTR and the release of the update are highlighted in orange .

Table of Contents

New Hero: Blaze

Fire has always been a passion of Corporal Blaze Miles Lewis, but his pyromania only came to practical use when he joined the Raynor Raiders.He is a true veteran who knows how to add sparkle to the game.

Skill

• Pyromania
  • For 4 sec. gives 25 pts. armor and during this time deals 40 damage. damage to nearby enemies every 0.5 sec. Each hit of Jet of Flame on an enemy Hero reduces the cooldown of Pyromania by 5 sec.

Basic Abilities

• Flame Jet (Q)
  • Launches two jets of flame, inflicting 83 damage to each enemy hit.damage. The Jet of Flame also ignites the Puddles of Fuel Oil.
• Fuel oil puddle (W)
  • Vector action.
  • For 5 sec. Creates a puddle of fuel oil that slows enemies caught in it by 40%. Jet of Flame ignites puddles of fuel oil for 2.5 seconds, while enemies in the puddle receive 18 damage. damage every 0.3 sec, and the slow effect is removed. Standing in a burning puddle of fuel oil, Blaze restores 49 health. health every 0.3 sec. The maximum number of charges is 2.
• Jet thrust (E key)
  • After 0.5 sec. Blaze dashes forward, colliding with the first enemy hero in his path and inflicting 52 Shadow damage to him and nearby heroes. damage, as well as stunning them for 1.25 seconds.

Heroic abilities

• Bunker call (R key)
  • After 0.5 sec. Blaze summons a 1300 bunker.and enters into it. Blaze and his allies are free to enter and exit the bunker. Heroes in the bunker gain access to a flamethrower that inflicts 179 damage. damage to enemies in a straight line. Exiting the bunker, Blaze and his allies receive 25 damage. armor for 2 sec. The bunker lasts 10 seconds. or until it is destroyed.
• Combustion (R key)
  • Blaze maintains the ability for 2.6 seconds. (maximum), causing nearby enemies to be slowed by 60% for 48 damage.damage every 0.5 sec. The longer the ability is maintained, the longer the slow and damage over time lasts (from 1 to 5 seconds). Blaze’s movement speed is reduced by 50% while channeling.

Start

Decoration

Heroes, abilities and talents

• Malfurion’s visuals have been updated to reflect the changes in his talents.

Start

Battlegrounds

Regeneration spheres

• 5 seconds health regeneration reduced from 11.7% of maximum health to 9%.
• 5 seconds mana regen reduced from 7.8% of maximum mana to 7%.

Mercenaries

• Gellitrons
  • Neutral
    • Reduced armor reduction from 5% to 4% per hit.
    • Base health reduced from 4275 to 3420
  • Online
    • Reduced armor reduction from 5% to 4% per hit.
    • Base health reduced from 4700 to 3760
      • Health gain over time (first 5 minutes) reduced from 50 to 40.
      • Health gain over time (from 6th to 10th minutes) increased from 75 to 110
      • Health gain over time (from 11th to 15th minutes) increased from 100 to 150
      • Health gain over time (from 16th to 20th minutes) increased from 125 to 235.
• Knights
  • Neutral Mage Knight
    • Aura energy armor increased from 15 to 20.
  • Lane Knight Mage
    • Energy armor from aura reduced from 30 to 20.
• Slizevik (at the “Nuclear Test Site”)
  • Online
    • Base health reduced from 20,000 to 16,000.
      • Health gain over time (first 5 minutes) reduced from 630 to 500 pts.
      • Health gain over time (from 6th to 10th minutes) increased from 945 to 1050
      • Health gain over time (from 11th to 15th minutes) increased from 1260 to 1400
      • Health gain over time (from 16th to 20th minutes) increased from 1575 to 2250
    • Basic attack damage reduced from 400 to 320.
      • Basic attack damage over time (first 5 minutes) reduced from 10 to 8.
      • Basic attack damage over time (from 6th to 10th minutes) increased from 15 to 17.
      • Basic attack damage over time (from 11th to 15th minutes) increased from 20 to 23
      • Basic attack damage over time (from 16th to 20th minutes) increased from 25 to 38
    • Base Slime Projectile damage reduced from 250 to 200
      • Damage growth over time (from 6th to 10th minutes) increased from 5% to 6.25%.
      • Damage growth over time (from 11th to 15th minutes) increased from 6% to 7.25%.
      • Damage growth over time (from 16th to 20th minutes) increased from 6% to 8.25%.
    • Base Slime attack damage over time reduced from 150 to 120.
      • Damage growth over time (from 6th to 10th minutes) increased from 5% to 6.25%.
      • Damage growth over time (from 11th to 15th minutes) increased from 6% to 7.25%.
      • Damage growth over time (from 16th to 20th minutes) increased from 6% to 8.25%.
    • Acid Trail base damage reduced from 80 to 64.
      • Damage growth over time (from 6th to 10th minutes) increased from 5% to 6.25%.
      • Damage growth over time (from 11th to 15th minutes) increased from 6% to 7.25%.
      • Damage growth over time (from 16th to 20th minutes) increased from 6% to 8.25%.

Forts

• Damage dealt by Gate Towers to Warriors, Mercenaries, Monsters and Heroes increased by 33%.
• Forts damage to warriors, mercenaries, monsters and heroes increased by 33%.

Fortresses

• Damage dealt by Gate Towers to Warriors, Mercenaries, Monsters and Heroes increased by 33%.
• Damage dealt by fortresses to warriors, mercenaries, monsters and heroes increased by 33%.
• Strength of fortresses increased from 16,000 to 17,000 HP.

Rock Towers

• Altars spawn time increased from 90 to 110 seconds.

Eternal Battle

• The starting positions of the Immortals in the first event will always be the same: the Heavenly Immortal in the south, the Underworld Immortal in the north.
• The positions of the Immortals in the second stage of the first event will always be the same: the Immortal of Heaven in the east, the Immortal of the Underworld in the west.
  • The positions of the Immortals during the following events will be determined randomly.
• Immortals will now appear on the minimap after 30 seconds.after the start of the game.
  • The next appearance of the Immortals will be indicated on the minimap shortly after the summoned Immortal is defeated.
  • When one of the Immortals reaches 50% health, new positions on the minimap will not be displayed.

Developer Comment: As expected, the 2018 gameplay update had a big impact on most systems in the game. Overall, we like the changes that have taken place, but not without side effects, which we hope to eliminate.We overestimated the impact of unlimited building ammo, and the mechanics associated with pressure on the lines became too powerful. As a result, the duration of the game has been reduced on almost all maps. With this update, towers will once again be able to fight back, which will help heroes face off against mercenaries and protect structures during events. In addition, we analyzed the effectiveness of the mercenaries and slightly changed their characteristics. The Gellitrons and the Knights were especially strong, so we weakened them a little.In addition, we reduced the stats of the boss in the Nuclear Proving Ground early and mid-game because it was too powerful when combined with warheads. Finally, we have reduced the power of Regeneration Orbs. We love the mini-game that neutral orbs of regeneration provide in lane confrontation, but the advantage they give the leading team is overwhelming. We’ve also noticed that players are picking up orbs more often, so a slight debuff will help bring the heroes’ overall health and mana back to normal.This gameplay update has been significant, and more changes are likely to be required in the future. We will monitor the situation and release additional updates as needed.

Fights

• Bouncer Brawl
  • Chromie’s health increased from 3 to 5.
  • Player names are now displayed above Chromie’s ghosts.
  • The game camera will now be tied to Chromie’s ghost until the next round.

Battleground rotation in ranked games

• Deleted
  • Nuclear test site

90,071 90,023 Added

• Volskaya Plant

Start

Heroes

Assassins

Hanzo

Abilities

• Cluster Arrow (W key)
  • Decreased the angle of spread of arrows by 20%.
  • Damage reduced from 93 to 90.

• Natural Agility (D)
  • Cooldown reduced from 25 to 20 seconds.
  • Range increased from 8 to 10 m.

Talents

• Level 7
  • Faceted Nibs (Q)
    • Talent removed.
  • Sharp Nibs (W)
    • Moved from Level 20
    • Operating principle changed:
      • Hero hit by Stormbow or Basic Attack is reduced by 5 Armor. for 4 sec. This effect stacks up to 25 units.
• Level 13
  • Horse Archery (Z)
    • Movement speed bonus reduced from 30% to 20%.
• Level 16
  • Giant Slayer (W)
    • Damage increased from 1.25% to 1.5% of the enemy hero’s maximum health.
• Level 20
  • (New Talent) Flawless Agility (D)
    • Grants an additional charge of Natural Agility and reduces the cooldown of your skill by 5 sec.

Developer Comment: We have reduced the Cluster Arrow’s angle of spread in an effort to make it more effective against opponents standing far from the walls. To compensate, we’ve slightly reduced the ability’s damage. We’ve increased the range of Natural Agility to give Hanzo the ability to jump over wider obstacles. We removed the Faceted Arrows talent, since its scope was rather narrow, but at the same time it turned out to be too strong in certain situations.Instead, we’ve moved the Sharp Tips talent, changing how it works so that its effectiveness is less situational.

Nova

Abilities

• Sniper Shot (Q)
  • Damage reduced from 245 to 230
• Crippling Shot (W)
  • Damage reduced from 105 to 100
• Precision Strike (R key)
  • Damage reduced from 456 to 435
• Sniper Master (Trait)
  • Increased damage bonus for each accumulated effect from 5% to 6%.

Abilities

• Level 7
  • Perfect Shot (Q)
    • Cooldown for hitting a hero is now reduced by 3 seconds. (earlier – by 2 sec.).
  • Reinforced Ammo (Passive)
    • Damage bonus reduced from 70% to 60%.
• Level 16
  • Deadly Decoy (E)
    • Double damage reduced from 40% to 35%.

Developer Comment: It’s nice to see that the recent update of Nova has been warmly received by a lot of players. However, it seems to us that the new ability to exit combat and the ability to create multiple doubles at the same time made Nova too strong against single targets.The data shows that her talent tree is well balanced (with the exception of some of the areas you see above), so we have reduced her base damage, offsetting this slightly by increasing the bonus damage from Masterful Sniper.

Samuro

Specifications

• Base Max Health increased from 1650 to 1725
• Health regeneration increased from 3.4 to 3.6.in sec.

Abilities

• Mirror Copy (Q Key)
  • Copied health increased from 825 to 862.5.
  • Copy health regeneration increased from 1.7 to 1.8. in sec.

Talents

• 4th Level
  • Parry (Trait)
    • Armor increased from 25 to 30
• Level 7
  • Burning Blade (W)
    • Damage bonus reduced from 65% to 50%.
  • Phantom Pain (W)
    • Damage bonus increased from 40% to 45%.
  • Crushing Strikes (W)
    • Basic Attacks now reduce the cooldown of Critical Strike by 1.75 sec. (earlier – by 1.5 sec.).

Developer Comment: The updated Samuro has become more balanced in terms of talent, win rate and overall efficiency in the game. In addition to talent changes, we decided to slightly increase his health pool, because after the update, Samuro has to expose himself to more danger in order to cause noticeable damage.

Valeera

Abilities

• Garrote (E key)
  • Silence duration reduced from 2.75 seconds to 2.5 seconds.

Talents

• Level 1
  • Crippling Poison (Active)
    • Decreased deceleration efficiency from 25% to 20%.
• 4th Level
  • Hemorrhage (E)
    • Damage bonus reduced from 50% to 30%.

Developer Comment: We have slightly reduced the duration of Garrote’s silence to encourage players to use other initiating abilities, and have reduced the damage from Hemorrhage.Now it will be a little more difficult for Valeera to incapacitate a victim and inflict significant damage on her at once.

Zeratul

Talents

• Level 1
  • Crouching Shadows (Trait)
    • Movement speed bonus increased from 25% to 30%.
• 4th Level
  • Darkness Approaches (Active)
    • Passive attack speed bonus increased from 10% to 20%.
• Level 7
  • Swift Punisher (Key 1)
    • Attack damage bonus increased from 30% to 40%.

Developer Comment: Zeratul is still lagging behind the rest of the cloaking heroes in terms of victory statistics, so we decided to strengthen some of his less effective talents. As a rule, his potential is revealed only to the players who have mastered him, so we will follow the development of events and contribute changes if necessary.

Support

Malfurion

Specifications

• Basic attack damage reduced from 64 to 60.

Abilities

• Recovery (Q key)
  • Mana cost reduced from 45 to 35.
  • Instant healing has been removed.
  • Healing per tick reduced from 27 to 20.
  • Duration increased from 15 to 20 seconds.
• Moonfire (W)
  • Mana cost reduced from 15 to 10.
  • Damage reduced from 100 to 90.
  • New effect added:
    • For each enemy Hero hit by Moonfire, allies under the influence of Restoration instantly restore 140 health. health.
• Entangling Roots (E)
  • Now only affects heroes.
• Tranquility (R key)
  • Effect duration reduced from 10 seconds to 8 seconds.
  • Cooldown reduced from 100 to 80 seconds.
  • Mana cost of this ability has been reduced from 100 to 80.
  • New effect added:
    • While in Tranquility, all Heroes affected by Restoration gain 10 damage. armor.

Talents

• Level 1
  • Sha’do’s Insight (D)
    • The principle of operation has been changed.
      • Innervate regenerates 25% faster for each active Restoration effect.
  • Reconnaissance Drone (Active)
    • Talent removed.
  • (New Talent) Nature’s Swiftness (Q)
    • Malfurion’s movement speed is increased by 5% for each active Regeneration effect.
• 4th Level
  • Full Moon Fire (W)
    • Talent removed.
  • Choking Vines (E)
    • Moved from Level 7.
    • The principle of operation has been changed.
      • Reduces the healing received by enemy Heroes who are rooted by Entangling Roots by 25% for 2 seconds.
  • (New Talent) Deep Roots (E)
    • Increases the area and duration of Entangling Roots by 25%.
• Level 7
  • Grasping Roots (E)
    • Moved from Level 16
    • The principle of operation has been changed.
      • Root duration increased by 25%. If Malfurion is stunned, the cooldown of Entangling Roots is reset.
  • (New Talent) Natural Healer (Active)
    • When activated, removes all Stun, Root, and Slow effects from allies affected by Regeneration.All recovery – 45 sec.
  • (New Talent) Wild Growth (W)
    • The duration of each active Regrowth effect is increased by 1 sec. for each hit of the “Moonfire” on the enemy hero.
• Level 13
  • Reducing Beam (Active)
    • Talent removed.
  • Seed of Life (Passive)
    • Talent removed.
  • Encouragement (Trait)
    • Moved from Level 16
  • Lunar Tether (W)
    • Moved from Level 7.
• Level 16
  • Ysera’s Gift (Q)
    • Healing efficiency bonus increased from 40% to 60%.
  • (New Talent) Moonlight Harmony (W)
    • The healing effect of Moonfire is increased by 15% for each active Restoration effect.
  • (New Talent) Natural Balance (W)
    • Increases the area of ​​effect of Moonfire by 25% and the duration of Regrowth by 5 sec.
• Level 20
  • Serenity (R)
    • The principle of operation has been changed.
      • The cooldown of Tranquility is reduced by 3 sec. for each hit by Moonfire on the enemy hero.The healing done by Tranquility is increased by 10% for each Regeneration effect active at the same time.
  • Storm Shield (Active)
    • Talent removed.
  • Rewind (Activated Effect)
    • Talent removed.
  • Lunar Stream (W)
    • Moved from Level 7.
    • The principle of operation has been changed.
      • Hitting an enemy Hero reduces the cooldown of Moonfire by 1 sec. and increases the damage of your next Moonfire by 20%. Damage increase effect stacks up to 3 times.
  • (New Talent) Lifebloom (Q)
    • Regrowth instantly heals an allied Hero for 10% of their missing health.

• Exclamation point (!) Indicates talents with tasks.
• Italicized emphasizes NEW talents.
• The underscore means the talent was MOVED .

Developer Comment: Although Malfurion has undergone a number of changes over the years, its immediate healing mechanics have remained fairly simple. The purpose of these changes is to make the gameplay of the hero more dynamic and interesting. Turning offensive pressure into healing efficiency will allow Malfurion lovers to try something new, as well as raise the level of skill at which the hero will be most effective.We can’t wait to hear what you think of these changes after playing as the wise druid – may the power of Elune be with us!

Start

Fighters

Blaze

Abilities

• Bunker call (R key)
  • Health increased from 1300 to 1305 pts.

Garrosh

Abilities

• Earthbreaker (Q)
  • Slow efficiency increased from 30% to 35%.
  • Cooldown reduced from 8 to 7 seconds.
  • Mana cost reduced from 35 to 30.
• Living Projectile (E)
  • Cooldown reduced from 14 to 12 seconds.
  • Mana cost reduced from 65 to 60.

Talents

• Level 1
  • Peacemaker (Q)
    • Now reduces cooldown by 2 seconds instead of 3.
    • Damage increased from 50 to 55
  • Unrivaled Strength (E)
    • Damage bonus reduced from 125% to 75%.
• Level 7
  • Into the Battle (1)
    • Cooldown increased from 40 to 45 seconds.
• Level 16
  • Earthquake (E)
    • Stun duration reduced from 0.6 seconds to 0.5 seconds.
  • Deadly Move (E)
    • Now reduces cooldown by 7 seconds instead of 8.
  • Hard Landing (Q)
    • Slow bonus reduced from 20% to 15%.

Developer Comment: The recent changes to Earthbreaker have made playing Garrosh less grueling, but we want this ability to be better able to help allies and maintain control on the battlefield.In addition, we are making changes to some of the talents to make them more popular and effective.

Joanna

Abilities

• Falling Sword (R)
  • While using Falling Sword, Joanna can no longer be targeted and takes no damage.

Collection

General

• Improved the readability of the collection interface: updated the color scheme.

New kit!

• Blaze Heroic Bundle – In store until January 22, 2018

New commentators

• Blaze
• Tyrael

New Skins

• Blaze
  • Explosive Blaze
  • Veteran Blaze
  • Fel Reaver Blaze
    • Disgusting Fel Reaver Blaze
    • Ice Fel Reaver Blaze
    • Infernal Fel Reaver Blaze
    • Blaze Fel Reaver Blaze
• Probius
  • Ara Tribe Probius
  • Nonrazim Probius

Start

Hotfixes

General

• Several typos and errors in tooltips have been fixed.

Decoration

• Abathur: Casting Crown of Evolution no longer leaves VFX on the surface at Abathur’s previous location.
• Valla: The color of the Lavender Deputy Valla scarf has been adjusted to match the scale of the look.

Heroes, abilities and talents

• Hanzo: When you choose the Explosive Arrows talent, hits on enemies with the Storm Bow are no longer ignored by the Piercing Arrows talent.
• Abathur: Locusts now retain their selected appearance when using Crown of Evolution.
• Chen: Fixed an issue that could prevent the player from being able to control Chen if the Wandering Barrel expired when it was too close to an impassable obstacle.
• Garrosh: The descriptions of the Inner Rage and Brute Force talents no longer swap when either of these talents is selected.
• Junkrat: Total Chaos no longer triggers twice if Junkrat is killed with a secondary attack damage while the Giant Slayer talent is learned.
• Junkrat: Casting the Junkrat no longer causes an empty health bar to appear.
• Junkrat: Fixed an issue where the Talent Bursting the Air could speed up the cooldown of High Explosive Mine if the mine explosion affected a tumor, healing idol, or other summoned object.
• Nazeebo: Ground Slam is now unavailable while Stunned or Transformed.
• Nazeebo : Fixed an issue that caused Ghastly Infection to deal additional damage when selecting certain talents.
• Samuro: “Master of Illusion” is no longer available while Samuro is flying through the air due to an effect caused, for example, by the explosion of Junkrat’s high-explosive mine.
• Samuro: If the player gives the “Hold Position” command to the mirror copies of Samuro and then selects one of them, the “Hold Position” command will not be canceled for the rest.
• Zul’jin: The Laceration talent icon is now correctly colored blue instead of purple.

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Dry Control for sweating (hyperhidrosis)

Sweating is a physiological process that protects the human body from overheating when the ambient temperature rises above a comfortable level.However, many people suffer from excessive sweating and in normal weather, even at rest. Dry Control antiperspirant ampoules will help to cope with the problem. This innovative complex includes oral ampoules and external spray. Such a two-way effect allows you to eliminate hyperhidrosis, as well as get rid of the repulsive smell of sweat.

Why can sweating increase?

Hyperhidrosis (or excessive sweating) ruins the lives of millions of people on the planet.Sweaty palms, excessive sweating of the legs, rivulets of sweat flowing down the face, neck, leaving wet marks on clothes – all this causes negative emotions both in the person himself and in those around him – colleagues, loved ones, completely strangers. There are many reasons for increased sweating:

• Taking certain medications. In the form of increased sweating, side effects of some medications appear.
• Disorders in the endocrine system.During hormonal changes in the body (transitional age, pregnancy, menopause), excessive sweating turns a person’s life into hell.
• Stressful situations. In a state of psycho-emotional stress, a strong shock, an increased “release” of moisture occurs, which allows you to calm down a little.
• Infectious diseases. Viruses, pathogenic bacteria that invade our body, cause serious disruptions in the work of internal organs and systems.
• Overweight.Excess weight is always an increased load on all joints, all body systems. Even the slightest physical activity leads to heavy sweating, resulting in wet spots on clothes. In addition, being overweight is always a metabolic disorder, which means that the smell of sweat becomes repulsive.

Dry Control Hyperhidrosis Complex will help to cope with this difficult problem. By regularly using ampoules and spray, you will noticeably reduce the volume of sweat and get rid of the suffocating odor.

What is this innovative product?

In the course of many years of research and development, scientists have managed to create a unique two-phase preparation Dry Control against excessive sweating, which includes ampoules and a special spray.

• Spray will be an excellent alternative to all known antiperspirant deodorants, which contain a lot of harmful chemical components and give only a short-term effect. The active ingredients of the spray have excellent penetrating ability, which helps to reduce perspiration and at the same time eliminates the side effects of skin irritation and clogged pores.
• Dry Control antiperspirant ampoules contain an active bioconcentrate for oral administration. The innovative composition has an effect on the body at the cellular level: cleanses from toxins that cause a repulsive odor; normalizes thermoregulation, which reduces sweating.

Regular use of this unique product is a real chance to get rid of increased perspiration and repellent sweat odor.

Method of using the remedy for hyperhidrosis

To get a noticeable result and fix it, you must regularly use the drug, strictly following the instructions:

• Add the contents of the Dry Control ampoule against hyperhidrosis into a glass of warm water and wait until it is completely dissolved.
• Take the resulting drink with or without food.
• Regular external application of a spray to areas with increased perspiration will help strengthen and consolidate the positive effect.

Thousands of buyers have already seen the effectiveness of the complex, and experts recommend it as an alternative to harmful sticks and expensive Botox injections.

Buy Dry Control antiperspirant ampoules in our online store and don’t give hyperhidrosis a single chance to ruin your mood!

You can buy Dry Control for sweating (hyperhidrosis) with delivery throughout Kazakhstan: Aktau, Aktobe, Almaty, Astana, Atyrau, Balkhash, Zhanaozen, Zhezkazgan, Karaganda, Kokshetau, Kostanay, Kyzylorda, Pavlodar, Petropavlovsk, Taldykorg, Semey, Semey , Taraz, Temirtau, Turkestan, Uralsk, Ust-Kamenogorsk, Shymkent, Ekibastuz, etc.

Russia is ready to arm the Syrian President Assad with S-300 complexes

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The White House welcomes the lifting of the rebel arms embargo, but is against Russian aid to Damascus

Under the talk about the need to resolve the Syrian conflict, the roles of external players are clearly distributed: the West supports the militants fighting against President Assad, while Russia supports official Damascus.The EU has opened up the opportunity to arm the opposition, while Moscow is ready to supply the Syrian army with S-300 air defense systems.

The Russian Foreign Ministry issued an appeal to the West to refrain from actions that could be “misinterpreted by the Syrian parties, to push them to continue armed confrontation, and not to negotiations and dialogue.”

Earlier, at the summit of the foreign ministers of the countries of the European Union, it was decided to lift the embargo on the supply of weapons to Syria (read – to the Syrian anti-government militants).This embargo expires on May 31, but so far European diplomats have agreed not to supply weapons to Syria over the next two months.

The reaction of Smolenskaya Square to the decision of the ministers of the EU countries looks ambiguous. According to the official representative of the Russian Foreign Ministry, Alexander Lukashevich, “in Moscow, the decisions and assessments contained in these documents were received with mixed feelings. On the one hand, the fact that the European Union welcomed the call of Russia and the United States to hold a peace conference on Syria confirms that we have a common goal with the Europeans, which is to end bloodshed and humanitarian suffering in this country as soon as possible and achieve a political settlement of the crisis.On the other hand, against this background, we do not understand the logic of the decision to extend the financial and economic sanctions that are strangling the Syrian people for another 12 months. Even more perplexing is the exclusion from the previous restrictions of “weapons and related materials, as well as means that can be used for the needs of internal suppression” due to the fact that the respective EU member states intend to supply these products to the opposition. True, the “Statement of the EU Council on Syria” contains a separate clause stating that the supplies of the said products will not be carried out now, but after the adoption by August 1 of this year.d. an additional decision, including in conjunction with the development of the Russian-American initiative for a settlement in Syria. But this does not change the essence of the adopted decision ”.

Against the background of the fact that Brussels gave the green light to the armament of Syrian militants by European countries, Moscow made it clear that it could supply S-300 anti-aircraft missile systems to Syria, which will allow Damascus to resist foreign intervention. “We believe that such steps are largely holding back some hotheads in the possibility of considering a scenario when the conflict can be given an international character with the participation of external forces that are not alien to such ideas,” said Deputy Foreign Minister Sergei Ryabkov.Russian diplomats did not specify whether the supply of air defense systems to the Syrian army has already been made, but Israel states that the S-300 complexes have not arrived in Syria. Previously, there were rumors that the Russian Federation had abandoned plans to send the S-300 to the Syrian government. In particular, the British “Sunday Times” reported, referring to a high-ranking Russian official, that an agreement to cancel the supply of these air defense systems was reached the other day during a meeting in Sochi between Putin and Israeli Prime Minister Netanyahu. However, this information was denied both by the Israelis and, as can be seen from the statements of Sergei Ryabkov, by Russian diplomats.

And the US took a very surprising position – the White House welcomed the EU’s decision to lift the embargo on the supply of weapons to the rebels in Syria, but at the same time urged Russia not to continue its defense supplies to Damascus. It seems that this is what is called “one-sided game”.

STRANGLE HOLD. Fundamentals of Personal Safety

STRANGLE HOLD

Purpose

The chokehold is designed to incapacitate the enemy.Fairbairn himself defined it as “a way to end the enemy if you cannot achieve it with blows.” In addition, strangulation was used to silently eliminate the enemy.

Impact

The technique deprives the enemy of the ability to breathe as a result of squeezing the trachea. A side effect of mechanical action on the trachea is very severe pain. A transition to a traumatic effect on the cervical spine is possible.

Attention!

Strangulation technique is potentially fatal.Damage to the trachea can be irreversible, and the opponent can die even if you let him go without completing the move. The use of strangulation in a self-defense situation is very difficult to explain, since the successful implementation of a strangle implies a helpless position of the opponent. In other words, the moment you strangle him, he no longer poses a threat to you, as a result of which your actions are in excess of the necessary self-defense measures. However, performing a choke hold does not violate the law as long as you pull the opponent away from the person you are protecting.

Execution

The technique is applicable only if you are behind the enemy’s back, close to him. Your right hand is sliding in a snake-like motion under the opponent’s chin so that your wrist is pressed against his throat with the edge from the side of the thumb. One of the OSS agents in his memoirs writes that this movement was explained to them as follows: “Imagine that a short blade sticks out of the first phalanx of your thumb, stick it into the opponent’s neck and open it.”The bottom line is not to try to just bring your hand under your chin, you need to stick it in from the side, maintaining contact with the neck throughout the movement.

After the rib of your right wrist is on the opponent’s throat, your left hand is inserted, palm up, under the palm of your right hand, and you lock them into a lock. With an explosive movement, you bend your right hand towards yourself, unbalancing your opponent and squeezing his windpipe with your wrist (Fig. 39). At the same time, you help yourself with your left hand, which pulls the right hand towards you.In this case, you lean your right shoulder and right pectoral muscle on the back of the opponent’s head, pushing his head through your right hand to his chest. This not only increases the pressure on the neck, but also prevents the opponent from hitting you with the back of the head in the face.

To enhance the impact on the trachea, the rib of the right wrist does not just press across the opponent’s neck, but as if draws under the Adam’s apple, turning as it is pressed and moving towards you and up.

To perform this technique effectively, your shoulders should be at the same level with the opponent’s shoulders or slightly higher.If the opponent is taller than you, then you need to either throw him back on yourself, or bend the opponent’s legs, pressing sharply under the knee with your foot.

Possible continuation

In a situation where the enemy fiercely resists and, for example, tries to grab you by the genitals, Fairbairn recommended to lean even more with your chest and shoulder on the back of the opponent’s head, tilting his head even more towards his chest through your hand, conducting strangulation, displacing this opponent’s cervical vertebrae. If strangulation is carried out while standing, then this effect on the cervical spine can be enhanced by retreating back.You seem to drop the enemy down, at the same time you are piling the whole mass on top of him on the back of his head, twisting his neck.

Brief historical information

In the course of the evolution of the Fairbairn system, not only the name of this technique changed, but also the way of its implementation. Initially, Fairbairn called this technique a back strangle hold and was performed similarly to the classic hadaka jime strangulation, in which the hands are not locked, and the right hand lies in the elbow bend of the left, pressing the opponent’s back of the head with the palm of the hand.

The main difference of the first option is that the neck was squeezed not by the wrist bone, but by the elbow, affecting the reflexogenic zones on its lateral surfaces (see the chapter “Selecting targets”). Thanks to this, the enemy’s blood pressure to the brain decreased, and he lost consciousness without receiving a serious tracheal injury. This allowed the Shanghai police to apprehend the criminal without killing him.

At the same time, such “blood strangulation” takes much longer to achieve the effect.At the same time, the enemy will retain almost full combat capability if he manages to escape or for some reason will have to release him without completing the technique (for example, to repel the attack of the second enemy). Moreover, strangulation with the fleshy part of the forearm leaves the opponent more chances to free himself or at least delay the loss of consciousness by turning his head towards the elbow, grabbing your hand, pressing your chin to your chest, etc., etc.

Tracheal trauma will remain tracheal trauma even if the opponent shakes you off.

Possible origin

The technique was taken by Fairbairn from judo. He even called this technique the Japanese strangle hold at one time.

An identical strangulation technique with compression of the trachea is described in many books on Kodokan judo [13–15], including the book of the founder of judo Jigoro Kano [16].