Neck holds are used by law enforcement agencies to subdue violent individuals. Rarely, one will encounter a death alleged to have occurred due to application of either a choke hold or a carotid sleeper hold.38-41 These terms are often used interchangeably, but, in fact, refer to two different holds whose purpose is to produce transient cerebral ischemia and unconsciousness. Neither involves use of a mechanical implement. Rather, the arm and forearm are used to compress the neck, producing cerebral ischemia and unconsciousness. Occasionally, a baton, large metal flashlight, or some other device, will be used to compress the neck. The authors have seen a number of deaths involving use of such instruments. In such cases, there is usually extensive hemorrhage in the neck and fractures of the hyoid or larynx.
With choke (bar arm) holds, the forearm is placed straight across the front of the neck. The free hand grips the wrist, pulling it back, collapsing the airway and displacing the tongue rearward, which occludes the hypophar-ynx. Incapacitation is caused by collapse of the airway and the carotid arteries with resultant decrease in the supply of oxygen to the brain. Compression of the carotid arteries is the prime mechanism for loss of consciousness. If too much force is used, there could be fracture of the larynx or hyoid. In two cases reported by Reay and Eisele and in a case seen by the authors, there were unilateral fractures of the greater cornu of the thyroid cartilage.38 Both of Reay and Eisele's cases had fractures on the left side of the neck, the right forearm was across the neck and the left hand was used to pull it backward. Thus, pressure was eccentrically transferred to the neck, predominantly to the left side. In the case seen by the authors, the left forearm was across the neck and the fractures were on the right side of the neck. The authors' case also had a fracture of the hyoid bone on the same side. Following loss of consciousness, the chokehold is released and the victim should regain consciousness within 30 sec. There should be no permanent sequelae. Obviously, if the choke hold is maintained for too long, death will ensue, and one now has a case of manual strangulation.
In the carotid sleeper hold, symmetrical force is applied by the forearm and upper arm to the front of the neck such that there is compression of only the carotid arteries and jugular veins and not the trachea. The arm is placed about the neck with the antecubital fossa or crook of the arm centered at the midline of the neck. The free hand grips the wrist of the other arm and pulls it backward, creating a pincher effect. This produces transient cerebral ischemia. The carotid sleeper hold impedes blood flow in the carotid arteries by pressure exerted on both sides of the neck by the pincher effect of the arm and forearm. If properly applied, the compression of the carotid arteries will cause loss of consciousness in approximately 10-15 sec. On relaxation of the hold, cerebral blood flow will be restored and consciousness will return in approximately 10-20 sec, without any serious side effects. Experiments by Reay and Holloway demonstrated that, during application of the carotid sleeper hold, blood flow is decreased an average of 85% to the head.39 The range in five subjects was 82 to 96%. The time to minimum blood flow averaged 6 sec (range 3.2 to 7.2 sec).
In theory, the carotid sleeper hold will cause rapid unconsciousness without injury to the individual. Unfortunately, in violently struggling individuals, a carotid sleeper hold can easily and unintentionally be converted into a choke hold, as the individual twists and turns to break the hold.
Maintenance of the pressure in a carotid sleeper hold, after loss of consciousness, becomes manual strangulation and, if continued long enough, will cause death. One would not expect trauma to the structures of the neck in such an instance. The compression of the carotid arteries, with resultant decreased cerebral blood flow, can theoretically precipitate a stroke in an individual with atherosclerotic disease of the carotid or cerebral vasculature. The pressure can cause dislodgment of atherosclerotic material with a stroke caused by an embolus. Blood flow to the brain is from both the carotid and the vertebral arteries. If the vertebral arteries have impaired blood flow due to atherosclerosis, then occlusion of the carotid arteries can threaten an already compromised circulation, resulting in thrombosis or stroke.
Both choke and carotid sleeper holds are safe if properly used, though the latter is the safer of the two. In weighing how much force is acceptable in a situation, one must realize that any action involving force always has the potential of producing severe injury and death.
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