Half of them have no mark on the neck. That is not a reason to send them home.

The adult guideline is explicit: “Ultrasound/carotid doppler ultrasound and plain X-rays are NOT RECOMMENDED for evaluation of the vascular or soft tissue structures in this setting.” And observation is not a substitute for the scan: “(NOTE: ‘Observation only’ has NO role in a suspected vascular injury and appropriate imaging is required)”.

In July 2026 IFAS published the imaging section of the paediatric guideline ahead of the rest, because clinicians had been using the adult guideline for children in the absence of anything else, and there was “concern that children and young people are being imaged unnecessarily.”

The evidence it relied on: UK data informally collected from 30 hospitals over three months, on 106 consecutive children and young people aged 17 and under who had CT neck angiography after strangulation. None had a cervical vascular injury or a cervical bony fracture. What they did have was hypoxic brain injury — 10 of the 66 who had a CT head, all 10 with a GCS of 3–5 and a cardiac arrest at the time, and two of them died. The published series point the same way: blunt cerebrovascular injury in 0.9% of 1929 children after near-hanging, 53 of 54 CTAs normal in another series, no arterial injury in a third of 66.

So the paediatric pathway moves the imaging towards what does harm children after strangulation — the airway, the chest and the brain — and away from the vessels.

The adult guideline scans patients within four weeks of strangulation, or later if they are symptomatic. It is candid that the number is a judgement: “The four-week timescale for non-symptomatic patients that has been chosen is a balance of the current evidence base regarding risk of significant vascular injury, with its life changing potential, versus pragmatism”.

Beyond four weeks and asymptomatic, the patient is not scanned in the ED — but they are not finished with either. Patients in this group “may still be at risk of vascular problems such as carotid artery dissection due to the blunt neck trauma for up to 12 months post event.” Those who screen positive for a red flag “may require outpatient imaging”, which needs a local arrangement, and the guideline adds: “Consider antiplatelet treatment for those being referred for outpatient imaging.”

The paediatric pathway has no four-week rule. It asks only whether there are signs or symptoms now.

In both flowcharts, every route — scanned, not scanned, and outside the window — passes through the safeguarding box before admission or discharge. There is no branch that skips it.

16 and over (Box D)

• Safeguarding assessment, including any children or vulnerable adults who may be at risk.
• Discuss the options of reporting to police, taking into account capacity, confidentiality and best interest.
• Suicide and self-harm risk assessment. “Self-harm by hanging/strangulation often indicates a very high suicide intent.”
• Domestic abuse: complete the DASH risk checklist and refer to an IDVA — and note that the guideline says NFS in itself “would warrant a MARAC referral, regardless of overall DASH score”.
• Sexual assault or rape: all of the above, plus a SARC referral or advice (self or police referral) for forensic examination, ISVA support and counselling; assess for emergency contraception and HIV and hepatitis B post-exposure prophylaxis; signpost the window period for STI screening.

Under 16 (Boxes D and E)

• Safeguarding assessment, and referral for a child protection medical assessment where appropriate. Skeletal survey decisions belong to the safeguarding assessment.
• Age of consent is 16 in all four UK nations. Sexual activity involving a child under 16 is a potential safeguarding concern, and “Sexual activity involving a child under the age of 13 should always result in a child protection referral.”
• A developmentally appropriate assessment of emotional and mental health needs for every child. Where the strangulation was self-harm, a face-to-face biopsychosocial assessment by an experienced mental health professional — and “Do not delay the psychosocial assessment until after medical treatment”.
• In an intimate or peer relationship, screen for wider coercive control and consider MARAC pathways.
• Sexual assault: emergency contraception, HIV and hepatitis B PEP, STI signposting, and SARC referral or advice.

Admission may be needed for the injury, for safeguarding, or both. The considerations are the same in both guidelines: concern about the airway; the clinical condition; a history of significant blunt force or pressure to the neck or head; significant findings on imaging; an unsafe discharge setting; and a vulnerable patient or a safeguarding requirement. The adult guideline names the vulnerable groups — “children, elderly, pregnant, homeless” — and includes self-harm risk; the paediatric guideline adds immediate mental health-related risk, and says that where home is unsafe for a child, refer to children's social care for a suitable place of safety.

On early presentations, both say to consider a period of observation: “Delayed airway difficulties are rare and likely to occur within the first 6 hours post assault, dependent on factors such as type/extent of injury etc.”

• Safety-netting: written information on strangulation and the symptoms that need urgent review. IFAS publishes patient leaflets for adults and for children and young people.
• Acquired brain injury: strangulation can cause hypoxic-ischaemic brain injury, with cognitive, speech and language, and emotional or behavioural effects. For adults, an assessment by a clinical neuropsychologist or similar “should be undertaken 3 months post the strangulation”, arranged via the GP or directly depending on local arrangements. For children, consider neuropsychological assessment and community neurorehabilitation, and record the strangulation clearly: childhood brain injury can be silent and only show itself years later.
• The GP letter should name the strangulation and the actions requested, remembering that victims “are likely to require psychological support”.
• Online record access is a risk here. The paediatric guideline warns that a patient at ongoing risk may be coerced into sharing access to their records, and that redaction flags can themselves be visible on screen during a consultation. The adult guideline asks you to consider confidentiality and risk around access to the record. Discuss it with the patient where you can.
• Coding: record it as strangulation. The paediatric guideline lists the ICD-11 codes — PE62 assault by strangulation, PC72 intentional self-harm by hanging, strangulation or suffocation, PB02 unintentional, PH22 undetermined intent, NF05 asphyxiation by strangulation.

These cases often end up in court. IFAS publishes a free non-fatal strangulation pro forma (January 2026) designed to be used alongside your ED notes. What it asks for is a good checklist even if you do not use the form:

• The event: method (one hand, two hands, ligature, headlock, other), the time, how many episodes, grip strength and pain on a 1–10 scale, whether the head was shaken, what the assailant said, what made it stop, and whether it has happened before.
• At the time: visual changes (flashing lights, tunnel vision, spots, stars, blurring or loss), buzzing or roaring in the ears, loss of consciousness, dizziness, difficulty breathing or speaking, pain, incontinence of urine or faeces, loss of strength.
• Since: neck pain and swelling, cough, dysphagia or drooling, painful swallowing, voice change, dyspnoea, vomiting, headache, memory disturbance.
• Examination: Fitzpatrick skin type, vital signs, and a body chart of the neck (including carotid bruit and surgical emphysema), face, eyes with fundoscopy, scalp, mouth, behind the ears, neurology and GCS, and voice quality.

The places to look are not only the neck: “Bruising from NFS may occur on the scalp, in the mouth, and/or behind the ears.”

England and Wales. Since 7 June 2022, section 75A of the Serious Crime Act 2015 (inserted by section 70 of the Domestic Abuse Act 2021) makes it an offence if a person “intentionally strangles another person”, or does any other act that affects their ability to breathe and constitutes battery. Consent is a defence — but not if serious harm results and the person intended it or was reckless about it. Maximum sentence on indictment: 5 years.

Northern Ireland. Section 28 of the Justice (Sexual Offences and Trafficking Victims) Act (Northern Ireland) 2022 creates an offence of non-fatal strangulation or asphyxiation, which is committed “irrespective of whether in fact A’s act affects B’s ability to breathe or the flow of blood to B’s brain.”

Consent to serious harm. In England and Wales, section 71 of the Domestic Abuse Act 2021 provides that it is not a defence that the victim consented to serious harm for the purposes of sexual gratification. This is why the IFAS guideline asks you to take a non-judgemental approach to consensual strangulation while making sure the person knows about “the potential harm and the law related to ability to consent to serious harm if that occurs.”

Scotland is not covered here — this module does not state the Scottish legal position.

• It does not use the presence or absence of a mark. Visible bruising is a red flag in the adult list; its absence is not reassuring, and the tool has no option that would let it be.
• It does not apply the adult CTA pathway to under-16s, or the paediatric pathway to 16- and 17-year-olds. IFAS draws the line at 16 and so does this page.
• It does not give drug doses. Neither guideline does. For antiplatelet treatment before outpatient imaging, and for post-exposure prophylaxis, use your local protocol.
• It does not replace your safeguarding team, your SARC, or senior review. Both guidelines require senior decision-maker input for every patient.

• Institute for Addressing Strangulation (IFAS). Guidelines for clinical management of non-fatal strangulation in acute and emergency care services. July 2025, review date July 2026. Produced by Professor Catherine White with an intercollegiate development group including RCEM, FFLM, RCR, RCPCH, RCS, RCGP, RCN, ENT UK, the College of Paramedics and NHS England. Content unchanged from the February 2024 edition apart from dates.
• IFAS. Guidelines for clinical management of paediatric (under 16) non-fatal strangulation. July 2026, review date July 2028. Intercollegiate working group including RCEM, RCPCH, RCR, BSPR, the Royal College of Psychiatrists and ENT UK.
• IFAS. Announcement: imaging guidelines as part of the clinical management of paediatric (under 16) strangulation. 1 July 2026.
• IFAS. Non-fatal strangulation pro forma. January 2026.
• Serious Crime Act 2015 s.75A; Domestic Abuse Act 2021 ss.70–71; Justice (Sexual Offences and Trafficking Victims) Act (Northern Ireland) 2022 s.28 — all from legislation.gov.uk.

Every quotation on this page is verbatim from the source named beside it. The IFAS guidelines are free to use for non-commercial purposes and must not be reproduced in amended form; this page quotes and links to them rather than reproducing them — read the originals at ifas.org.uk.