Telltale Petechiae and Bruises: Abusive Strangulation of an Adolescent Girl

Marilyn McKim Barnes, MN, RN, ARNP, PPCNP-BC

A 17-year-old girl presented to a Child Protection Team clinic for concerns that her father had beaten her the day before. She described an altercation with her father that had started when she confronted him about saying that she deserved to die. She said he had kicked her, punched her, grabbed her by the throat, and “body slammed” her into the grass. She said she had difficulty breathing while being choked.

At presentation, she complained of a sore neck and back, a headache, and dizziness. She denied visual changes, vomiting, or loss of consciousness. The girl also disclosed having been kicked by her father approximately a month earlier and having been hit in the face on other occasions by her mother and stepfather.

The girl’s past medical history and family history were both negative for bleeding disorders. She had received a diagnosis of bipolar disorder, for which she was being treated with citalopram. She had been taking ibuprofen since the incident, which had offered some relief of her headache.

Her social history included 3 prior child welfare referrals for intimate partner violence, and a history of substance abuse in both parents. The patient described ongoing prescription drug abuse by her father and stated that her mother had been a heavy drinker but had quit a year prior. Her father also had been in prison on a homicide charge.

Physical examination findings included numerous bruises on her back, her superior shoulder, and her extremities (Figures 1 and 2), including bruising over the soft tissue of her anterior thighs, left forearm, and lateral right upper arm. Showers of petechiae were prominent on her upper eyelids (Figures 3 and 4) and in the concha of the right ear, just anterior to the ear canal (Figure 5). No petechiae were present elsewhere on her body, and she had no subconjunctival hemorrhages. Results of a neurologic examination were normal. 

Physical abuse was medically confirmed based on the physical findings matching her description of being body slammed and choked. At the conclusion of the examination, the adolescent was routed to a local emergency department due to her persistent headache and dizziness.

The Child Protection Team’s recommendations to child welfare authorities included her having no contact with her father until and unless he successfully completed a remedial case plan. It was recommended that the case plan include a substance abuse evaluation for the father with subsequent treatment if indicated, a batterer’s intervention program for the father, mental health counseling for the girl to address her victimization, and her having no physical discipline by any caregiver.


When a child describes being choked as a part of an assault, petechiae may be present on the neck, face, eyes, and ears. In this case, the father’s choking action was substantially forceful and lasted more than just a few seconds, as evidenced by the petechial showers below the girl’s eyebrows and on the pinna of the ear. Strangulation can cause the blood vessels in the skin to rupture above the area of constriction if the strangulation obstructs venous return while allowing arterial blood flow. Pressure builds in the venules and capillaries, and in areas of little connective support tissue, rupture of these vessels causes petechiae.1

Strangulation is potentially life-threatening if it causes hypoxia or anoxia or damages the spinal cord. This fact should be made clear to child welfare authorities if they are involved.

Because both intimate partner violence and substance abuse are linked with child abuse,2,3 the team’s assessment also included statements about the father’s history of violence against the girl and her mother, as well as the child’s exposure to parental substance abuse.

Marilyn McKim Barnes, MN, RN, ARNP, PPCNP-BC, is a nurse practitioner on the Child Protection Team in the Department of Pediatrics at the University of Florida College of Medicine in Gainesville, Florida.


1. Ely SF, Hirsch CS. Asphyxial deaths and petechiae: a review. J Forensic Sci. 2000;45(6):1274-1277.

2. Herrenkohl TI, Sousa C, Tajima EA, Herrenkohl RC, Moylan CA. Intersection of child abuse and children’s exposure to domestic violence. Trauma Violence Abuse. 2008;9(2):84-99.

3. Barth RP. Preventing child abuse and neglect with parent training: evidence and opportunities. Future Child. 2009;19(2):95-118.