Brain & Vascular Choke. Definition. The Choke Hold Don Muzzi MD & Larry Lovelace DO. Submission Breakdown UFC Events 4/27/17! 15% of Cardiac Output

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The Choke Hold Don Muzzi MD & Larry Lovelace DO Submission Breakdown UFC Events 25% of fights end in submission anaconda! d acre!

Combative Sports, PA Athletic Commission, Ojibwe Tribal Commission, Fon du Lac Tribal Commission MMA121 July 2015 (UFC 189)!

neck. Neuro-vascular reflexes yield decrease in cerebral blood flow (CBF) May result in unconsciousness, injury to larynx or

1 The Choke Hold Don Muzzi MD & Larry Lovelace DO Submission Breakdown UFC Events 25% of fights end in submission anaconda! d acre! 74% of submissions are result of choke hold Does not reflect opinions of the NYSAC, FL Boxing Commission, MN, & WI Office of Combative Sports, PA Athletic Commission, Ojibwe Tribal Commission, Fon du Lac Tribal Commission MMA121 July 2015 (UFC 189)! Definition A grappling hold that critically reduces or prevents air (choking) and or blood (strangling) from passing through the neck. Neuro-vascular reflexes yield decrease in cerebral blood flow (CBF) May result in unconsciousness, injury to larynx or trachea, airway compromise significant morbidity or mortality Vascular Choke vs Airway Choke Brain & Vascular Choke 15% of Cardiac Output 1!

Reflex (BRR): Mechanoreceptors (stretch) in carotid vasculature that sense BP and relay information to the brain in order to

2 Blood Supply to Brain Mechanisms and Reflexes Auto-regulation: (AR) Intrinsic ability of the cerebral vasculature to alter its resistance in order to maintain cerebral blood flow constant over a wide range of cerebral perfusion pressures Baroreceptor Reflex (BRR): Mechanoreceptors (stretch) in carotid vasculature that sense BP and relay information to the brain in order to maintain a proper blood pressure Cerebral Hemodynamics Baroreceptor Reflex CPP = MAP - ICP (or CVP whichever is greater) CBF = CPP/CVR 2!

3 Baroreceptor Reflex Pathway CBF Venous Compression Stretched firing Sympathetic Parasympathetic Peripheral vasodilatation MAP & CPP" HR, inotropic state of heart, CO CPP = MAP-ICP Autoregulation of CBF Autoregulation of CBF CPP= MAP-ICP (or CVP whichever is greater)! 3!

CPP, CBF & Vascular Choke (CPP = MAP - ICP) Cerebral Vascular

CO (BRR) ICP (jugular venous compression) CPP = MAP - ICP CPP, CBF, O2

compression of carotid arteries decreases radius Head turn limit blood

4 CPP, CBF & Vascular Choke (CPP = MAP - ICP) Cerebral Vascular Resistance(AR) Peripheral Vasodilatation MAP (BRR) HR inotropic state CO (BRR) ICP (jugular venous compression) CPP = MAP - ICP CPP, CBF, O2 delivery to brain LOC Mechanical Artery Compression Mechanical compression of carotid arteries decreases radius Head turn limit blood flow through one vertebral artery LOC in seconds, Consciousness returns seconds 4!

Airway Choke (compression of larynx or trachea) Airway Choke SLN: sensory above cords, cricothyroid muscle, tenses/adducts

airway obstruction RLN: sensory below cords, innervates all intrinsic muscles of larynx except cricothyroid (less susceptible

$Low velocity, high amplitude injury potential to result in multiple fractures of laryngeal structures, generally without$

5 Airway Choke (compression of larynx or trachea) Airway Choke SLN: sensory above cords, cricothyroid muscle, tenses/adducts (more susceptible to injury) SLN: injury of little consequence (voice change) RLN: injury more significant may result in airway obstruction RLN: sensory below cords, innervates all intrinsic muscles of larynx except cricothyroid (less susceptible to injury) Airway Choke! Low velocity, high amplitude injury potential to result in multiple fractures of laryngeal structures, generally without significant displacement, early hematoma, or laryngeal mucosal tears Signs and Symptoms of Laryngeal Trauma! Pain or tenderness over laryngeal area Hoarseness or change in voice Dysphagia Odynophagia Odynophonia, Aphonia Hemoptysis Dyspnea 5!

$tracheal injury -Biphasic inspiratory & expiratory injury at level of glottis Ecchymosis over laryngeal area Subcutaneous emphysema Deviation of larynx or palpable fracture Loss of laryngeal$

6 Signs and Symptoms of Laryngeal Trauma! Stridor (type may indicate level of injury) -Inspiratory implies supra-glottic obstruction e.g. edema or hematoma -Expiratory sub-glottic source such as tracheal injury -Biphasic inspiratory & expiratory injury at level of glottis Ecchymosis over laryngeal area Subcutaneous emphysema Deviation of larynx or palpable fracture Loss of laryngeal crepitance Airway Choke Interferes with breathing may lead to asphyxia (can be life threatening) Less effective at yielding LOC than vascular choke Combatant more likely to submit Greater risk to combatant Forearm across the front of the neck free hand on wrist pulling back forearm Airway Choke Hold Evaluation & Treatment Ascertain severity of injury & identify patient that requires immediate airway intervention C-spine evaluation *Airway Management* Elevate Head, Ice Transfer to hospital (CT, CXR, C-spine) Steroids, Humidification, Voice Rest Anti-Reflux Medications, Antibiotics 6!

7 Choke Summary Frequent Event Cardiac Reflexes (Decreased CO) Vascular Reflexes (Cerebral & Peripheral) Decreases in Cerebral Blood Flow Airway Trauma 7!

International Journal of Scientific & Engineering Research, Volume 5, Issue 9, September ISSN

International Journal of Scientific & Engineering Research, Volume 5, Issue 9, September-2014 1196 Pneumomediastinum and subcutaneous emphysema secondary to blunt laryngeal traumafavourable outcome with