Sleeper hold

Movies have become very graphic over the years, and often a modern action adventure movie will portray the use of a sleeper hold, either used by or against the hero. Applied from behind, a grip around the neck compresses both carotid arteries, and within a matter of seconds unconsciousness results from the reduction in cerebral blood flow. This maneuver has its roots in judo, initially termed shime-waza (constriction technique), and over time has been referred to as a chokehold, stranglehold, blood choke, mugger’s yoke, and the carotid choke.1 Use of the sleeper hold has its risks.

A recent report describes bilateral blunt carotid artery injury in a young man due to strangulation. He arrived at the hospital with a normal Glasgow Coma Scale but computed tomography (CT) angiography revealed injuries to both carotid arteries. Fortunately, after six weeks of conservative management with anticoagulation, a repeat CT study showed complete resolution of an intimal flap.2

The website defines the carotid (also called carotid artery) as “either of the two large arteries, one on each side of the head, that carry blood to the head.”3 The word has its origin from “Greek karōtídes neck arteries, equivalent to karōt (ikós) soporific (kár (os) stupor + -ōtikos -otic) + -ides -id; so called by Galen, who found that their compression causes stupor.”3 Blunt carotid artery injury has been an enigma, but over the past 15 years, it has come to the forefront. As trauma system development spread throughout the country bringing larger numbers of injured patients to trauma centers, diagnostic algorithms with screening protocols were developed and patterns of injury were recognized. As technology improved along with the availability and use of multi-slice CT angiography, most institutions now report blunt cerebrovascular injuries occurring in 1 percent to 2 percent of trauma admissions.4

Occurence of injury

Emergency department disposition

To examine the occurrence of blunt carotid artery injuries in the National Trauma Data Bank® (NTDB®) research dataset for 2012, admissions medical records with a blunt mechanism of injury were searched using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Specifically searched were injury codes 900.0, carotid artery unspecified; 900.01, common carotid artery; 900.02, external carotid artery; and 900.03, internal carotid artery. A total of 957 records was uncovered. Of these records, 921 contained a discharge status, including 372 patients discharged to home, 250 to acute care/rehab, and 135 sent to skilled nursing facilities; 164 died. Of these patients, 65 percent were male, on average 39.2 years of age, had an average hospital length of stay (LOS) of 15.2 days, an intensive care unit (ICU) length of stay of 10.3 days, an average injury severity score (ISS) of 28.3, and were on the ventilator for an average of 9.1 days. Emergency department disposition resulted in only 11 percent going to a general surgical floor, while 62 percent went to the ICU, another 21 percent went directly to the operating room, and 6 percent went to telemetry. This group had significant injuries based upon the high average ISS, the majority requiring ICU admission, and the high average hospital and ICU LOS (see figure).

Most blunt carotid artery injuries are unilateral and the result of motor vehicle crashes; however, other mechanisms have been implicated, as mentioned previously in this column.

Play it safe

Horseplay is a rite of passage, especially among siblings close in age or among friends that may have had a few drinks and try and relive their earlier days wrestling around on the floor. Just remember that the sleeper hold is not an innocent maneuver and may cause arterial injury and put you to sleep permanently.

Throughout the year, we will be highlighting data through brief reports in the Bulletin. The NTDB Annual Report 2012 is available on the ACS website as a PDF file and as a PowerPoint presentation at In addition, information regarding how to obtain NTDB data for more detailed study is available on the website. If you are interested in submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at

Statistical support for this article has been provided by Chrystal Caden-Price, data analyst, NTDB.


  1. Mifune K. The Canon of Judo: Classic Teachings on Principles and Techniques. 2nd ed. Bunkyo-ku, Tokyo: Kodansha International Ltd.; 2004:128, 132.
  2. Cheddie S, Pillay B, Goga R. Bilateral blunt carotid artery injury: A case report and review of the literature. S Afr J Surg. 2013;51(2):77-79. doi: 10.7196/sajs.1381. PubMed PMID: 23725899.
  3. Carotid. Available at: Accessed September 29, 2013.
  4. Fabian TC. Blunt cerebrovascular injuries: Anatomic and pathologic heterogeneity create management enigmas. J Am Coll Surg. 2013;216(5):873-885. doi: 10.1016/j.jamcollsurg.2012.12.053. Epub March 18, 2013. PubMed PMID: 23518252.

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