II. Definitions

  1. Strangulation
    1. External neck compression affecting underlying large vessel perfusion or tracheal airflow
  2. Hanging
    1. External neck compression generated from force of gravitational pull on body weight
  3. Incomplete Hanging
    1. Hanging in which feet touch the ground (attempted Suicide)
  4. Complete Hanging
    1. Hanging in which feet do not touch the ground (judicial hanging)
    2. Associated with Cervical Spine Fracture and other head and neck Trauma

III. Epidemiology

  1. Hanging Incidence: 10,000 deaths per year in U.S.
    1. Hanging is the second most common mechanism for Suicide in the U.S. (firearms are first)

IV. Pathophysiology

  1. Suicidal Hanging mechanism for death
    1. Vascular Occlusion with secondary anoxic brain injury (most common)
    2. Vertebral Artery Dissection, Cervical Spine injuries, Laryngeal Fractures may also occur, but are less common
  2. Judicial hanging mechanism for death
    1. Cervical Spine Fracture
    2. Airway injury
    3. Arterial dissection

V. Symptoms

VI. Signs

VII. Imaging

  1. Chest XRay
    1. Evaluate for Interstitial Edema (Acute Respiratory Distress Syndrome or ARDS)
    2. Evaluate for Aspiration Pneumonitis
  2. CT Head
    1. Indicated in Altered Mental Status
  3. CT Angiogram Neck (CTA neck)
    1. See Strangulation for indications
    2. Evaluate for Carotid Artery Dissection, Laryngeal Fracture, Cervical Spine Fracture, Hemorrhage
    3. Carotid ArteryUltrasound may be considered as an alternative in some cases
  4. Precautions
    1. Advanced imaging was negative in Near-Hanging survivors with normal GCS and normal exam (without tenderness)
      1. Subramanian (2016) J Trauma Acute Care Surg 81(5): 925-30 +PMID: 27537511 [PubMed]
    2. However, in clear cases of Near-Hanging or Strangulation imaging including neck CTA is typically recommended

VIII. Management

  1. See ABC Management
  2. See Trauma Evaluation
  3. Cervical Spine and Airway
    1. Cervical Spine Immobilization
      1. Protect C-Spine throughout evaluation and Resuscitation (including during Endotracheal Intubation)
    2. Endotracheal Intubation Indications
      1. See Endotracheal Intubation for all indications
      2. Airway obstruction (e.g. Stridor)
      3. Impending airway compromise (e.g. subcutaneous Emphysema, Laryngeal Fracture)
      4. Respiratory insufficiency or distress (e.g. Hypoxemia)
      5. Altered Mental Status (e.g. Glasgow Coma Scale 8)
    3. Consider Cricothyrotomy in failed airway
  4. Cardiopulmonary
    1. Manage Acute Respiratory Distress Syndrome (ARDS)
      1. See Lung Protective Ventilator Strategy
      2. Avoid excessive fluid infusion
    2. Monitor for cardiovascular adverse effects
      1. Cardiac monitoring for Dysrhythmia
      2. Avoid excessive fluid infusion (see ARDS above)
      3. Hypotension suggests other cause beyond Near-Hanging
        1. Hemorrhagic Shock from other Trauma
        2. Unknown Ingestion
        3. Neurogenic Shock
  5. Manage Increased Intracranial Pressure in Closed Head Injury
    1. Elevate the head of the bed to 30 degrees
    2. Avoid Mannitol (risk of worsening ARDS)
  6. Associated Injuries and Ingestions
    1. See Unknown Ingestion
    2. Perform toxicology evaluation for Unknown Ingestions
  7. Additional measures
    1. Consider Corticosteroids in laryngeal edema
    2. Consider antibiotics in subcutaneous Emphysema or aspiration
    3. Seizure Prophylaxis in anoxic brain injury
  8. Disposition
    1. Admit all symptomatic patients to the Intensive Care unit
    2. Asymptomatic patients may be cleared for mental health admission after full medical evaluation

IX. Prognosis

  1. Cardiac Arrest is associated with poor prognosis and high mortality
  2. Neurologic outcome is not predicted by presenting neurologic status
    1. Recovery from severe neurologic deficit on presentation may occur with good supportive care
    2. However, delayed presentations are associated with worse outcomes
  3. References
    1. de Charentenay (2020) Chest 158(6):2404-13 +PMID: 32758563 [PubMed]

X. References

  1. Swadron and Inaba in Swadron (2022) EM:Rap 22(5): 4-8
  2. Schellenberg (2019) J Trauma Acute Care Surg 86(3):454-7 +PMID: 30444857 [PubMed]

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