Near-Hanging

Aka: Near-Hanging, Attempted Hanging, Attempted Suicide by Hanging, Asphyxia by Hanging, Suicidal Hanging, Hanging Injury, Complete Hanging

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II. Definitions

  1. Strangulation
    1. External neck compression affecting underlying large vessel perfusion or tracheal airflow
    2. Types of Strangulation include hanging, manual Strangulation, ligature Strangulation
  2. Hanging
    1. External neck compression generated from force of gravitational pull on body weight
    2. Person suspended by the neck with ligature (ropes, ties, cables, clothing)
  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. Risk Factors

  1. Male gender
  2. Mental illness
  3. Prior Suicide attempt

VI. Symptoms

  1. See Strangulation
  2. Odynophagia
  3. Dysphagia
  4. Dysphonia
  5. Stridor
  6. Dyspnea

VII. Signs

  1. See Strangulation
  2. Ligature marks
  3. Facial Petechiae
  4. Subconjunctival Hemorrhage

VIII. 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 and CT Cervical Spine)
    1. See Strangulation for indications
    2. See Denver Screening Criteria for Blunt Cerebrovascular Injury
    3. Evaluate for Carotid Artery Dissection, Laryngeal Fracture, Cervical Spine Fracture, Hemorrhage
    4. Carotid ArteryUltrasound may be considered as an alternative in some cases
  4. Precautions
    1. In clear cases of Near-Hanging or Strangulation, imaging including neck CTA is typically recommended
    2. 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]

IX. Management

  1. See ABC Management
  2. See Post-Cardiac Arrest Care
  3. See Trauma Evaluation
  4. See Blunt Neck Injury
  5. See Neck Vascular Injury in Blunt Force Trauma
  6. See Traumatic Brain Injury
  7. 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
  8. 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
  9. 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)
  10. Associated Injuries and Ingestions
    1. See Unknown Ingestion
    2. Perform toxicology evaluation for Unknown Ingestions
  11. Additional measures
    1. Consider Corticosteroids in laryngeal edema
    2. Consider Antibiotics in subcutaneous Emphysema or aspiration
    3. Seizure Prophylaxis in anoxic brain injury
  12. 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

X. 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]

XI. Complications

  1. Airway compromise (e.g. Laryngeal Fracture)
  2. Cervical Spine Fracture
  3. Carotid Artery Dissection
  4. Hypoxic brain injury
  5. Pulmonary Edema

XII. 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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