Author: Angela Hua, MD (EM Resident Physician, Mount Sinai Hospital) // Edited by: Alex Koyfman, MD (EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital, @EMHighAK) and Brit Long, MD (EM Chief Resident at SAUSHEC, USAF, @long_brit)

A 41 yo M is brought in by EMS after an attempted hanging. He was found by his father-in-law, who cut him down with a neighbor’s assistance. Unwitnessed hanging, estimated 1-45min of hang time.

How should this case be managed? What are the issues to be immediately addressed, and of what complications should an emergency physician be aware?

DEFINITION/CLASSIFICATION

WHY IS AWARENESS OF HANGING INJURIES IMPORTANT?

Hanging has become the 2 nd most common form of successful suicide in the US, and is one of the more common forms in the UK and Canada

most common form of successful suicide in the US, and is one of the more common forms in the UK and Canada In the jail system, hanging is the most common form of successful suicide

PATHOPHYSIOLOGY

Judicial Hanging



Drop is at least as long as the height of the victim, hanging is complete

Head hyperextends => Fracture of upper cervical spine , most commonly traumatic spondylolisthesis of C2, “hangman’s fracture” Transection of the spinal cord



Other Strangulation Injuries

Death ultimately results from cerebral hypoxia and ischemic neuronal death

Airway compromise plays minimal role in the immediate death of successful strangulation victims, but initial survivors may suffer significant pulmonary complications (see below)

PHYSICAL EXAM

Abrasions, lacerations, contusions, edema to neck

Abrasions, lacerations, contusions, edema to neck Tardieu spots

Severe pain on gentle palpation of the larynx (laryngeal fracture)

Mild cough

Stridor

Muffled voice

Respiratory distress

Hypoxia (usually late finding)

Mental status changes

INITIAL EMERGENCY DEPARTMENT CARE – ABCs

Endotracheal intubation (ETI) may become necessary with little warning

If ETI unsuccessful, consider cricothyroidotomy; if unsuccessful, percutaneous trans-laryngeal ventilation may be used temporarily

Fluid resuscitation must be performed judiciously – risk of ARDS and cerebral edema

– risk of ARDS and cerebral edema Monitor for cardiac arrhythmias

Altered / comatose patient => treat as cerebral edema with elevated ICP

IMAGING STUDIES

Soft-tissue neck x-ray

Chest radiograph

CT brain

CT C-spine

Consider CTA head/neck or MRA head/neck http://www.virtualmedstudent.com/links/musculoskeletal/hangmans_fracture.html

FURTHER CARE AND POTENTIAL COMPLICATIONS

Even if the initial presentation is clinically benign, all near-hanging victims and those with vascular compromise should be admitted for 24 hours observation => risk of delayed airway and pulmonary complications

BEWARE COMPLICATIONS!

Respiratory complications = major cause of delayed mortality in near-hanging victims

in near-hanging victims Pulmonary edema Neurogenic : centrally mediated, massive sympathetic discharge; often in association with serious brain injury, poor prognostic implication Post-obstructive : due to marked negative intrapleural pressure, generated by forceful inspiratory effort against extrathoracic obstruction; when obstruction removed, may have rapid onset pulmonary edema leading to ARDS

Aspiration pneumonia

Carotid intimal dissection or thrombus formation

Tracheal stenosis

Neurologic sequelae Transient hemiplegia Central cord syndrome Seizures Spinal cord injury Long-term paraplegia/quadriplegia Short-term autonomic dysfunction



PROGNOSIS

GCS on presentation is NOT predictor of outcome

Predictors of poor clinical outcome:

-Anoxic brain injury on head CT

-Long hanging time

-Cardiopulmonary arrest

-Cervical spine injury

-Hypotension on arrival

-PaO2/FiO2 < 100 at admission

References / Further Reading

Berdai AM, Labib S, Harandou M. Postobstructive pulmonary edema following accidental near-hanging. American Journal of Case Reports 2014; 14: 350-353

Borgquist O, Friberg H. Therapeutic hypothermia for comatose survivors after near-hanging—a retrospective analysis. Resuscitation 80(2009): 210-212.

Casha S, Christie S. A systematic review of intensive cardiopulmonary management after spinal cord injury. Journal of Neurotrauma 28: 1479-1495.

Furlan JC, Fehlings MG. Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and management. Neurosurgery Focus 2008; 25(5): E13

Gandhi R, Taneja N, Mazumder P. Near hanging: early intervention can save lives. Indian Journal of Anaestehsia 2011, 55(4): 388-391

Kaki A, Crosby ET, Lui ACP. Airway and respiratory management following non-lethal hanging. Can J Anaesth 1997 44(4): 445-450

Irvin CB, Szpunar S, Cindrich LA, et al. Should trauma patients with a Glasgow Coma Scale score of 3 be intubated prior to hospital arrival? Prehospital Disaster Medicine 2010 25(6) 541-6.

Mack EH. Neurogenic shock. The Open Pediatric Medicine Journal 2013, 7 (suppl 1: M4) 16-18

Mansoor S, Afshar M, Barett M, et al. Acute respiratory distress syndrome and outcomes after near hanging. American Journal of Emergency Medicine 2015, 33: 359-362.

Newton K, Claudius I. Rosen’s Emergency Medicine – Concepts and Clinical Practice. 8 th Edition (2014). Volume 1, Part II, Chapter 44 pp 421-431.

Edition (2014). Volume 1, Part II, Chapter 44 pp 421-431. Nickson C. Trauma! Spinal injury. Life in the Fast Lane. http://lifeinthefastlane.com/trauma-tribulation-016/

Salim A, Martin M, Sangthong B. Near-hanging injuries: a 10-year experience. Injury, Int J Care Injured 2006, 37: 435-439.

Trujillo MH, Fragachan CF, Tortoledo F. Noncardiogenic pulmonary edema following accidental near-hanging. Heart & Lung. 2007 36(5) 363-366.