- Email: [email protected]
Prognostic outcome indicators following hanging injuries
Resuscitation 54 (2002) 27 /29 www.elsevier.com/locate/resuscitation
Prognostic outcome indicators following hanging injuries D.J. Penney, A.H.L. Stewart, M.J.A. Parr * Intensive Care Unit, Liverpool Hospital, University of New South Wales, Locked Bag 7103, Liverpool NSW 1871, Australia Received 22 February 2002; received in revised form 4 March 2002; accepted 6 March 2002
Abstract Hanging as a method of attempting suicide is increasing in incidence. A retrospective review of victims of hanging injuries presenting to our institution over a 5-year period was performed. Forty-two cases were reviewed. Drug and/or alcohol ingestion was identified in 70% of cases. There were no cervical spine injuries identified, although two unexpected thoracic spine fractures were found. There was an 88% survival rate, with a low incidence (5%) of poor neurological outcome. The Glasgow Coma Score at scene or on arrival at hospital was found to be a prognostic indicator. Victims without spontaneous cardiac output at scene did not survive, even if cardiopulmonary resuscitation was successful initially. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Trauma; Hanging injury; Patient
1. Introduction Over the past 30 years, in many developed countries of the world, suicide rates in young males have almost doubled [1]. Although rates of suicide have changed little in females, in both sexes there have been substantial increases in the use of hanging as a method of attempting suicide. Hanging victims will present in increasing numbers to emergency departments and intensive care units [1 /4]. The objective of this study was to identify prognostic indicators related to outcome for patients presenting to hospital following a hanging injury.
Basic demographics Previous psychiatric history Previous suicide attempt Drug and/or alcohol use Cardiovascular parameters at scene and on arrival to hospital . Glasgow Coma Score (GCS) at scene and on arrival to hospital . Patient outcome: non-survival or survival to discharge to home or nursing home . . . . .
All radiological investigations performed were reviewed.
2. Method
3. Results
All patients with an International Classification of Disease code of hanging/near-hanging/asphyxiation (ICD X70 and E953) who presented to our institution over a 5-year period from January 1996 to January 2001 were identified. The following data was recorded:
A total of 44 patients presented to Liverpool Hospital during the 5-year period from January 1996 to January 2001. Forty-two medical records with radiological investigations were available for review. All the hangings were suicide attempts. Of the 42 case notes available for review, 38 (90%) were males and 4 were females. The ages ranged from 13 to 68 years old, with 80% being less than 40 years old. Twenty-two (50%) had a psychiatric history. Seventeen (40%) had made a previous suicide attempt. Drug and/or alcohol ingestion was identified in 30 (70%) cases.
* Corresponding author. Tel.: /612-9828-3400; fax: /612-98283551 E-mail address: [email protected] (M.J.A. Parr).
0300-9572/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 0 - 9 5 7 2 ( 0 2 ) 0 0 0 5 0 - 3
28
D.J. Penney et al. / Resuscitation 54 (2002) 27 /29
Fig. 1. Distribution of survivors Glasgow Coma Score at scene and on arrival to hospital.
Nine (25%), of all the patients who were discharged from hospital well had a GCS of 3 at scene (Fig. 1). Seven patients reported as GCS 3 on scene with fixed and dilated pupils left hospital with no neurological sequelae. Of the nine victims with GCS of 3 at scene and also on arrival to hospital, three (33%) left hospital well, one was discharged to a nursing home with severe neurological disability and the other five patients died. Two patients had no radiological investigation performed. Forty patients had a lateral cervical spine radiograph performed. Computed tomography (CT) of the cervical spine were performed in 17 patients. No cervical injuries were identified. Fifteen CT scans of the head were performed. One scan demonstrated cerebral oedema (in a non-survivor following out-of-hospital cardiac arrest). Two patients were shown to have fractures of the twelfth thoracic vertebra. One laryngeal injury was recorded, which was thought to be iatrogenic following difficult on-scene intubation. In this series of hanging injuries, 37 (88%) victims survived. Two patients (5%) demonstrated persistent severe neurological impairment and were discharged to nursing homes. The remainder of the survivors were discharged home. There were five deaths (12%). All of these nonsurvivors were pulseless at scene. However, in four of these victims, cardiopulmonary resuscitation was successful with return of spontaneous circulation on arrival at hospital. None of these patients survived to discharge.
4. Discussion Judicial hanging has been a method of legal execution at least since the time of the Roman Empire [5]. The technique involves a drop from a height with abrupt arrest of the fall with a neck ligature [6]. Death may occur by a variety of pathologies [7]. The classic ‘Hangman’s fracture’ through the neural arch of the second cervical vertebra produces death by spinal cord injury. The larynx may also be injured with airway
disruption, the carotid arteries may be lacerated or avulsed and traumatic decapitation may occur. In suicidal hanging however, the body does not usually fall from a great height and the patterns of injury are different to judicial hangings [8 /10]. Spinal cord and skeletal injuries are rare [8]. In one review of the literature on near hanging, cervical spine injury occurred in four of 689 patients (0.6%) [11]. The mechanism of death in suicidal hanging is debated. Local neck compression may cause venous obstruction and stagnant cerebral hypoxia. Carotid artery occlusion may occur with consequent ischaemic brain injury. Airway injuries severe enough to interfere with airway management are uncommon [12], and although airway disruption has been described, airway closure is not thought to be a significant factor [13,14]. Traumatic decapitation has been described, although only in patients who suffered a drop from a considerable height [15]. In this series all hangings were alleged suicide attempts. We found 90% were male and 80% were less than 40 years of age. Half of the patients had a psychiatric history and 40% had made a previous suicide attempt. Drugs and/or alcohol were identified in 70% of cases. This may contribute to depression of the level of consciousness and GCS score, and may have an impact on the initial assessment of prognosis. Of the 42 patients, 88% survived with only two patients (5%) having a poor neurological outcome, resulting in dependence in nursing homes. In our study the GCS was a poor prognostic indicator of outcome which is a finding consistent with a previous study [16]. Seven patients with GCS of 3 and fixed dilated pupils at scene left hospital with no neurological sequelae. A GCS of 3 and cardiac arrest at scene led to 100% mortality, even if a spontaneous circulation was achieved by arrival at hospital. All patients with spontaneous circulation at scene survived. No cervical injuries were identified which is in keeping with previous studies [8,10,11]. Therefore, the routine use of plain X-rays and computed imaging of the cervical spine could be questioned. The finding of thoracic vertebral injury was unexpected. Possible causes of unusual mechanisms of trauma or particularly high cut-down heights in patients with low GCS were postulated but on review of the records neither were found. Both injuries were suspected following secondary survey clinical examinations and serves to emphasize the importance of a full examination.
5. Conclusion This study of victims of hanging injuries demonstrated that nearly 90% of victims who reach hospital alive survived with a low incidence of poor neurological
D.J. Penney et al. / Resuscitation 54 (2002) 27 /29
outcome. Therefore, aggressive resuscitation and management of hanging victims is justified. Cervical spine injury has a low incidence but needs to be considered and care should be taken to identify unexpected thoracic spinal injuries. GCS at scene and on admission to hospital is a poor prognostic indicator of outcome. Patients with cardiac arrest at scene do not survive, even if a spontaneous circulation is re-established by arrival to hospital.
References [1] Wilkinson D., Gunnell D.. Comparison of trends in methodspecific suicide rates in Australia and England and Wales, 1968 / 97. Aust NZ J Public Health 1968;24:153 /7. [2] Snowdon J.. Suicide rates and methods in different age groups: Australian data and perceptions. Int J Geriatr Psychiat 2000;12:253 /8. [3] Wilkinson D., Gunnell D.. Youth suicide trends in Australian metropolitan and non-metropolitan areas, 1988 /1997. Aust NZ J Psychiat 1988;34:822 /8. [4] Hawton K., Houston K., Shepperd R.. Suicide in young people. Study of 174 cases, aged under 25 years, based on coroners’ and medical records. Br J Psychiat 1999;175:271 /6.
29
[5] Wood-Jones F.. The examination of the bodies of 100 men executed in Nubia in Roman times. Br Med J 1908;1:736. [6] Hammond G.M.. On the proper method of executing the sentence of death by hanging. Med Rec 1882;22:426 /8. [7] McHugh T.P., Stout M. Near-hanging injury, Ann Emerg Med 1983;12:774 /6. [8] Bradshaw D.A. Complications of suicidal hanging: a case report and brief review, Military Med 1994;159:720 /1. [9] Iserson K.V.. Strangulation: a review of ligature, manual, and postural neck compression injuries. Ann Emerg Med 1984;13:179 /85. [10] Aufderheide T.P., Aprahamian C., Mateer J.R., et al. Emergency airway management in hanging victims. Ann Emerg Med 1994;24:879 /84. [11] Adams N.. Near hanging. Emerg Med 1999;11:17 /21. [12] Kaki A., Crosby E.T., Lui A.C.P.. Airway and respiratory management following non-lethal hanging. Can J Anaesth 1997;44:445 /50. [13] Deshpande S.. Laryngotracheal separation after attempted hanging. Br J Anaesth 1998;81:612 /4. [14] Simonsen J.. Path-anatomic findings in neck structures in asphyxiation due to hanging. Forensic Sci Int 1998;38:83 /91. [15] Raja U., Sivaloganathan S.. Decapitation-a rare complication in hanging. Med Sci Law 1997;37:81 /3. [16] Krol L.V., Wolfe R.. The emergency department management of near-hanging victims. J Emerg Med 1994;12:285 /92.
Portuguese Abstract and Keywords O enforcamento como me´todo de tentativa de suı´cidio tem aumentado a sua incideˆncia. Foi feita uma revisa˜o retrospectiva das vı´timas com leso˜es de enforcamento que apareceram na nossa instituic¸a˜o durante um perı´odo de 5 anos. Foram revistos quarenta e dois casos. A ingesta˜o de drogas e/ou a´lcool foi identificada em 70% dos casos. Na˜o se identificaram leso˜es da coluna cervical embora fossem encontradas inesperadamente duas fracturas da coluna tora´cica. A taxa de sobrevida foi de 88%, com uma baixa incideˆncia (5%) de ma´ evoluc¸a˜o neurolo´gica. A pontuac¸a˜o da Escala de Coma de Glasgow no local ou a´ chegada ao hospital foi identificada como um indicador de progno´stico. As vı´timas sem de´bito cardı´aco espontaˆneo no local na˜o sobreviveram, mesmo que a reanimac¸a˜o cardiopulmonar fosse inicialmente bem sucedida. Palavras chave : Trauma; Lesa˜o por enforcamento; Doente
Spanish Abstract and Keywords El ahorcamiento como me´todo de intentar suicidio esta´ aumentando en incidencia. Se realizo´ una revisio´n retrospectiva de las vı´ctimas con lesiones por ahorcamiento, que se presentaron en nuestra institucio´n en un perı´odo de cinco an˜os. Se revisaron cuarenta y dos casos. Se identifico´ ingestio´n de alcohol y/o drogas en 70% de los casos. No se identificaron lesiones de columna cervical, aunque se encontraron dos fracturas inesperadas de columna tora´cica. La tasa de sobreviva fue de 88%, con baja incidencia de resultado neurolo´gico pobre (5%). Se encontro´ que la puntuacio´n en la Escala de Coma de Glasgow en la escena o al ingreso es un indicador de prono´stico. Las vı´ctimas sin gasto cardı´aco esponta´neo en la escena no sobrevivieron, aun si la reanimacio´n cardiopulmonar fuera inicialmente exitosa. Palabras clave : Trauma; Lesio´n por ahorcamiento; Paciente
Prognostic outcome indicators following hanging injuries D.J. Penney, A.H.L. Stewart, M.J.A. Parr * Intensive Care Unit, Liverpool Hospital, University of New South Wales, Locked Bag 7103, Liverpool NSW 1871, Australia Received 22 February 2002; received in revised form 4 March 2002; accepted 6 March 2002
Abstract Hanging as a method of attempting suicide is increasing in incidence. A retrospective review of victims of hanging injuries presenting to our institution over a 5-year period was performed. Forty-two cases were reviewed. Drug and/or alcohol ingestion was identified in 70% of cases. There were no cervical spine injuries identified, although two unexpected thoracic spine fractures were found. There was an 88% survival rate, with a low incidence (5%) of poor neurological outcome. The Glasgow Coma Score at scene or on arrival at hospital was found to be a prognostic indicator. Victims without spontaneous cardiac output at scene did not survive, even if cardiopulmonary resuscitation was successful initially. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Trauma; Hanging injury; Patient
1. Introduction Over the past 30 years, in many developed countries of the world, suicide rates in young males have almost doubled [1]. Although rates of suicide have changed little in females, in both sexes there have been substantial increases in the use of hanging as a method of attempting suicide. Hanging victims will present in increasing numbers to emergency departments and intensive care units [1 /4]. The objective of this study was to identify prognostic indicators related to outcome for patients presenting to hospital following a hanging injury.
Basic demographics Previous psychiatric history Previous suicide attempt Drug and/or alcohol use Cardiovascular parameters at scene and on arrival to hospital . Glasgow Coma Score (GCS) at scene and on arrival to hospital . Patient outcome: non-survival or survival to discharge to home or nursing home . . . . .
All radiological investigations performed were reviewed.
2. Method
3. Results
All patients with an International Classification of Disease code of hanging/near-hanging/asphyxiation (ICD X70 and E953) who presented to our institution over a 5-year period from January 1996 to January 2001 were identified. The following data was recorded:
A total of 44 patients presented to Liverpool Hospital during the 5-year period from January 1996 to January 2001. Forty-two medical records with radiological investigations were available for review. All the hangings were suicide attempts. Of the 42 case notes available for review, 38 (90%) were males and 4 were females. The ages ranged from 13 to 68 years old, with 80% being less than 40 years old. Twenty-two (50%) had a psychiatric history. Seventeen (40%) had made a previous suicide attempt. Drug and/or alcohol ingestion was identified in 30 (70%) cases.
* Corresponding author. Tel.: /612-9828-3400; fax: /612-98283551 E-mail address: [email protected] (M.J.A. Parr).
0300-9572/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 0 - 9 5 7 2 ( 0 2 ) 0 0 0 5 0 - 3
28
D.J. Penney et al. / Resuscitation 54 (2002) 27 /29
Fig. 1. Distribution of survivors Glasgow Coma Score at scene and on arrival to hospital.
Nine (25%), of all the patients who were discharged from hospital well had a GCS of 3 at scene (Fig. 1). Seven patients reported as GCS 3 on scene with fixed and dilated pupils left hospital with no neurological sequelae. Of the nine victims with GCS of 3 at scene and also on arrival to hospital, three (33%) left hospital well, one was discharged to a nursing home with severe neurological disability and the other five patients died. Two patients had no radiological investigation performed. Forty patients had a lateral cervical spine radiograph performed. Computed tomography (CT) of the cervical spine were performed in 17 patients. No cervical injuries were identified. Fifteen CT scans of the head were performed. One scan demonstrated cerebral oedema (in a non-survivor following out-of-hospital cardiac arrest). Two patients were shown to have fractures of the twelfth thoracic vertebra. One laryngeal injury was recorded, which was thought to be iatrogenic following difficult on-scene intubation. In this series of hanging injuries, 37 (88%) victims survived. Two patients (5%) demonstrated persistent severe neurological impairment and were discharged to nursing homes. The remainder of the survivors were discharged home. There were five deaths (12%). All of these nonsurvivors were pulseless at scene. However, in four of these victims, cardiopulmonary resuscitation was successful with return of spontaneous circulation on arrival at hospital. None of these patients survived to discharge.
4. Discussion Judicial hanging has been a method of legal execution at least since the time of the Roman Empire [5]. The technique involves a drop from a height with abrupt arrest of the fall with a neck ligature [6]. Death may occur by a variety of pathologies [7]. The classic ‘Hangman’s fracture’ through the neural arch of the second cervical vertebra produces death by spinal cord injury. The larynx may also be injured with airway
disruption, the carotid arteries may be lacerated or avulsed and traumatic decapitation may occur. In suicidal hanging however, the body does not usually fall from a great height and the patterns of injury are different to judicial hangings [8 /10]. Spinal cord and skeletal injuries are rare [8]. In one review of the literature on near hanging, cervical spine injury occurred in four of 689 patients (0.6%) [11]. The mechanism of death in suicidal hanging is debated. Local neck compression may cause venous obstruction and stagnant cerebral hypoxia. Carotid artery occlusion may occur with consequent ischaemic brain injury. Airway injuries severe enough to interfere with airway management are uncommon [12], and although airway disruption has been described, airway closure is not thought to be a significant factor [13,14]. Traumatic decapitation has been described, although only in patients who suffered a drop from a considerable height [15]. In this series all hangings were alleged suicide attempts. We found 90% were male and 80% were less than 40 years of age. Half of the patients had a psychiatric history and 40% had made a previous suicide attempt. Drugs and/or alcohol were identified in 70% of cases. This may contribute to depression of the level of consciousness and GCS score, and may have an impact on the initial assessment of prognosis. Of the 42 patients, 88% survived with only two patients (5%) having a poor neurological outcome, resulting in dependence in nursing homes. In our study the GCS was a poor prognostic indicator of outcome which is a finding consistent with a previous study [16]. Seven patients with GCS of 3 and fixed dilated pupils at scene left hospital with no neurological sequelae. A GCS of 3 and cardiac arrest at scene led to 100% mortality, even if a spontaneous circulation was achieved by arrival at hospital. All patients with spontaneous circulation at scene survived. No cervical injuries were identified which is in keeping with previous studies [8,10,11]. Therefore, the routine use of plain X-rays and computed imaging of the cervical spine could be questioned. The finding of thoracic vertebral injury was unexpected. Possible causes of unusual mechanisms of trauma or particularly high cut-down heights in patients with low GCS were postulated but on review of the records neither were found. Both injuries were suspected following secondary survey clinical examinations and serves to emphasize the importance of a full examination.
5. Conclusion This study of victims of hanging injuries demonstrated that nearly 90% of victims who reach hospital alive survived with a low incidence of poor neurological
D.J. Penney et al. / Resuscitation 54 (2002) 27 /29
outcome. Therefore, aggressive resuscitation and management of hanging victims is justified. Cervical spine injury has a low incidence but needs to be considered and care should be taken to identify unexpected thoracic spinal injuries. GCS at scene and on admission to hospital is a poor prognostic indicator of outcome. Patients with cardiac arrest at scene do not survive, even if a spontaneous circulation is re-established by arrival to hospital.
References [1] Wilkinson D., Gunnell D.. Comparison of trends in methodspecific suicide rates in Australia and England and Wales, 1968 / 97. Aust NZ J Public Health 1968;24:153 /7. [2] Snowdon J.. Suicide rates and methods in different age groups: Australian data and perceptions. Int J Geriatr Psychiat 2000;12:253 /8. [3] Wilkinson D., Gunnell D.. Youth suicide trends in Australian metropolitan and non-metropolitan areas, 1988 /1997. Aust NZ J Psychiat 1988;34:822 /8. [4] Hawton K., Houston K., Shepperd R.. Suicide in young people. Study of 174 cases, aged under 25 years, based on coroners’ and medical records. Br J Psychiat 1999;175:271 /6.
29
[5] Wood-Jones F.. The examination of the bodies of 100 men executed in Nubia in Roman times. Br Med J 1908;1:736. [6] Hammond G.M.. On the proper method of executing the sentence of death by hanging. Med Rec 1882;22:426 /8. [7] McHugh T.P., Stout M. Near-hanging injury, Ann Emerg Med 1983;12:774 /6. [8] Bradshaw D.A. Complications of suicidal hanging: a case report and brief review, Military Med 1994;159:720 /1. [9] Iserson K.V.. Strangulation: a review of ligature, manual, and postural neck compression injuries. Ann Emerg Med 1984;13:179 /85. [10] Aufderheide T.P., Aprahamian C., Mateer J.R., et al. Emergency airway management in hanging victims. Ann Emerg Med 1994;24:879 /84. [11] Adams N.. Near hanging. Emerg Med 1999;11:17 /21. [12] Kaki A., Crosby E.T., Lui A.C.P.. Airway and respiratory management following non-lethal hanging. Can J Anaesth 1997;44:445 /50. [13] Deshpande S.. Laryngotracheal separation after attempted hanging. Br J Anaesth 1998;81:612 /4. [14] Simonsen J.. Path-anatomic findings in neck structures in asphyxiation due to hanging. Forensic Sci Int 1998;38:83 /91. [15] Raja U., Sivaloganathan S.. Decapitation-a rare complication in hanging. Med Sci Law 1997;37:81 /3. [16] Krol L.V., Wolfe R.. The emergency department management of near-hanging victims. J Emerg Med 1994;12:285 /92.
Portuguese Abstract and Keywords O enforcamento como me´todo de tentativa de suı´cidio tem aumentado a sua incideˆncia. Foi feita uma revisa˜o retrospectiva das vı´timas com leso˜es de enforcamento que apareceram na nossa instituic¸a˜o durante um perı´odo de 5 anos. Foram revistos quarenta e dois casos. A ingesta˜o de drogas e/ou a´lcool foi identificada em 70% dos casos. Na˜o se identificaram leso˜es da coluna cervical embora fossem encontradas inesperadamente duas fracturas da coluna tora´cica. A taxa de sobrevida foi de 88%, com uma baixa incideˆncia (5%) de ma´ evoluc¸a˜o neurolo´gica. A pontuac¸a˜o da Escala de Coma de Glasgow no local ou a´ chegada ao hospital foi identificada como um indicador de progno´stico. As vı´timas sem de´bito cardı´aco espontaˆneo no local na˜o sobreviveram, mesmo que a reanimac¸a˜o cardiopulmonar fosse inicialmente bem sucedida. Palavras chave : Trauma; Lesa˜o por enforcamento; Doente
Spanish Abstract and Keywords El ahorcamiento como me´todo de intentar suicidio esta´ aumentando en incidencia. Se realizo´ una revisio´n retrospectiva de las vı´ctimas con lesiones por ahorcamiento, que se presentaron en nuestra institucio´n en un perı´odo de cinco an˜os. Se revisaron cuarenta y dos casos. Se identifico´ ingestio´n de alcohol y/o drogas en 70% de los casos. No se identificaron lesiones de columna cervical, aunque se encontraron dos fracturas inesperadas de columna tora´cica. La tasa de sobreviva fue de 88%, con baja incidencia de resultado neurolo´gico pobre (5%). Se encontro´ que la puntuacio´n en la Escala de Coma de Glasgow en la escena o al ingreso es un indicador de prono´stico. Las vı´ctimas sin gasto cardı´aco esponta´neo en la escena no sobrevivieron, aun si la reanimacio´n cardiopulmonar fuera inicialmente exitosa. Palabras clave : Trauma; Lesio´n por ahorcamiento; Paciente