Suicidal Hanging

activity, w h i c h t h e y t e r m e d " t r i g g e r e d a c t i v i t y . " T h e s e investigators concluded that such activity might cause 8

the types of a r r h y t h m i a s t h a t usually w e r e a t t r i b u t e d t o reentry.

According

to

this

concept,

junctional

auto-

m a t i c i t y m i g h t b e t r i g g e r e d at critical H ^ H " intervals in our c a s e .

This study of two victims of suicidal hanging describes a previously unknown association between near-fatal hanging and the adult respiratory distress syndrome. We report on the pathophysiologic results of this pulmonary complication and the implications of this finding regarding the treatment of these patients.

T h e induction of p a r o x y s m a l s u p r a v e n t r i c u l a r t a c h y c a r d i a in F i g u r e 3 m i g h t also b e e x p l a i n e d b y

two

alternative m e c h a n i s m s . If this w a s r e e n t r y , r e t r o g r a d e block in t h e fast p a t h w a y a n d i n t e r f e r e n c e in t h e slow p a t h w a y m i g h t o c c u r d u r i n g S , a n d t h e following sinus 4

b e a t c o u l d c o n d u c t via t h e fast p a t h w a y with a n A - H interval of 1 4 0 m s e c a n d t h e n r e t u r n via t h e slow p a t h way

with

occurrence

of p a r o x y s m a l

T n suicidal hanging, death often occurs within minutes. If rescued, most victims later succumb to respiratory failure. ' The cases in this report suggest that the adult respiratory distress syndrome is a frequent complication of near-fatal hanging and that therapy directed toward this complication may result in improvement. 1 2

supraventricular

t a c h y c a r d i a . If this w a s a t r i g g e r e d a u t o m a t i c i t y ,

S

CASE

4

c o u l d c o n c e a l t h e His b u n d l e , a n d c o n d u c t i o n of t h e subsequent sinus b e a t t o t h e H i s b u n d l e c o u l d a c h i e v e t h e critical H - H interval a n d t r i g g e r t h e t a c h y c a r d i a . REFERENCES 1 Bigger J T Jr, Goldreyer B N : The mechanism of paroxysmal supraventricular tachycardia. Circulation 42:673, 1970 2 Goldreyer BN, Bigger J T J r : T h e site of reentry in paroxysmal supraventricular tachycardia in man. Circulation 4 3 : 1 5 , 1971 3 Goldreyer BN, Damato A N : The essential role of atrioventricular delay in the initiation of paroxysmal supraventricular tachycardia. Circulation 4 3 : 6 7 9 , 1 9 7 1 4 Denes P, W u D, Dhingra RC, et al: Demonstration of dual A-V nodal pathways in patients with paroxysmal supraventricular tachycardia. Circulation 4 8 : 5 4 9 , 1 9 7 3 5 Rosen KM, Mehta A, Miller RA: Demonstration of dual atrioventricular nodal pathways in man. A m J Cardiol 33:291,1974 6 W u D, Denes P, Wyndham C, et al: Demonstration of dual atrioventricular nodal pathways utilizing a ventricular extrastimulus in patients with atrioventricular nodal re-entrant paroxysmal supraventricular tachycardia. Circulation 52:789, 1975 7 Cranefield P F , Aronson R S : Initiation of sustained rhythmic activity by single propagated action potentials in canine cardiac Purkinje fibers exposed to sodium-free solution or to ouabain. Circ Res 3 4 : 4 7 7 , 1 9 7 4 8 Wit A L , Cranefield P F : Triggered activity in cardiac muscle fibers of the simian mitral valve. Circ Res 3 8 : 8 5 , 1976

CASE

REPORTS

I

A 22-year-old man was found hanging in his cell at a local jail. Guards claimed he was cut down within one minute after hanging himself and immediately brought to Jackson Memorial Hospital. His rectal temperature was 3 9 . 6 ' C ( 1 0 3 . 3 ° F ) , the pulse rate was 100 beats per minute, blood pressure was 1 4 0 / 8 0 mm Hg, and the respiratory rate was 40/min. Bilateral coarse rhonchi were heard. T h e patient was comatose and unresponsive, and was aspirating vomitus. H e was intubated and placed on a volume respirator, and penicillin and hydrocortisone were administered. Results of blood gas analysis on a sample of arterial blood drawn while the patient was receiving 100-percent oxygen revealed a n arterial-tovenous shunt of 3 2 percent. Estimated central venous pressure was 12 cm H2O. The findings from a complete blood cell count were normal. A chest roentgenogram showed generalized, fluffy alveolar densities in both pulmonary fields ( F i g 1 ) . High-volume ventilation with positive end-expiratory pressure ( P E E P ) was begun, and therapy with dexamethasone sodium phosphate and clindamycin phosphate was added to the patient's regimen. H e improved over the next 4 8 hours, and a repeat chest x-ray film showed marked clearing of the infiltrates ( F i g 2 ) . After four weeks, the patient evidenced marked pulmonary improvement and had normal

Suicidal Hanging A n Association with t h e A d u l t Respiratory Distress Syndrome Charles M. Fischman, M.D.;*<> Michael and Laurence B. Gardner, M . D . t

S. Goldstein,

M.D.;t

" F r o m the Division of General Medicine, University of Miami School of Medicine, and Jackson Memorial Hospital, Miami, Fla. ""Medical Resident. fAssistant Professor of Medicine. Reprint requests: Dr. Fischman, Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami 33136 CHEST, 7 1 : 2 , F E B R U A R Y ,

1977

F I G U R E 1. Chest roentgenogram on admission, showing floccular nodular infiltrates scattered throughout both pulmonary fields ( c a s e 1 ) .

SUICIDAL HANGING

225

increasing respiratory distress over the next few hours, and a repeat chest x-ray film showed a diffuse bilateral interstitial infiltrate (Fig 3 ) . The arterial-to-venous shunt was 5 0 percent. Morphine sulfate and furosemide were given, and the respirator was adjusted to deliver high volumes and PEEP. The patient steadily improved and 1 7 days later was released from the hospital with normal respiratory function. DISCUSSION

Over 3,500 deaths from suicidal hanging and strangulation were reported in the United States for 1973. The cause of death in this setting has been attributed to many factors, including jugular venous compression, carotid and vertebral arterial occlusion, tracheal obstruction, and stimulation of the carotid sinus and pericarotid sympathetic and parasympathetic network. The management of these patients is often complicated by progressive respiratory failure and subsequent death. Postmortem findings of marked pulmonary congestion and hemorrhage have been reported. 3

4

F I G U R E 2 . Repeat chest x-ray film taken 4 8 hours after a d mission shows marked clearing of infiltrates following treatment (case 1 ) . blood gas levels while breathing room air. CASE 2

1,2

It is believed that for suicidal hanging to be successful, cerebral hypoxia must occur. This is probably secondary to carotid arterial compression, since patients with tracheotomies have committed suicide by hanging themselves with the ligature above the site of the tracheotomy. ' Most survivors of near-fatal hanging die of pulmonary edema or bronchopneumonia. ' Although the bronchopneumonia can frequently be attributed to aspiration, a centrineurogenic cause for the pulmonary edema may be operative. The initial insult in our patients was stagnant cerebral hypoxia. Both patients subsequently developed the clinical findings characteristic of adult respiratory distress syndrome. They exhibited marked respiratory distress and severe hypoxemia and had large right-to-left shunting in the presence of a normal cardiac size. High inflation pressures and PEEP were required for adequate ventilatory support. This syndrome is believed to result from damage to the alveolar capillary membrane, resulting in the exudation of fluid into alveolar spaces and a subsequent loss of surfactant activity. Postmortem findings of vascular congestion, hemorrhages, edema, and atelectasis have been reported. ' 4

4 5

A 22-year-old man was brought to Jackson Memorial Hospital from a local jail, where he was found hanging in his cell by another inmate. It was believed that the victim was hanging for less than five minutes. T h e rectal temperature was 3 8 . 3 ° C ( 1 0 0 . 9 ° F ) , the pulse rate was 1 4 0 beats per minute, the blood pressure was 1 1 0 / 9 0 mm Hg, and the respiratory rate was 2 8 / m i n . Laryngeal stridor was present. The patient's lungs were clear, and he had a regular rhythm, without murmurs or gallops. He was unconscious but responsive to painful stimuli. The patient was intubated and placed on a volume respirator. A chest x-ray film and the results of a complete blood cell count were normal. T h e patient had

1 2

6 7

The adult respiratory distress syndrome has been produced in experimental animals solely by perfusion of the brain with hypoxic blood. " It has been postulated that the mechanism involves disruption of cerebral autonomic function which, in the presence of intact nervous connections, results in increased muscular tone in the pulmonary venules. A tourniquet-like reaction ensues, producing vascular congestion and the other pulmonary complications associated with the respiratory distress syndrome. The first case described was undoubtedly complicated by aspiration, and it is difficult to define the extent to which this contributed to the pathogenesis of the patient's respiratory distress syndrome. The second patient's course had no factors which have been associated with the pathogenesis of the adult respiratory distress 8

10

8

F I G U R E 3 . Chest roentgenogram showing diffuse, ill-defined ground-glass infiltrate, with some sparing of lower lobes (case 2 ) .

226

FISCHMAN, GOLDSTEIN, GARDNER

CHEST, 7 1 : 2 , FEBRUARY,

1977

s y n d r o m e other than c e r e b r a l h y p o x i a . T o our k n o w l e d g e , t h e adult respiratory distress synd r o m e has not been r e p o r t e d following suicidal h a n g i n g ; h o w e v e r , c e r e b r a l hypoxia u n d o u b t e d l y o c c u r s

during

suicidal hanging, and it c a n b e h y p o t h e s i z e d t h a t t h e subsequent p u l m o n a r y c o m p l i c a t i o n s result from centrineurogenic

adult

respiratory

distress

syndrome.

This

s y n d r o m e c o u l d readily explain t h e p o o r prognosis a n d postmortem

findings

in

previously

reported

victims.

pericardial friction rub and a changing pansystolic murmur appeared during the third week of hospitalization. The presence of a false aneurysm was once again demonstrated on ventriculographic studies. This was successfully repaired, employing cardiopulmonary bypass. The sequence of events in this patient suggests that bacterial endocarditis at the site of a previous cardiomyotomy might have led to the development of the second pseudoaneurysm.

T h e s e findings suggest t h a t respiratory m a n a g e m e n t dir e c t e d t o w a r d s t h e t r e a t m e n t of t h e adult

respiratory

distress s y n d r o m e m a y i m p r o v e t h e prognosis in t h e s e patients.

T n f e c t i v e e n d o c a r d i t i s is a w e l l - r e c o g n i z e d c o m p l i c a tion of c a r d i a c s u r g e r y .

1

A l t h o u g h t h e infection is

generally r e l a t e d t o a r e c e n t l y inserted p r o s t h e t i c v a l v e ,

2

sterile t h r o m b i of platelets a n d fibrin at t h e site of a previous c a r d i o m y o t o m y m a y facilitate m u r a l infection.

REFERENCES 1 Sen Gupta BK: Studies on 101 cases of death due to hanging. J Indian Med Assoc 4 5 : 1 3 5 - 1 4 0 , 1965 2 El-Guindy MK, Abdul-Haleem: Delayed asphyxia: A cause of death in interrupted hanging and throttling. J Egypt Med Assoc 5 4 : 4 1 0 - 4 1 6 , 1971 3 Statistical Abstract of the United States ( 9 6 t h e d ) . US Bureau of the Census, 1975, p 155 4 Berlyne N, Strachan M: Neuropsychiatry sequelae of attempted hanging. Br J Psychiatry 1 1 4 : 4 1 1 - 4 2 2 , 1968 5 Stromgren E : Mental sequelae of suicidal attempts by hanging. Acta Psychiatr Neurol Scand 2 1 : 7 5 3 - 7 8 0 , 1946 6 Ferstenfeld J E , Schlueter DP, Rytel MW, et al: Becognition and treatment of adult respiratory distress syndrome secondary to viral interstitial pneumonia. Am J Med 5 8 : 7 0 9 - 7 1 7 , 1975 7 Petty T, Ashbaugh D G : The adult respiratory distress syndrome: Clinical features, factors influencing prognosis, and principles of management. Chest 6 0 : 2 3 3 - 2 3 9 , 1971 8 Moss G, Staunton C, Stein AA: The centrineurogenic etiology of the acute respiratory distress syndromes: Universal, species-independent phenomenon. Am J Surg 1 2 6 : 3 7 - 4 1 , 1973 9 Moss G, Staunton C, Stein AA: Cerebral hypoxia as the primary event in the pathogenesis of the shock lung syndrome. Surg Forum 2 2 : 2 1 1 - 2 1 3 , 1971 10 Moss G, Staunton C, Stein AA: Cerebral etiology of the "shock lung syndrome." J Trauma 1 2 : 8 8 5 - 8 9 0 , 1972

M u r a l Endocarditis Associated w i t h Recurrent False A n e u r y s m of t h e Left V e n t r i c l e * Silvio Pitlik, M.D.; Leon Cohen, and Joseph Rosenfeld, M.D.

M.D.;

Ruth Melamed,

M.D.;

Acute bacterial endocarditis developed in a 65-year-old man two years after surgical resection of a false aneurysm of the left ventricle. The patient had cerebral embolic manifestations, and coagulase-positive Staphylococcus aureus was cultured from each of six blood samples. A " F r o m the Department of Medicine " C " and the Toor Heart Institute, Beilinson Medical Center, Petah Tiqva, Israel, and the Tel Aviv University School of Medicine, Tel Aviv, Israel. Reprint requests: Dr. Rosenfeld, Beilinson Medical Center, Petach Tikva, Israel CHEST, 7 1 : 2 , F E B R U A R Y ,

1977

E x t e n s i o n of t h e infection f r o m t h e e n d o c a r d i u m l e a d t o disruption of t h e s u t u r e line a n d perforation of t h e v e n t r i c u l a r w a l l .

3

may

consequent

O n r a r e occasions,

this a c c i d e n t m a y result in t h e d e v e l o p m e n t of a false a n e u r y s m of t h e h e a r t .

4

T h i s r e p o r t describes t h e unusual association of a c u t e b a c t e r i a l e n d o c a r d i t i s a n d a false a n e u r y s m of t h e left ventricle. T h e p a t i e n t h a d a previous history of m y o c a r dial infarction followed b y t h e d e v e l o p m e n t of a left v e n t r i c u l a r a n e u r y s m , for w h i c h an a n e u r y s m e c t o m y was p e r f o r m e d . O n e y e a r laser, a false a n e u r y s m d e v e l o p e d at t h e site of t h e previous repair. T h i s , t o o , w a s surgically r e p a i r e d , a n d t h e r e a f t e r t h e p a t i e n t r e m a i n e d well for t w o y e a r s until t h e d e v e l o p m e n t of b a c t e r i a l e n d o c a r d i tis. CASE REPORT A 65-year-old man sustained an anterolateral myocardial infarction in April 1970. Following the infarction, he developed congestive heart failure with ventricular premature beats, for which he was treated with digitalis and quinidine. Clinical examination at that time revealed a paradoxical uplift which was apparent over a wide area of the precordium, and on ventricular angiographic studies a true aneurysm of the left ventricle was demonstrated. Aneurysmectomy was performed in July, 1972. Therapy with digitalis and quinidine was discontinued after the operation, and the patient remained well until March, 1973, when he was readmitted to the hospital because of increasing exertional dyspnea and chest pain. A chest roentgenogram showed bulging left ventricle, and ventriculographic studies disclosed a false aneurysm at the site of the previous cardiomyotomy. No evidence of bacterial endocarditis was found at that time. Surgical resection of the pseudoaneurysm was performed, and the patient remained asymptomatic for a further period of two years. During this time, he was under regular surveillance by our cardiac clinic. No cardiac murmurs were audible, and a review of serial x-ray films of his chest taken at six-month intervals showed that, despite a distorted left ventricular contour from die surgical repair, the cardiac silhouette remained unchanged throughout this period. In May, 1975, the patient was readmitted to the hospital because of the sudden onset of fever and the sudden development of facial weakness with aphasia. The physical examination revealed pyrexia of 3 8 ° C ( 1 0 0 . 4 ° F ) , and the neurological examination showed combined sensory and

MURAL ENDOCARDITIS

227