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The emergency department management of near-hanging victims
The Journal of EmergencyMedicine, Vol12, No 3, pp 285-292, 1994 Copyright 0 1994 Elsevier ScienceLtd Printed in the USA. All rights reserved
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Original
Contributions
THE EMERGENCY DEPARTMENT MANAGEMENT OF NEAR-HANGCNG VICTWS Laurie Vande Krol,
MD,
and Richard Wolfe,
MD
Department of Emergency Medicine, Denver General Hospital Reprint Address: Laurie Vande Krol, MD, Department of Emergency Medicine, Denver General Hospital, 777 Bannock Street, Denver, CO 80204
juries that occur after hangings, the demographics of patients who attempt suicide by hanging, the range of injury, diagnostic, and therapeutic modalities used in treating victims, and outcomes.
Cl Abstract-A 7-year retrospective review was performed to assesstic complications of near-hangings injuries. Thiity-nine casesof near hanging were seen during this period. There were no hanging drops greater than 5 feet and no cervical spine fr&ures. One patient required intubation for soft tissue sweJKng.The adult respiratory distress syndrome (ARDS) occurred in three patknts. All victims with field Glasgow Coma Scale levels >3, and three of eight with GCS = 3 survived to discharge with a normal mental status. We conclude that aggressiveresuscitation and treatment of postanoxic brain injury is indicated even in patients without evident neurdogic function in the field, as full recovery may still occur. Cervkal spine fractures have not been reporttd in near-hanging victims and should only be considered if there is a possibility of a several foot drop or if a focal neurologic defkit is present. Injury to the anterior soft tissues of the neck may cause respiratory obstruction. Close attention to the development of pulmonary compliaxtions is required.
MATERIALS AND METHODS All patients presenting to our Emergency Department (ED) from August 1, 1984 through January 1, 1992, whose final diagnosis was hanging were included in the study. Victims pronounced dead in the field were excluded. Charts were reviewed for the following information: age, sex, weight, date of incident, drop length, hang time, time to resuscitation, and etiology (suicide, homicide, accident, or autoerotic). Central nervous system (CNS) injuries were evaluated by the Glasgow Coma Scale (GCS) at the scene on arrival of the paramedics, on arrival to the Emergency Department, and on admission to the hospital. Where a GCS was not specifically reported, the value was calculated from the reported examination data. The presenceof spinal or peripheral neurologic sequelaeas well as any preceding or subsequent psychologic diagnoses were tabulated. Results of computed tomography (CT scan) studies of the head or neck were reviewed. Evaluation of the spine and soft tissues of the neck was recorded as to the presence of physical findings of a ligature mark and Tardieu’s spots, which are petechial marks indicating ex-
C Keywords-hanging; Glasgow Coma Scale; suicide; cervical spine injury; anoxic brain damage
INTRODUCTION
Since the time of the Roman empire, hanging has been a legal form of execution (l-7). Although judiclal hangings are rarely performed in the United States, suicidal hangings have persisted, as well as the less common homicidal and accidental hangings (7,22-24). This study is a retrospective review of in-Original Contributions presentsarticlesof interestto both academic and practicing physicians. This section of JEiU is coordinatedby John A. Marx, MD, of the CarolinasMedical Center,Charlotte,North Carolina. RECEIVED: 30September 1992; FINALSUBMISSIONRECEIVED: 22September 1993; ACCEPTED: 30 September 1993 285
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tremely high local venous pressureabove the ligature (66). Cervical spine and neck soft tissueradiographs, otolaryngologic consultation, CT scan of the neck, and laryngoscopy were also recorded. Intubation or intubation attempts were interpreted as evidence of airway compromise due to cervical crush or apnea. Pulmonary injuries were measured by documented intubation for apnea or subsequentx-ray study showing aspiration pneumonia, bacterial pneumonia, or the adult respiratory distress syndrome (ARDS). Concomitant toxicologic findings, including suicidal ingestions and alcohol intoxication, were reported. Patient disposition from the Emergency Department was recorded, including servicesinvolved, length of hospital stay, complications while in the hospital, and condition at discharge.
old brother, malicious intent was not suspected.The 21-month-old was suspendedwith his head caught in a window frame. Autoeroticism was not reported as an etiology in any case. Drop Force
Drop length was reported in only 24 of the 39 hangings. In 16 casesit was reported as none to minimal. Four patients had drop lengths of l-3 feet, and three had drops of 3-5 feet. No patient had a recorded drop length greater than 5 feet. Patient weight was not recorded in any chart, thus, the force of the drop in foot-pounds could not be calculated. Duration of Hanging
RESULTS
Forty-eight charts were reviewed. Sevenpatients were excluded whose charts were not available or whose records were incomplete for the near-hanging visit. One patient was excluded becausehis mechanism of injury was a kick to the spine, not hanging. Another patient was excluded who had only threatened to hang himself. The remaining 39 charts were reviewed for data. One patient attempted hanging on two separate occasionsbut was seen at another hospital for the first attempt. Only the secondepisodeis included in these data. Another patient suspended himself twice in close successionbefore calling 911. This was considered a single hanging.
The duration of insult was measured by reporting both the length of suspensionand the time to resuscitation when a tight ligature was loosened from the neck. This was poorly documented on charts. Hang times were usually only approximate, based on an alert patient’s estimate or, more often, the family’s report of when the victim was last seen.Duration of hanging by these estimatesranged from secondsup to 1 hour (Table 1). We could not establisha relationship between hanging duration and outcome when the duration was less than 5 minutes. A duration greater than 5 minutes predicted a poorer field and ED GCS (p < 0.01 Kruskal-Wallis test). However, suspensionup to 30 minutes occurred with a normal neurologic outcome.
Incidence Physical Findings
The incidence of hanging changed over time, with a peak of 13 in 1988 and a nadir of 1 in 1990. The age of victims ranged from 21 months to 51 years with a mean of 23.15 years. There were 12 victims (31%) under the age of 18 and 4 (10%) under the age of 10 years. The majority of hanging victims were men with only 4 women among the 39 patients (10%). One of the female patients was part of a pair of 13-year-oldswho hung themselveson the samedate. Etiology
The etiology of hanging was suicidal in 35 cases,including all adults. Six of theseoccurred during incarceration. Accidental hangings occurred in four children, ages21 months, 3 years, 6 years, and 8 years. Although the 3-year-old had been hung by his g-year-
Tardieu’s spots were reported in only 2 of the 39 cases.The presenceof Tardieu’s spots were not predictive of severity of injury; one of these patients suffered cardiac arrest while the other did not even have loss of consciousnessduring the event. Ligature or strangulation marks were seen more consistently, being reported on 31 charts and described variously as ecchymoses,abrasions, contusions, and lacerations. Four charts reported that no external mark was visible and four did not document the presence or absenceof marks. Glasgow Coma Scale
The mean field and ED GCSs are shown in Table 1. Eight patients had a GCS of 3 in the field. Of these,
Near-Hanging Victims
287 Table 1. Duntlon of Hanging and Outcome Duration Unknown < 1 second l-5 minutes > 5 minutes
Number of Patients
Mean Field GCS
Mean ED GCS
16 6 9 7
10.3 13.4 11.7 5.2
11.9 13.4 14.2 5.4
three died, two were discharged from the hospital witn persistent cognitive defects, and three were discharged with a return to their baseline mental status. All patients with a field GCS r4 survived and had returned to their baseline mental status on discharge from the hospital. -911three patients presenting to the ED with a GCS of 3 died in the hospital. The ED GCS were 4 and 15 in the two patients with permanent cognitive deficits. Sixteen patients had a GCS < 15 on arrival at the Emergency Department. The usual course of those who presented with abnormal GCS was gradual improvement to normal over hours to days. No patient wit.h a normal mental status had secondary worsening of his condition. Four patients were amnestic to the event. One of these patients had impaired shortterm memory that resolved to normal in the hospital over 10 days. The other was agitated whenever pressedto recall the event. He also had cortical blindness and aphasia that resolved over 3 days. He was discharged with persistent deficits in short-term memory and abstraction abilities. Another patient had moderate anoxic encephalopathy and was discharged with a mild and nonspecific cognitive deficit. Two patients had transient left hemiparesis that spontaneously resolved in both cases. All patients with field GCS greater than 3 had a normal recovery. The outcome of patients with a field GCS of 3 is shown in Table 2.
Table 2. Outcome In Hanging Victlme with a Field GCS of 3 GCS in the ED
-
3 3 3 4 4 4 6 9 15
Outcome Died Died Died Short-term Memory and Abstraction Deficit Normal Normal Normal Normal Mild Cognitive Deficit
Deaths 0 0 0 3 (p < 0.01)
Head CT Scan Eleven (73%) of 15 patients with an abnormal GCS in the ED had computed tomography (CT scan). One was positive for minimal subarachnoid hemorrhage in a patient who had CPR and who later died. The remaining 10 had normal studies. Three patients with abnormal neurologic examinations in the ED did not undergo CT scan. One showed no recovery of brain function and was pronounced dead; the other two had rapid resolution of their mental functions to normal. One patient with an abnormal GCS of 15 in the ED had a CT scan becauseof decreasedmental status in the field. The scan was normal. Cervical Spine and Neck Evaluation The extent of evaluation for neck injuries varied without clear relationship to mechanism or apparent severity of injury. Ten patients had no cervical radiographs performed; nine of these had a GCS of 15, but one had a GCS of 6 in the field and 7 on ED arrival. No cervical spine injury was detected in any patient throughout the hospital stay. Twenty-two had either a lateral or 3-view series of cervical spine x-ray studies. One x-ray study was interpreted as showing an abnormal atlanto-occipital joint after a 3 foot fall. However, a follow-up CT scan of the joint showed it to be normal. Another patient had a normal cervical spine x-ray study but had a CT scan of his neck becausehe was unconscious. This, too, was normal. Ten patients had cervical soft tissue neck x-ray studies, of which two were abnormal. One showed abnormal soft tissue swelling, prompting a CT scan. This also demonstrated soft tissue swelling in the lower prevertebral region. No fracture, hematoma, or perforation was detected. The other positive study showed retropharyngeal air after nasotracheal intubation in the field. This patient underwent laryngoscopy, esophagoscopy,and barium swallow, A contusion behind the left tonsil was reported but no site of perforation was discovered. Four patients had both cervical spine and soft tis-
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sue x-ray studies. All studies were normal. No patient had a cervical spine fracture, spinal cord injury, or peripheral nerve injury. No patient complained of shortness of breath or difficulty swallowing.
Psychiatric Disorders Multiple patients were diagnosed with one or more psychiatric disorders. A history of drug or alcohol abuse was most common, recorded in 16. Eleven patients had positive alcohol levels on arrival in the ED and three had other intoxications with chlordiazepoxide (Librium) in one; ibuprofen in one; and cocaine, diazepam (Valium), and barbiturates in one. Prior suicide attempts had been made by two patients. One had previously made unsuccessful attempts via hanging, drug overdose, carbon monoxide, burning, and shooting. Another patient returned soon after his near-hanging event stating he intended to hang himself again. Recorded formal psychiatric diagnoses included: major depression (4), personality disorder (4), drug abuse (4), schizophrenia (2), undefined psychosis (2), and bipolar disorder (1).
Complications and Outcome Three patients died in the hospital; all were less than 14 years of age. One patient was declared brain dead after a waiting period during which no brain function could be measured. A second developed intractable bradycardia leading to asystole. A third developed ARDS and died of its complications. A total of three patients (8%) developed ARDS, two following suspected aspirations. One patient developed bilateral upper lobe infiltrates felt to be pulmonary edema, and another grew out staphylococcus aureus and Streptococcus pneumoniae after developing a fever and diffuse rhonchi. Miscellaneous complications included pneumoperitoneum in one patient with an ileus and one patient who developed alcohol withdrawal. DISCUSSION There are 3,500 deaths per year due to hanging in the United States (15). It is the third most common form of suicide behind firearms and ingestions (16). Men attempt hanging three times more often than women. Newly jailed prisoners are at increased risk for suicide (19-21), and these deaths are, almost without exception, due to hanging. Homicidal hangings have been reported, but are rare. These are almost invariably disguised as suicides and may not be recognized
as homicide (24). Whether our 3-year-old victim was intentionally hung by his brother will never be known. Accidental hanging is most common in infants and children but may also occur in adults involved in industrial accidents or during alcohol intoxication (22,25). There is also an increasing incidence of accidental hangings due to autoeroticism, the induction of asphyxia by hanging during masturbation. The asphyxia is thought to heighten orgasmic sensation. There are often elaborate but clearly fallible systems of ropes and pulleys designed to release tension on the neck before death occurs (26,27). Despite increasing incidence of this practice, there is no scientific evidence that compression of carotid arteries with cerebral hypoxia produces erection, sexual excitement, or anything other than the sensation of lightheadedness and possibly a tingling sensation in the extremities (1,32). Hangings in the pediatric age group are common. In New York, 2-3% of hangings are in patients less than 20 years of age (18), as compared to 31% in our study population. It is unclear why our group had a disproportionate number of children. The cause of the hanging varies with age. For children less than 5 years old, hanging is almost exclusively accidental (33). These occur secondary to heads caught in crib slats and curtain cords, and, in our group, electric windows, Venetian blinds, and hammock cords. However, homicides in infants have been reported (22). From age 5 to 12 there are both accidental and suicidal hangings (33). There are two reports of children playing “hangman,” one after seeing a western movie where the hero survived a hanging (23,34). Above the age of 12, most hangings are suicidal or accidental during autoeroticism (29,33,35). Suicide is the third leading cause of death in adolescents in North America (11). One accidental hanging is reported in a lCyear-old boy who tried to stretch himself by hanging to make himself taller (36).
Cervical Fractures Based on the literature regarding judicial hangings, two factors appear important in determining whether a Hangman’s fracture, a fracture through the neural arch of the second cervical vertebra, will occur. These are drop force (patient weight multiplied by length of drop) and knot position (3,65). A noose, positioned with the knot under the chin (submental) provides the most hyperextension and, thus, force against the lever arm of the odontoid. While this has been argued to increase the chance of producing a cervical fracture, there are no controlled studies doc-
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umenting this point. A publication in 1871 reported consistent production of a Hangman’s fracture with the knot placed suboccipitally and a drop of only 3 to 4 feet (62). Thus, it is not clear that knot position plays an important role. One does not require a drop equal to the height of the patient to produce a Hangman’s fracture (62). The minimum drop required has never been determined and could be expected to vary with the patient’s weight, cervical supporting tissue strength, and bony strength. Published autopsy seriestotalling 368 victims of suicidal hanging document one Hangman’s fracture and one fracture of the third cervical vertebra (6364). There is no report in the English literature of a hanging victim who survived a Hangman’s fracture. According to the judicial literature, fracture of the neural arch of C-2 invariably produces instantaneous death by crushing or tearing the spnnal cord (3,560). Thus, unstable fractures need not be sought in survivors of near hanging.
soft-tissue lateral x-ray study of the neck may show swelling. If the cartilages are calcified, a fracture may be visualized. If there remains a concern for fracture after this evaluation, an ENT consultation is warranted. After hanging, one may seecongestion and edema of the uvula, epiglottis, larynx, or vocal cords (44). Delayed onset of inability to swallow or breathe may develop with swelling in the retropharyngeal, laryngeal, and paratracheal regions (6,15). Early ENT evaluation has been advocated for patients with more than very mild oropharyngeal edema (42). A CT scan or laryngoscopy may be necessaryto rule out laryngeal cartilage fracture. Other serious laryngotracheal injuries reported include piriform sinus hematoma, tear of the upper tracheal mucosa, and complete laryngotracheal separation. In our series, one victim required intubation for soft tissue swelling. All victims with significant mechanism of injury should be observed in the hospital for 24 hours, given the possibility of late-developing airway obstruction (45).
ffvoid Bone and Cartilage Fractures Fractures of the hyoid bone or the laryngeal or cricoid cartilages occur frequently and may be overlooked if not specifically assessed.A commonly held belief is that a jump or fall is necessaryto disrupt the larynx (59). However, a series of 61 deaths showed 26% had hyoid or thyroid fractures. These occurred regardless of whether the body was suspended completely by the neck or partially to fully supported from below (37). A combined retrospective and prospective postmortem study showed fracture of the hyoid bone or thyroid or cricoid cartilage in 20% of victims studied retrospectively and 46% studied prospectively, when the diagnosis was actively sought. The incidence of injury was increased in older victims (43). In another study, 36 of 80 hanging victims had hyoid bone or cartilage fractures (38). None of these hangings were of the drop type. None of the patients in our series was found to have hyoid or cartilage fractures, although endoscopy was performed in only 4/39 (10%) and ENT consultation in only 9/39 (23%). As other studies show frequent fractures, the possibility of hyoid or cartilage fracture should be considered in all hanging victims. Fracture of the hyoid bone or cervical cartilages may result in immediate or delayed respiratory obstruction (7,15,39,40). Minimal evaluation should include consideration of the quality of the voice, ability to swallow, and tenderness or crepitance of the hyoid bone and cervical cartilages. The site and depth of the ligature mark may provide clues to injuries. A
CNS Sequelae Hanging causesa multifactorial hypoxic insult to the central nervous system: airway obstruction with systemic hypoxia, arterial or venous vascular obstruction, or cardiovascular arrest from autonomic stimulation (15-17,41,50). In some cases, the ligature draws the base of the tongue upwards against the posterior pharyngeal wall and folds the epiglottis over the entrance to the larynx, thus obstructing the airway (7,16,40,41). More commonly, obstruction of venous drainage without arterial occlusion causes death by vascular congestion and stagnation (16,39). Autopsy specimens show generalized hyperemia without focal intracranial bleeds (17,41,56). Arterial obstruction may occur with a tight ligature, arterial spasm, or venous obstruction (16). Distraction forces may also obstruct arterial flow. A 17k force during hanging has been reported to “drastically” reduce common carotid artery blood flow and will compress the vertebral arteries as they enter the vertebral foramina (24). Automatic reflex activity, either sympathetic or parasympathetic, may be produced by neck traction stimulating the carotid sinus and the pericarotid sympathetic and parasympathetic networks. Death in these casesis produced primarily by cardiac arrest (16,40). Tears of the carotid vessels are rare (9,24). An autopsy series of 101 hangings showed none with even an intimal tear (17). Survivors of immediate hanging many succumb to a variety of se-
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quelae including ARDS, anoxic brain damage, and various neurologic sequelae. Regardless of cause, there is agreement that permanent brain damage occurs after 4-5 m inutes of complete cerebral anoxia (46-48). In hangings, vascular obstruction is the most common mechanism of ischemia and is frequently incomplete, accounting for successful resuscitation after 30-60 m inutes of suspension. The Glasgow Coma Scale measures of our seriesshowed that poor CNS function in the field did not always result in poor outcome. Of eight patients with a field GCS of 3, three were discharged with normal mental status. A field GCS of > 3 resulted in a normal mental status on discharge in all patients. Unless there has been concomitant head trauma, a CT scan of the head is of no value in hanging victims. A previous seriesreported no intracranial hemorrhage in hanging victims and advocated against obtaining a head CT scan. One patient in our series did have a head CT scan showing a small subarachnoid hemorrhage. This patient had CPR performed in the field and later died. His hemorrhage is not thought to have contributed to his death. Maximal cerebral perfusion depends on lim iting elevation of intracranial pressure. Accepted practices include elevation of the head, hyperventilation, adequate oxygenation, and sedation for the agitated patient. Also used but more controversial interventions include fluid restriction, diuretics, glucocorticoids, mannitol, and barbiturates (54).
Neuropsychiatric Sequelae Neuropsychiatric consequencesof hanging have long been noted. These may result from either cerebral ischemia or preexisting mental illness. A loss of memory selective for the depression and suicide attempt associatedwith elation is a disorder specific to survivors of near hanging (52,55). The amnesia starts as global, and over the course of a week shrinks to cover the suicide attempt and its immediate aftermath (41,55). The amnesia is often associated with varying degrees of spatial and temporal disorientation, confabulation, and inability to retain newly acquired information in the absenceof gross dementia. The memory loss and elation may be transient or permanent. Hypotheses for the etiology of the amnesia range from physiologic due to hippocampal anoxia to psychologic due to hysterical amnesia (55). However, no explanation is entirely satisfactory, as this condition is not seenin patients with other mechanisms of anoxic brain damage or suicide attempts. Four of the patients in this serieshad permanent am-
L. Vande Krol and R. Wolfe
nesia for the event but none had the combination of amnesia and euphoria previously described. Several casesof Korsakoff dementia and progressive dementia after hanging have been reported (41,55). A similar syndrome has been noted following whiplash injuries and in auto accidents (41,56). The pathophysiology of this is unknown but cannot be explained by anoxia as in hanging injuries. The whiplash effect of the drop in hanging may play a role in amnesia following hanging. Other reported neuropsychiatric sequelaeinclude seizure disorders, hyperthermia, bizarre movements, choreoathetosis, localized muscle spasms, and transient hemiplegia (41,57). Two patients in our series had transient left hemiparesis. Other neurologic sequelaeof hanging include one case report of a central cord syndrome caused by cervical hyperextension without a hangman’s fracture (58). Two case reports note damage to the spinal accessory nerve with hanging (59). Multiple transient focal neurologic findings have also been reported (24). No focal neurologic findings were recorded in our series. Pulmonary Sequelae Pulmonary complications occurred infrequently in our series. There were casesof all complications associated with near hanging: aspiration, pneumonia, pulmonary edema, and ARDS. In other series, pulmonary complications were more common and are considered the leading cause of death following near hanging. There are many causesof pulmonary failure in near-hanging victims (15,44,60). Vomiting with aspiration pneumonia, bronchopneumonia, iatrogenic fluid overload, and delayed airway obstruction have been reported (29,40,44,51). The adult respiratory distress syndrome (ARDS) is a frequent complication. Hypoxia causing peripheral vasoconstriction increasesleft ventricular after load and may contribute to left ventricular failure and pulmonary edema (15,61). Autonomic reflex activity, either sympathetic or parasympathetic, may also lead to cardiac compromise or arrest (16). EMERGENCY MANAGEMENT OF NEAR-HANGING VICTIMS Comatose near-hanging victims should undergo aggressiveresuscitation, as the GCS is a poor predictor of outcome. Vascular obstruction is often incomplete during suspension. Thus, complete recovery from near hanging can occur despite prolonged hanging
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time and initially severe neurologic abnormalities. E,ndotracheal intubation and hyperventilation are necessaryto decreaseintracranial pressure and protect the airway from aspiration. Admission to the intensive care unit is indicated for respiratory support as well as to monitor the patient for neurologic and pulmonary complications. Computed tomography yields little information, and is only indicated when a traumatic event is suspected to have occurred prior to the hanging. In alert near-hanging victims, emphasis should be placed on possible trachea-laryngeal trauma. Soft tissue films of the neck may be useful in detecting a trachea-laryngeal injury and are indicated in patients c80mplaining of difficulty swallowing, dyspnea, or hoarseness.Cervical spine injuries are extremely rare with nonjudicial hangings, and a case has yet to be reported in a near-hanging victim. Thus, the routine
use of cervical spine films is not indicated in the emergencymanagement of these patients.
CONCLUSION In our series, near-hanging victims with a GCS >3 on presentation to the ED had a good chance not only of survival but of normal neurologic outcome. Emergency physicians should treat these patients aggressively, focusing on airway protection and intracranial pressure control. Pulmonary complications are relatively common, and patients should be observed for ARDS, aspiration pneumonia, and delayed airway obstruction. Routine use of cervical spine films and CT scans of the head do not appear to be warranted.
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28. Rosenblum S, Faber MM. The adolescent sexual asphyxia syndrome. Am Acad Child Psvchiatrv. 1979:18:546-58. 29. Sternbach G, Bresler MJ. Near-fatal suicidal hanging. J Emerg Med. 1989;7:513-6. 30. Danto BL. A case of female autoerotic death. Am J Forensic Med Pathol. 1980;1:117-20. 31. Sass FA. Sexual asphyxia in the female. J Forensic Sci. 1975; 20:181-5. 32. Sheehan W, Garfinkel B. A case study, adolescent autoerotic deaths. J Am Acad Child Psychiatry. 1988;27:367-70. 33. Perrol LJ, Froede RC, Jones AM. Asphyxiation by hanging in two young Hispanic children-homicide, suicide, or accidental deaths. Am J Forensic Med Pathol. 1985;6:284-8. 34. Levin DL. McLain M. Blaw M. “Hana ‘Em Hi&“-A direct effect of television vioience. J Pediatr. ‘i976;89:1>34-5. 35. Herman SP. Recovery from hanging in an adolescent male. Clin Pediatr. 1974;13:854-60. 36. Kramer I. Uncommon cases of suicide in the youth. Excerpta Med. 1977;49:787. 37. Somonsen J. Pathoanatomic findings in neck structures in asphyxiation due to hanging: A survey of 80 cases. Forensoc Sci Int. 1988;38:83-91. 38. Luke JL, Reay DT, Eisele JW, Bonnell HJ. Correlation of circumstances with pathological findings in deaths by hanging. J Forensic Sci. 1985:30:1140-7.
292 39. Cappello N, Langan P. Suicidal hanging, asphyxiation not cervical fracture. Orthopaed Rev. 1979;8:81-85. 40. Fischman CM, Goldstein MS, Gardner LB. Suicidal hanging. Chest. 1977;71:2. 41. Berlyne N, Strachan M. Neuropsychiatric sequelae of attempted hanging. Br J Psychiatry. 1%8;114:411-22. 42. Line WS, Stanley RB, Choi JH. Strangulation: A full spectrum of blunt neck trauma. Ann Oto Rhin Laryng. 1985;94:542-6. 43. Paparo GP, Siegel H. Neck markings and fractures in suicidal hangings. Forensic Sci Int. 1984;%:27-35. 44. El-Guindy MK, Abdul-Haleem. Delayed asphyxia: A cause of death in interrupted hanging and throttling. J Egypt Med Assoc. 1971;54:410-16. 45. Iserson KV. Strangulation: A review of ligature, manual, and postural neck compression injuries. AM Emerg Med. 1984; 13:179-85. 46. Nemoto EM. Pathogenesis of cerebral ischemia-anoxia. Crit Care Med. 1978;6:203-14. 47. Read RC, Lillehei CW, Varco RL. Cardiac resuscitation and neurologic tolerance to anoxia. Circ Res. 1956;4:45. 48. Richardson JC, Chambers BM, Heywood PM. Encephalopathies of anoxia and hypoglycemia. Arch Neurol. 1959;1:178. 49. Fieschi C, MacKenzie E, Lenzi GL et al. Facts and trends in cerebral blood flow and metabolism. J Cereb Blood Flow Metab. 1989;9:573-8. 50. Gadxinski DS, White BC, Hoehner PJ, Hoehner T, Krome C, White JD. Canine cerebral cortical blood flow and vascular resistancepost cardiac arrest. AM Emerg Med. 1982;11:58-63. 5 1. Moss G, Staunton C, Stein AA. The centrineurogenic etiology of the acute respiratory distress syndrome. Am J Surg. 1973; 126:37-40.
L. Vande Krol and R. Wolfe 52. Nilsson B, Norberg K, Siesjo BK. Biochemical events in cerebral ischemia. Br J-Anaesth. 1975;47:751. 53. Avelduno MI. Baxan NG. Raoid nroduction of diacvlalvcerols enriched in arachidonate and stearate during early bra& ischemia. J Neurochem. 1975;25:919. 54. Rosen P, Wolfe RE. Therapeutic legends of emergency medicine. J Emerg Med. 1989;7:387-9. 55. Stromgren E. Mental sequelaeof suicidal attempts by hanging. Acta Psycho1Neurol. 1946;21:753-80. 56. Nielsen JM. Whiplash injury with amnesia for life experiences. Los Angeles Neurol Sot. 1959;24:27. 57. Calvanese JC, Spohr MH. Hyperthermia from a near hanging. Ann Emerg Med. 1982;11:152-5. 58. Ahuja J. Central cord syndrome resulting from near-hanging injury. CMAJ. 1987;1137:221-2. 59. Singh S, Schlagenhauff RE. Pressure palsy of the accessory nerve. Neurol India. 1971;19:122-5. 60. Jenkins MT, Jones RF, Wilson B et al. Congestive atalectasis-A complication of the intravenous infusion of fluids. Ann Surg. 1950;132:327-47. 61. Luisada AA. Mechanism of neurogenic pulmonary edema. Am J Cardiol. 1967;20:66. 62. Anonymous: Hanging from a historical and physiological point of view. Med Times Gazette. 1871;June 10:669-71. 63. Skold G. Fractures of the axis caused by hanging. Z Rechtsmedizin. 1978;80:329-31. 64. Clark MA, Kerr FC. Unusual hanging deaths. J Forensic Sci. 1986;31:747-55. 65. Marshall JJ. Judicial hanging. Lancet. 1913;March 1:639-40. 66. Simpson K. Forensic Medicine. Baltimore: Williams and Wilkins; 1985:91.
Pergamon
0136-4619/94 $6.00 + .OO
0736-4679(94)Emo7-I -
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Original
Contributions
THE EMERGENCY DEPARTMENT MANAGEMENT OF NEAR-HANGCNG VICTWS Laurie Vande Krol,
MD,
and Richard Wolfe,
MD
Department of Emergency Medicine, Denver General Hospital Reprint Address: Laurie Vande Krol, MD, Department of Emergency Medicine, Denver General Hospital, 777 Bannock Street, Denver, CO 80204
juries that occur after hangings, the demographics of patients who attempt suicide by hanging, the range of injury, diagnostic, and therapeutic modalities used in treating victims, and outcomes.
Cl Abstract-A 7-year retrospective review was performed to assesstic complications of near-hangings injuries. Thiity-nine casesof near hanging were seen during this period. There were no hanging drops greater than 5 feet and no cervical spine fr&ures. One patient required intubation for soft tissue sweJKng.The adult respiratory distress syndrome (ARDS) occurred in three patknts. All victims with field Glasgow Coma Scale levels >3, and three of eight with GCS = 3 survived to discharge with a normal mental status. We conclude that aggressiveresuscitation and treatment of postanoxic brain injury is indicated even in patients without evident neurdogic function in the field, as full recovery may still occur. Cervkal spine fractures have not been reporttd in near-hanging victims and should only be considered if there is a possibility of a several foot drop or if a focal neurologic defkit is present. Injury to the anterior soft tissues of the neck may cause respiratory obstruction. Close attention to the development of pulmonary compliaxtions is required.
MATERIALS AND METHODS All patients presenting to our Emergency Department (ED) from August 1, 1984 through January 1, 1992, whose final diagnosis was hanging were included in the study. Victims pronounced dead in the field were excluded. Charts were reviewed for the following information: age, sex, weight, date of incident, drop length, hang time, time to resuscitation, and etiology (suicide, homicide, accident, or autoerotic). Central nervous system (CNS) injuries were evaluated by the Glasgow Coma Scale (GCS) at the scene on arrival of the paramedics, on arrival to the Emergency Department, and on admission to the hospital. Where a GCS was not specifically reported, the value was calculated from the reported examination data. The presenceof spinal or peripheral neurologic sequelaeas well as any preceding or subsequent psychologic diagnoses were tabulated. Results of computed tomography (CT scan) studies of the head or neck were reviewed. Evaluation of the spine and soft tissues of the neck was recorded as to the presence of physical findings of a ligature mark and Tardieu’s spots, which are petechial marks indicating ex-
C Keywords-hanging; Glasgow Coma Scale; suicide; cervical spine injury; anoxic brain damage
INTRODUCTION
Since the time of the Roman empire, hanging has been a legal form of execution (l-7). Although judiclal hangings are rarely performed in the United States, suicidal hangings have persisted, as well as the less common homicidal and accidental hangings (7,22-24). This study is a retrospective review of in-Original Contributions presentsarticlesof interestto both academic and practicing physicians. This section of JEiU is coordinatedby John A. Marx, MD, of the CarolinasMedical Center,Charlotte,North Carolina. RECEIVED: 30September 1992; FINALSUBMISSIONRECEIVED: 22September 1993; ACCEPTED: 30 September 1993 285
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tremely high local venous pressureabove the ligature (66). Cervical spine and neck soft tissueradiographs, otolaryngologic consultation, CT scan of the neck, and laryngoscopy were also recorded. Intubation or intubation attempts were interpreted as evidence of airway compromise due to cervical crush or apnea. Pulmonary injuries were measured by documented intubation for apnea or subsequentx-ray study showing aspiration pneumonia, bacterial pneumonia, or the adult respiratory distress syndrome (ARDS). Concomitant toxicologic findings, including suicidal ingestions and alcohol intoxication, were reported. Patient disposition from the Emergency Department was recorded, including servicesinvolved, length of hospital stay, complications while in the hospital, and condition at discharge.
old brother, malicious intent was not suspected.The 21-month-old was suspendedwith his head caught in a window frame. Autoeroticism was not reported as an etiology in any case. Drop Force
Drop length was reported in only 24 of the 39 hangings. In 16 casesit was reported as none to minimal. Four patients had drop lengths of l-3 feet, and three had drops of 3-5 feet. No patient had a recorded drop length greater than 5 feet. Patient weight was not recorded in any chart, thus, the force of the drop in foot-pounds could not be calculated. Duration of Hanging
RESULTS
Forty-eight charts were reviewed. Sevenpatients were excluded whose charts were not available or whose records were incomplete for the near-hanging visit. One patient was excluded becausehis mechanism of injury was a kick to the spine, not hanging. Another patient was excluded who had only threatened to hang himself. The remaining 39 charts were reviewed for data. One patient attempted hanging on two separate occasionsbut was seen at another hospital for the first attempt. Only the secondepisodeis included in these data. Another patient suspended himself twice in close successionbefore calling 911. This was considered a single hanging.
The duration of insult was measured by reporting both the length of suspensionand the time to resuscitation when a tight ligature was loosened from the neck. This was poorly documented on charts. Hang times were usually only approximate, based on an alert patient’s estimate or, more often, the family’s report of when the victim was last seen.Duration of hanging by these estimatesranged from secondsup to 1 hour (Table 1). We could not establisha relationship between hanging duration and outcome when the duration was less than 5 minutes. A duration greater than 5 minutes predicted a poorer field and ED GCS (p < 0.01 Kruskal-Wallis test). However, suspensionup to 30 minutes occurred with a normal neurologic outcome.
Incidence Physical Findings
The incidence of hanging changed over time, with a peak of 13 in 1988 and a nadir of 1 in 1990. The age of victims ranged from 21 months to 51 years with a mean of 23.15 years. There were 12 victims (31%) under the age of 18 and 4 (10%) under the age of 10 years. The majority of hanging victims were men with only 4 women among the 39 patients (10%). One of the female patients was part of a pair of 13-year-oldswho hung themselveson the samedate. Etiology
The etiology of hanging was suicidal in 35 cases,including all adults. Six of theseoccurred during incarceration. Accidental hangings occurred in four children, ages21 months, 3 years, 6 years, and 8 years. Although the 3-year-old had been hung by his g-year-
Tardieu’s spots were reported in only 2 of the 39 cases.The presenceof Tardieu’s spots were not predictive of severity of injury; one of these patients suffered cardiac arrest while the other did not even have loss of consciousnessduring the event. Ligature or strangulation marks were seen more consistently, being reported on 31 charts and described variously as ecchymoses,abrasions, contusions, and lacerations. Four charts reported that no external mark was visible and four did not document the presence or absenceof marks. Glasgow Coma Scale
The mean field and ED GCSs are shown in Table 1. Eight patients had a GCS of 3 in the field. Of these,
Near-Hanging Victims
287 Table 1. Duntlon of Hanging and Outcome Duration Unknown < 1 second l-5 minutes > 5 minutes
Number of Patients
Mean Field GCS
Mean ED GCS
16 6 9 7
10.3 13.4 11.7 5.2
11.9 13.4 14.2 5.4
three died, two were discharged from the hospital witn persistent cognitive defects, and three were discharged with a return to their baseline mental status. All patients with a field GCS r4 survived and had returned to their baseline mental status on discharge from the hospital. -911three patients presenting to the ED with a GCS of 3 died in the hospital. The ED GCS were 4 and 15 in the two patients with permanent cognitive deficits. Sixteen patients had a GCS < 15 on arrival at the Emergency Department. The usual course of those who presented with abnormal GCS was gradual improvement to normal over hours to days. No patient wit.h a normal mental status had secondary worsening of his condition. Four patients were amnestic to the event. One of these patients had impaired shortterm memory that resolved to normal in the hospital over 10 days. The other was agitated whenever pressedto recall the event. He also had cortical blindness and aphasia that resolved over 3 days. He was discharged with persistent deficits in short-term memory and abstraction abilities. Another patient had moderate anoxic encephalopathy and was discharged with a mild and nonspecific cognitive deficit. Two patients had transient left hemiparesis that spontaneously resolved in both cases. All patients with field GCS greater than 3 had a normal recovery. The outcome of patients with a field GCS of 3 is shown in Table 2.
Table 2. Outcome In Hanging Victlme with a Field GCS of 3 GCS in the ED
-
3 3 3 4 4 4 6 9 15
Outcome Died Died Died Short-term Memory and Abstraction Deficit Normal Normal Normal Normal Mild Cognitive Deficit
Deaths 0 0 0 3 (p < 0.01)
Head CT Scan Eleven (73%) of 15 patients with an abnormal GCS in the ED had computed tomography (CT scan). One was positive for minimal subarachnoid hemorrhage in a patient who had CPR and who later died. The remaining 10 had normal studies. Three patients with abnormal neurologic examinations in the ED did not undergo CT scan. One showed no recovery of brain function and was pronounced dead; the other two had rapid resolution of their mental functions to normal. One patient with an abnormal GCS of 15 in the ED had a CT scan becauseof decreasedmental status in the field. The scan was normal. Cervical Spine and Neck Evaluation The extent of evaluation for neck injuries varied without clear relationship to mechanism or apparent severity of injury. Ten patients had no cervical radiographs performed; nine of these had a GCS of 15, but one had a GCS of 6 in the field and 7 on ED arrival. No cervical spine injury was detected in any patient throughout the hospital stay. Twenty-two had either a lateral or 3-view series of cervical spine x-ray studies. One x-ray study was interpreted as showing an abnormal atlanto-occipital joint after a 3 foot fall. However, a follow-up CT scan of the joint showed it to be normal. Another patient had a normal cervical spine x-ray study but had a CT scan of his neck becausehe was unconscious. This, too, was normal. Ten patients had cervical soft tissue neck x-ray studies, of which two were abnormal. One showed abnormal soft tissue swelling, prompting a CT scan. This also demonstrated soft tissue swelling in the lower prevertebral region. No fracture, hematoma, or perforation was detected. The other positive study showed retropharyngeal air after nasotracheal intubation in the field. This patient underwent laryngoscopy, esophagoscopy,and barium swallow, A contusion behind the left tonsil was reported but no site of perforation was discovered. Four patients had both cervical spine and soft tis-
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sue x-ray studies. All studies were normal. No patient had a cervical spine fracture, spinal cord injury, or peripheral nerve injury. No patient complained of shortness of breath or difficulty swallowing.
Psychiatric Disorders Multiple patients were diagnosed with one or more psychiatric disorders. A history of drug or alcohol abuse was most common, recorded in 16. Eleven patients had positive alcohol levels on arrival in the ED and three had other intoxications with chlordiazepoxide (Librium) in one; ibuprofen in one; and cocaine, diazepam (Valium), and barbiturates in one. Prior suicide attempts had been made by two patients. One had previously made unsuccessful attempts via hanging, drug overdose, carbon monoxide, burning, and shooting. Another patient returned soon after his near-hanging event stating he intended to hang himself again. Recorded formal psychiatric diagnoses included: major depression (4), personality disorder (4), drug abuse (4), schizophrenia (2), undefined psychosis (2), and bipolar disorder (1).
Complications and Outcome Three patients died in the hospital; all were less than 14 years of age. One patient was declared brain dead after a waiting period during which no brain function could be measured. A second developed intractable bradycardia leading to asystole. A third developed ARDS and died of its complications. A total of three patients (8%) developed ARDS, two following suspected aspirations. One patient developed bilateral upper lobe infiltrates felt to be pulmonary edema, and another grew out staphylococcus aureus and Streptococcus pneumoniae after developing a fever and diffuse rhonchi. Miscellaneous complications included pneumoperitoneum in one patient with an ileus and one patient who developed alcohol withdrawal. DISCUSSION There are 3,500 deaths per year due to hanging in the United States (15). It is the third most common form of suicide behind firearms and ingestions (16). Men attempt hanging three times more often than women. Newly jailed prisoners are at increased risk for suicide (19-21), and these deaths are, almost without exception, due to hanging. Homicidal hangings have been reported, but are rare. These are almost invariably disguised as suicides and may not be recognized
as homicide (24). Whether our 3-year-old victim was intentionally hung by his brother will never be known. Accidental hanging is most common in infants and children but may also occur in adults involved in industrial accidents or during alcohol intoxication (22,25). There is also an increasing incidence of accidental hangings due to autoeroticism, the induction of asphyxia by hanging during masturbation. The asphyxia is thought to heighten orgasmic sensation. There are often elaborate but clearly fallible systems of ropes and pulleys designed to release tension on the neck before death occurs (26,27). Despite increasing incidence of this practice, there is no scientific evidence that compression of carotid arteries with cerebral hypoxia produces erection, sexual excitement, or anything other than the sensation of lightheadedness and possibly a tingling sensation in the extremities (1,32). Hangings in the pediatric age group are common. In New York, 2-3% of hangings are in patients less than 20 years of age (18), as compared to 31% in our study population. It is unclear why our group had a disproportionate number of children. The cause of the hanging varies with age. For children less than 5 years old, hanging is almost exclusively accidental (33). These occur secondary to heads caught in crib slats and curtain cords, and, in our group, electric windows, Venetian blinds, and hammock cords. However, homicides in infants have been reported (22). From age 5 to 12 there are both accidental and suicidal hangings (33). There are two reports of children playing “hangman,” one after seeing a western movie where the hero survived a hanging (23,34). Above the age of 12, most hangings are suicidal or accidental during autoeroticism (29,33,35). Suicide is the third leading cause of death in adolescents in North America (11). One accidental hanging is reported in a lCyear-old boy who tried to stretch himself by hanging to make himself taller (36).
Cervical Fractures Based on the literature regarding judicial hangings, two factors appear important in determining whether a Hangman’s fracture, a fracture through the neural arch of the second cervical vertebra, will occur. These are drop force (patient weight multiplied by length of drop) and knot position (3,65). A noose, positioned with the knot under the chin (submental) provides the most hyperextension and, thus, force against the lever arm of the odontoid. While this has been argued to increase the chance of producing a cervical fracture, there are no controlled studies doc-
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umenting this point. A publication in 1871 reported consistent production of a Hangman’s fracture with the knot placed suboccipitally and a drop of only 3 to 4 feet (62). Thus, it is not clear that knot position plays an important role. One does not require a drop equal to the height of the patient to produce a Hangman’s fracture (62). The minimum drop required has never been determined and could be expected to vary with the patient’s weight, cervical supporting tissue strength, and bony strength. Published autopsy seriestotalling 368 victims of suicidal hanging document one Hangman’s fracture and one fracture of the third cervical vertebra (6364). There is no report in the English literature of a hanging victim who survived a Hangman’s fracture. According to the judicial literature, fracture of the neural arch of C-2 invariably produces instantaneous death by crushing or tearing the spnnal cord (3,560). Thus, unstable fractures need not be sought in survivors of near hanging.
soft-tissue lateral x-ray study of the neck may show swelling. If the cartilages are calcified, a fracture may be visualized. If there remains a concern for fracture after this evaluation, an ENT consultation is warranted. After hanging, one may seecongestion and edema of the uvula, epiglottis, larynx, or vocal cords (44). Delayed onset of inability to swallow or breathe may develop with swelling in the retropharyngeal, laryngeal, and paratracheal regions (6,15). Early ENT evaluation has been advocated for patients with more than very mild oropharyngeal edema (42). A CT scan or laryngoscopy may be necessaryto rule out laryngeal cartilage fracture. Other serious laryngotracheal injuries reported include piriform sinus hematoma, tear of the upper tracheal mucosa, and complete laryngotracheal separation. In our series, one victim required intubation for soft tissue swelling. All victims with significant mechanism of injury should be observed in the hospital for 24 hours, given the possibility of late-developing airway obstruction (45).
ffvoid Bone and Cartilage Fractures Fractures of the hyoid bone or the laryngeal or cricoid cartilages occur frequently and may be overlooked if not specifically assessed.A commonly held belief is that a jump or fall is necessaryto disrupt the larynx (59). However, a series of 61 deaths showed 26% had hyoid or thyroid fractures. These occurred regardless of whether the body was suspended completely by the neck or partially to fully supported from below (37). A combined retrospective and prospective postmortem study showed fracture of the hyoid bone or thyroid or cricoid cartilage in 20% of victims studied retrospectively and 46% studied prospectively, when the diagnosis was actively sought. The incidence of injury was increased in older victims (43). In another study, 36 of 80 hanging victims had hyoid bone or cartilage fractures (38). None of these hangings were of the drop type. None of the patients in our series was found to have hyoid or cartilage fractures, although endoscopy was performed in only 4/39 (10%) and ENT consultation in only 9/39 (23%). As other studies show frequent fractures, the possibility of hyoid or cartilage fracture should be considered in all hanging victims. Fracture of the hyoid bone or cervical cartilages may result in immediate or delayed respiratory obstruction (7,15,39,40). Minimal evaluation should include consideration of the quality of the voice, ability to swallow, and tenderness or crepitance of the hyoid bone and cervical cartilages. The site and depth of the ligature mark may provide clues to injuries. A
CNS Sequelae Hanging causesa multifactorial hypoxic insult to the central nervous system: airway obstruction with systemic hypoxia, arterial or venous vascular obstruction, or cardiovascular arrest from autonomic stimulation (15-17,41,50). In some cases, the ligature draws the base of the tongue upwards against the posterior pharyngeal wall and folds the epiglottis over the entrance to the larynx, thus obstructing the airway (7,16,40,41). More commonly, obstruction of venous drainage without arterial occlusion causes death by vascular congestion and stagnation (16,39). Autopsy specimens show generalized hyperemia without focal intracranial bleeds (17,41,56). Arterial obstruction may occur with a tight ligature, arterial spasm, or venous obstruction (16). Distraction forces may also obstruct arterial flow. A 17k force during hanging has been reported to “drastically” reduce common carotid artery blood flow and will compress the vertebral arteries as they enter the vertebral foramina (24). Automatic reflex activity, either sympathetic or parasympathetic, may be produced by neck traction stimulating the carotid sinus and the pericarotid sympathetic and parasympathetic networks. Death in these casesis produced primarily by cardiac arrest (16,40). Tears of the carotid vessels are rare (9,24). An autopsy series of 101 hangings showed none with even an intimal tear (17). Survivors of immediate hanging many succumb to a variety of se-
290
quelae including ARDS, anoxic brain damage, and various neurologic sequelae. Regardless of cause, there is agreement that permanent brain damage occurs after 4-5 m inutes of complete cerebral anoxia (46-48). In hangings, vascular obstruction is the most common mechanism of ischemia and is frequently incomplete, accounting for successful resuscitation after 30-60 m inutes of suspension. The Glasgow Coma Scale measures of our seriesshowed that poor CNS function in the field did not always result in poor outcome. Of eight patients with a field GCS of 3, three were discharged with normal mental status. A field GCS of > 3 resulted in a normal mental status on discharge in all patients. Unless there has been concomitant head trauma, a CT scan of the head is of no value in hanging victims. A previous seriesreported no intracranial hemorrhage in hanging victims and advocated against obtaining a head CT scan. One patient in our series did have a head CT scan showing a small subarachnoid hemorrhage. This patient had CPR performed in the field and later died. His hemorrhage is not thought to have contributed to his death. Maximal cerebral perfusion depends on lim iting elevation of intracranial pressure. Accepted practices include elevation of the head, hyperventilation, adequate oxygenation, and sedation for the agitated patient. Also used but more controversial interventions include fluid restriction, diuretics, glucocorticoids, mannitol, and barbiturates (54).
Neuropsychiatric Sequelae Neuropsychiatric consequencesof hanging have long been noted. These may result from either cerebral ischemia or preexisting mental illness. A loss of memory selective for the depression and suicide attempt associatedwith elation is a disorder specific to survivors of near hanging (52,55). The amnesia starts as global, and over the course of a week shrinks to cover the suicide attempt and its immediate aftermath (41,55). The amnesia is often associated with varying degrees of spatial and temporal disorientation, confabulation, and inability to retain newly acquired information in the absenceof gross dementia. The memory loss and elation may be transient or permanent. Hypotheses for the etiology of the amnesia range from physiologic due to hippocampal anoxia to psychologic due to hysterical amnesia (55). However, no explanation is entirely satisfactory, as this condition is not seenin patients with other mechanisms of anoxic brain damage or suicide attempts. Four of the patients in this serieshad permanent am-
L. Vande Krol and R. Wolfe
nesia for the event but none had the combination of amnesia and euphoria previously described. Several casesof Korsakoff dementia and progressive dementia after hanging have been reported (41,55). A similar syndrome has been noted following whiplash injuries and in auto accidents (41,56). The pathophysiology of this is unknown but cannot be explained by anoxia as in hanging injuries. The whiplash effect of the drop in hanging may play a role in amnesia following hanging. Other reported neuropsychiatric sequelaeinclude seizure disorders, hyperthermia, bizarre movements, choreoathetosis, localized muscle spasms, and transient hemiplegia (41,57). Two patients in our series had transient left hemiparesis. Other neurologic sequelaeof hanging include one case report of a central cord syndrome caused by cervical hyperextension without a hangman’s fracture (58). Two case reports note damage to the spinal accessory nerve with hanging (59). Multiple transient focal neurologic findings have also been reported (24). No focal neurologic findings were recorded in our series. Pulmonary Sequelae Pulmonary complications occurred infrequently in our series. There were casesof all complications associated with near hanging: aspiration, pneumonia, pulmonary edema, and ARDS. In other series, pulmonary complications were more common and are considered the leading cause of death following near hanging. There are many causesof pulmonary failure in near-hanging victims (15,44,60). Vomiting with aspiration pneumonia, bronchopneumonia, iatrogenic fluid overload, and delayed airway obstruction have been reported (29,40,44,51). The adult respiratory distress syndrome (ARDS) is a frequent complication. Hypoxia causing peripheral vasoconstriction increasesleft ventricular after load and may contribute to left ventricular failure and pulmonary edema (15,61). Autonomic reflex activity, either sympathetic or parasympathetic, may also lead to cardiac compromise or arrest (16). EMERGENCY MANAGEMENT OF NEAR-HANGING VICTIMS Comatose near-hanging victims should undergo aggressiveresuscitation, as the GCS is a poor predictor of outcome. Vascular obstruction is often incomplete during suspension. Thus, complete recovery from near hanging can occur despite prolonged hanging
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time and initially severe neurologic abnormalities. E,ndotracheal intubation and hyperventilation are necessaryto decreaseintracranial pressure and protect the airway from aspiration. Admission to the intensive care unit is indicated for respiratory support as well as to monitor the patient for neurologic and pulmonary complications. Computed tomography yields little information, and is only indicated when a traumatic event is suspected to have occurred prior to the hanging. In alert near-hanging victims, emphasis should be placed on possible trachea-laryngeal trauma. Soft tissue films of the neck may be useful in detecting a trachea-laryngeal injury and are indicated in patients c80mplaining of difficulty swallowing, dyspnea, or hoarseness.Cervical spine injuries are extremely rare with nonjudicial hangings, and a case has yet to be reported in a near-hanging victim. Thus, the routine
use of cervical spine films is not indicated in the emergencymanagement of these patients.
CONCLUSION In our series, near-hanging victims with a GCS >3 on presentation to the ED had a good chance not only of survival but of normal neurologic outcome. Emergency physicians should treat these patients aggressively, focusing on airway protection and intracranial pressure control. Pulmonary complications are relatively common, and patients should be observed for ARDS, aspiration pneumonia, and delayed airway obstruction. Routine use of cervical spine films and CT scans of the head do not appear to be warranted.
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