Managing the Hanging Injury

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

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

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

DEFINITION/CLASSIFICATION

WHY IS AWARENESS OF HANGING INJURIES IMPORTANT?

• Hanging has become the 2^nd most common form of successful suicide in the US, and is one of the  more common forms in the UK and Canada
• In the jail system, hanging is the most common form of successful suicide

PATHOPHYSIOLOGY

Judicial Hanging

• Drop is at least as long as the height of the victim, hanging is complete
• Head hyperextends =>
  • Fracture of upper cervical spine, most commonly traumatic spondylolisthesis of C2, “hangman’s fracture”
  • Transection of the spinal cord

Other Strangulation Injuries

• Death ultimately results from cerebral hypoxia and ischemic neuronal death
• Airway compromise plays minimal role in the immediate death of successful strangulation victims, but initial survivors may suffer significant pulmonary complications (see below)

 PHYSICAL EXAM

• Abrasions, lacerations, contusions, edema to neck
• Tardieu spots
• Severe pain on gentle palpation of the larynx (laryngeal fracture)
• Mild cough
• Stridor
• Muffled voice
• Respiratory distress
• Hypoxia (usually late finding)
• Mental status changes

INITIAL EMERGENCY DEPARTMENT CARE – ABCs

• Endotracheal intubation (ETI) may become necessary with little warning
• If ETI unsuccessful, consider cricothyroidotomy; if unsuccessful, percutaneous trans-laryngeal ventilation may be used temporarily
• Fluid resuscitation must be performed judiciously – risk of ARDS and cerebral edema
• Monitor for cardiac arrhythmias
• Altered / comatose patient => treat as cerebral edema with elevated ICP

IMAGING STUDIES

• Soft-tissue neck x-ray
• Chest radiograph
• CT brain
• CT C-spine
• Consider CTA head/neck or MRA head/neck      http://www.virtualmedstudent.com/links/musculoskeletal/hangmans_fracture.html

FURTHER CARE AND POTENTIAL COMPLICATIONS

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

BEWARE COMPLICATIONS!

• Respiratory complications = major cause of delayed mortality in near-hanging victims
• Pulmonary edema
  • Neurogenic: centrally mediated, massive sympathetic discharge; often in association with serious brain injury, poor prognostic implication
  • Post-obstructive: due to marked negative intrapleural pressure, generated by forceful inspiratory effort against extrathoracic obstruction; when obstruction removed, may have rapid onset pulmonary edema leading to ARDS
• Aspiration pneumonia
• Carotid intimal dissection or thrombus formation
• Tracheal stenosis
• Neurologic sequelae
  • Transient hemiplegia
  • Central cord syndrome
  • Seizures
  • Spinal cord injury
    • Long-term paraplegia/quadriplegia
    • Short-term autonomic dysfunction

PROGNOSIS

• GCS on presentation is NOT predictor of outcome
• Predictors of poor clinical outcome:

-Anoxic brain injury on head CT

-Long hanging time

-Cardiopulmonary arrest

-Cervical spine injury

-Hypotension on arrival

-PaO2/FiO2 < 100 at admission

References / Further Reading

• Berdai AM, Labib S, Harandou M. Postobstructive pulmonary edema following accidental near-hanging. American Journal of Case Reports 2014; 14: 350-353
• Borgquist O, Friberg H. Therapeutic hypothermia for comatose survivors after near-hanging—a retrospective analysis. Resuscitation 80(2009): 210-212.
• Casha S, Christie S. A systematic review of intensive cardiopulmonary management after spinal cord injury. Journal of Neurotrauma 28: 1479-1495.
• Furlan JC, Fehlings MG. Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and management. Neurosurgery Focus 2008; 25(5): E13
• Gandhi R, Taneja N, Mazumder P. Near hanging: early intervention can save lives. Indian Journal of Anaestehsia 2011, 55(4): 388-391
• Kaki A, Crosby ET, Lui ACP. Airway and respiratory management following non-lethal hanging. Can J Anaesth 1997 44(4): 445-450
• Irvin CB, Szpunar S, Cindrich LA, et al. Should trauma patients with a Glasgow Coma Scale score of 3 be intubated prior to hospital arrival? Prehospital Disaster Medicine 2010 25(6) 541-6.
• Mack EH. Neurogenic shock. The Open Pediatric Medicine Journal 2013, 7 (suppl 1: M4) 16-18
• Mansoor S, Afshar M, Barett M, et al. Acute respiratory distress syndrome and outcomes after near hanging. American Journal of Emergency Medicine 2015, 33: 359-362.
• Newton K, Claudius I. Rosen’s Emergency Medicine – Concepts and Clinical Practice. 8^th Edition (2014). Volume 1, Part II, Chapter 44 pp 421-431.
• Nickson C. Trauma! Spinal injury. Life in the Fast Lane. http://lifeinthefastlane.com/trauma-tribulation-016/
• Salim A, Martin M, Sangthong B. Near-hanging injuries: a 10-year experience. Injury, Int J Care Injured 2006, 37: 435-439.
• Trujillo MH, Fragachan CF, Tortoledo F. Noncardiogenic pulmonary edema following accidental near-hanging. Heart & Lung. 2007 36(5) 363-366.