Hanging Injuries and Strangulation Clinical Presentation: History, Physica...

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Hanging Injuries and Strangulation Clinical
Presentation
Updated: Jan 19, 2016
Author: William Ernoehazy, Jr, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH more...

PRESENTATION

History
Several specific patterns of presentations are common.
Assault victims may present after being either manually strangled or garroted.
Hanging victims may be brought to the emergency department by Emergency Medical
Services (EMS) after being found by strangers, friends, or family members. These patients
may have been suicidal. However, they also may have been experimenting with autoerotic
asphyxia, or other forms of "breath play," and were hanged by accident. (See Causes.)
Attempts to determine the height of the drop in near-hanging victims are important, as
different patterns of injury occur as the drop height increases. This, in turn, affects
management.
Infants generally present after being caught by the neck between crib slats, fence slats, or on
objects such as hanging window cords.

Physical
Physical signs include the following:
Abrasions, lacerations, contusions, or edema to the neck, depending on how the patient was
strangled
Subconjunctival and skin petechiae cephalad to the site of choking (Tardieu spots)
Severe pain on gentle palpation of the larynx, which may indicate laryngeal fracture [7]
Mild cough
Stridor
Muffled voice
Respiratory distress
Hypoxia (usually a late finding)
Mental status changes

Causes
Common causes of strangulation injuries include the following:

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Assault: Risk factors follow other types of assault, with the exception that women are more
likely than men to be victims of strangulation.
Depression can lead to hangings, especially in subgroups (eg, prisons, where hangings are
easier to do than other methods) or veterans. [8]
Erotic experimentation: Some people experiment with hypoxia as a means of intensifying
orgasm. Marquis de Sade first described this practice in his writings. Autoerotic play using a
ligature or noose to produce hypoxia during masturbation can result in accidental
strangulation. [9] Sado-masochistic activities can also result in inadvertent death. [10]
Another form of "breath play" is increasingly common among adolescent and young adults.
Most commonly known as the "choking game," it involves voluntary choking, throttling, or
near-hanging in order to enjoy the altered sensations that occur as the "player" becomes
unconscious. [5, 6] Other slang names at this writing include "flatline," "space monkey," and
"suffocation roulette."
Differential Diagnoses
References

1. Godin A, Kremer C, Sauvageau A. Fracture of the cricoid as a potential pointer to homicide. A
6-year retrospective study of neck structures fractures in hanging victims. Am J Forensic Med
Pathol. 2012 Mar. 33(1):4-7. [Medline].
2. National Center for Injury Prevention and Control. WISQARS Injury Mortality Reports, 1999 2005. WISQARS (Web-based Injury Statistics Query and Reporting System) Home. Available
at http://webappa.cdc.gov/sasweb/ncipc/mortrate10_sy.html. Accessed: 12/09/2007.
3. Shah A, Buckley L. The current status of methods used by the elderly for suicides in England
and Wales. J Inj Violence Res. 2011 Jul. 3(2):68-73. [Medline]. [Full Text].
4. Sarma K, Kola S. The socio-demographic profile of hanging suicides in Ireland from 1980 to
2005. J Forensic Leg Med. 2010 Oct. 17(7):374-7. [Medline].
5. Davies D, Lang M, Watts R. Paediatric hanging and strangulation injuries: A 10-year
retrospective description of clinical factors and outcomes. Paediatr Child Health. 2011 Dec.
16 (10):e78-81. [Medline].
6. Re L, Birkhoff JM, Sozzi M, Andrello L, Osculati AM. The choking game: A deadly game.
Analysis of two cases of "self-strangulation" in young boys and review of the literature. J
Forensic Leg Med. 2015 Feb. 30:29-33. [Medline].
7. Dunsby AM, Davison AM. Causes of laryngeal cartilage and hyoid bone fractures found at
postmortem. Med Sci Law. 2011 Apr. 51(2):109-13. [Medline].
8. Mills PD, Watts BV, Derosier JM, Tomolo AM, Bagian JP. Suicide attempts and completions in
the emergency department in Veterans Affairs Hospitals. Emerg Med J. 2011 Apr 13.
[Medline].
9. Sauvageau A, Ambrosi C, Kelly S. Three nonlethal ligature strangulations filmed by an
autoerotic practitioner: comparison of early agonal responses in strangulation by ligature,
hanging, and manual strangulation. Am J Forensic Med Pathol. 2012 Dec. 33(4):339-40.

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[Medline].
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Comments on the Estimation of the Time to Irreversibility in Hanging. Am J Forensic Med
Pathol. 2011 Jul 20. [Medline].
11. Maiese A, Gitto L, dell'Aquila M, Bolino G. When the hidden features become evident: the
usefulness of PMCT in a strangulation-related death. Leg Med (Tokyo). 2014 Nov. 16
(6):364-6. [Medline].
12. Nichols SD, McCarthy MC, Ekeh AP, et al. Outcome of cervical near-hanging injuries. J
Trauma. 2009 Jan. 66(1):174-8. [Medline].
13. Aufderheide TP, Aprahamian C, Mateer JR, et al. Emergency airway management in hanging
victims. Ann Emerg Med. 1994 Nov. 24(5):879-84. [Medline].
14. Behrendt N, Buhl N, Seidl S. The lethal paraphiliac syndrome: accidental autoerotic deaths in
four women and a review of the literature. Int J Legal Med. 2002 Jun. 116(3):148-52.
[Medline].
15. Centers for Disease Control and Prevention. Suicide trends among youths and young adults
aged 10-24 years--United States, 1990-2004. MMWR Morb Mortal Wkly Rep. 2007 Sep 7.
56(35):905-8. [Medline]. [Full Text].
16. Fischman CM, Goldstein MS, Gardner LB. Suicidal hanging. An association with the adult
respiratory distress syndrome. Chest. 1977 Feb. 71(2):225-7. [Medline].
17. Gilbert JA Jr, Gossett CW. Hanging and strangulation injuries. The Clinical Practice of
Emergency Medicine. 2nd ed. Lippincott Williams & Wilkins; 1996. 566.
18. Iserson KV. Strangulation: a review of ligature, manual, and postural neck compression
injuries. Ann Emerg Med. 1984 Mar. 13(3):179-85. [Medline].
19. Kleinsasser NH, Priemer FG, Schulze W, et al. External trauma to the larynx: classification,
diagnosis, therapy. Eur Arch Otorhinolaryngol. 2000. 257(8):439-44. [Medline].
20. Le D, Macnab AJ. Self strangulation by hanging from cloth towel dispensers in Canadian
schools. Inj Prev. 2001 Sep. 7(3):231-3. [Medline].
21. McHugh TP, Stout M. Near-hanging injury. Ann Emerg Med. 1983 Dec. 12(12):774-6.
[Medline].
22. Mohanty MK, Rastogi P, Kumar GP, et al. Periligature injuries in hanging. J Clin Forensic
Med. 2003 Dec. 10(4):255-8. [Medline].
23. National Safety Council. What are the odds of dying? [e11th-hour.org Web site]. August 15,
2004. Accessed August 1, 2005. [Full Text].
24. Pesola GR, Westfal RE. Hanging-induced status epilepticus. Am J Emerg Med. 1999 Jan.
17(1):38-40. [Medline].
25. Schild JA, Denneny EC. Evaluation and treatment of acute laryngeal fractures. Head Neck.

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1989 Nov-Dec. 11(6):491-6. [Medline].
26. Seabourne A, Seabourne G. Suicide or accident - self-killing in medieval England: series of
198 cases from the Eyre records. Br J Psychiatry. 2001 Jan. 178(1):42-7. [Medline].
27. Shlamovitz GZ, Assia A, Ben-Sira L, et al. "Suffocation roulette": a case of recurrent syncope
in an adolescent boy. Ann Emerg Med. 2003 Feb. 41(2):223-6. [Medline].
28. US Statistical Abstract of the United States. Government Printing Office. 2003.
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Contributor Information and Disclosures

Author
William Ernoehazy, Jr, MD, FACEP Medical Director, Emergency Department, Ed Fraser
Memorial Hospital, Florida
William Ernoehazy, Jr, MD, FACEP is a member of the following medical societies: American
College of Emergency Physicians
Disclosure: Nothing to disclose.
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical
Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health
Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities
College of Medicine
David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of
Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American
Medical Informatics Association, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

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Chief Editor
Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California
Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine,
University of California, Davis, School of Medicine
Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of
Emergency Medicine, American College of Emergency Physicians
Disclosure: Nothing to disclose.
Additional Contributors
Dan Danzl, MD Chair, Professor, Department of Emergency Medicine, University of Louisville
Hospital
Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency
Medicine, American College of Emergency Physicians, American Medical Association, Kentucky
Medical Association, Society for Academic Emergency Medicine, Wilderness Medical Society
Disclosure: Nothing to disclose.
Acknowledgements
I wish to recognize the inspiration and help given by my father, Dr. William Ernoehazy, FACP (d.
2005), co-author of the original version of this article.
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