CASE BASED

DISCUSSION
BY DR.CATHARINE LEO
 HISTORY
23 year old female was brought to ED with history of suicidal attempt by
hanging from a ceiling fan with a saree at her residence.
Duration of hanging - ? 3 to 4 mins
Post event, patient became unconscious.
CPR was attempted by her relatives at home and she was taken to a nearby
hospital.
Patient was intubated in view of low GCS and treated.
History of one episode of seizure.
Patient was treated and extubated in 2 days.
VITALS
BP – 130/80 mmHg
HR – 116 bpm
SpO2 – 98% with 4L of O2
RR – 30 breaths/min
CBG – 128 mg/dL
EXAMINATION
O/E – Patient conscious,
Afebrile, Dehydrated
S/E –
CVS – S1 S2 +
RS – B/L AE +
P/A – Soft, bowel sounds sluggish
CNS – Opens eyes on calling her name
Incomprehensible sounds
She was localizing to pain
Tone – normal
Power – Could not be assessed
Local examination
Ligature mark on right side of neck
GCS
Power grading
ABG
ECG
C SPINE ???
Outside Investigations
Hb – 10.3 gm/dL
TC – 15,500
Cr- 0.47
Na 139
K 4.1
CT BRAIN – Normal study
ECHO – 60%, good LV
INVESTIGATIONS

CBC
UREA
CREAT
LFT
URINE ROUTINE
ELECTROLYTES
ECG
CHEST XRAY
COAGULATION PROFILE
URINE PREGNANCY TEST
HANGING
 Classification

 Depending on the degree of suspension:

•A) Complete hanging: When the whole body is suspended from the ligature material and no
portion of the body is touching the ground.
•B) Partial hanging: As the name suggests, the body is partially suspended, the toe or feet or either
part of the body touching the ground.
The deceased may be in kneeling down position, sitting position etc. here the weight of the
head is where the constricting force comes from.
Depending on position of the knot:
A) Typical hanging: Where the ligature runs from the midline, above the thyroid cartilage,
symmetrically upwards on both sides of the neck, to the occipital region and the knot is placed
over the central part of the back of neck.
B) Atypical hanging: The knot is anywhere other than the central part of the back of neck.
OTHERS
Depending on the manner of hanging:
A) Suicidal hanging
B) Homicidal hanging
C) Accidental hanging for e.g. autoerotic asphyxia
D) Judicial hanging.
PHYSICAL EXAMINATION
•"Ligature marks" or abrasions, lacerations, contusions, bruising, edema of the neck
•Tardieu spots of the eyes
•Severe pain on gentle palpation of the larynx (laryngeal fracture)
•Respiratory signs: cough, stridor, dysphonia/muffled voice, aphonia
•Varying levels of respiratory distress
•Hypoxia
•Mental status changes
EARLY MANAGEMENT
•ABCs as always
•Early endotracheal intubation is advocated.
•If ETI unsuccessful, consider cricothyroidotomy
•Judicious and cautious fluid resuscitation - avoid large fluid volume resuscitation and consider
early pressors, as fluids increases the risk/severity of ARDS and cerebral edema.
•Monitor for cardiac arrhythmias.
•The altered/comatose patient should be assumed to have cerebral edema with elevated ICP.
For clearing the cervical spine
Patients can be divided into two groups:
•Conscious cooperative patients: Patients who are able to cooperate with clinical assessment.
We use –
 NEXUS Low Risk Criteria
 Canadian Cervical Spine Rules

•Unconscious/uncooperative patients: These patients are not able to have their cervical spines
cleared clinically as a reliable clinical assessment cannot be made. These patients require imaging
to clear their spines.
NEXUS Low Risk Criteria
The study looked at 5 criteria; if all were negative the patient was classified as having a low risk
of injury.
Five NEXUS criteria:
1. No midline cervical tenderness
2. No focal neurological deficit
3. Normal alertness
4. No intoxication
5. No painful distracting injury
CANADIAN C SPINE

The cervical spine can reliably be

‘cleared’ if either the NEXUS low risk
criteria or Canadian C-Spine rules are
satisfied
 CHOICE OF IMAGING
Plain radiographs are not adequate to exclude significant cervical spine
injury in unconscious patients and these patients will require CT (or
MRI) imaging (see below).
Normal imaging of the cervical spine consists of three views - The
Lateral, Antero-posterior (AP) and odontoid peg views.

The current NICE Guidelines do not recommend MRI to routinely clear

the cervical spine. The EAST guidelines from the USA are non-
committal, leaving the decision to use MRI up to the individual hospital.
PATHOPHYSIOLOGY OF
INJURY
SPINE / SPINAL CORD
•When the drop is greater than or equal to the height of the victim,
as in a judicial hanging, there will almost always be cervical spine
injury.
•The head hyperextends, leading to fracture of the upper cervical
spine ("hangman's fracture” of C2) and transection of the spinal
cord.
VASCULAR
•The major pathologic mechanism of death in hanging/strangulation is neck vessel occlusion, not
airway obstruction.
•Death ultimately results from cerebral hypoxia and global ischemia.
•There are two mechanisms by which this happens:
• Venous: The most implicated cause of death is actually venous obstruction. Jugular veins are
superficial and easily compressible. Obstruction of venous outflow from the brain leads to stagnant
hypoxia and loss of consciousness in as little as 15 seconds.

• Arterial: The risk of damage to the major arterial blood flow to the brain (such as carotid artery
dissection) is rare, but should suspected in patients.
CARDIAC
Carotid body reflex-mediated cardiac dysrhythmias are reported which can eventually lead to
cardiac arrest.
PULMONARY
• Airway compromise plays less of a role in the immediate death of complete
hanging/strangulation. However, it is a major cause of delayed mortality in near-hanging victims.
• Significant pulmonary edema occurs through two mechanisms:
• Neurogenic: centrally mediated, massive sympathetic discharge; often in association with serious
brain injury and a poor prognostic implication.
• Post-obstructive: strangulation causes marked negative intrapleural pressure, generated by forceful
inspiratory effort against extra-thoracic obstruction; when the obstruction is removed, there is a
rapid onset pulmonary edema leading to ARDS.

• Aspiration pneumonia later sequela of near-hanging injury.

• Airway edema from mechanical trauma to the airway, which can make intubation difficult.
• Tracheal stenosis can develop later in the hospital course.
FURTHER MANAGEMENT
•Early intubation and airway management are important.
•Expect pulmonary complications early.
•Non-intubated patients with pulmonary edema may benefit from positive end-expiratory pressure
ventilation.
•Patients with symptoms of laryngeal or tracheal injury (e.g. dyspnea, dysphonia, aphonia, or
odynophagia), should undergo laryngobronchoscopy with ENT.
•Address cerebral edema from anoxic brain injury, using strategies to reduce intracranial pressure
or seizure prophylaxis.
•Address vascular complications and coordinate intervention with CTVS.
•Therapeutic Hypothermia
• There is some evidence for therapeutic hypothermia in those with cardiac arrest from hanging
injury and those who are comatose from hanging injury.
• While the evidence is weak, in the absence of better evidence, it is reasonable to consider
hypothermia treatment in all comatose near-hanging victim.
•When suicide is suspected, evaluate patients for other methods of self-harm (e.g. wrist lacerations,
self-stabbing, ingestions). It is also important to consider drug and alcohol intoxication.
THANK YOU