WORKUP	Section 5 of 9
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Lab Studies:

• Laboratory tests should not be drawn until after the airway has been assessed and secured if necessary.

• Arterial blood gases (ABGs) should be evaluated in all patients who require intubation and airway management.

• Given the ready availability of pulse oximetry, ABGs are probably unnecessary in patients who do not require endotracheal intubation.

Imaging Studies:

• In nonjudicial hangings, cervical spine injury is rare.

• Judicial hangings are characterized by drops that are greater than the victim's height.

• In such drops, the head hyperextends as the noose stops the victim. Classically, the result is bilateral fracture through the pedicles of C2; the body of C2 is displaced anterior to the vertebral body of C3.

• These hangman fractures are seen best on the lateral radiograph of the cervical spine.

• Soft-tissue neck radiographs should be obtained in nearly all strangulation victims and patients with a mechanism consistent with hanging.

• Generally, a fractured hyoid bone indicates a severe, occult soft-tissue injury, even in a patient whose medical condition is otherwise stable.

• Defer such studies until the airway is secure.

• Chest radiographs are indicated after endotracheal intubation for placement confirmation and to establish a baseline against which to measure the patient's course. Acute respiratory distress syndrome (ARDS) can occur as a complication of these injuries.

• CT scanning of the head is indicated when the neurologic status is compromised.

• CT scanning of the neck provides increased sensitivity for the detection of subtle fractures and other soft-tissue abnormalities. Additionally, clinically subtle injuries to the laryngeal cartilage may not be apparent on plain radiographs.

• Doppler vascular imaging or arteriography of the carotids should be considered in cases of garroting. The thin wires or cords used in these assaults often produce deep vascular thrombosis.

Procedures:

• In patients who are not at immediate risk of airway compromise, direct fiberoptic laryngoscopy and microlaryngoscopy may play a role in establishing the full pattern of injuries. ENT consultation can establish both the need for, and the timing of, these studies.

	TREATMENT	Section 6 of 9
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Prehospital Care:

• C-spine stabilization and airway assessment are of paramount importance.

• Do not attempt endotracheal intubation in the field unless the airway is acutely compromised.

• If respiratory failure or airway obstruction is present, prehospital intubation of the patient is indicated.

Emergency Department Care:

• Assessment and treatment of airway status and breathing is paramount.

• Generally, strict enforcement of cervical spine immobilization is not imperative unless the fall is significant (ie, a drop equal to or greater than the height of the victim).

• Unless the patient experiences volume loss, fluid restriction is prudent to help prevent ARDS and cerebral edema.

• Monitor the patient for cardiac arrhythmias.

• Tracheal intubation may be required emergently with little warning.

• Cricothyroidotomy is indicated for any patient with airway deterioration, should endotracheal intubation be unsuccessful.

• Alternately, percutaneous translaryngeal ventilation may be used to temporarily ventilate a patient.

Consultations:

• Consider early consultation with an ENT, trauma, or general surgeon for strangulation injuries.

• Psychiatric consultation should be obtained in cases of suicidal or autoerotic strangulation.

	FOLLOW-UP	Section 7 of 9
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Further Inpatient Care:

• All patients who have required endotracheal intubation for airway management must be admitted to a critical care unit.

• Even if the initial presentation is clinically benign, all near-hanging victims and patients with evidence of vascular compromise secondary to strangulation should be admitted for 24 hours observation to watch for delayed airway and pulmonary complications.

Further Outpatient Care:

• Psychiatric support for near-hanging survivors is recommended, as these patients are prone to depression, personality disorders, and violence.

In/Out Patient Meds:

• Phenytoin may help to prevent additional insult from cerebral ischemia and to treat hanging-induced seizures.

Transfer:

• Once stabilized, patients who have sustained a spinal cord injury from a hanging or through any mechanism from strangulation should be transferred to a designated spinal cord center.

Deterrence/Prevention:

• Caution parents about the dangers of postural asphyxiation in toddlers. This occurs when the child places his or her neck over an object and the body's weight on the neck produces compression and strangulation.

Complications:

• Respiratory complications: These are the major cause of delayed mortality in near-hanging victims. Both aspiration pneumonia and ARDS may develop, complicating the clinical course.

• Tracheal stenosis

• Neurologic sequelae: A wide array of complications may occur in survivors of strangulations and near-hangings, including muscle spasms, transient hemiplegia, central cord syndrome, and seizures. Spinal cord injury also can cause long-term paraplegia or quadriplegia and short-term autonomic dysfunction.

• Scarring of neck tissue

• Psychiatric disturbances: Psychosis, Korsakoff syndrome, amnesia, and progressive dementia all have been reported after surviving a hanging or strangulation. Nearly all patients who have undergone strangulation or near-hanging demonstrate restlessness and a propensity for violence.

Prognosis:

• The prognosis for survivors of hanging and strangulations varies, depending on which complications occur.

	MISCELLANEOUS	Section 8 of 9
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Medical/Legal Pitfalls:

• Failure to adequately stabilize or address associated cervical spine injuries in near-hanging victims

• Failure to refer near-hanging victims for psychiatric evaluation

• Failure to obtain soft-tissue neck radiographs when evaluating strangulation victims

• Failure to address the potential for delayed airway compromise in strangulation and near-hanging victims

• Failure to obtain appropriate consultation for evaluation of suspected laryngeal injuries

• Failure to seek other injuries or illnesses in the potentially suicidal patient with a near-hanging

• Failure to consider carotid artery injury in patients with neurologic sequelae