Emergency Department 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. Consider early consultation with trauma, ENT, trauma, or general surgery for strangulation injuries. Psychiatric consultation should be obtained in cases of suicidal or autoerotic strangulation.^{[8, 33]}

Assessment and treatment of airway status and breathing is paramount. In assessing the patient prior to possible endotracheal intubation, the likelihood of spinal cord injury increases substantially in hanging victims whose drop was equal to or greater than their height, even in incomplete hangings. Fluid resuscitation must be performed judiciously, given the risk of subsequent ARDS and cerebral edema.

Monitor the patient for cardiac arrhythmias.

Endotracheal intubation may become necessary with very little warning.

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

If associated neck injuries render cricothyroidotomy difficult, percutaneous translaryngeal ventilation may be used to temporarily oxygenate a patient. Definitive airway management (laryngotomy) must follow swiftly.

A cervical collar or other immobilization device should be immediately applied In any patients who have extensive cervical injury findings.

Shane J, Petrosky E, Lyons BH, et al. Surveillance for Violent Deaths — National Violent Death Reporting System, 27 States, 2015. Surveillance Summaries / September 28, 2018 / 67(11);1–32. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/mmwr/volumes/67/ss/ss6711a1.htm. 2018; Accessed: December 3, 2020.
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Sauvageau A. About strangulation and hanging: Language matters. J Emerg Trauma Shock. 2011 Apr. 4 (2):320. [QxMD MEDLINE Link].
Dunn RJ, Sukhija K, Lopez RA. Strangulation Injuries. 2020 Jan. [QxMD MEDLINE Link]. [Full Text].
Tugaleva E, Gorassini DR, Shkrum MJ. Retrospective Analysis of Hanging Deaths in Ontario. J Forensic Sci. 2016 Nov. 61 (6):1498-1507. [QxMD MEDLINE Link].
Dunsby AM, Davison AM. Causes of laryngeal cartilage and hyoid bone fractures found at postmortem. Med Sci Law. 2011 Apr. 51(2):109-13. [QxMD MEDLINE Link].
Ma J, Jing H, Zeng Y, Tao L, Yang Y, Ma K, et al. Retrospective analysis of 319 hanging and strangulation cases between 2001 and 2014 in Shanghai. J Forensic Leg Med. 2016 Aug. 42:19-24. [QxMD MEDLINE Link].
Sauvageau A, Boghossian E. Classification of asphyxia: the need for standardization. J Forensic Sci. 2010 Sep. 55 (5):1259-67. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Sauvageau A, Ambrosi C, Kelly S. Autoerotic Nonlethal Filmed Hangings: A Case Series and Comments on the Estimation of the Time to Irreversibility in Hanging. Am J Forensic Med Pathol. 2011 Jul 20. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Paul SP, Paul R, Heaton PA. Accidental hanging injuries in children: recognition and management. Br J Hosp Med (Lond). 2017 Oct 2. 78 (10):572-577. [QxMD MEDLINE Link].
van Hasselt TJ, Hartshorn S. Hanging and near hanging in children: injury patterns and a clinical approach to early management. Arch Dis Child Educ Pract Ed. 2019 Apr. 104 (2):84-87. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Hsu CH, Haac B, McQuillan KA, et al. Outcome of suicidal hanging patients and the role of targeted temperature management in hanging-induced cardiac arrest. J Trauma Acute Care Surg. 2017 Feb. 82 (2):387-391. [QxMD MEDLINE Link].
Gantois G, Parmentier-Decrucq E, Duburcq T, et al. Prognosis at 6 and 12months after self-attempted hanging. Am J Emerg Med. 2017 Nov. 35 (11):1672-1676. [QxMD MEDLINE Link].
Tharmarajah M, Ijaz H, Vallabhai M, et al. Reducing mortality in near-hanging patients with a novel early management protocol. Am J Emerg Med. 2018 Nov. 36 (11):2050-2053. [QxMD MEDLINE Link].
La Count S, Lovett ME, Zhao S, et al. Factors Associated With Poor Outcome in Pediatric Near-Hanging Injuries. J Emerg Med. 2019 Jul. 57 (1):21-28. [QxMD MEDLINE Link].
Antigone Investigators. Outcomes in 886 Critically Ill Patients After Near-Hanging Injury. Chest. 2020 Aug 3. [QxMD MEDLINE Link].
Sane MR, Mugadlimath AB, Zine KU, Farooqui JM, Phalke BJ. Course of Near-hanging Victims Succumbed to Death: A Seven Year Study. J Clin Diagn Res. 2015 Mar. 9 (3):HC01-3. [QxMD MEDLINE Link].
Hunter BR, Keim SM, Seupaul RA, Hern G. Are plain radiographs sufficient to exclude cervical spine injuries in low-risk adults?. J Emerg Med. 2014 Feb. 46 (2):257-63. [QxMD MEDLINE Link]. [Full Text].
Heimer J, Tappero C, Gascho D, et al. Value of 3T craniocervical magnetic resonance imaging following nonfatal strangulation. Eur Radiol. 2019 Jul. 29 (7):3458-3466. [QxMD MEDLINE Link].
Schulze K, Ebert LC, Ruder TD, et al. The gas bubble sign-a reliable indicator of laryngeal fractures in hanging on post-mortem CT. Br J Radiol. 2018 Apr. 91 (1084):20170479. [QxMD MEDLINE Link].
Schuberg S, Gupta N, Shah K. Aggressive imaging protocol for hanging patients yields no significant findings: Over-imaging of hanging injuries. Am J Emerg Med. 2019 Apr. 37 (4):737-739. [QxMD MEDLINE Link].
Decker LA, Hatch GM, Lathrop SL, Nolte KB. The Role of Postmortem Computed Tomography in the Evaluation of Strangulation Deaths. J Forensic Sci. 2018 Sep. 63 (5):1401-1405. [QxMD MEDLINE Link].
Deininger-Czermak E, Heimer J, Tappero C, Thali MJ, Gascho D. Postmortem Magnetic Resonance Imaging and Postmortem Computed Tomography in Ligature and Manual Strangulation. Am J Forensic Med Pathol. 2020 Jun. 41 (2):97-103. [QxMD MEDLINE Link].
Deininger-Czermak E, Heimer J, Tappero C, Thali MJ, Gascho D. The added value of postmortem magnetic resonance imaging in cases of hanging compared to postmortem computed tomography and autopsy. Forensic Sci Med Pathol. 2020 Jun. 16 (2):234-242. [QxMD MEDLINE Link].
Gascho D, Heimer J, Tappero C, Schaerli S. Relevant findings on postmortem CT and postmortem MRI in hanging, ligature strangulation and manual strangulation and their additional value compared to autopsy - a systematic review. Forensic Sci Med Pathol. 2019 Mar. 15 (1):84-92. [QxMD MEDLINE Link].
Rehn M, Davies G, Foster E, Lockey DJ. Prehospital Management of Pediatric Hanging. Pediatr Emerg Care. 2018 Apr. 34 (4):263-266. [QxMD MEDLINE Link].
Ferreira AD, Sponholz A Jr, Mantovani C, Pazin-Filho A, Passos AD, Botega NJ, et al. Clinical Features, Psychiatric Assessment, and Longitudinal Outcome of Suicide Attempters Admitted to a Tertiary Emergency Hospital. Arch Suicide Res. 2016. 20 (2):191-204. [QxMD MEDLINE Link].
Nichols SD, McCarthy MC, Ekeh AP, et al. Outcome of cervical near-hanging injuries. J Trauma. 2009 Jan. 66(1):174-8. [QxMD MEDLINE Link].
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.
US methods of suicide 2012. Lost All Hope. Available at http://lostallhope.com/suicide-statistics/us-methods-suicide. Accessed: Dec 3, 2018.
Baker SP, Hu G, Wilcox HC, Baker TD. Increase in suicide by hanging/suffocation in the U.S., 2000-2010. Am J Prev Med. 2013 Feb. 44 (2):146-9. [QxMD MEDLINE Link].
Aufderheide TP, Aprahamian C, Mateer JR, et al. Emergency airway management in hanging victims. Ann Emerg Med. 1994 Nov. 24(5):879-84. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Fischman CM, Goldstein MS, Gardner LB. Suicidal hanging. An association with the adult respiratory distress syndrome. Chest. 1977 Feb. 71(2):225-7. [QxMD MEDLINE Link].
Gilbert JA Jr, Gossett CW. Hanging and strangulation injuries. The Clinical Practice of Emergency Medicine. 2nd ed. Lippincott Williams & Wilkins; 1996. 566.
Iserson KV. Strangulation: a review of ligature, manual, and postural neck compression injuries. Ann Emerg Med. 1984 Mar. 13(3):179-85. [QxMD MEDLINE Link].
Kleinsasser NH, Priemer FG, Schulze W, et al. External trauma to the larynx: classification, diagnosis, therapy. Eur Arch Otorhinolaryngol. 2000. 257(8):439-44. [QxMD MEDLINE Link].
Le D, Macnab AJ. Self strangulation by hanging from cloth towel dispensers in Canadian schools. Inj Prev. 2001 Sep. 7(3):231-3. [QxMD MEDLINE Link].
McHugh TP, Stout M. Near-hanging injury. Ann Emerg Med. 1983 Dec. 12(12):774-6. [QxMD MEDLINE Link].
Mohanty MK, Rastogi P, Kumar GP, et al. Periligature injuries in hanging. J Clin Forensic Med. 2003 Dec. 10(4):255-8. [QxMD MEDLINE Link].
National Safety Council. What are the odds of dying? [e11th-hour.org Web site]. August 15, 2004. Accessed August 1, 2005. [Full Text].
Pesola GR, Westfal RE. Hanging-induced status epilepticus. Am J Emerg Med. 1999 Jan. 17(1):38-40. [QxMD MEDLINE Link].
Schild JA, Denneny EC. Evaluation and treatment of acute laryngeal fractures. Head Neck. 1989 Nov-Dec. 11(6):491-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
US Statistical Abstract of the United States. Government Printing Office. 2003.

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Author

Scott I Goldstein, DO, FACEP, EMT-T/PHP Clinical Associate Professor, Director, Division of EMS/Disaster Medicine, Director, Division of Tactical Medicine, Einstein Healthcare Network

Scott I Goldstein, DO, FACEP, EMT-T/PHP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine

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.

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

William S Ernoehazy, Jr, MD, FACEP Attending Physician, Department of Emergency Medicine, Flagler Hospital; Attending Physician, Baptist Emergency at Town Center

William S Ernoehazy, Jr, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

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.