Hanging
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Here is a comprehensive clinical overview of hanging from a forensic and emergency medicine perspective:
Hanging — Clinical & Forensic Overview
(Source: ROSEN's Emergency Medicine: Concepts and Clinical Practice)
Mechanism of Injury
Hanging is a specific type of blunt neck injury. The mechanism differs significantly between judicial and modern (suicidal) hangings:
- Judicial hangings: Death from cervical fracture and spinal cord transection due to the sudden forceful drop.
- Modern suicidal hangings: Death results from the external force of the ligature, which causes:
- Venous congestion → unconsciousness
- Progressive tightening of the noose → arterial occlusion → cerebral hypoxia
- Vagal reflexes from carotid body pressure → fatal dysrhythmias
- Sympathetic tone increase from pericarotid sinus pressure
- Airway compression plays a less significant role than commonly assumed.
Sequelae in Survivors (Near-Hanging)
Patients who survive a hanging can suffer multi-system complications:
| System | Injury |
|---|---|
| Brain | Hypoxic-ischemic brain injury (primary driver of mortality/morbidity) |
| Pulmonary | Neurogenic pulmonary edema, post-obstructive pulmonary edema, cardiogenic pulmonary edema |
| Cardiac | Takotsubo (stress) cardiomyopathy — increasingly recognized |
| Skin/capillaries | Tardieu spots — punctate petechial lesions from gravitational capillary rupture; a key forensic sign of hanging mechanism |
Imaging
- CTA of the neck is adequate for evaluating neck injury.
- Additional imaging is often indicated given the likely greater pathology:
- Brain MRI — for cerebral hypoxia/anoxia
- Chest imaging — for pulmonary edema
- Echocardiography — to detect Takotsubo cardiomyopathy
Management
Definitive evidence-based guidelines specific to near-hanging are limited. Available evidence suggests:
- Induced mild hypothermia in comatose survivors of strangulation: one case series showed 43% survival to discharge and 6% return of neurological function with hypothermia protocols after arrest.
- Thrombolysis for carotid injury-related stroke has been reported in case reports but is not confirmed by larger studies.
- Currently, insufficient data exists to formally recommend either hypothermia or thrombolysis for routine clinical practice.
Key Forensic Points
| Feature | Detail |
|---|---|
| Tardieu spots | Punctate petechial hemorrhages; diagnostic of ligature/compression mechanism |
| Cause of death | Cerebral hypoxia (via venous congestion + arterial occlusion) and/or dysrhythmia |
| Airway compression | Less important than vascular/neurological mechanisms |
| Judicial vs. suicidal | Judicial → spinal fracture; Suicidal → vascular/hypoxic |
— ROSEN's Emergency Medicine: Concepts and Clinical Practice, pp. 452 ff.
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