Hanging - Symptoms and Evaluation

Definition

• Complete hanging: Feet do not touch the ground; full body weight acts as the constricting force
• Partial (incomplete) hanging: Only the head weight (~5-6 kg) acts; toes, feet, knees, or buttocks still touch the ground - still fatal
• Typical hanging: Knot positioned at the back of the neck (suboccipital)
• Atypical hanging: Knot at side, front, or submental

Types by Manner

Mechanism of Death (Causes)

1. Cerebral ischaemia and anoxia - carotid artery compression stops arterial inflow to the brain
2. Cerebral venous congestion - jugular vein compression causes venous back-pressure
3. Airway obstruction - direct compression of trachea or upward displacement of the tongue root by the ligature
4. Vagal inhibition - pressure on the vagus nerve or carotid sinus causes cardiac arrest via reflex
5. Spinal cord injury - fracture-dislocation at C2 (hangman's fracture) in judicial/long-drop hangings
6. Combination of the above

Symptoms in the Living (During/After Near-Hanging)

1. Flashes of light before the eyes
2. Ringing in the ears (tinnitus)
3. Sudden loss of consciousness (within seconds)
4. Death

Neurological

• Hypoxic-ischemic brain injury (primary driver of mortality/morbidity)
• Neurological deficit consistent with stroke (from blunt cerebrovascular injury - BCVI)
• Transient ischemic attack (TIA) symptoms, especially in vertebrobasilar territory
• Delayed stroke risk: 10-40% untreated; highest within first 7 days after BCVI
• 43% of patients have focal neurological finding at time of diagnosis

Pulmonary

• Pulmonary oedema - via three distinct mechanisms:
  • Neurogenic: massive sympathetic discharge (centrally mediated)
  • Post-obstructive: marked negative intrapleural pressure from forceful inspiratory effort against external obstruction
  • Cardiogenic: from Takotsubo (stress) cardiomyopathy associated with hanging

Cardiovascular

• Takotsubo cardiomyopathy - increasingly recognized; cardiogenic pulmonary oedema
• Dysrhythmias from vagal/sympathetic stimulation
• Carotid or vertebral artery dissection (BCVI)

Neck/Aerodigestive

• Hard signs (require immediate surgical consultation):
  • Severe/uncontrolled haemorrhage, refractory shock
  • Large, expanding, or pulsatile haematoma
  • Unilateral pulse deficit
  • Bruit/thrill
  • Stroke-consistent neurological deficit
  • Airway compromise, stridor, subcutaneous emphysema
• Soft signs (warrant further workup):
  • Minor bleeding, small non-expanding haematoma
  • Dysphonia, dysphagia, mild haemoptysis/haematemesis
  • Mild subcutaneous emphysema

Other

• Thyroid gland rupture (especially with pre-existing goitre) - may present up to 24 hours later with painful swelling, dyspnoea, or airway obstruction
• Petechiae (Tardieu spots) on conjunctivae, sclera, face - from capillary rupture due to venous hypertension

Fatal Period

• Judicial hanging (long drop): Instantaneous death from C-spine fracture; heart may beat 15-20 minutes thereafter
• Partial/incomplete airway block: 5-8 minutes is the common fatal period
• Loss of consciousness typically occurs within seconds of carotid compression

Evaluation of Survivors (Emergency Assessment)

Initial Priorities

1. Airway - immediate assessment; intubate early if there are hard signs of aerodigestive injury or altered consciousness
2. Breathing - assess for pulmonary oedema
3. Circulation - haemodynamic status, rhythm monitoring

Diagnostic Workup

• CT Angiography (CTA) of neck - imaging modality of choice; adequate for evaluation of vascular injury in hanging; evaluates cervical spine simultaneously
• Brain MRI - for cerebral anoxia/hypoxic injury assessment
• Chest imaging (CXR/CT) - pulmonary oedema, pneumothorax
• Echocardiography - to detect Takotsubo cardiomyopathy
• DSA (digital subtraction angiography) - still useful when CTA is normal despite high suspicion, or when endovascular treatment is planned; gold standard historically for vascular injury but time-consuming

• Serial haemoglobin (if significant bleeding)
• Platelet count and coagulation studies (anticipated surgery or bleeding)
• Type and cross if surgery anticipated
• Thromboelastography elevated clot strength = higher stroke risk in BCVI

• e-FAST exam: exclude pericardial effusion and pneumothorax
• 12-lead ECG: dysrhythmias, Takotsubo pattern

Blunt Cerebrovascular Injury (BCVI) Grading (Biffl Scale)

Postmortem Appearances (Forensic)

External Findings

• Neck stretched, head inclined to side opposite the knot
• Face: usually pale; congested with petechiae if venous obstruction predominated
• Tongue: protruding, turgid, may be dark brown-black from drying
• Eyes: prominent, congested; conjunctival petechiae (Tardieu spots)
• Cyanosis of hands and nail beds
• Saliva dribbling from corner of mouth opposite the knot (pressure on salivary glands)
• Postmortem lividity: circumferential on dependent arms/legs, face, and neck above the ligature

Ligature Mark

• Appears as a groove/furrow - pale early, becomes yellowish-brown, dry, hard, parchment-like
• In complete hanging: situated above the thyroid cartilage (between larynx and chin), directed obliquely upward toward mastoid processes; absent/faint at back
• In partial hanging: may be at a lower level
• Shaped like an inverted V with the apex at the knot
• Thin line of congestion/haemorrhage at the groove margins
• Fibres from the ligature may adhere to skin
• Skin tags in the groove indicate upward direction of force

Internal Findings (Asphyxial Death)

• Petechial haemorrhages on serous surfaces (visceral pleura, epicardium, conjunctivae)
• Lungs: congested, oedematous, with subpleural petechiae
• Blood: dark, fluid (unclotted)
• In judicial hanging: fracture of cervical vertebrae (C2 - "hangman's fracture") with cord injury
• Hyoid bone or thyroid cartilage fracture (more common in strangulation; can occur in hanging, especially in older individuals)

• Parikh's Textbook of Medical Jurisprudence, Forensic Medicine and Toxicology, pp. 204-205
• P.C. Dikshit Textbook of Forensic Medicine and Toxicology, pp. 291-292
• Rosen's Emergency Medicine: Concepts and Clinical Practice, pp. 452-456