Acute Management of Hanging in the Emergency Department

Background & Pathophysiology

1. Airway obstruction - direct compression of the trachea/larynx
2. Venous obstruction - jugular vein compression raising intracranial pressure before arterial flow stops
3. Arterial compromise - carotid artery compression causing cerebral ischemia
4. Cervical spine injury - axial traction (rare in non-judicial/partial hangings; <1% incidence in near-hangings)

Scene/Pre-hospital

• Cut the ligature (but note and preserve the knot configuration for forensic purposes)
• Cervical spine immobilization from point of rescue - apply hard collar; assume unstable C-spine until proven otherwise
• Begin CPR immediately if pulseless
• Supplemental high-flow oxygen

Immediate ED Priorities (ABCDE)

A - Airway (highest priority)

• Have surgical airway equipment physically open and ready before intubation attempt
• Soft tissue swelling can progress insidiously - delayed airway compromise can occur even in initially stable patients
• Subcutaneous emphysema suggests laryngotracheal disruption - treat as impending complete airway loss

B - Breathing

• Targets: SpO2 92-98%, PaCO2 35-45 mmHg (normocapnia)
• Watch for post-obstructive pulmonary edema (POPE) - negative pressure pulmonary edema from forced inspiration against a closed glottis
• If non-intubated with pulmonary edema: CPAP/BiPAP with positive end-expiratory pressure
• Aspiration pneumonia is common - suspect if PaO2/FiO2 ratio is poor
• Avoid excessive tidal volumes in ventilated patients

C - Circulation & Cerebral Perfusion

• Monitor cardiac rhythm continuously - arrhythmias (including hypoxic bradycardia, VF) are common
• Maintain MAP >60-65 mmHg
• Judicious fluid resuscitation - avoid large volumes; excess fluid worsens ARDS risk and cerebral edema
• Use vasopressors early (noradrenaline preferred) rather than excessive crystalloid
• Post-cardiac arrest: follow standard post-ROSC protocol

D - Disability (Neurological)

• Absent pupillary/corneal reflexes
• Bilaterally absent N20 SSEP wave
• Highly malignant EEG pattern
• Myoclonus
• Neuron-specific enolase (NSE) >60 µg/L at 48 and 72 h
• Diffuse anoxic injury on MRI/CT

Investigations

Red Flags Warranting Immediate Action

• Stridor or progressive hoarseness - imminent airway loss
• Subcutaneous emphysema - laryngotracheal disruption
• Declining GCS - cerebral edema or vascular injury
• Neurological deficits - C-spine injury or carotid dissection
• Hemoptysis - tracheal tear
• Tachycardia with hypotension - consider tension pneumothorax (rare) or vascular injury

Disposition

Specific Injury Management

Laryngotracheal Injury

• Thyroid cartilage is the most commonly fractured structure
• Narrow ligatures cause more airway injury than broad ones
• ENT/surgery consult for laryngobronchoscopy
• Tracheostomy may be required if laryngeal disruption is extensive

Blunt Cerebrovascular Injury (BCVI)

• Carotid or vertebral artery dissection can occur from direct compression
• May present with delayed neurological deficits hours after initial presentation
• Manage per institutional BCVI protocol (anticoagulation or antiplatelet therapy depending on injury grade and associated hemorrhage)

Post-Obstructive Pulmonary Edema (POPE)

• Mechanism: massive negative intrathoracic pressure generated against closed glottis
• Typically appears within 4 hours
• Management: CPAP/BiPAP, supplemental O2; rarely requires mechanical ventilation
• Usually resolves within 12-24 hours with supportive care

Non-Clinical (Mandatory) Considerations

• Forensic documentation: Photograph injuries, document ligature mark characteristics (location, direction, pattern), before cleaning wounds
• Safeguarding: Assess for children or vulnerable adults at risk
• Psychiatry referral: Hanging/strangulation as self-harm indicates very high suicide intent - this is not optional
• Reporting obligations: Consider medico-legal reporting requirements per local jurisdiction

Quick Reference Management Summary

HANGING IN ED
│
├── Cardiac arrest → CPR + ACLS → Post-ROSC care → TTM if GCS poor
│
├── Unconscious/GCS <8 → RSI (in-line C-spine) → Vent (SpO2 92-98%, PaCO2 35-45)
│                         → CT head/neck/CTA → ICU
│
├── Symptomatic (stridor/hoarseness/neuro signs)
│     → Prepare difficult airway → Early ETI
│     → CT neck + CTA + CXR → Admit
│
└── Awake/asymptomatic
      → CT neck + CXR + ECG + Labs
      → 24-hour monitored observation
      → Psych consult (if intentional)