Morning Report: 4/9/2012

Today’s Morning Report is thanks to Dr. Willis with some clinical pearls about strangulation/hanging injuries:

Strangulation / Hanging injuries

Mortality:

Death from injury to spinal cord or brainstem, mechanical constriction of neck structures, bradycardic cardiac arrest (carotid sinus stimulation and increased vagal tone)

Types:

1. Complete –> feet off ground
2. Incomplete –> feet touch ground
3. Typical –> pt of knot over occiput, arterial occlusion

Mechanism:

• Hanging after dropping a distance greater than pt’s height –> upper cspine fx and transection of spinal cord. Traumatic spondylolysis of C2 in the classic hangman fracture, and transection of the spinal cord. (Judicial Hanging)

• Incomplete or drop < pt’s height –> cspine is spared. Constriction of jugular, stagnant cerebral blood flow and brain ischemia –> LOC, muscle tone decreases. Arterial or airway occlusion causes death.

• Ligature and manual strangulation –> death from airway obstruction or vascular occlusion.

Injury:

• Fx of thyroid cartilage, hyoid bone, and larynx
• Delayed mortality due to pulmonary edema and aspiration pneumonia

History:

• Height of the drop in near-hanging victims is important

• GCS (3 vs >3) important factor of mortality

• Hanging time important: <5 min = all survived; >30 min =  all dies. 5 minutes is the critical time.

Physical:

• circumferential ligature marks significant for survival
• Severe hoarseness and stridor are signs of impending airway obstruction
• Increase in venous pressure suggested by skin and/or conjunctival petechiae (Tardieu spots)
• Severe pain on gentle palpation of the larynx, which may indicate laryngeal fracture
• A fractured hyoid bone indicates a severe, occult soft-tissue injury, even in a patient whose medical condition is otherwise stable.

Management:

• ABCs (advanced airway, surgical airway) and C-spine precautions

• Soft tissue neck XR in all cases. More severe cases CXR (ARDs, pulm edema), CT head (edema), CT neck, doppler, CTA, fiberoptic

• Trauma, ENT, Psych consults

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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