How to manage a patient with a history of hanging?

Management of Patients with Hanging History

Patients with a history of hanging require immediate and aggressive resuscitation regardless of their initial presentation, as early intervention can lead to favorable outcomes despite severe initial symptoms.

Initial Assessment and Management

Immediate Actions

• Ensure scene safety before approaching the patient 1
• Activate emergency medical services immediately 1
• Check responsiveness by tapping the victim and shouting 1
• If unresponsive, assess airway, breathing, and circulation 1
• If no breathing or abnormal breathing (gasping), begin CPR immediately 1

Airway Management

• Open the airway using head tilt-chin lift maneuver 1
• Remove any visible obstruction from the mouth 1
• Consider early intubation if signs of airway compromise due to soft tissue swelling 2
• Avoid maneuvers to relieve foreign body airway obstruction as they are not indicated and may cause harm 1

Circulation Support

• Begin chest compressions if no pulse is detected within 10 seconds 1
• Perform chest compressions at a rate of about 100 compressions per minute, depressing the sternum 4-5 cm 1
• Continue CPR with a ratio of 30 compressions to 2 breaths until advanced care arrives 1

Secondary Assessment and Management

Cervical Spine Considerations

• Cervical spine injuries are rare in hanging victims unless there was a significant drop distance (>5 feet) 2
• Consider cervical spine immobilization only if there is a history of a significant drop or focal neurologic deficits 2

Neurological Assessment

• Perform detailed neurological examination including Glasgow Coma Scale assessment 2
• Aggressive treatment is indicated even in patients with poor initial neurological function, as full recovery may still occur 3, 2
• Patients with initial GCS >3 have better outcomes, but even those with GCS=3 may recover with proper care 2

Respiratory Monitoring

• Monitor closely for development of pulmonary complications including Adult Respiratory Distress Syndrome (ARDS) 2
• Consider supplemental oxygen for hypoxemic patients (oxygen saturation <94%) 1
• Watch for signs of upper airway obstruction due to soft tissue injury 2

Psychiatric Evaluation

• All survivors of hanging attempts require comprehensive psychiatric evaluation 3
• Assess for risk factors for suicidal behavior including mood disorders, anxiety disorders, or substance abuse 1
• Consider the possibility of homicidal hanging, especially if the circumstances are suspicious 4

Prognostic Factors

• Bystander CPR is associated with higher likelihood of return of spontaneous circulation (ROSC) 5
• Initial cardiac rhythm is often asystole (94% in pediatric cases) 5
• Outcomes are generally poor, with survivors at risk for severe neurological injury 5
• The mechanism of injury is primarily ligature strangulation rather than cervical spinal cord injury 6

Special Considerations

Pediatric Patients

• Hanging is a significant cause of out-of-hospital cardiac arrest in pediatric patients 5
• Most pediatric hanging incidents occur in the home (85%) 5
• Distinguish between accidental hanging (typically younger children) and intentional hanging (typically adolescents) 5

Recovery Position

• If the patient is breathing but unresponsive, place in recovery position to maintain airway patency 1
• Monitor peripheral circulation if using recovery position 1

Key Pitfalls to Avoid

• Do not delay resuscitation efforts based on initial poor presentation, as initial features correlate poorly with eventual outcome 6, 3
• Do not assume cervical spine injury without evidence of significant drop or focal neurologic deficits 2
• Do not perform abdominal thrusts or back slaps as these are not indicated for hanging victims 1
• Do not transport patients without attempting resuscitation if they appear severely injured; aggressive treatment should be initiated regardless of initial presentation 3