What is the management of a patient with hanging in the emergency department (ED)?

Management of Hanging Patients in the Emergency Department

Patients with hanging injuries should be aggressively resuscitated and treated regardless of their initial presentation, as early intervention can lead to excellent outcomes despite poor initial condition. 1

Initial Assessment and Stabilization

• Immediately place the patient on a cardiac monitor with emergency resuscitation equipment, including a defibrillator, nearby 2
• Assess and secure the airway - early intubation is often required for patients presenting with respiratory distress or decreased level of consciousness 1
• Stabilize cervical spine until injury is ruled out - cervical spine injuries are possible but not universal in hanging cases 1
• Establish IV access and provide hemodynamic support as needed 2
• Perform rapid neurological assessment to establish baseline 2
• Obtain oxygen saturation and provide supplemental oxygen to maximize oxygen delivery 2

Diagnostic Evaluation

• Obtain immediate CT scan of head, neck, and cervical spine to evaluate for:
  • Cerebral edema or hypoxic brain injury
  • Vascular injuries (particularly carotid artery damage)
  • Cervical spine fractures
  • Laryngeal or tracheal injuries 3
• Obtain chest X-ray to evaluate for aspiration pneumonia and pulmonary edema 1
• Order arterial blood gas to assess for hypoxemia and acid-base disturbances 1
• Perform ECG to evaluate for cardiac arrhythmias or ischemia 2
• Consider angiography if vascular injury is suspected 3

Treatment Priorities

• Provide aggressive respiratory support:
  • Early intubation for airway protection and ventilatory support 1
  • Maintain adequate oxygenation and ventilation 2
• Manage cerebral edema if present:
  • Consider head elevation
  • Maintain normothermia
  • Avoid hypotension 1, 4
• Treat any identified complications:
  • Aspiration pneumonia with appropriate antibiotics
  • Pulmonary edema with diuretics
  • Cardiac arrhythmias as appropriate 1, 4
• Surgical intervention may be required for vascular injuries - prompt repair of carotid artery injuries can lead to good outcomes 3

Cardiac Arrest Management

• For patients presenting in cardiac arrest:
  • Begin immediate high-quality CPR 5
  • Follow standard ACLS protocols 2
  • Do not terminate resuscitation prematurely - survivors have been documented even with initially poor prognostic factors 5
  • The presence of immediate basic life support significantly improves outcomes, but its absence should not preclude aggressive resuscitation efforts 5

Mental Health Evaluation

• Once medically stabilized, all patients require comprehensive psychiatric evaluation 6
• Assess for ongoing suicidal ideation and risk factors:
  • Persistence in endorsing desire to die
  • Continuous agitation or severe hopelessness
  • Inability to participate in safety planning
  • Inadequate support system
  • Previous high-lethality suicide attempts 6
• Consider additional risk factors such as gender, comorbid substance abuse, and high levels of anger or impulsivity 6

Disposition Planning

• Patients with significant injuries or neurological deficits require ICU admission 1
• Patients with minimal or no physical injuries still require psychiatric evaluation and likely admission 6
• For patients being discharged after medical clearance:
  • Develop a comprehensive safety plan including identification of warning signs, coping strategies, social supports, and emergency contacts 6
  • Ensure means restriction counseling (especially important as hanging attempts are often impulsive) 6
  • Arrange expedited mental health follow-up 6

Prognosis

• Despite dismal initial presentations, patients with hanging injuries can make full recoveries without neurological deficits when treated aggressively 1, 7
• The greatest risk period for repeat suicide attempt is in the months following the initial attempt 6
• Neurological deficits may be reversible even in severe cases 7

Special Considerations

• Maintain a low threshold for surgical exploration in patients with suspected vascular injuries 3
• Consider the possibility of delayed respiratory complications, which may develop hours after the initial injury 4
• Be aware that 24% of suicide attempts are implemented within 0-5 minutes of the decision, highlighting the impulsive nature of many attempts 6