Diagnosis and Management of Neck Bruising from Attempted Suicide by Hanging
The bruise on the neck from attempted hanging represents a ligature mark with possible peri-ligature injuries (bruising, abrasions, or blisters), and this patient requires immediate psychiatric evaluation with consideration for hospitalization given the high-risk suicide attempt method. 1
Immediate Medical Assessment
Physical Examination Priorities
- Assess airway patency, breathing adequacy, and circulatory status immediately, as hanging causes vascular compromise leading to cerebral edema rather than primarily asphyxia or spinal injury 1, 2
- Document the ligature mark characteristics: location, pattern, direction (typically oblique and ascending toward the knot), and any surrounding peri-ligature injuries including bruises, abrasions, or blisters 3
- Evaluate for neurological complications including altered consciousness, focal deficits, or signs of increased intracranial pressure, as venous hypertension during hanging can cause endothelial damage and potential intracranial hemorrhage 4
- Monitor for delayed complications including hypoxic-ischemic brain injury, cerebral edema, or rare intracranial hemorrhage that may develop after reperfusion 4, 5
Critical Management Caveat
- Avoid or promptly remove cervical collars if applied by prehospital teams, as they can dangerously increase intracranial pressure by further impeding venous return from the brain 2
- Hanging deaths result from blockage of blood flow to the brain causing vasogenic and cytotoxic cerebral edema, not primarily from spinal fracture 2
Psychiatric Risk Stratification
High-Risk Classification
This patient is at HIGH RISK for completed suicide based on the following factors 6:
- Hanging represents an unusual and highly lethal attempt method (not ingestion or superficial cutting), which predicts further suicide attempts and ultimate death by suicide 6
- Medically serious attempts by unusual methods require the most intensive intervention 6
Mandatory Psychiatric Assessment
- Arrange immediate mental health professional evaluation during the current medical visit with options including psychiatric hospitalization, emergency department transfer, or same-day psychiatric appointment 6, 7
- Hospitalization is likely the safest course of action, providing a protected environment for complete medical and psychiatric evaluation with treatment initiation in a controlled setting 6
- Although no controlled studies prove hospitalization saves lives, it remains the recommended approach for high-risk patients 6
Risk Factor Assessment
Evaluate for Underlying Conditions
- Screen for mood disorders, anxiety disorders, or substance abuse, as these are primary risk factors for suicide attempts in both genders 6
- Assess for history of physical or sexual abuse, as 15-20% of suicide attempters have abuse history, and abuse increases suicide risk even when other factors are controlled 6
- Inquire about sexual orientation, as gay, lesbian, and bisexual youth have 2-7 fold increased risk for suicide attempts requiring medical attention 6
- Evaluate family dynamics and support, as serious family disturbances significantly increase suicide attempt risk 6
Safety Planning
Immediate Environmental Modifications
- Remove all firearms from the home, as adolescents may access even locked guns 6
- Lock up all medications, both prescription and over-the-counter 7
- Develop a specific safety plan including identification of warning signs, triggers, coping strategies, healthy distraction activities, responsible social supports to contact, and emergency services information 7
Follow-Up Care
Collaborative Management
- Maintain contact with the patient even after psychiatric referral to enhance continuity of care and treatment adherence 6
- Ensure frequent monitoring, especially during initial treatment phases 7
- Consider evidence-based psychotherapy such as cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT) 7