What is the immediate medical management for a patient with asphyxia from a suicide attempt?

Immediate Medical Management of Asphyxia from Suicide Attempt

For a patient with asphyxia from a suicide attempt, immediately assess responsiveness and breathing, activate emergency services, open the airway using head tilt-chin lift, provide rescue breathing if pulse is present but breathing is absent, and initiate high-quality CPR with chest compressions at 100-120/min if pulseless, while simultaneously preparing for advanced airway management and psychiatric evaluation once stabilized. 1, 2

Initial Assessment and Resuscitation (ABCDE Approach)

Airway and Breathing Management

• Check responsiveness by shaking the patient and shouting; if unresponsive, immediately activate emergency medical services 1, 3
• Open the airway using head tilt-chin lift maneuver: place one hand on the forehead tilting the head back while lifting the chin with fingers of the other hand 1
• Assess breathing for no more than 10 seconds by looking for chest movements, listening at the mouth for breath sounds, and feeling for air with your cheek 1

If Breathing is Absent but Pulse Present

• Provide rescue breathing at 10 breaths per minute (one breath every 6 seconds), with each breath taking approximately 2 seconds and achieving visible chest rise of 800-1200 ml tidal volume 1
• Maintain airway patency continuously with head tilt-chin lift throughout rescue breathing 1
• Reassess pulse every 2 minutes while continuing ventilation 1
• Consider advanced airway (endotracheal intubation or supraglottic device) as soon as personnel trained in airway management arrive 1, 4

If Pulse is Absent (Cardiac Arrest)

• Begin high-quality CPR immediately with chest compressions at 100-120 per minute, pushing hard (at least 5 cm depth) and allowing complete chest recoil 1
• Position hands correctly on the lower half of the sternum: locate where the ribs join the sternum, place middle finger at this point with index finger on sternum, then slide heel of other hand down to meet the index finger 1
• Deliver compressions and breaths in a 30:2 ratio if alone, or 15:2 if two rescuers, minimizing interruptions in compressions 1
• Apply AED as soon as available and follow prompts for rhythm analysis and defibrillation 1
• Administer epinephrine 1 mg IV/IO every 3-5 minutes once vascular access is established 1

Critical Airway Considerations Specific to Hanging/Asphyxia

Cervical Spine Precautions

• Maintain cervical spine immobilization during airway management until spinal injury is excluded, though cervical spine fractures are uncommon in survivors (occurring in <5% of cases) 5, 4
• Perform jaw thrust without head tilt if cervical spine injury is suspected 3

Laryngotracheal Injury Assessment

• Examine for signs of laryngeal injury including hoarseness, stridor, subcutaneous emphysema, or palpable crepitus, though these injuries are infrequent in survivors and rarely interfere with airway management 5, 4
• Obtain CT angiography once stabilized to identify blunt cerebrovascular injury, cervical spine fracture, and airway injuries 5

Pulmonary Complications

• Anticipate pulmonary edema which may develop from neurogenic factors or negative intrathoracic pressure and is implicated in most in-hospital deaths among near-hanging patients 5, 4
• Monitor for bronchopneumonia as a secondary complication requiring aggressive respiratory support 4

Post-Resuscitation Stabilization

Positioning and Monitoring

• Place in recovery position (lateral recumbent with arm nearest you at right angle, far knee flexed) if breathing spontaneously but unconscious, to prevent aspiration and maintain airway patency 1
• Continue monitoring for signs of airway occlusion, inadequate breathing, or deterioration in responsiveness 1
• Reposition supine immediately if any signs of life are uncertain or if respiratory status deteriorates 1

Ventilatory Support

• Provide mechanical ventilation for patients requiring intubation, with aggressive oxygenation to optimize cerebral perfusion regardless of initial neurological presentation 4
• Avoid excessive ventilation which can increase intrathoracic pressure and impair venous return 1

Prognostic Considerations

• Do not withhold aggressive resuscitation based on initial neurological assessment, as poor initial condition does not exclude good recovery; in one series, >50% of critically ill near-hanging patients survived to hospital discharge 5, 4
• Recognize that cardiac arrest predicts poor outcome, though individual cases may still recover with full neurological function 5, 6

Mandatory Psychiatric and Safety Interventions

Immediate Risk Assessment

• Arrange immediate psychiatric evaluation during or immediately after medical stabilization to determine need for inpatient hospitalization 1, 2
• Assess for high-risk indicators including persistent wish to die, continued suicidal intent, current agitation, serious depression, active substance use disorder, and inadequate support system 1, 2

Hospitalization Criteria

• Admit to psychiatric facility if any high-risk indicator is present, as this provides protected environment for complete evaluation and therapy initiation 1, 2
• Use involuntary commitment if patient or family refuses necessary hospitalization when immediate risk of self-harm exists 2

Means Restriction (Critical Safety Measure)

• Remove all firearms from the home immediately, as simply having a gun in the home doubles youth suicide risk and parents consistently underestimate children's ability to access locked firearms 2
• Lock up all medications including prescription and over-the-counter drugs 1
• Develop structured safety plan collaboratively with patient and family, including warning signs, coping strategies, social support contacts, and professional crisis resources 1, 2

Critical Pitfalls to Avoid

• Do not delay CPR to assess for injuries or obtain history; resuscitation takes absolute priority 1
• Do not rely on "no-suicide contracts" as these have not been proven effective in preventing suicidal behavior 1, 2
• Do not discharge without confirmed psychiatric follow-up and means restriction verification 2
• Do not assume low risk based on method lethality alone; intent and psychiatric factors are more important than the actual danger of the method used 1
• Do not underestimate access to locked firearms; adolescents frequently find ways to access supposedly secured weapons 2

Follow-Up Care Structure

• Maintain contact with patient even after psychiatric referral to enhance continuity of care and treatment adherence 1, 2
• Schedule closely-spaced follow-up appointments with flexibility for crisis visits 2
• Initiate evidence-based psychotherapy: cognitive-behavioral therapy (CBT) reduces post-treatment suicide attempt risk by half, while dialectical behavior therapy (DBT) is effective for patients with borderline personality disorder and reduces both suicidal and non-suicidal self-directed violence 1, 2