What is the management approach for a patient who has been hanging, with potential for respiratory distress, cardiac arrest, or neurological compromise?

Management of Hanging

Immediate Scene Safety and Victim Removal

Rapidly cut down or remove the victim from the hanging position using the fastest means available, and do NOT routinely perform cervical spine immobilization unless specific trauma indicators are present. 1, 2

• Ensure scene safety for rescuers before approaching—danger to the rescuer must never be ignored 1
• Cervical spine injury is rare in hanging victims (documented in 0% of transported patients in one series), and cerebral hypoxia rather than spinal cord injury is the primary cause of death 2, 3
• Cervical spine immobilization should only be considered if there are obvious clinical signs of injury, alcohol intoxication, or history of diving into shallow water 4

Airway and Breathing Assessment

Check responsiveness by gently shaking shoulders and asking loudly "Are you all right?" then immediately open the airway using head tilt-chin lift maneuver. 1

• Remove any visible obstruction from the mouth, including dislodged dentures (leave well-fitting dentures in place) 1
• Look, listen, and feel for breathing for 10 seconds: look for chest movements, listen for breath sounds at the mouth, feel for air on your cheek 1
• Treat occasional gasps as absent breathing—gasps do not provide adequate ventilation 1, 4

Rescue Breathing and Circulation

If the victim is not breathing normally but has a pulse, give 2 effective rescue breaths (1.5-2 seconds each, 400-600 ml air) that make the chest rise and fall, then continue rescue breathing at approximately 10 breaths per minute. 1

• Assess for signs of circulation: look for any movement, swallowing, or breathing; check carotid pulse 1
• Take no more than 10 seconds to check for pulse—if not definitely felt, start chest compressions immediately 1, 4
• Recheck for signs of circulation every minute (no more than 10 seconds each time) 1

Cardiopulmonary Resuscitation

If no pulse is definitely felt within 10 seconds or the patient is in cardiac arrest, begin chest compressions immediately at a depth of at least 2 inches (5 cm) at a rate of 100 compressions per minute. 1, 4

• Standard BLS and ACLS measures should take priority, with a focus on high-quality CPR (compressions plus ventilation) 4
• The first monitored cardiac rhythms in hanging victims are typically asystole or pulseless electrical activity (PEA), which are nonshockable rhythms 3
• Continue resuscitative efforts until the patient is evaluated by advanced care providers 4

Advanced Airway Management

Following external stabilization of the neck, nasal or oral endotracheal intubation is appropriate emergency airway management in hanging victims. 2

• The most experienced available operator should manage the airway in critically ill patients with potential airway obstruction 4
• Videolaryngoscopy is recommended as it is superior to direct laryngoscopy, leading to better glottic view, higher success rate, and fewer complications 4, 5
• Manual-in-line stabilization should be used during intubation if cervical spine injury is suspected, with removal of at least the anterior part of the cervical collar to facilitate mouth opening 4
• Front-of-neck access (FONA) equipment must be immediately available if intubation fails 4

Critical Pitfalls to Avoid

• Do NOT delay resuscitation to assess for cervical spine injury unless specific trauma indicators are present 1, 2
• Do NOT use abdominal thrusts or Heimlich maneuver—these are not indicated for hanging victims and can cause injury, vomiting, and aspiration 1, 4
• Do NOT mistake occasional gasps for adequate breathing 1, 4
• Do NOT take more than 10 seconds to check pulse before initiating compressions 1, 4
• Do NOT delay activating emergency response systems while awaiting the patient's response to interventions 4

Post-Resuscitation Considerations

• Cardiac arrest predicts poor outcome in hanging victims, with survival rates of approximately 9.6% in one series 3
• In survivors, more than 50% may survive to hospital discharge if they did not experience cardiac arrest 6
• All survivors require evaluation for blunt cerebrovascular injury, laryngeal injury, and tracheal/oropharyngeal injury, though these occur in less than 5% of patients 6
• Underlying mental health issues must be addressed to avoid recurrent suicide attempts, as 30% of patients may be admitted for their second attempt 6