What is the management approach for a patient who has experienced a stable hanging?

Management of Stable Hanging Patient

Patients who are neurologically intact (GCS 15) after hanging require minimal workup—imaging should be reserved only for those with cervical spine tenderness PLUS additional concerning signs (dysphagia, dysphonia, stridor, or crepitus), as this approach is 100% sensitive for identifying clinically significant injuries. 1

Initial Assessment and Stabilization

Immediate Priorities

• Assess airway patency and breathing adequacy immediately upon patient arrival, as laryngotracheal injuries can compromise the airway even in initially stable patients 2, 3
• Monitor vital signs continuously including respiratory rate, oxygen saturation, blood pressure, heart rate, level of consciousness, and temperature 4, 5
• Establish IV access and provide supplemental oxygen if SpO2 falls below 94% 5
• Position patient with head elevated 30-35 degrees to optimize oxygenation and reduce aspiration risk 4, 5

Neurological Examination

• Document Glasgow Coma Scale score precisely—this is the single most important stratification tool for determining workup intensity 1, 3
• Patients with GCS 15 represent 66% of near-hanging presentations and have excellent outcomes with minimal intervention 1
• Cardiac arrest at presentation predicts poor outcome, with >50% of critically ill patients without arrest surviving to discharge 3

Risk Stratification for Imaging

Low-Risk Patients (No Imaging Required)

Patients with GCS 15 and no cervical spine tenderness require NO additional imaging workup 1

• This approach avoids unnecessary radiation exposure and healthcare costs
• In a large series, only 2 injuries were identified among 83 neurologically normal patients (C5 facet fracture and low-grade vertebral artery dissection), neither requiring intervention 1

Selective Imaging Criteria

Order CT angiography ONLY if the patient has:

• Cervical spine tenderness AND at least one of the following: dysphagia, dysphonia, stridor, or crepitus 1
• This combination is 100% sensitive and 79% specific for underlying injury 1
• Decreased GCS score (<15) warrants comprehensive imaging per standard trauma protocols 1, 3

Injuries to Evaluate (When Imaging is Indicated)

CT angiography remains the standard for identifying the following uncommon injuries, each occurring in <5% of patients 3:

• Cervical spine fracture
• Blunt cerebrovascular injury
• Laryngeal injury
• Tracheal and oropharyngeal injury

Airway Management Considerations

Intubation Success Rates

• Experienced physician-led teams achieve 100% intubation success rates in pediatric hanging cases despite theoretical concerns about laryngeal edema 6
• Failed airway attempts are rare when performed by skilled providers 6
• Have supraglottic airway devices immediately available as backup 6

Indications for Advanced Airway

• Respiratory distress (use of accessory muscles, nasal flaring, tachypnea, paradoxical breathing) 5
• Inability to maintain adequate oxygenation despite supplemental oxygen
• Decreased level of consciousness requiring airway protection 7

Respiratory Complications Management

Monitoring for Delayed Complications

• Aspiration pneumonia can develop even in initially stable patients 7
• Monitor for fever, increased work of breathing, or declining oxygen saturation over the first 24-48 hours 4, 7
• Pulse oximetry alone is insufficient—directly observe respiratory rate and pattern 5

Treatment of Respiratory Compromise

• Non-invasive positive pressure ventilation (CPAP or high-flow nasal cannula) for SpO2 <90% without contraindications 5
• Opioids are first-line for dyspnea management without causing clinically significant respiratory depression when appropriately dosed 5
• Consider ICU transfer if condition deteriorates or fails to improve with initial interventions 5

Aggressive Resuscitation Principle

All near-hanging patients should be aggressively resuscitated regardless of initial presentation severity 7

• Three consecutive cases with poor initial clinical status (gasping, requiring immediate intubation) all made full neurological recovery with standard intensive care 7
• Early intervention is critical—do not withhold treatment based on dismal initial appearance 7

Targeted Temperature Management

• Evidence for targeted temperature management is limited to one large retrospective multicenter trial with significant selection bias 3
• No firm recommendations can be made regarding routine use of therapeutic hypothermia in asphyxia-related arrest from hanging 3
• Decision should be made in consultation with critical care specialists on a case-by-case basis

Psychiatric Evaluation and Follow-up

Mandatory Mental Health Assessment

• 74% of pediatric hangings and the majority of adult cases involve suicidal intent 6, 3
• 30% of near-hanging admissions represent a second suicide attempt 3
• Psychiatric evaluation must occur before discharge for all intentional hanging cases 3

Discharge Planning

• Ensure psychiatric follow-up is arranged prior to hospital discharge
• Involve social work and case management for safety planning
• Consider inpatient psychiatric admission for high-risk patients

Common Pitfalls to Avoid

• Do not order comprehensive imaging on all hanging patients—this leads to unnecessary radiation exposure and cost without improving outcomes in neurologically normal patients 1
• Do not assume poor initial presentation means futile care—aggressive early intervention yields excellent neurological outcomes even in critically ill patients 7
• Do not discharge without psychiatric evaluation in intentional hanging cases—recurrent attempts are common 3
• Do not rely solely on pulse oximetry for respiratory monitoring—direct observation of respiratory effort is essential 5