What is the management approach for a patient who has survived a hanging incident?

Management of Hanging Survivors

All hanging survivors require immediate aggressive resuscitation with standard BLS/ACLS protocols, prioritizing airway management and oxygenation over cervical spine precautions, as cervical spine injury is exceedingly rare in non-judicial hangings and cerebral hypoxia is the primary cause of death. 1, 2

Scene Safety and Initial Response

• Ensure your own safety before approaching the victim, as scene hazards may still be present 3, 1
• Cut down or remove the victim from the hanging position immediately using the fastest means available 1
• Do NOT routinely perform cervical spine immobilization unless there are specific indicators of traumatic injury—cervical spine fractures occur in less than 1% of non-judicial hanging cases and delays in airway management increase mortality 1, 2, 4
• Activate emergency medical services immediately if not already done 3

Airway Management (Priority #1)

Airway compromise from cerebral hypoxia is the primary threat to survival, not spinal injury. 2

• Check responsiveness by tapping shoulders and shouting "Are you all right?" 1
• Open the airway using head tilt-chin lift maneuver (place hand on forehead, tilt head back, lift chin with fingertips) 3, 1
• Remove any visible obstructions from the mouth, including dislodged dentures 1
• Do NOT use abdominal thrusts or Heimlich maneuver—these are not indicated for hanging victims and can cause injury, vomiting, and aspiration 1

Breathing Assessment

• Look, listen, and feel for breathing for 10 seconds: observe 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
• If no breathing or only gasping: give 2 effective rescue breaths (1.5-2 seconds each, making chest rise and fall) 1

Circulation Assessment

• Check for signs of circulation: look for any movement, swallowing, or breathing; palpate carotid pulse 1
• Take no more than 10 seconds to check for pulse—if not definitely felt, start chest compressions immediately 1, 5
• Victims without spontaneous cardiac output at scene have zero survival even with successful initial CPR 4

CPR Protocol (If No Pulse)

• Begin chest compressions immediately at rate of 100-120 per minute 5
• Compress at least 5 cm (2 inches) deep 1, 5
• Perform cycles of 30 compressions to 2 breaths 5
• Minimize interruptions in compressions 5
• Change compressors every 2 minutes to maintain quality 5

If Breathing But Unconscious

• Place in recovery position to maintain airway patency 3
• Monitor peripheral circulation if using recovery position 3
• Provide supplemental oxygen to maintain saturation >94% 3

Hospital Management

• Intubate patients presenting with gasping or poor clinical status immediately, regardless of initial GCS 6
• Provide assisted ventilation and intensive care monitoring 6
• Glasgow Coma Score at scene or on hospital arrival is the strongest prognostic indicator 4
• Monitor for delayed complications including aspiration pneumonia 6
• Aggressive treatment should be initiated regardless of dismal initial presentation—88% survival rate with only 5% poor neurological outcomes in transported patients 6, 4

Psychiatric Evaluation

• Assess for mood disorders, anxiety disorders, or substance abuse once medically stable 3
• Note that 70% of hanging victims have concurrent drug and/or alcohol ingestion 4

Critical Pitfalls to Avoid

• Do NOT delay airway management for cervical spine imaging or immobilization unless obvious traumatic indicators are present 1, 2
• Do NOT mistake gasps for adequate breathing 1
• Do NOT spend more than 10 seconds checking pulse before initiating compressions 1, 5
• Do NOT withhold aggressive resuscitation based on poor initial presentation—severe neurologic deficits are often reversible 6, 7

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