What is the management approach for a patient with partial hanging, potential cervical spine trauma, and possible spinal cord injury?

Management of Partial Hanging

Immediately immobilize the cervical spine with a rigid cervical collar and manual in-line stabilization (MILS), maintain systolic blood pressure >110 mmHg, secure the airway if needed using rapid sequence intubation with videolaryngoscopy while removing the anterior collar portion, and obtain CT cervical spine followed by CT angiography to evaluate for vascular injury. 1, 2

Initial Stabilization and Spinal Immobilization

Apply a rigid cervical collar with head-neck-chest stabilization immediately upon arrival, as partial hanging creates high suspicion for cervical spine injury even without fracture. 3 Early immobilization limits onset or aggravation of neurological deficit. 3

• Maintain manual in-line stabilization (MILS) continuously during all patient movements and procedures, as this significantly reduces complications despite low-quality evidence. 3, 2
• Transport directly to a Level 1 trauma center within the first hours, as this reduces morbidity, mortality, and improves neurological outcomes through earlier surgical intervention. 2

Hemodynamic Management

Maintain systolic blood pressure >110 mmHg continuously before and during injury assessment to reduce mortality. 1, 2, 4 This is critical in partial hanging victims who may have concurrent spinal cord injury.

• Target mean arterial pressure ≥70 mmHg during the first week post-injury to limit neurological deterioration. 1
• Place an arterial line immediately for continuous accurate blood pressure monitoring. 1, 2

Airway Management

Partial hanging victims frequently require airway intervention due to laryngeal injury, cerebral edema from anoxia, or altered mental status. Scene or ED Glasgow Coma Score of 3 does not preclude neurologically intact survival, although mortality is high. 5 The most useful prognostic factors include need for airway control by intubation or cricothyrotomy, cardiopulmonary resuscitation, lower scene and ED GCS, and cerebral edema on CT. 5

If intubation is required:

• Use rapid sequence induction with videolaryngoscopy in emergency conditions to reduce intubation failure risk (RR 0.53,95% CI 0.35-0.80). 1, 2
• Remove the anterior portion of the cervical collar during intubation attempts while maintaining MILS to improve mouth opening and glottic exposure. 3, 1, 2, 4
• Use a gum elastic bougie and retain the cervical spine in axis. 3, 2, 4
• Do not use Sellick maneuver as it increases cervical spine movement. 1, 2, 4
• Succinylcholine can be safely used within 48 hours of injury; after 48 hours, switch to rocuronium to avoid hyperkalemia risk from denervation. 2

Diagnostic Imaging Protocol

Obtain CT cervical spine without IV contrast as the initial imaging study for all patients with suspected cervical spine trauma from partial hanging. 1, 4

• For patients with suspected ligamentous injury without fracture on CT, obtain MRI of the cervical spine without IV contrast as the appropriate next imaging modality. 1, 4 Subluxations can occur in hanging injuries even without fractures. 5
• Perform CT angiography of the neck to evaluate for carotid arterial injuries, which are detected in partial hanging victims (sensitivity 90-100%, specificity 98.6-100%). 1, 4, 5 Laryngeal fractures should also be evaluated. 5
• Obtain head CT to assess for cerebral edema from anoxic brain injury, which carries 83% mortality. 5

Temperature Management

Prevent hypothermia aggressively with target core temperature 36-37°C. 1, 2

• Remove all wet clothing immediately and cover the patient. 2
• Apply forced air warming devices as first-line active warming. 2
• Administer only warm intravenous fluids; never use cold IV fluids. 2
• Each 1°C drop reduces coagulation factor function by 10%, and temperatures <34°C are associated with >80% mortality. 1, 2

Respiratory Management

Implement a comprehensive respiratory bundle for cervical spinal cord injury patients combining abdominal contention belt during spontaneous breathing periods, active physiotherapy with mechanically-assisted insufflation/exsufflator device, and aerosol therapy combining beta-2 mimetics and anticholinergics. 1, 2

• **Perform early tracheostomy (<7 days)** for upper cervical injuries (C2-C5), as these patients have >50% reduction in vital capacity and high risk of ventilator weaning failure. 1, 2
• Provide oxygen support and have a low threshold for tracheotomy in patients with serious difficulty breathing. 6

Surgical Considerations

If spinal cord injury is confirmed, early surgery (within 24 hours) is associated with improved neurological recovery as measured by ASIA score improvement (RR of recovery = 8.9,95% CI [1.12-70.64], P = 0.01) and reduced pulmonary complications. 1

• Ultra-early surgery (<8 hours) may further reduce complications and increase neurological recovery in stable patients at well-organized trauma centers. 1

Pain Management

Introduce multimodal analgesia combining non-opioid analgesics, ketamine, and opioids during surgical management to prevent prolonged pain. 1, 2

• Initiate oral gabapentinoid treatment for >6 months to control neuropathic pain. 1, 2

Early Rehabilitation

Begin joint range-of-motion exercises and positioning immediately upon ICU admission to prevent contractures and deformities. 1, 2

• Perform stretching for at least 20 minutes per zone. 1, 2
• Apply simple posture orthoses (elbow extension, metacarpophalangeal joint flexion-torsion, thumb-index commissure opening). 1, 2

Critical Pitfalls to Avoid

• Never leave the cervical collar fully in place during intubation, as this significantly worsens glottic visualization and increases failure rates. 1
• Do not allow systolic blood pressure to drop below 110 mmHg, as this increases mortality risk. 1
• Avoid prolonged rigid collar immobilization beyond 48-72 hours without definitive treatment, as complications rapidly escalate. 1, 4
• Do not delay surgical decompression beyond 24 hours when spinal cord injury is confirmed, as this worsens neurological outcomes. 1
• Do not assume a GCS of 3 is futile—neurologically intact survival is possible in partial hanging victims. 5