What is the appropriate initial assessment and management of a patient found hanging, including airway, breathing, circulation, cervical spine protection, neurologic evaluation, and necessary imaging?

Initial Assessment and Management of Hanging Patients

Immediately cut down the patient and begin simultaneous assessment of airway, breathing, and circulation while maintaining cervical spine precautions, as hanging injuries carry risk of both cervical spine injury and hypoxic brain damage requiring aggressive resuscitation regardless of initial presentation. 1, 2

Scene Safety and Initial Actions

• Ensure scene safety first before approaching the patient, looking for ongoing hazards such as structural instability or other dangers. 1
• Cut down the patient immediately and place on a firm surface for assessment. 2
• Check responsiveness by gently shaking shoulders while asking loudly "Are you all right?" to determine consciousness level. 1

Cervical Spine Protection (Critical in Hanging)

• Assume cervical spine injury until proven otherwise in all hanging patients, as the mechanism involves significant force to the neck. 3, 4
• Apply manual in-line stabilization immediately rather than rigid collars during initial airway management, as this provides optimal immobilization while allowing airway access. 3, 5
• Avoid head tilt maneuvers if trauma to the neck is suspected; instead use jaw thrust without head extension to open the airway while minimizing cervical spine movement. 3, 1

Airway Assessment and Management

• Open the airway using jaw thrust (not head tilt-chin lift) given the presumed cervical spine injury, placing fingertips under the bony part of the chin and lifting anteriorly. 3, 1
• Remove visible obstructions from the mouth including dislodged dentures, but leave well-fitting dentures in place. 3, 1
• Prepare for immediate intubation if the patient is gasping or has poor respiratory effort, as hanging victims often require assisted ventilation. 2
• Consider videolaryngoscopy as the preferred intubation technique in cervical spine injury, though multiple techniques are acceptable with manual in-line stabilization maintained. 3, 6

Breathing Assessment

• Look, listen, and feel for breathing for exactly 10 seconds: look for chest movements, listen at the victim's mouth for breath sounds, and feel for air on your cheek. 1
• Recognize that occasional gasps do not count as normal breathing and require immediate intervention. 1
• If not breathing or only gasping, provide 2 effective rescue breaths (each 1.5-2 seconds, 400-600 ml volume) that make the chest rise and fall. 3
• If rescue breaths are unsuccessful after 5 attempts, move immediately to circulation assessment rather than persisting. 1

Circulation Assessment

• Assess for signs of circulation by checking the carotid pulse at a single site while simultaneously looking for movement, taking no more than 10 seconds total. 1
• If no pulse is detected or you are uncertain after 10 seconds, immediately begin chest compressions at a rate of 100 per minute with 4-5 cm depth. 3, 1
• If circulation is present but breathing is absent, continue rescue breathing and recheck circulation every minute. 1

Neurologic Evaluation

• Assess level of consciousness using the Glasgow Coma Scale, as scores less than 8 increase the likelihood of cervical spine injury. 6
• Document any focal neurologic deficits including motor and sensory function in all extremities. 4, 6
• Recognize that severe neurologic deficits are often reversible in near-hanging cases, so aggressive treatment should proceed regardless of initial presentation. 2, 7
• Understand that 2-10% of patients may develop delayed neurological deterioration even without clear causative factors, which should not be automatically attributed to airway interventions. 3, 6

Imaging Requirements

• Obtain CT scan of the cervical spine as the primary imaging modality to evaluate for bony injury. 4
• Follow with MRI of the spinal column to assess ligamentous injury and spinal cord damage, which guides surgical management. 4
• Complete a three-view x-ray series supplemented with CT as an effective strategy to rule out cervical spine injury. 6

Critical Timing Considerations

• Complete the entire initial assessment rapidly: responsiveness check in seconds, breathing assessment in exactly 10 seconds, and circulation check in no more than 10 seconds. 1
• Do not delay resuscitation for imaging in unstable patients; stabilize airway, breathing, and circulation first. 4, 2
• Initiate intensive care management immediately as hanging victims require close monitoring for complications including aspiration pneumonia and metabolic derangements. 4, 2

Common Pitfalls to Avoid

• Never use head tilt-chin lift in hanging patients due to the high risk of cervical spine injury; always use jaw thrust. 3, 1
• Do not withhold aggressive resuscitation based on poor initial presentation, as excellent outcomes are possible even in patients presenting with gasping and dismal clinical status. 2, 7
• Avoid bilateral carotid pulse checks or checking multiple sites sequentially, as this wastes critical time without improving assessment accuracy. 1
• Do not exceed 10 seconds for pulse assessment; if uncertain, start compressions immediately as the risk of unnecessary compressions is low compared to delayed CPR. 1
• Never assume absence of cervical spine injury even if the patient is conscious, as injury patterns vary and immobilization should be maintained until imaging excludes injury. 5, 6