What is the immediate management of a patient found after a complete hanging?

Immediate Management of Complete Hanging

Immediately secure the airway with endotracheal intubation while maintaining cervical spine precautions, begin high-quality CPR if the patient is pulseless, and aggressively resuscitate regardless of initial presentation as cerebral hypoxia—not spinal cord injury—is the primary threat to survival. 1, 2

Scene Safety and Initial Assessment

• Ensure scene safety before approaching the victim 3
• Remove the patient from the ligature immediately and lower to the ground 1
• Check for responsiveness by tapping and shouting, while simultaneously assessing for normal breathing 3, 4
• Check for a pulse within 10 seconds—if no pulse is definitely felt, assume cardiac arrest 3, 4

Immediate Resuscitation Based on Patient Status

If Patient is Pulseless (Cardiac Arrest)

Begin high-quality CPR immediately:

• Start chest compressions at a rate of 100-120 per minute with depth of at least 2 inches (5 cm) 4
• Use 30:2 compression-to-ventilation ratio if single rescuer 4
• Minimize interruptions in compressions to less than 10 seconds 4
• Activate emergency response system and retrieve AED/defibrillator 3, 4
• Administer epinephrine 1 mg IV/IO every 3-5 minutes once vascular access is established 4
• Defibrillate immediately if shockable rhythm is identified 4

If Patient Has a Pulse but Inadequate Breathing

Secure the airway immediately:

• Perform endotracheal intubation or use alternative airway management without delay 3, 5
• Provide rescue breathing at 1 breath every 5-6 seconds (10 breaths/minute) 6, 4
• Administer supplemental oxygen to maintain oxygen saturation 94-98% 6

Airway Management with Cervical Spine Considerations

Critical Point: Cervical spine injury is rare in hanging victims, occurring in 0% of cases in the largest study of non-judicial hangings. 1

• Apply external cervical spine stabilization during airway management 3, 1
• Proceed with oral or nasal endotracheal intubation following stabilization—do not delay airway management due to theoretical cervical spine concerns 1, 5
• Use rapid sequence intubation with direct laryngoscopy as the primary method 5
• Confirm tube placement immediately with waveform capnography 4, 5
• Consider video laryngoscopy or supraglottic airway devices if direct laryngoscopy is difficult 5

The evidence strongly supports that cerebral hypoxia, not spinal cord injury, is the cause of death in hanging victims—aggressive airway management should not be delayed. 1, 2

Post-Resuscitation Management

Ventilation Strategy

• Maintain normoventilation with end-tidal CO2 monitoring 3
• Avoid hyperventilation which decreases cerebral blood flow 6, 4
• Titrate oxygen to maintain saturation 94-98% to avoid both hypoxemia and hyperoxemia 6

Hemodynamic Support

• Monitor blood pressure continuously and maintain mean arterial pressure ≥65 mmHg 6
• Administer vasopressors as needed for hemodynamic support 6
• Establish IV/IO access for medication administration 6

Neurological Management

• Initiate targeted temperature management for patients who do not follow commands after return of spontaneous circulation 6
• Monitor for and treat seizures, which are common after hypoxic injury 6

Diagnostic Evaluation

• Obtain 12-lead ECG to identify potential cardiac causes 6
• Check arterial blood gases, electrolytes, glucose, and cardiac biomarkers 6
• Perform cervical spine imaging only if there are obvious clinical signs of injury, history of fall from height, or other trauma mechanism 3, 1

Critical Pitfalls to Avoid

Do not withhold aggressive resuscitation based on poor initial presentation—all three patients in one case series made full neurological recovery despite dismal initial status. 2

• Do not delay intubation due to concerns about cervical spine injury—the risk is minimal and hypoxia is the primary killer 1, 2
• Do not perform maneuvers to relieve foreign body airway obstruction, as these are unnecessary and delay CPR 3
• Do not use excessive ventilation, which increases intrathoracic pressure and decreases cardiac output 6, 4
• Do not assume futility—early aggressive intervention can result in complete recovery even in patients presenting with gasping respirations and poor clinical status 2

Transport Considerations

• Transport to appropriate trauma facility as rapidly as possible 3
• Continue resuscitation efforts during transport 3
• Minimize elapsed time between injury and definitive care 3