Classification and Management of Neck Compression and Strangulation Injuries The Devil Inside - PowerPoint PPT Presentation

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Classification and Management of Neck Compression and Strangulation Injuries The Devil Inside

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Anesthesia on-call team called to 19S for an airway ... Hypoxia (usually a late finding) Mental status changes. Classification of hanging injuries ... – PowerPoint PPT presentation

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Title: Classification and Management of Neck Compression and Strangulation Injuries The Devil Inside


1
Classification and Management of Neck Compression
and Strangulation Injuries(The Devil Inside)
  • Resident James Mura
  • Attending J. David Roccaforte
  • Bellevue Hospital

2
The Case
  • Anesthesia on-call team called to 19S for an
    airway
  • On arrival, male patient on the floor, ACLS
    performed by medical staff
  • Per guards and nursing staff, pt found hanging
    from a door and cut down by guard ligature by
    SCD tubing
  • Unknown down time

3
The Case (cont.)
  • Quick first assessment pt not breathing, faint
    femoral pulse
  • Went to the head, with in-line stabilization,
    intubated by TRACC resident with one attempt
  • Pt transferred to stretcher with continued neck
    stabilization and transferred to MICU

4
In the MICU
  • ABGs initially 6.78/141/74, BE -13.8, lactate 16
  • Subsequently in MICU while mechanically
    ventilated 7.36/37/201
  • Pt background (obtained later) 36 y/o male with
    a history of schizophrenia and a history of a
    prior suicide attempt by hanging

5
Subsequent Course
  • Cervical Xrays negative for bony injury
  • Head CT (2 days post-injury) complete loss of
    gray/white discrimination in both hemispheres
    increased attenuation within the subarachnoid
    space, suggestive of brain compression.
    Consistent with severe anoxic brain injury
  • Neck CT no cervical fractures or displacements
    soft tissue swelling.
  • EEG (3 days post-injury) single spike every 3 or
    4 seconds severe diffuse bilateral cerebral
    dysfunction consistent with anoxic injury
  • Tracheostomy performed 6 days post-injury
  • Ten days post-injury, pt had profound bradycardia
    progressing to cardiac arrest ACLS protocols
    attempted, but ultimately unsuccessful. Pt
    pronounced dead.

6
Epidemiology
  • Up to 2.5 of all traumatic deaths worldwide
  • National Center for Health Statistics (2001)
  • 279 deaths nationwide from "other accidental
    hanging and strangulation
  • 456 deaths from accidental suffocation and
    strangulation in bed"
  • 131 deaths from "hanging, strangulation, and
    suffocation"
  • 5555 deaths from "other accidental threats to
    breathing"
  • At-risk populations
  • prisoners
  • adolescent males
  • patients with psychiatric histories
  • infants/toddlers
  • Luke, 1964 106 sequential hanging deaths in NYC.
  • 79 at home
  • 8 in hospital
  • 6 at work

7
Common causes
  • Assault
  • Depression
  • Other causes
  • (autoerotic strangulation)

Annals of Emergency Medicine
8
Initial Physical Exam Findings
  • Abrasions, lacerations, contusions, or edema to
    the neck, depending on how the patient was
    strangled
  • Subconjunctival and skin petechiae cephalad to
    the site of choking (Tardieu spots)
  • Severe pain on gentle palpation of the larynx,
    which may indicate laryngeal/hyoid fracture
  • Mild cough
  • Stridor
  • Muffled voice
  • Respiratory distress
  • Hypoxia (usually a late finding)
  • Mental status changes

9
Classification of hanging injuries
  • Complete vs.
    incomplete

10
Classification (continued)
  • Judicial strangulation and hanging
  • Ligature/manual strangulation
  • Postural strangulation

11
Cervical spine anatomy
12
Pathophysiology Judicial Strangulation
  • Judicial hanging death by c-spine injury
  • The long drop vs. the short drop
  • Hangmans fracture vs. asphyxia
  • gt14 feet decapitation

13
British Hanging Formula The Long Drop
14
Pathophysiology (cont.) The Short
Drop/Ligature Strangulation
  • Mechanism unclear
  • injury of spinal cord and brain stem
  • mechanical obstruction of neck structures
    (arterial and/or venous)
  • cardiac arrest (carotid sinus involved)

Hadaka-jime Aikido hold
15
Mechanism of Ligature Strangulation
16
(No Transcript)
17
Management
  • Aggressive management despite initial neurologic
    findings
  • neck stabilization
  • radiologic imaging
  • intubation and mechanical ventilation with PEEP
  • treatment of possible increased ICP.
  • Determine mechanism
  • Poor prognostic indicators
  • agonal/absent respirations
  • absent pulse
  • requirement for immediate intubation
  • pHlt7.2.

18
Management (cont.)
Annals of Emergency Medicine
19
What role can we play?
  • Important questions
  • mechanism
  • fall
  • type of ligature
  • Airway management
  • substances affecting respiratory function
  • cervical instability
  • full stomach
  • edema of airway structures
  • increased intracranial pressure/herniation
  • Subsequent ICU care

20
Important issues not to be missed/medicolegal
pitfalls
  • Failure to
  • adequately stabilize or address associated
    cervical spine injuries
  • refer near-hanging victims for psychiatric
    evaluation
  • obtain soft-tissue neck radiographs
  • address the potential for delayed airway
    compromise
  • obtain appropriate consultation for evaluation of
    suspected laryngeal injuries
  • seek other injuries or illnesses in the
    potentially suicidal patient
  • consider carotid artery injury in patients with
    neurologic sequelae

21
References
  • Swann H, Brucer M The cardiorespiratory and
    biochemical events during rapid anoxic death
    obstructive asphyxia.Tex Rep Biol Med,
    19497593-603.
  • Iserson, Kenneth Strangulation A review of
    ligature, manual, and postural neck compression
    injuries. Ann Emerg Med, 198413179-185.
  • Luke, JL Asphyxial deaths by hanging in New York
    City, 1964-1965. J Forensic Sci. 1967
    Jul12(3)359-69.
  • Nikolic et al Analysis of neck injuries in
    hanging. Am J Forensic Med Pathol. 2003
    Jun24(2)179-82.
  • DiMaio, J. Forensic Pathology, 2nd Ed. 2001.

22
The End
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