Title: Classification and Management of Neck Compression and Strangulation Injuries The Devil Inside
1Classification and Management of Neck Compression
and Strangulation Injuries(The Devil Inside)
- Resident James Mura
- Attending J. David Roccaforte
- Bellevue Hospital
2The 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
3The 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
4In 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
5Subsequent 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.
6Epidemiology
- 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
7Common causes
- Assault
- Depression
- Other causes
- (autoerotic strangulation)
Annals of Emergency Medicine
8Initial 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
9Classification of hanging injuries
10Classification (continued)
- Judicial strangulation and hanging
- Ligature/manual strangulation
- Postural strangulation
11Cervical spine anatomy
12Pathophysiology Judicial Strangulation
- Judicial hanging death by c-spine injury
- The long drop vs. the short drop
- Hangmans fracture vs. asphyxia
- gt14 feet decapitation
13British Hanging Formula The Long Drop
14Pathophysiology (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
15Mechanism of Ligature Strangulation
16(No Transcript)
17Management
- 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.
18Management (cont.)
Annals of Emergency Medicine
19What 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
20Important 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
21References
- 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.
22The End