Hanging

By intern

Introduction
About 3500 people die each year in

the United States form suicidal

hanging or strangulation.
Its the 3rd common form of suicide.
Hanging is the most common choice
for people who suicide successfully in
recent 10 years in Taiwan.

Introduction
Judicial hanging

Since Biblical time

Slow strangulation with victim Dancing
Clean and instantaneous
Thickness of rope
Position of the knot
Length of drop
Not performed in majority of countries now

Classification of hanging
Non-judicial vs Judicial
Suicide, homicide and accidental

Suicidal: Most common, Male:Female=3:1

Homicide: Rare
Accidental:Most common in childhood
Autoerotic hanging

Complete vs Incomplete
Typical vs atypical

Clinical Feature of Hanging

Clinical feature

Hemorrhage in area of ligature

Brownish groove in the neck
Hoarseness and stridor
Pain on swallowing
Subconjunctival hemorrhage
Tardieus spot

The mechanism of hanging

death
Airway compression?
How about victim with tracheostomy
Vomitus in the airway of hanging victim

Cervical fracture with spinal cord

transection?

Believed to be the main reason of judicial

hanging.
Few victim has cervical fracture in autopsy
Hanging on the bed?

The mechanism of hanging

death
Decapitation
Cases reported in extreme situation:
heavy body, inelastic/thin rope, fall from
great distance.

Hyperactive

parasympathetic/sympathetic nerve
by carotid compression?
Hypothesis that has been proposed

The mechanism of hanging

death
Vascular compression with brain
asphyxia

Believed to be the main mechanism

Vessels
Internal jugular vein(2kg)
Common carotid artery(5kg)
Vertebral artery(30kg)
Collateral circulation
(Trachea 15kg)

Related Anatomy of
Hanging
(past the atlas)

Human experiment
Acute obliteration of neck circulation
with 600mmHg cuff (part I)

Blurring of vision
Constriction of visual fields
Loss of conscious (6-6.5 sec)
Hypoxic convulsion
EKG minimal change

Human experiment
Prolonged occlusion of cerebral
circulation up to 100 sec.

Convulsion,Cyanosis, Involuntary
urination, Involuntary defection,
Bradycardia and dilation of pupils
occurred after loss of consciousness

Pathophysiology of Hanging
Neck pressure

Venous obstruction(stasis hypoxia)

Common carotid artery obstruction?

Loss of consciousness

Decreased neck muscle tone

Vetebral and common carotid artery obstruction

DEATH

Complication of hanging
patient
Laryngeal
Fracture of larynx(9%)
Soft tissue edema
Stridor, hoaresness, dysphagia

Pulmonary

Bronchopneumonia
Lung edema
ARDS

Complication of hanging
patient
Neurological
Delayed neurological damage?

Bilateral basal ganglia damage

Reperfusion injury?
Excessive catecholamine or amino acid?
Calcium?

Korsakoff syndrome, progressive dementia

Amnesia
Accessory nerve injury

Others

Thrombosis of cervical artery?

intimal and media injury in neck artery has been reported

Prognosis
Unpredictable!!!!!
Risk factors identified in pediatric study
Failed to resume heartbeat an drespiration
with administration of first aid
Apneic or had agonal respiration in ER
Initial pH less than 7.2
Required ventilator

Management
ABC
Aggressive airway management is essential
Most delayed mortality result from pulmonary
complication!!!

Sympathomimetics and judicious use of fluid for

hypotension
Cardiac arrhythmia be identified and treated
Treat IICP

Other investigation
X-ray of neck

Observe in hospital at least 24 hours

Management
Potential useful drug
Phenytoin?
Reduce the chance of seizure
Has been shown helpful in arresting the development
of centroneurogenic ARDS

Naloxone
Reverse the signs of cerebrovascular ischemia in
animal model

Calcium channel blocker

Barbiturate and steroid: controversial

Thank for your attention

Reference
Strangulation: A Review of ligature, Manual and
Postural Neck Compression Injuries-

Annals of Emergency

Medicine March 1984;13:179-185

Hanging and Strangulation Injuries- The Clinical Practice of

Emergency Medicine,2nd edition by Harwood-Nuss etc. 566-567

Asphyxia- Forensic Pathology, 2nd edition by DiMaio etc.229-277

Delayed death after attempted suicide by hangingInt. J. Legal Med.1997;110:164-66

The neuropsychological sequelae of attempted

hanging-J. of Neurology, Neurosurgery and Psychiatry.1991;54:546-88