Hanging Injuries and Strangulation Clinical Presentation

Updated: Jan 19, 2016
  • Author: William Ernoehazy, Jr, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
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Several specific patterns of presentations are common.

  • Assault victims may present after being either manually strangled or garroted.
  • Hanging victims may be brought to the emergency department by Emergency Medical Services (EMS) after being found by strangers, friends, or family members. These patients may have been suicidal. However, they also may have been experimenting with autoerotic asphyxia, or other forms of "breath play," and were hanged by accident. (See Causes.) Attempts to determine the height of the drop in near-hanging victims are important, as different patterns of injury occur as the drop height increases. This, in turn, affects management.
  • Infants generally present after being caught by the neck between crib slats, fence slats, or on objects such as hanging window cords.


Physical signs include the following:

  • 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 fracture [7]
  • Mild cough
  • Stridor
  • Muffled voice
  • Respiratory distress
  • Hypoxia (usually a late finding)
  • Mental status changes


Common causes of strangulation injuries include the following:

  • Assault: Risk factors follow other types of assault, with the exception that women are more likely than men to be victims of strangulation.
  • Depression can lead to hangings, especially in subgroups (eg, prisons, where hangings are easier to do than other methods) or veterans. [8]
  • Erotic experimentation: Some people experiment with hypoxia as a means of intensifying orgasm. Marquis de Sade first described this practice in his writings. Autoerotic play using a ligature or noose to produce hypoxia during masturbation can result in accidental strangulation. [9] Sado-masochistic activities can also result in inadvertent death. [10]
  • Another form of "breath play" is increasingly common among adolescent and young adults. Most commonly known as the "choking game," it involves voluntary choking, throttling, or near-hanging in order to enjoy the altered sensations that occur as the "player" becomes unconscious. [5, 6] Other slang names at this writing include "flatline," "space monkey," and "suffocation roulette."