Hanging Injuries and Strangulation Workup

Updated: Jan 19, 2016
  • Author: William Ernoehazy, Jr, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
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Laboratory Studies

Laboratory tests should not be drawn until after the airway has been assessed and, if necessary, secured. Arterial blood gases (ABGs) analysis should be obtained in all patients who require intubation, for subsequent ventilator management. Given the ready availability of pulse oximetry, ABGs are unnecessary in patients who do not require endotracheal intubation.


Imaging Studies

In nonjudicial hangings, cervical spine injury is rare.

Judicial hangings are characterized by drops that are greater than the victim's height. In such drops, the head hyperextends as the noose stops the victim. Classically, the result is bilateral fracture through the pedicles of C2; the body of C2 is displaced anterior to the vertebral body of C3. These hangman fractures are seen best on the lateral radiograph of the cervical spine.

Soft-tissue neck radiographs should be obtained in nearly all strangulation victims and patients with a mechanism consistent with hanging. Generally, a fractured hyoid bone indicates a severe, occult soft-tissue injury, even in a patient whose medical condition is otherwise stable. Defer such studies until the airway is secure.

Chest radiographs are indicated after endotracheal intubation for placement confirmation and to establish a baseline against which to measure the patient's course. Acute respiratory distress syndrome (ARDS) can occur as a complication of these injuries.

CT scanning of the head is indicated when the neurologic status is compromised. CT scanning of the neck provides increased sensitivity for the detection of subtle fractures and other soft-tissue abnormalities. Additionally, clinically subtle injuries to the laryngeal cartilage may not be apparent on plain radiographs. [11]

Doppler vascular imaging, CT angiography, or arteriography of the carotids should be considered in cases of garroting. The thin wires or cords used in these assaults often produce deep vascular thrombosis. MRI may be a reasonable choice in centers where it is readily available.



In patients who are not at immediate risk of airway compromise, direct fiberoptic laryngoscopy and microlaryngoscopy may play a role in establishing the full pattern of injuries. An ENT consultation can establish both the need for, and the timing of, these studies.