Hanging Injuries and Strangulation Workup

Updated: Dec 03, 2020
  • Author: Scott I Goldstein, DO, FACEP, EMT-T/PHP; Chief Editor: Trevor John Mills, MD, MPH  more...
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Workup

Approach Considerations

Laboratory tests should not be drawn until after the airway has been assessed and, if necessary, secured. Arterial blood gas (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.

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.

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Laboratory Studies

As with any traumatic injury, begin with an evaluation of the patient’s airway, breathing, and circulation. Immediate resuscitation should take priority over imaging. After the patient is stabilized, laboratory studies may include complete blood count (CBC), CMP, coagulation studies, beta-HCG, toxicology panel (alcohol, drug, aspirin, and acetaminophen levels), lactic acid, and arterial blood gasses. Laboratory tests should not be drawn until after the airway has been assessed and, if necessary, secured. Arterial blood gas (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. [8]

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Imaging Studies

There are numerous studies that can be inituated in the strangulated/hanged patient. The goal is to make sure that there is no continued active life-threatening injuries (eg, hemorrhage, expanding hematoma, airway compromise). Once the patient is stabilized, continued imaging is appropriate to evaluate for various other injuries, which can lead to chronic conditions. 

Given the varied injuries associated with hanging and strangulation and the superiority of CT over plain films in the evaluation of the cervical spine, [15, 25]  early CT imaging and CT angiography should be obtained in any symptomatic hanging survivor. If there is any neurologic abnormality on initial assessment, CT imaging of the head is also indicated. MRI may have a role in further defining injuries found at initial imaging.

As always, 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.

Postmortem CT (PMCT) is used to identify fractures after hanging and strangulation. Decker et al noted that although PMCT may not detect soft-tissue injuries in decomposed remains or subtle internal hemorrhages in neck injury, it is able to detect bony injuries as well as autopsy and might surpass autopsy in detecting subtle fractures. [29]

MRI has been shown on autopsy to successfully detect soft-tissue lesions in relation to strangulation and can serve as an alternative method or provide additional value to autopsy. Deininger-Czermak et al noted that MRI showed a high efficiency in verifying intramuscular hemorrhages that were confirmed on autopsy. [30, 31]

In a systematic review by Gascho et al, when compared to autopsy, CT demonstrated equivalent results regarding detection of fractures (mainly fractures of the hyoid bone or thyroid cartilage were investigated). They noted that the gas-bubble sign may even facilitate the detection of laryngeal fractures on CT. For detection of hemorrhages in the soft tissue of the neck, postmortem MRI was found to be more suitable for the detection of the gas-bubble sign in cases of strangulation. [32]

 

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