CASE DISCUSSION

Presenter : Dr. Shalini Sagar hospitals

CASE - 1
27 yrs, male, No H/0 Major illness Alleged h/o hanging on 26/6/10. 10:30 pm Brought to casuality after 11/2 hrs

IN CASUALITY
Deeply unconscious Pupils b/l equal, reactive Flexor Response to Pain GCS 6 Vitals stable , Sinus TACHYCARDIA sPo2 92% (RA) Sugars normal LIGATURE MARK IN NECK +

INTUBATED AT ER SHIFTED TO ICU CT BRAIN AND Cx SPINE NORMAL 24 hrs Ventilated with CMV mode and Sedation with FENTANYL

MANAGEMENT
Ventilated for 24 hrs nootrophil Nominal antibiotics Fully conscious, alert, moving all limbs/On Desedation EOM normal, no facial deficit Extubated Psychiatry opinion Transferred to ward

CASE - 2
17 yrs, female, No H/o Major illness h/o hanging around 4 pm, Ligature removed after about 2 min Immediately brought to hospital after ~ 1hour

IN CASUALITY
Unconscious Pupil b/l equal and reactive Localising to painful stimuli Sinus tachycardia Vitals stable Intubated Shifted to ICU LIGATURE MARK - +

FURTHER EVENTS
CT BRAIN & Cx SPINE NORMAL CXR Lt lung collapse ET > Rt bronchus ET repositioned Bronchoscopy no mucus plug or Secretions causing collapse

Management
Ventilated for 24 hrs Nootrophil, nebulisation Antibiotics and Physiotherapy

After 24 hrs
Fully conscious, alert No focal deficits Improved CXR T-piece trial and extubated Psychiatry evaluation Shifted to wards Discharged after 5 days

CASE - 3
27 yrs, female, Presented to ER with Seizures, H/o Hanging CT Brain / CT Spine -Normal Intubated , Antiepileptics,Steriods ECG at ER Normal ECG on 2nd day minimal ST Elevation in INF leads and T Depression in ANT Leads but Haemodynamically stable ECHO,Trop I -Normal

DISCUSSION

HANGING
Form of Asphyxia, which is caused by suspension of Body by a Ligature,which encircles the neck .The constricting force being the weight of the body. Most common form of sucessful suicide. Types 1. Classified by Intent Homicidal,Sucidal,Autoerotic,Accidental, Judicial

Classification
1. complete or incomplete When the whole body hangs off the ground and the entire weight of the victim is suspended at the neck, the hanging is said to be complete. Incomplete hangings imply that some part of the body is touching the ground and that the weight of the victim is not fully supported by the neck.

 Judicial hanging, in which the body drops a distance greater than the height of the victim and death occurs by spinal cord transection, non-judicial hanging, where there is no significant drop and injury occurs due to compression of neck structures.' Non-judicial hanging may be fatal or nonfatal; in the latter case the term "near hanging" is used.

NON JUDICIAL HANGING

1. Mechanical constriction of Neck structures, Asphyxia,Venous occlusion or Arterial occlusion. 2. Carotid Sinus compression 3. Injury of Spinal cord and Brain stem [<1%]. 4. Soft Tissues Injuries of Neck

COMPLICATIONS
Injuries, including fractures, of the larynx and Cx spine, Tracheolaryngeal Injury . Pulmonary complications, including aspiration pneumonia, bronchopneumonia, and ARDS, are a major cause of mortality and morbidity in near hanging victims, and are the major complications. Long term survivors may display a variety of neuropsychiatric sequelae ranging from psychosis to amnesia, thought to be due to hippocampal sensitivity to anoxia. Status Epilepticus,Esophageal Rupture

International Journal of Epid 19th Jan 2005 Rx of Non Judicial Hanging [Modified from Iserson]
Pre Hospital 1. Stabalize neck, cut of ligature ,donotcut knot ED 1. Maintain cervical stabilization 2. Secure airway with inline cervical stabilize prepared for surgical airway. 3. Maintain high flow oxygen & continue ventilat 4. Check other self induced injuries [Gun shot wound poison laceration] 5. X-ray/CT Neck R/o bony injury and dislocation 6. Look raised ICP and Rx 7. Admit for observat and even with ~ neurological and pulmonary status.

INTENSIVE CARE UNIT

Generally supportive, being directed at airway control with endotracheal intubation. ventilation using positive end expiratory pressure (PEEP), and hyperventilation. Fluids are restricted and mannitol may be indicated. The role of prophylactic anticonvulsants, naloxone, and steroids remains controversial.

J Anaethesia 1997 Apr Airway in Nonlethal Hanging

1. Laryngotracheal Injuries [20-50% post mortem] rare in survivors 2. Spinal injuries [<1%] Cerebral Hypoxia is the cause of death . 3. Pulmonary complications-Pulm Edema Bronchopneumonia ,ARDS Hospital death Pulmonary EDEMA Likely due to Neurogenic factors or ve Intrathoracic pressure

Conclusion
Airway Injuries severe enough to interfere with airway Rx are uncommon after attempted Sucidal Hanging Irrespective of initial neurological assessment,Aggressive /Early resusitation to optimize cereral oxygenation is recommended

Pulmonary Distress Following attempted sucidal hanging IJM Feb 2009

1. Post obstrutive pulmonary distress caused by pulmonary or neurogenic pulm EDEMA,ARDS,ASPIR,Neck vessel compression 2. Post obstructive pulm distress 11% . 3. GCS,type of Duration of Hang ,Delay in medical Aid did not affect.

J Emer Medicine 1994 May Assess complication of near Hanging

1. Aggressive resusicitation of post Anoxic Brain injury/Even with Victims GCS~ 3 Survived to be D/C with ~ Mental Status 2. No Cervical spine injuries [Consider if foot drop/Focal neurological deficits

EVIDENCE BASED PROGNOSTIC INDICATORS

Duration of hanging corelates with outcome , studies suggested that <5min has favourable outcome. (VanderKrolL, WolfeR. The emergency department management of near hanging victims. J EmergMed1 994;12:28592.) Anoxic brain injury seen on head CT is the only independent predictor of poor outcome with mortality as high as 75%. (MatsuyamaT, OkuchiK, SekiT, MuraoY. Prognostic factors in hanging injuries. AmJ EmergMed2004;22:20710)

 Patients admitted with a GCS >3 had a 50% survival. (Penney DJ, Stewart AHL, ParrMJA. Prognostic outcome indicators following hanging injuries. Resuscitation 2002;54:279) Presence of cardiac arrest inuenced outcome. (VanderKrolL, WolfeR. The emergency department management of nearhanging victims. J EmergMed 1994;12:28592)

TAKE HOME POINTS

1. Aggressive Resucitation irrespective of on arrival neurology 2. Cervical Spine injury Rare [<1%]. 3. Ventilate ~24 Hrs post Hypoxemic Injury

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