Near-hanging as presenting to hospitals in Queensland: recommendations for practice.
Near-hanging is an increasing presentation to hospitals in Australasia. We reviewed the clinical management and outcome of these patients as they presented to public hospitals in Queensland. A retrospective clinical record audit was made at five public hospitals between 1991 and 2000. Of 161 patients enrolled, 82% were male, 8% were indigenous and 10% had made a previous hanging attempt. Chronic medical illnesses were documented in 11% and previous psychiatric disorders in 42%. Of the 38 patients with a Glasgow Coma Scale score (GCS) of 3 on arrival at hospital, 32% returned to independent living and 63% died. Fifty-two patients received CPR, of whom 46% had an independent functional outcome. Independent predictors of mortality were a GCS on hospital arrival of 3 (AOR 150, CI 95% 12.4-1818, P<0.001), taking plain X-rays of the cervical spine (AOR 0.06, CI 95% 0.004-0.97, P=0.047) and contact with the ground (AOR 0.03, CI 95% 0.002-0.62, P=0.02). Only 66% had imaging of the cervical spine performed with other imaging performed infrequently. There were three laryngeal, two hyoid bone and three cervical spine injuries and one carotid dissection. The number of cervical spine X-rays required to find a significant cervical spine fracture was 54. Near-hanging presenting to hospital with a poor conscious state or even cardiac arrest can have a favourable clinical outcome. Radiological investigations are infrequently performed despite a low GCS precluding early accurate assessment. Given the general favourable outcome, an aggressive approach to searching for correctable injuries is recommended.
Key Words: near hanging, clinical practice, epidemiology, retrospective study
The incidence of suicide has decreased from an age-adjusted peak of 14.6 per 100,000 in Australia in 1997 to 12 per 100,000 in 2003, with death from hanging and strangulation increasing from 36% of all suicides to be the most common method of suicide at 45% (1,2). Judicial hanging is no longer carried out in Australia and New Zealand. Hanging is a particularly lethal method of suicide compared to other common presentations such as overdose and self-mutilation (3). However, near-hanging presenting to hospital represents a different entity in terms of its associated injuries and risks of permanent disability.
This study aimed to determine the epidemiology of near-hanging presenting to pubic hospitals in Queensland by performing a retrospective chart review. We have evaluated published management guidelines for their applicability in relation to appropriate imaging and management.
A retrospective chart audit was made in five public hospitals, three tertiary metropolitan and two regional centres. The participating hospitals had volunteered to take part after requests for expressions of interest were sent to all major regional and metropolitan public hospitals in Queensland. ICD-9 and ICD-10 codes for hanging and near-hanging were used to find cases. Only patients presenting to hospital who were subsequently admitted for either suicidal, accidental or indeterminant causes of near-hanging were included. The definition of near-hanging used for this study was the application of external pressure on the neck from a ligature tightened by an individual's body weight through suspension of all or part of the body (4).
The study period was from 1991 to 2000. Data were collected using a standardized proforma including demographics and McCabe's comorbidity score (comorbidity present but of no influence on longevity, survival expected <5 years or survival < 1 year) (5), injuries recorded, prehospital and hospital management, diagnostic and imaging tools used and therapeutic measures adopted. The charts were assessed for documentation of a precipitating life stress or a marital/relationship issue. The near-hanging was categorized as suicidal, homicidal, autoerotic or accidental. Clinical outcomes were assessed as the patient able to return home with independence, home but not independent, nursing home care or death in hospital. Episodes of aspiration pneumonia, pulmonary oedema and acute respiratory distress syndrome were specifically recorded.
Appropriate permission was obtained from the local institutional ethics committee. Data was de-identified and the information stored on a secure database (ACCESS 97 [TM]). Data was analysed using STATA 9 statistical software (College Station, Texas. U.S.A.).
The demographic characteristics of the patients are summarized in Table 1. From 1991 to 2000, there were 161 cases of near-hanging presenting to the participating hospitals. The majority of the patients were male (N=132, 82%) with 13 (8%) identified as of Aboriginal or Torres Straight Islander descent. Most patients were unmarried, either single or in a de facto relationship. Chronic medical illness were found in 17 (11%) of patients with 67 (42%) having a previous history of psychiatric illness. Previous histories of self-harm, drug overdose and alcoholism were common. Sixteen (10%) had a previous attempted hanging. We found the peak presentations in March (11%) and November (14%) with a fairly constant rate of presentation between 5 and 10% for the remainder of the year.
The circumstances of the near-hanging are detailed in Table 2. There were 184 precipitants recognised for the hanging attempt with multiple reasons found in 32 patients (21%). Life stress or marriage/ relationship problems were found in the majority of patients. Concomitant drug use at the time of the near-hanging was noted in 91(57%) of patients, most commonly alcohol. All near-hangings were the result of suicide attempts (N=157, 98%) where information was available. Near-suicides occurring in psychiatric hospitals/unit or prisons represented 7% and 11% respectively of presentations.
Where the circumstances of the near-hanging were clearly recorded, one third of patients had some contact of their body with the ground when found (Table 3). The majority (85%) fell less than 1 metre in height. Ropes or cords (42%) and clothing or bed linen (23%) were the most commonly used ligatures. Most near-hangings occurred inside buildings (66%) and the time to cutting down was generally less than 15 minutes (88%).
At the scene, the median Glasgow Coma Scale score (GCS) was 7 improving to 13 by arrival in hospital (Table 4). Thirty-six patients (22 %) had a GCS of 3 at the scene and 3 on arrival to hospital. Where an ambulance was used (73%), the response time was less than 10 minutes with 32% requiring cardiopulmonary resuscitation at the scene by bystanders, ambulance or paramedics. The duration of resuscitation or rhythm was not recorded. Seventy (43%) required intubation which was mainly performed in hospital. Most patients were intubated for a low GCS (91%) but ten patients (10%) had several reasons documented. Three patients (2%) required a tracheostomy after hospital arrival to secure the airway due to airway swelling precluding intubation.
The majority of patients (N=107, 66%) had a ligature mark visible on external examination of the neck. However, petechiae were uncommon (N=22, 14%). Table 5 summarizes the complications found in the near-hangings. Investigations were inconsistently performed (Table 6). Only 66% of patients had cervical spine X-rays performed with few patients having additional investigations. Five significant injuries were not suspected based upon plain cervical spine X-rays. Two patients with fractures to the thyroid cartilage found on CT had cervical spine plain films reported as normal. One patient with hyoid swelling and hyoid fracture had normal plain cervical spine films. One patient with free cervical gas on CT had no abnormality noted on plain cervical spine X-rays and on endoscopy had glottic swelling. The patient with a small tracheal tear on endoscopy had a normal cervical spine film but did not have a CT of the neck performed. Only one patient had a carotid dissection, documented by both CT and conventional angiography. This patient also had a C2 pedicle fracture with a C2/3 spondylolisthesis and fracture of the thyroid cartilage. Of the 86 patients arriving at hospital with a GCS [less than or equal to] 8, only 48 (56%) had a cervical spine X-ray, 7 (8%) a CT Head, 7 (8%) a CT neck and 2 (2%) an imaging study of the carotid vessels. The number of cervical spine X-rays required to find a significant cervical spine injury was 54 whereas six cervical CT scans were needed to find one significant abnormality. However, the CT scans of the neck were only performed in selected patients with a probable high index of suspicion.
The influence of the clinical presentation on the performance of investigations is detailed in Table 7. The independent predictors of performing a cervical spine X-ray were the GCS at the scene and a history of the patient's body having contact with the ground. A CT head scan was independently predicted by a GCS < 10 at the scene, a need for cardiopulmonary resuscitation, the near-hanging taking place inside a building and the presence of a neck ligature. A CT of the neck was more likely when the patient required intubation and was younger. Only the need for intubation seemed associated with the performance of a Doppler ultrasound of the neck.
Table 8 details subsequent patient management. Although the majority of patients received an initial psychiatry referral, this was not invariable. Only a small number of patients continued with psychiatric follow-up. The median duration of hospitalization was 6 days (1-40). For those patients intubated, the median duration of mechanical ventilation was one day (1-9). The median duration of ICU stay was two days (1-10). Thirty patients received inpatient rehabilitation with a median of 9 days (1-860).
The clinical outcome could be determined in 157 patients (Table 8). Twenty-six patients (17%) died in hospital with 118 (75%) returning home to an independent life while 8 (5%) were dependent at home. Only one patient was known to have been transferred to a nursing home while another four (3%) were transferred to other hospitals where their subsequent outcome was not known. The patient with the carotid dissection returned home and was independent. Indigenous mortality rates and independent functional outcomes from near suicide were similar to non-indigenous patients (15% compared to 16%, P=0.94 and 77% compared to 75%, P=0.88 respectively).
An independent functional outcome was not predicted for all patients nor in patients requiring intubation by the site the near-hanging occurred (P=0.95 and P=0.34 respectively), the height fallen (P=0.36 and P=0.29 respectively), ethnicity (P=0.88 and P=0.81 respectively) or gender (P=0.71 and P=0.49 respectively) nor any of the comorbidities (P=0.23-0.91 and P=0.13-0.82 respectively). A previous history of drug abuse did increase the likelihood (OR 4.29, CI 95% 1.1-16.9, P=0.02) of an independent outcome in intubated patients. An independent functional outcome was however positively associated with some part of the body being in contact with the ground (OR 3.2, CI 95% 1.02-10.3, P=0.03) and inversely associated with the need for cardiopulmonary resuscitation (OR 0.10, CI 95% 0.04-0.23, P<0.001), a GCS of 3 at the scene (OR 0.08, CI 95% 0.03-0.19, P<0.001) or on arrival to hospital (OR 0.06, CI 95% 0.02-0.14, P<0.001), older patients (OR 0.97, CI 95% 0.94-0.99, P=0.007), cerebral oedema on the CT scan (OR 0.07, CI 95% 0.01-0.69, P=0.01). The independent predictors of mortality are detailed in Table 9.
However, despite these associations, of the 48 patients with a GCS of 3 at the scene, 20 (42%) returned to independent living and 23 (48%) died. Of the 38 patients with a GCS of 3 on arrival at hospital, 12 (32%) returned to independent living and 24 (63%) died. There were 35 patients with known outcome with a GCS of 3 at the scene and on arrival to hospital. Ten (29%) returned to independent living and 66% died. Of the 52 patients who received CPR, 24 (46%) had an independent functional outcome. Five patients (3%) survived with an independent functional outcome having received CPR who had a GCS of 3 both at the scene and upon arrival to hospital. One patient with cerebral oedema on the CT scan had an independent functional outcome. For the three patients needing a tracheostomy as an initial procedure, only one returned to independence at home.
Hanging is presently the most common method of suicide in Australia representing 46% of all suicides (2). This is similar to other countries such as the United Kingdom where, like Australasia, increasing rates of suicide have occurred over the last 10 years especially amongst males < 65 years of age 6. Near-hanging refers to patients not killed by the attempt. The cause for the rising incidence of hanging in Australia is debated (7,8). As with many other countries, suicide rates have increased generally, particularly in rural areas and concordant with the decrease in firearm availability (9). The present study described the epidemiology of near-hangings as they presented to several public hospitals in Queensland.
Consistent with previous descriptions, young males between their late teenage years and mid 30s predominated in our study, often with histories of previous psychiatric illness, drug overdose and self harm (8). Aboriginal and Torres Straight Islander presentations with near-suicides vary greatly between the states, being 8% in the present study but 74% in a series from the Northern Territory (10). Our study found that mortality rates from near-hanging were similar to those in non-indigenous patients. Previous suicide attempts were noted in 42% of patients, similar to previous reports, as were the rates of previous psychiatric illness or concomitant drug use (10,11). Multiple life stresses were common at the time of the near-hanging as were concomitant medical problems (10).
Judicial hanging has not been performed in Australia since 1967. Most near-hangings are suicidal as found in this study (12). Autoerotic hangings are uncommon and accidental hangings more prevalent in children (12). Near-hangings occurring in institutional care (prisons and psychiatric hospitals) vary regionally (6) and were found to be 11% and 7% respectively in the present study, similar to that found in the Northern Territory (10) but higher than that reported in England and Wales (3% and 3.9% respectively) (6,13). Of deaths occurring in police or prison custody, approximately one third are from suicide with 75% of these due to hanging (8). Rates of Aboriginal suicide in custody are similar to those in non-Aboriginal people (8).
Presentations have previously been reported most commonly in the Australian spring (14), similar to our findings. The annual rate of readmission for near-suicide after an index case is 23% with the subsequent annual suicide death being 4.6%, notably higher in males, older patients and when the index method is of high lethality (3,15). We noted similar rates of presentations for drug overdoses and self harm. The case fatality rate from hanging is approximated at 70% (16-19). Within the limits of the accuracy of the chart records, only 93 (58%) had formal psychiatric follow-up. Given the rates of recurrent suicide attempts, this is of considerable concern.
There is considerable debate as to the need for ancillary investigations when near-hanging presents to hospital due to the low incidence of associated injuries (4,12,20-23). The reported rate of cervical spine fracture is less than 1% (4), in our study 54 patients needed cervical spine plain X-rays in order to find one significant cervical spine injury. Although C2-C3 fracture dislocation of the cervical spine is thought to be common and the cause of death in judicial hanging, it actually occurs in less than 20% of such hangings (24). Sudden death in hanging is generally due to acute transection or contusion of the spinal cord (with or without fracture) and massive subarachnoid haemorrhage occurring from vertebral artery tears (24-26). Consistent with other descriptions of nonjudicial hanging, we found that there was little or no drop height amongst our patients. Consequently, as in our series, the incidence of cervical spine fracture is low (2%), with other series reporting incidences up 9% from autopsies of non judicial hanging (27). Death in non-judicial hanging is most likely due to vascular obstruction of neck vessels and cerebral hypoxia (20,28) as death from hanging has been described in tracheostomized patients (20,28). Cervical spine fracture would appear to be a function of age, suspension time and drop height (29).
Our study noted 54 patients needing to have adequate cervical spine X-rays to find a significant injury. As plain radiology of the neck is inexpensive and the majority of patients have a good prognosis, the aggressive search for concomitant injuries would seem appropriate, especially where the initial neurological status precludes an adequate clinical assessment. The low yield of positive findings is contaminated by the relatively low numbers of patients included in recent series with relatively poor descriptions of the hanging event to assist in prognostication as a result of their retrospective designs (30). The presence of a cervical spine injury should increase the suspicion for associated injuries.
The need for vascular imaging of the neck is similarly debated due to the low incidence of abnormality. The gold standard investigation of blunt carotid injuries is traditionally angiography. Duplex ultrasound is described as only useful when the carotid injury is associated with more than 50% narrowing (31,32), however sensitivities from 95-100% for carotid dissection are reported (33,34), principally using altered flow waveform velocities. Magnetic resonance angiography (MRA) has sensitivities approaching that of conventional angiography, however MRI is also needed to detect intramural haematoma. Reported performances of MRI and MRA for carotid dissection are sensitivities of 95% and 84% with specificities of 99% and 99% respectively (35), although there are problems with prolonged scan times and overestimation of degree of stenosis. Although CT-angiography has shorter scan times, there is a tendency to underestimate the degree of stenosis and failure to define grade I-III lesions. (Grade 1; irregularity of the vessel wall or a dissection or intramural haematoma with <25% luminal stenosis. Grade II; intraluminal thrombus or a raised intimal flap not being haemodynamically significant, arteriovenous fistulae, or dissection or intramural haematoma with [greater than or equal to]25% luminal narrowing. Grade III; pseudoaneurysms) (32). The reported performance of CT angiography in 1994 for carotid dissection is a sensitivity of 68%, specificity of 67%, positive predictive value of 65% with a negative predictive value of 70% (35). The one carotid dissection in this study was recognised with a hemiparesis at initial presentation. Delayed presentations of carotid dissection however, have been described 36,37. Complications in our near-hanging patient occurred in the minority of patients. However, these are potentially serious and life-threatening. Those that have been described in the literature are summarised in Table 10. Table 11 outlines a suggested hospital management for near-hangings.
The outcome of near-hanging in Queensland is generally favourable, with 75% surviving with a good functional outcome. This is similar to previous reports in Australia(10,38). An accurate description of the site of the hanging is important in determining prognosis. The height of the fall is difficult to determine retrospectively and the weight of the patient neither well nor accurately recorded at the time of acute presentation. A history of contact with the ground should be more easily obtained, and is independently predictive of outcome and perhaps useful in the prediction of likely associated injuries. The important elements of history for prognostication relate to whether the patient had contact with the ground, as did 70% of patients in this series. Its simplicity of recognition should improve its documentation with specific inquiry. Importantly, the neurological status at presentation to hospital makes prognostication difficult. The need for cardiopulmonary resuscitation has previously suggested uniform mortality (11,39). However, in our study there were five survivors despite needing CPR. It is intriguing to speculate as to the utility of induced hypothermia to improve neurological outcome as described for the management of post VT cardiac arrest (40). There are however no clinical data outside of this very defined group as to the benefit. Asystole in near-hanging maybe neurogenic induced rather than the result of prolonged hypoxia, so hypothermia may potentially benefit a wider group presenting with cardiac arrest in the setting of near-hanging. However, at this time it cannot be recommended. Similar good neurological outcomes to those found in our study have been reported in other series (11,12,21,41). Outcome was not predicted well by GCS at hospital presentation. The median time for patients with a good outcome to remain in ICU was two days. Although we were not able to specifically determine the period of observation to best predict a good functional outcome in our study, three days as recommended for neurological assessment and prognostication after cardiac arrest would seem appropriate for near-hanging patients.
The limitations of this study relate to its retrospective design and the limitation of information available in the clinical notes. Although the number of hospitals agreeing to take part was limited, the principal metropolitan hospitals took part as well as two regional centres, giving some validity to the descriptions of presentation. This also represents a greater generalizability from single-centre studies performed recently in Australia as our series is large by comparison. We did not have available clinical details on those fatal hangings that were not referred to hospital. However, in Queensland between 1999 and 2001 there were 642 hangings (5.9 per 100,000 population) and given the high lethality, near-hanging presentations to hospital represent the minority of all attempted hangings (42). The information on outcome was limited within the robustness of data available from the clinical record, as detailed psychometric testing was neither regularly recorded nor performed. However, a return to independent living at home was able to be regularly determined from the case-notes.
The outcome for near-hanging is generally favourable. The neurological status and the need for cardiopulmonary resuscitation are not invariable predictors of an independent functional outcome. Investigations for injury to anatomical structures in the neck are inconsistently performed, but given the good outcome of these patients and difficulties of initial assessment due to the presenting neurological status, a diligent search for treatable injuries that could cause significant morbidity that is not recognised early should be performed in all patients where clinical assessment is compromised. Ensuring that psychiatric follow-up is part of a routine of care is of paramount importance.
Accepted for publication on July 21, 2006.
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R. J. BOOTS *, C. JOYCE ([dagger]), D. V MULLANY ([double dagger]), C. ANSTEY ([section]), N. BLACKWELL **, P. M. GARRETT ([dagger][dagger]), S. GILLIS ([double dagger][double dagger]), N. ALEXANDER ([section][section])
Departments of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Nambour General Hospital, Nambour, The Prince Charles Hospital and Princess Alexandra Hospital, Brisbane and Mt Isa Hospital, Mt Isa, Queensland, Australia
* M.B.,B.S., M.Med.Sci., M.H.A.I.S., Ph.D., F.R.A.C.P., F.J.F.I.C.M., Associate Professor and Deputy Director of Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital and Burns, Trauma and Critical Care Research Centre, University of Queensland. ([dagger]) M.B.,B.S., Ph.D., F.A.N.Z.C.A., F.J.I.C.M., Director of Intensive Care, Princess Alexandra Hospital. ([double dagger]) M.B.,B.S., M.Med.Sci., F.A.N.Z.C.A., F.J.F.I.C.M., Director of Intensive Care, Prince Charles Hospital. ([section]) M.B.,B.S., B.Sci., F.A.N.Z.C.A., F.J.F.I.C.M., Director of Intensive Care, Nambour Hospital. ** M.B.,B.S., F.R.C.P, F.J.F.I.C.M., F.A.Ch.P.M., D.T.M.H., Director of Emergency Department, Mt Isa Hospital. [dagger][dagger] M.B.,B.S., F.A.N.Z.C.A., F.J.F.I.C.M., Staff Intensivist, Nambour Hospital. ([double dagger][double dagger]) M.B.,B.S., F.R.C.A., Consultant Anaesthetist, Whittington Hospital. Honorary Senior Lecturer, University College, London, United Kingdom. ([section][section]) MA, M.B.,B.S., M.R.C.S., Surgical Research Registrar, Institute of Child Health and Great Ormond Street Hospital, London, United Kingdom.
Address for reprints: Dr R. J. Boots, Deputy Director, Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston Road, Herston, Qld. 4029.
TABLE 1 Demographics of patients present with near-hanging Parameter N=161 (%) Age Mean 30.8 Median 28 Range 13-88 Male 132 (82) Aboriginal/Islander 13 (8) Male 11 (85) Month of presentation January 16 (10) February 8 (5) March 17 (11) April 12 (7) May 16 (10) June 11 (7) July 10 (10) August 8 (5) September 11 (7) October 7 (4) November 23 (14) December 16 (10) Marital status Single 63 (39.1) Married 30 (18.6) Defacto relationship 30 (18.6) Other relationship 12 (7.5) Unknown 9 (5.6) Separated 8 (5.0) Divorced 6 (3.7) Widowed 3 (1.9) Chronic medical illness 17 (11) Non fatal 13 (8) Fatal < 5 years 3 (2) Fatal < 1 year 1 (1) Previous psychiatric illness 67 (42) Non fatal 52 (32) Fatal < 5 years 15 (9) Previous self poisoning 36 (23) Non fatal 27 (17) Fatal < 5 years 9 (6) Alcoholism 34 (22) Non fatal 25 (16) Fatal < 5 years 9 (6) Previous self harm 42 (27) Non fatal 38 (24) Fatal < 5 years 5 (3) Drug abuse 37 (13) Non fatal 29 (18) Fatal < 5 years 6 (5) Homelessness 4 (2) Victim of child abuse 7 (4) Previous hanging attempts 16 (10) Multiple attempts 4 (2) TABLE 2 Circumstances of near-hanging Parameter N=161 (%) Precipitants (N=184) 1 112 (70) 2 30 (18.6) 3 4 (2.5) Life stress 73 (45) Marital/relationship 68 (42) Other 43 (27) Concomitant drug use Alcohol 60 (37) Other drugs 31 (19) Total 91 (57) Intent Suicide 157 (98) Undetermined 4 (2) Site Metropolitan 130 (81) Rural 31 (19) Institution Prison 18 (11) Psychiatric hospital 12 (7) TABLE 3 N (%) Method of hanging Parameter Position (N=112) No body part on ground 75 (67) Some body part on ground 37 (33) Height fallen (N=86) <30 cm 43 (50) [greater than or equal to]30 cm <90 cm 30 (35) [greater than or equal to]90 cm <150 cm 7 (8) >150 cm 6 (7) Ligature (N=149) Rope/cord 63 (42) Clothing/Bed Linen 34 (23) Electric wire 14 (9) Belt 11 (7) Other** 8 (5) Bandage 3 (2) Chain 3 (2) Clothes line 2 (1) Hose 2 (1) Wire 2 (1) Dog collar 1 (1) Site of hanging (N=149) Inside building 98 (66) Outside building 51 (34) Time to cut down (N=101) Few seconds 29 (28) [less than or equal to]5 mins 38 (38) 5 min to [less than or equal to]15 min 22 (22) >15 min to [less than or equal to]30 min 4 (4) >30 min 8 (8) **surfboard leash, elasticised rope, shoelace, necklace, towel, handbag strap, string, nylon webbing. TABLE 4 Initial presentation and field resuscitation Parameter N (%) Ambulance response (N=145) 106 (73) Time to ambulance arrival (N=96) Mean 9.25 minutes Median 8 minutes Range 1-60 minutes Cardiopulmonary resuscitation in field (N=161) No CPR required 95 (68) Bystander 31 (19) Ambulance 21 (13) GCS at scene/at hospital N=145 N=156 Motor (P <0.001) Mean 3.6 4.1 Median 4 6 Range 1-6 1-6 Motor score 1 52 (36) 41 (26) 2 13 (9) 11 (7) 3 5 (4) 5 (3) 4 8 (6) 9 (6) 5 9 (6) 10 (6) 6 58 (40) 80 (51) Eye (P=0.04) Mean 2.5 2.7 Median 2 4 Range 1-5 1-5 Eye score 1 69 (48) 65 (42) 2 6 (4) 4 (3) 3 7 (5) 6 (4) 4 63 (44) 81 (52) Verbal (P =0.004) Mean 2.7 3.1 Median 1 3 Range 1-5 1-5 Verbal score 1 75 (52) 63 (40) 2 9 (6) 11 (7) 3 2 (1) 4 (3) 4 4 (3) 4 (7) 5 55 (38) 71 (46) Airway management Not intubated 88 (55) Intubated prior to hospital 14 (9) Intubated in hospital 56 (35) Tracheostomy initial procedure 3 (2) Reason for intubation (N=70) GCS<10 64 (91) Stridor 7 (10) Agitation 4 (6) Elective for investigation 3 (4) Unknown 2 (3) Asystole 1 (1) Hypoxia 3 (4) More than one intubation reasons 10 (6) TABLE 5 Complications of near hanging Parameter N=161 (%) Pulmonary Aspiration 15 (9) Pulmonary oedema 3 (2) Pneumothorax 1 (0.5) Airway Laryngeal oedema 3 (2) Vocal cord paralysis 2 (bilateral X1) (1) Larynx and thyroid cartilage fracture 1 (0.5) Hyoid fracture 2 (1) Mucosal tear larynx s/c emphysema 1 (0.5) Pharyngeal tear with major haemorrhage 1 (0.5) Tracheal tear 1 (0.5) s/c emphysema in neck (no clear airway injury) 1 (0.5) Trismus and neck oedema 1 (0.5) Subglottic stenosis (from oedema) 1 (0.5) Vascular Cardiac arrest 5 (3) Carotid dissection 1 (0.5) Spinal C2 pedicle fracture and C2/3 spondylolisthesis 2 (1) Posterior ligament injury 1 (0.5) C1 peg fracture 1 (0.5) Other bony fractures Mandibular condyle 1 (0.5) Left scaphoid 1 (0.5) Pelvis 1 (0.5) Ribs 1 (0.5) Long bones 1 (0.5) Facial bones 1 (0.5) Acute neurological Seizures 2 (1) Cerebral contusions 2 (1) Cerebral oedema 5 (3) TABLE 6 Investigations performed in near hanging Investigation N (%) Finding Plain X-ray neck 107 # hyoid (66) # left mandibular condyle ligament disruption odontoid peg and C5 fracture Doppler carotids 8 (5) Nil Angiogram carotids 2 (1) 1 dissection* CT angiogram carotids 1 (1) L ICA dissection* CT head 46 (29) 2X contusions 6X cerebral oedema CT Neck 28 (17) 2X # thyroid cartilage # hyoid hyoid swelling # C2 (not picked on plain films) small free gas in neck Endoscopy of airway 11 (17) 2X cord oedema 1X laryngeal injury 1X tracheal tear * Same patient, #=fracture. TABLE 7 Predictors of investigations performed Investigation Parameter OR Cervical spine X-ray Neck ligature 4.33 CPR 2.84 Ground 0.35 Inside building 0.31 GCS scene >10 0.21 GCS hospital >10 0.29 Intubation 3.31 Cervical spine X-ray GCS scene >10 0.31 Multivariate Ground 0.32 Hosmer Lemeshow goodness-of-fit, chi-square 3.02, P=0.22 CT head GCS scene >10 0.07 GCS hospital >10 0.07 CPR 6.82 Inside 0.35 Intubation 26.1 Neck ligature 4.78 CT head GCS scene >10 0.13 Multivariate CPR 4.02 Inside 0.26 Neck ligature 3.28 Hosmer Lemeshow goodness-of-fit, chi-square 3.18, P=0.78 CT neck GCS scene >10 0.29 GCS hospital > 10 0.22 Intubation 13.8 CPR 2.5 Age 0.97 CT neck Intubation 16.1 Multivariate Age 0.96 Hosmer Lemeshow goodness-of-fit, chi-square 9.25, P=0.32 Doppler ultrasound neck* Intubation 8.75 Investigation CI 95% P Cervical spine X-ray 2.14-8.73 <0.001 1.29-6.25 0.006 0.14-8.88 0.03 0.13-0.72 0.007 0.09-0.45 <0.001 0.14-0.60 <0.001 1.61-6.73 <0.001 Cervical spine X-ray 0.11-0.85 0.02 Multivariate 0.11-0.87 0.03 Hosmer Lemeshow goodness-of-fit, chi-square 3.02, P=0.22 CT head 0.02-0.20 <0.001 0.03-0.18 <0.001 3.21-14.5 <0.001 0.17-0.73 0.005 8.67-78.6 <0.001 1.88-12.16 <0.001 CT head 0.03-0.45 0.001 Multivariate 1.41-11.47 0.009 0.09-0.72 0.01 0.98-10.9 0.05 Hosmer Lemeshow goodness-of-fit, chi-square 3.18, P=0.78 CT neck 0.11-0.76 0.001 0.09-0.56 0.002 3.97-48.2 <0.001 1.08-5.74 0.03 0.94-1.00 0.12 CT neck 4.53-57.0 <0.001 Multivariate 0.93-0.99 0.047 Hosmer Lemeshow goodness-of-fit, chi-square 9.25, P=0.32 Doppler ultrasound neck* 1.10-72.8 0.01 * All patients with Doppler had neck ligature marks. Ground=touching ground. TABLE 8 Subsequent management and outcomes Management N=161 (%) Outcome Dead 26 (16) Independent at home 118 (71) Dependent at home 8 (5) Nursing home 1 (1) Transferred to another hospital 4 (2) Not determined 4 (2) Outcome for patients GCS<10 N=70 Dead 24 (34) Independent at home 38 (54) Dependent at home 7 (10) Transferred to another hospital 1 (1) Clinical management Airway reparative surgery 2(1) Hard cervical collar 61 (38) Initial psychiatric referral 117 (73) Psychiatric follow-up 93 (58) Surgical stabilisation of cervical spine 2 (1) Tracheostomy 2 (1) Vascular exploration/repair 1 (0.6) Duration of acute hospitalisation (days) N=122 Mean 3.5 Median 1 Range 0.04-40 Time in ICU (days) N=68 Mean 2.4 Median 2 Range 0.02-10 Duration mechanical ventilation (days) N=61 Mean 1.9 Median 1 Range 0.02-9 Duration of inpatient rehabilitation (days) N=30 Mean 42 Median 8.5 Range 1-860 TABLE 9 Predictors of mortality for near-hanging Parameter OR CI 95% P GCS on hospital arrival=3 96 20.6-447.4 <0.001 GCS at scene=3 30.7 8.6-109.7 <0.001 CPR 14.1 4.9-40.4 <0.001 Age 1.04 1.01-1.06 0.008 Cerebral oedema 8.67 1.37-54.8 0.02 Cervical spine X-ray 0.52 0.22-1.23 0.14 Contact with ground 0.10 0.013-0.81 0.03 Multivariate AOR CI 95% P (Wald) GCS on hospital arrival=3 150 12.4-1818 <0.001 Cervical spine X-ray 0.06 0.004-0.97 0.047 Contact with ground 0.03 0.002-0.62 0.02 Homer Lemeshow, chi-square 3.86, P=0.43 TABLE 10 Reported complications of near-hanging System Injury Reference Pulmonary 1. ARDS 43 2. Noncardiogenic pulmonary 39,44,45 oedema 3. Aspiration 21 4. Pneumonia 22 5. Tracheal tears 20 Cardiac 1. Cardiac arrest (probable 46 direct carotid sinus autonomic stimulation) Miscellaneous 1. Oesophageal rupture 47 2. Hyperthermia 48 3. Tardieu's spots 21 4. Subconjunctival haemorrhages 21 5. Ligature mark Neurological 1. Cerebral oedema +/- raised 49 intracranial pressure 2. Multiple focal lesions transient 49 and permanent including hemiplegia 3. Spinal accessory nerve injury 50 4. Central cord syndrome 51 5. Korsikoffs syndrome 49 6. Amnesia +/- elation 16,23,41 49, 52-55, 7. Movement disorders-- 48,56 including choreoathetosis and local muscle spasms, bizarre movements 8. Status epilepsy (long-term 57, 58 follow-up risk of recurrent seizure unknown in anoxic cerebral injury) 9. Diabetes insipidus 49 10. Post-anoxic 49 encephalopathy-can be delayed for 1 month-1 week Cervical Spine 1. Fracture rate uncommon 38 (0.6%) 2. Cord injury in setting of 51 existing spinal disease and hyperextension injury (cord injury without bony injury not described) Larynx/airway 1. Airway obstruction from: -Tongue displacement -Swelling of retropharyngeal, 20,44,59 laryngeal and paratracheal regions (often delayed) -Tracheal obstruction 60 -Laryngo-tracheal separation 61 -Hyoid/thyroid cartilage 4 fracture (cricoid injury not described Cervical 1. Jugular venous obstruction 62 vascular 2. Carotid intimal tears (can be 36,37 delayed presentation) 3. Arterial spasm 63 4. Subarachnoid haemorrhage 64 5. Reflex bradycardia from 49 carotid body compression 6. Kinking/spasm of vertebral 49 arteries despite bone protection TABLE 11 Summary of hospital care plan for near-hanging 1 Secure airway as needed ensuring cervical spine stabilisation. Pharyngeal or laryngeal injury may necessitate a surgical airway. 2 Ensure adequate oxygenation and if ventilated, ensure normocapnia and normoxia. 3 Assess for concomitant drug use including drug screens for treatable overdoses such as paracetamol. Prophylactic thiamine to prevent Korsakoff's psychosis. 4 Cervical spine X-rays and CT to exclude bony injury if clinical assessment limited by conscious state. 5 CT scan of head as determined by neurological assessment. 6 CT angiogram of neck to assess for carotid injury depending on the performance of the test in the local area as carotid injury may be asymptomatic initially or difficult to assess (MRI/MRA may be more appropriate). Doppler ultrasound is insufficient. 7 Assess for raised intracranial pressure and treat appropriately. 8 Keep serum sodium ~145 mmol/l or higher if actively treating raised intracranial pressure. 9 Admit all patients regardless of neurological assessment due to the risk of delayed complications. 10 Ensure psychiatric assessment before discharge.