Outcomes of patients admitted for hanging injuries with decreased consciousness but without cardiac arrest

doi:10.1016/j.ajem.2013.08.061

The American Journal of Emergency Medicine

Volume 31, Issue 12, December 2013, Pages 1666-1670

https://doi.org/10.1016/j.ajem.2013.08.061 Get rights and content

Abstract

Objective

The objective of this study is to provide appropriate treatment of patients who showed decreased mentality but did not suffer cardiac arrest (CA) from hanging injury, from reviewing the characteristics and analyzing the outcomes in such patients.

Methods

A retrospective review of victims with decreased mentality but without CA due to hanging presenting to 2 tertiary general hospitals between January 2005 and August 2011 was performed. Treatments and examinations were evaluated, and the outcomes were assessed by cerebral performance category at hospital discharge.

Results

A total of 21 patients were included, and their initial Glasgow Coma Scale scores were between 3 and 11. No one received therapeutic hypothermia, but all regained consciousness spontaneously and were discharged with cerebral performance category 1. They received only conservative treatment such as respiratory care, fever control, and inotropic use. Computed tomography and magnetic resonance imaging studies revealed no definite abnormality if the patient did not show abnormal symptom and sign.

Conclusion

Unconscious patients without CA from hanging could recover consciousness through conservative treatment.

Introduction

For many years, hanging has been used as a method of suicide, homicide, and capital punishment. More recently, however, hanging has become more commonly used as a way to commit suicide. In fact, the average number of suicides per day in South Korea drastically increased following the suicide of a celebrity by hanging [1]. Many patients are admitted to the emergency department (ED) after attempting suicide by hanging, and their symptoms range from mild with an alert state of consciousness to severe with decreased mental capacity or even cardiac arrest (CA).

Cardiopulmonary resuscitation (CPR) is performed on patients who are admitted with CA due to hanging. Patients who received restoration of spontaneous circulation (ROSC) and those admitted with decreased states of mental function without CA receive intensive care. Many studies have been conducted to assess the effectiveness and predict the outcomes of such treatment. Therapeutic hypothermia (TH) for hypoxic-ischemic encephalopathy caused by asphyxia has been proven effective in experiments with animals and newborns [2], [3], and the application of TH is recommended for patients who achieved ROSC after an episode of CA [4]. Consequently, many institutions perform TH on CA survivors with hanging injuries [5], [6], [7], [8], [9]. As appropriate treatment guidelines are currently lacking for patients with hanging injuries who are admitted with a decreased mental state and without CA, the aim of the current study was to develop guidelines for the proper treatment of such patients by studying their clinical outcomes.

Section snippets

Materials and methods

Of the total number of patients older than 18 years who were admitted to the ED at the affiliated Seoul St Mary's Hospital and Yeouido St Mary's Hospital between January 2005 and August 2011 due to hanging injuries, we studied patients who were unresponsive to verbal commands at the time of ED admission. Patients who had CA before or at the time of hospital admission or after were excluded. Both of the affiliated hospitals involved in the study are tertiary university hospitals in which

Results

During the study period, 12 patients at Seoul St Mary's Hospital and 9 patients at Yeouido St Mary's Hospital were admitted with decreased consciousness but without CA due to hanging. Thus, a total of 21 patients were included in the study. In reviewing the medical record, we could find that any patients, who were decreased consciousness at the time of ED arrival, did not experience CA later in the hospital. Of these patients, 12 (57.1%) were female, and the average age was 46.48 ± 19.69 years.

Discussion

This study aimed to provide evidence for future treatment guidelines by investigating patients who had been admitted to ED due to injuries resulting from attempted hangings and who demonstrated a decreased mental status but did not experience CA. In addition, the current findings were compared with those of previous studies.

Previous studies have considered the presence of CA and the GCS score at the time of hospital admission as the prognostic factors for hanging injuries [10], [11], [12], [13]

Conclusion

From this small, retrospective study, unconscious patients without CA from hanging could be expected that he or she will recover consciousness through the administration of conservative care, such as airway management and fever control, rather than the administration of TH. Brain CT imaging does not offer a significant advantage to these patients if no lateralizing sign is observed. In addition, abnormalities can be screened for using C-spine lateral x-ray imaging, and additional analyses, such

Limitations

There are several study limitations. First, this study is retrospective study, and therefore, some information, such as initial neurologic status and vital signs, may be missing and inaccurate. Second, this study included a relatively small number of patients. Therefore, further studies including a large number of patients are needed to determine and suggest the accurate outcomes.

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Cited by (12)

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances
2021, Resuscitation
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
Outcomes in 886 Critically Ill Patients After Near-Hanging Injury
2020, Chest
Citation Excerpt :
Published studies of patients after near-hanging experiences are retrospective, as was ours, but included far fewer patients, usually from a single center. In keeping with their results, we found a strong predominance of men and of patients with at least one psychiatric diagnosis.10-16 Also consistent with earlier findings, nearly one-third of the current patients had attempted suicide previously, although only rarely by hanging,14 approximately one-fourth had an alcohol addiction, and approximately one-tenth abused other substances.14
Near-hanging experiences are life-threatening events about which few data are available.
What are the outcomes and early predictors of hospital mortality in critically ill patients who have undergone a near-hanging experience?
Adult patients who were resuscitated successfully after suicidal near-hanging injury admitted to 31 university or university-affiliated ICUs in France and Belgium between 1992 and 2014 were studied retrospectively. Patients were identified by searching the hospital databases for International Statistical Classification of Diseases and Related Health Problems, 9th and 10th revisions, codes and hospital charts for hanging. Logistic multivariate regression was performed to identify factors associated vital and functional outcomes at hospital discharge as the primary end points. Secondary outcomes were evaluation of temporal trends and identification of predictors of hospital mortality.
Of the 886 patients (181 women and 705 men; median age, 43 years; interquartile range, 34-52 years), 266 (30.0%) had attempted suicide previously, 600 (67.7%) had a diagnosed mental illness, and 55 (6.2%) attempted hanging while hospitalized. Median time from hanging awareness to unhanging was 0 min (interquartile range [IQR], 0-0; range, 0-82 min). Median Glasgow Coma Scale score was 3 (IQR, 3-5) at ICU admission. Hanging induced cardiac arrest in 450 of 886 patients (50.8%). Overall, 497 of 886 patients (56.1%) were alive at hospital discharge, including 479 of 497 patients (96.4%) with a favorable neurocognitive outcome (defined as a Glasgow Outcome Scale score of 4 or 5). By multivariate analysis, factors associated with hospital mortality were hanging-induced cardiac arrest (OR, 19.50; 95% CI, 7.21-60.90; P < .00001) and findings at ICU admission of glycemia level > 1.4 g/L (OR, 4.34; 95% CI, 1.82-10.81; P = .0007) and of lactate level > 3.5 mmol/L (OR, 9.98; 95% CI, 4.17-25.36; P < .00001).
The findings from this large multicenter retrospective cohort emphasize the very high mortality after hanging injury chiefly because of hanging-induced cardiac arrest. However, patients who survive near-hanging experiences achieve excellent neurocognitive recovery. Studies of early neuroprotective strategies for patients who have undergone near-hanging experiences are warranted.
ClinicalTrials.gov; No.: NCT04096976; URL: www.clinicaltrials.gov
Early diffusion-weighted imaging and outcome prediction of comatose survivors after suicidal hanging
2019, American Journal of Emergency Medicine
Citation Excerpt :
Victims of hanging without CA may present a broad spectrum of injuries, with the most common ones being cervical soft tissue trauma and hypoxic brain damage. The Glasgow Coma Scale (GCS) is the best independent predictor of neurological outcomes in patients admitted for hanging injuries with decreased consciousness but without CA [3,4]. Comatose survivors without CA may demonstrate different functional outcomes in contrast to those with CA.
Early outcome prediction after suicidal hanging is challenging in comatose survivors. We analysed the early patterns of brain diffusion-weighted magnetic resonance imaging (DWI) abnormalities in comatose survivors after suicidal hanging.
After suicidal hanging, 18 comatose survivors were prospectively evaluated from January 2013 to December 2016. DWI was performed within 3 h after hanging in comatose survivors. We evaluated Utstein style variables and analysed abnormal spatial profile of signal intensity on DWI, brain apparent diffusion coefficient (ADC) values, and qualitative DWI scores to predict neurological outcomes.
All hanging associated cardiac arrest (CA) patients demonstrated bad neurological outcomes; 80% of non-CA comatose patients experienced good neurological outcomes. In hanging survivors with CA, cortical grey matter structures and deep grey nuclei exhibited profound ADC reductions and high DWI scores within 3 h after hanging, which was associated with diffuse anoxic brain damage with poor cerebral performance categories scores. CA comatose survivors had significantly lower ADC values and higher DWI scores compared to non-CA comatose survivors in the cortex and deep grey nuclei.
Although the presence of CA is the most important clinical prognosticator in hanging-associated comatose survivors, HSI abnormalities and low ADC values in the cortex and deep grey nuclei on DWI performed within 3 h after hanging are well-correlated with unfavourable outcomes regardless of therapeutic hypothermia. Therefore, early DWI may increase the sensitivity of poor outcome prediction and may be an effective combinatorial screening method when available prognostic variables are not reliable or conclusive.
Neurologic outcome of comatose survivors after hanging: a retrospective multicenter study
2016, American Journal of Emergency Medicine
Citation Excerpt :
Hypothermia treatment has also been attempted in hanging victims and good neurologic outcomes have been reported [14–17]. On the other hand, some of the latest studies have reported that all hanging victims recovered completely if cardiac arrest did not occur, highlighting the uselessness of hypothermia treatment for these patients [18,19]. However, these studies included a small number of patients because the incidence of hanging without cardiac arrest was rare.
The aim of this study is to identify the neurologic outcome of hanging patients and prognostic factors.
We retrospectively investigated comatose hanging patients who arrived at the emergency departments (EDs) of twelve academic tertiary care centers during a period of seven years (2006–2012). Patients were analyzed separately according to whether out-of-hospital cardiac arrest (OHCA) occurred or not. The neurologic outcome was evaluated using the Cerebral Performance Category (CPC) at the time of hospital discharge.
A total of 1118 patients were admitted to the ED after hanging attempts. There were 159 comatose patients who did not experience OHCA. Twelve (7.5%) of 159 patients were discharged from the hospital with a poor neurologic outcome (CPC 3–5). These 12 patients received only conservative management without therapeutic hypothermia. On multivariate logistic regression analysis, mental state upon ED arrival and arterial pH were predicting factors for poor prognosis. One hundred twenty-one patients suffered OHCA and experienced restored spontaneous circulation after cardiopulmonary resuscitation. Among them, only five (4.1%) patients recovered consciousness to the level of CPC 1–2. The initial arterial pH and HCO₃⁻ were prognostic factors in hanging patients with OHCA.
Even though cardiac arrest did not occur after hanging injuries, 7.5% of patients could not recover consciousness. Therapeutic hypothermia should be considered for such patients. If OHCA occurred after the hanging injury, the proportion of patients with good neurologic outcome was very low at 4.1%.
European Resuscitation Council Guidelines for Resuscitation 2015. Section 1. Executive summary
2015, Resuscitation
Citation Excerpt :
Survival after cardiac arrest from asphyxia is rare and most survivors sustain severe neurological injury. Those who are unconscious but have not progressed to a cardiac arrest are much more likely to make a good neurological recovery.272,273 Electrolyte abnormalities can cause cardiac arrhythmias or cardiac arrest.
European Resuscitation Council Guidelines for Resuscitation 2015. Section 4. Cardiac arrest in special circumstances
2015, Resuscitation

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^☆: Funding sources/disclosures: None.

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Original ContributionOutcomes of patients admitted for hanging injuries with decreased consciousness but without cardiac arrest☆

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Limitations

Resuscitation

Am J Emerg Med

Am J Emerg Med

Am J Emerg Med

Resuscitation

Am J Emerg Med

Am J Emerg Med

Injury

Forensic Sci Int

Comparison of the effects of hypothermia at 33 degrees C or 35 degrees C after cardiac arrest in rats

Acad Emerg Med

Original Contribution
Outcomes of patients admitted for hanging injuries with decreased consciousness but without cardiac arrest☆