Treatment modalities for hypertensive patients with intracranial pathology: options and risks

Airway and respiratory management following non-lethal hanging

PURPOSE

To review the literature on airway and respiratory management following non-lethal (suicidal) hanging and to describe the anatomy, injury and pathophysiological sequelae and their impact on patient care.

SOURCE

A Medline literature search of English-language and English-abstracted papers for 1990-96. Keywords were hanging; strangulation; airway obstruction; pulmonary oedema. Filters were applied to limit the search to relevant citations. (i.e., keywords = pulmonary oedema; filters = postobstructive, neurogenic). Citations were then hand-culled to obtain current and relevant papers about an unusual cohort of patients. A hand search of the bibliographies of relevant papers supplemented the Medline search. A review of our experience at the University of Ottawa adult hospitals over the last decade was also undertaken to determine the relevance of the literature to our clinical experiences.

PRINCIPAL FINDINGS

Most victims are young men and survivors are uncommon. Laryngo-tracheal injuries, although reported in 20-50% of postmortem examinations, are infrequent in survivors and have little impact on airway management. Spinal injuries are rare in survivors but should be excluded. Pulmonary complications including pulmonary oedema and bronchopneumonia are implicated in most in-hospital deaths. Pulmonary oedema is likely due to neurogenic factors or negative intrathoracic pressure. Although neurological injury determines outcome following hanging, initial neurological presentation is of limited prognostic value: a poor initial condition does not exclude a good recovery.

CONCLUSION

Airway injuries severe enough to interfere with airway management are uncommon after attempted suicide by hanging. Irrespective of the initial neurological assessment, aggressive and early resuscitation to optimize cerebral oxygenation is recommended.

Management of hypertension in acute intracerebral hemorrhage

Hypertension commonly occurs in the acute period following spontaneous intracerebral hemorrhage. Management of this hypertension is controversial. Some advocate lowering blood pressure to reduce the risk of bleeding, edema formation, and systemic hypertensive complications, whereas others advocate allowing blood pressure to run its natural course as a protective measure against cerebral ischemia. This article reviews the pertinent clinical and experimental data regarding these issues and briefly discusses the use of antihypertensive agents commonly administered in this setting.