A case for less workup in near hanging

A Retrospective Analysis of the Clinical Use and Utility of Advanced Imaging in the Evaluation of Near-Hanging and Strangulation Injuries at a Canadian Level One Trauma Centre

INTRODUCTION

Computed tomography (CT) of the neck is highly sensitive and may effectively rule-out cervical spine, cerebrovascular, and aerodigestive injuries after blunt and penetrating trauma. However, CT may be overutilized in the evaluation of hanging or strangulation injuries. The objective of this study was to determine the diagnostic yield of CT imaging among patients evaluated for hanging or strangulation mechanisms at a Canadian level-1 trauma center.

METHODS

All adult patients evaluated for hanging or strangulation injuries over an eight-year period were reviewed. The primary outcome was the diagnostic yield of CT imaging for major aerodigestive, cervical spine, cerebrovascular, or neurological injuries. Multiple logistic regression were performed to determine predictive factors for the use of CT imaging and the identification of injury on imaging.

RESULTS

Among 124 patients evaluated for hanging or strangulation injuries during the study period, 101 (80%) were evaluated with CT of the head or neck. A total of 26 injuries were identified in 21 patients (18 anoxic brain injuries, 4 aerodigestive, 3 cerebrovascular, and 1 of cervical spine injury). The overall diagnostic yield of neck CT for cervical injuries was 7.8%, 4.7% for laryngeal-tracheal injuries, 3.5% for carotid and vertebral artery injuries, and 1.1% for cervical spine injury. The diagnostic yield of CT head for anoxic brain injury was 22.8%. Factors predicting the use of CT imaging were abnormal physical exam findings (RR 1.7 95% CI [1.2, 2.3]) and transfer accepted by the trauma team leader (RR 1.3 95% CI [1.1, 1.5]).

CONCLUSION

CT imaging is often used in the evaluation of patients presenting with hanging or strangulation mechanisms. Seven cerebrovascular, aerodigestive, or cervical spine injuries were identified on imaging during the study period, representing a diagnostic yield of 7%. No injuries were identified among patient with a normal GCS or physical exam. Factors predicting the use of CT imaging included transfer accepted by the trauma team leader and abnormal physical exam findings. The variable clinical presentation of near-hanging and strangulation injuries and the relatively low diagnostic yield of CT imaging should prompt the development of tools and institutional protocols to guide the evaluation of hanging and strangulation injuries.

Definitive management of near-hanging at major versus non-major trauma centres

OBJECTIVES

The Victorian State Trauma System recommends that all major trauma patients receive definitive care at a major trauma service (MTS). The aim of the present study was to assess the outcomes of patients with major trauma after near-hangings who received definitive management at an MTS compared to a non-MTS.

METHODS

This was a registry-based cohort study of all adult (age ≥16 years) patients with near-hanging included in the Victorian State Trauma Registry from 1 July 2010 to 30 June 2019. Outcomes of interest were death at hospital discharge, time to death and extended Glasgow Outcome Scale (GOSE) score of 5-8 (favourable) at 6 months.

RESULTS

There were 243 patients included and 134 (55.1%) in-hospital deaths. Among patients presenting to a non-MTS, 24 (16.8%) were transferred to an MTS. There were 59 (47.6%) deaths at an MTS and 75 (63.0%) at a non-MTS (odds ratio [OR] 0.53; 95% confidence interval [CI] 0.32-0.89). However, more patients were managed at a non-MTS after out-of-hospital cardiac arrest (58.8% vs 50.8%) and less patients had serious neck injury (0.8% vs 11.3%). After adjustment for out-of-hospital cardiac arrests and serious neck injury, management at an MTS was not associated with mortality (adjusted OR [aOR] 0.61; 95% CI 0.23-1.65) or favourable GOSE at 6 months (aOR 1.09; 95% CI 0.40-3.03).

CONCLUSIONS

After major trauma sustained from near-hanging, definitive management at an MTS did not offer a mortality benefit or better functional outcomes. Consistent with current practice, these findings suggest that most near-hanging related major trauma patients could be managed safely at a non-MTS.

Hanging and Strangulation Injuries: An Institutional Review From a Level 1 Pediatric Trauma Center

BACKGROUND

We sought to define the incidence and outcomes of pediatric hanging and strangulation injuries to inform best practices for trauma triage and management.

METHODS

A retrospective review was conducted that included all patients who presented after hanging or strangulation to a Level I Pediatric Trauma Center from 2011 through 2021. Patient demographics, injury characteristics, and clinical outcomes were collected. All imaging modalities of the head and neck were reviewed to determine if a bony fracture or vascular injury was present.

RESULTS

Over the 11-year study period, 128 patients met inclusion criteria. The median age of the cohort was 13 years [IQR: 8.5-15], most patients were male (60.9%), and the median GCS was 11 [3, 15]. There were 96 cases (75%) that were intentional injuries. 76 patients (59.4%) received imaging in the form of plain radiographs, CT, or MRI of the neck and cervical spine. No fractures were identified and there were 0 clinically significant cervical spine injuries. CT angiograms of the neck identified no cerebral vascular injuries. Mortality was high (32%), and 25% of patients with nonaccidental injuries had a documented prior suicide attempt.

CONCLUSION

We identified no cervical spine fractures and no blunt cerebral vascular injuries after a hanging or strangulation in over 10 years at a Level 1 Pediatric Trauma Center. Use of CT and CT angiography of the neck and cervical spine should be minimized in this patient population without high clinical index of suspicion and/or significant mechanism.

LEVEL OF EVIDENCE

IV.

[Dissection technique for organs of the neck in hanging]

The aim of this study is to develop a comprehensive dissection technique to examine the deep structures of the neck in hanging, including extraction of the cervical spine and investigation of the removed segment with access to vertebral arteries and spinal cord. Its advantages include the unnecessity of any special instruments usage, the short period of time, which is necessary for performing dissection techniques, as well as the possible detailed examination of the spine, spinal cord and vertebral arteries. The improved dissection technique simplifies the diagnosis of injuries and increases the objectivity of the forensic medical examination in hanging.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

Vascular injury is an infrequent finding following non-fatal strangulation in two Australian trauma centres

OBJECTIVE

Non-fatal strangulation assessment is challenging for clinicians as clear guidelines for evaluation are limited. The prevalence of non-fatal strangulation events, clinical findings, frequency of injury on computed tomography angiogram (CTA) and outcomes across two trauma centres will be used to improve this assessment process.

METHODS

This is a retrospective observational study of adult presentations during 2-year period to two major-trauma referral hospitals and subsequent 12 months to identify delayed vascular injury. Patients included using standardised search terms. Demographic data, clinical findings, radiological reports and outcomes were included for review.

RESULTS

A total of 425 patients were included for analysis. Self-inflicted injury comprised 62.1%, with domestic violence (28.5%) and assault (9.4%) the remainder. Manual strangulation events 36.7% of overall presentations and 63.3% following ligature strangulation (ligature strangulation, incomplete and complete hanging). On examination soft signs present in 133 (31.2%) cases, commonly neck tenderness in isolation. No hard signs suggesting vascular damage. Vascular injury was demonstrated in three cases (0.7% of the total cohort and 1.5% of CTA scans completed), and all occurred in ligature strangulation events as a result of hanging. No patients had delayed vascular injury in the 12-month period post-initial presentation.

CONCLUSIONS

In non-fatal strangulation presentations, the majority have subtle signs of neck injury on examination with inconsistent documentation of findings. Low rate of vascular injury overall (0.7%), and entirely in hanging events. No longer-term vascular sequalae identified. Improving documentation focusing on hypoxic insult and evidence of airway trauma is warranted, rather than a reliance on computed tomography imaging to delineate a traumatic event in non-fatal strangulation.

Do we need neuroimaging in every case of near-hanging?: experience from a level 1 trauma center and analysis of the National Trauma Data Bank

PURPOSE

Our study analyzes imaging results in near-hanging to determine what neuroimaging workup is necessary. We evaluate GCS as a clinical predictor to help guide imaging choice.

METHODS

This is a retrospective study of patients from a level one trauma center and from the National Trauma Data Bank (NTDB). We classified injuries into categories based on the likelihood that CT played an important role in their diagnosis and management. We assessed whether a normal Glasgow Coma Scale (GCS) could exclude clinically important injuries. Chi square was used to test for significance for categorical variables. Multivariate logistic regression was used for multivariate analysis.

RESULTS

CT showed structural brain findings in 0% of patients from our facility (local patients) and 11.7% of NTDB patients. Of local patients and NTDB patients, 1.4% and 6.6% had blunt cerebral vascular injury (BCVI) respectively. Of local patients and NTDB patients, 1.4% and 3.3% had a cervical spine fracture or dislocation, respectively. Mortality for patients with GCS 15 versus GCS < 15 was 0 versus 26.9% for local patients (p = 0.004) and 0 versus 43.8% for NTDB (p < 0.001). Structural brain injury for patients with GCS 15 versus GCS < 15 for isolated hanging was 0 versus 14.9% for NTDB (p < 0.001). GCS 15 was an independent predictor of survival and freedom from brain injury (p < 0.001), but not neck injury.

CONCLUSION

GCS 15 is a significant independent predictor of survival and freedom from brain injury in near-hanging. GCS 15 rules out intracranial injury likely to require intervention with negative predictive value of 100%. GCS of 15 does not rule out critical neck injury.

Hangings: Lessons Learned from the Coroner's Office

BACKGROUND

Hangings are an infrequent wounding mechanism among patients arriving alive to hospital but are frequently encountered by the Coroner's Office. It is unclear if classically described hanging injuries, such as the Hangman's fracture, are common among contemporary hangings patients who typically do not suspend from height. This study was undertaken to define patient and injury characteristics after hangings causing death.

METHODS

All patients presenting to the Los Angeles County Medical Examiner/Coroner's Office (January 2016 - May 2020) who died by hanging were included. Demographics, psychiatric history, hanging details, autopsy type, and sustained injuries were collected. Data variables were summarized with descriptive statistics and the diagnostic yield of a ligature mark in the diagnosis/exclusion of cervical injuries was calculated.

RESULTS

Over the study, 1,401 patients died by hanging. Patients underwent external exam alone (n = 1,282, 92%), traditional neck autopsy (n = 114, 8%), or traditional neck autopsy plus postmortem computed tomography scan (n = 5, <1%). Home was the most frequent hanging setting (n = 1,028, 73%) followed by public spaces (n = 80, 6%) and jail (n = 28, 2%). The manner of death was almost exclusively suicide (n = 1,395, >99%) and psychiatric disease was common (n = 968, 69%). Of the patients undergoing traditional autopsy, most had a ligature mark (n = 109, 92%) and only 9 (8%) had a cervical injury (hyoid fractures, n = 6, 5%; thyroid cartilage fractures, n = 4, 3%). None had a vertebral fracture/dislocation. Sensitivity, specificity, positive predictive value, and negative predictive value of a ligature mark were 100%, 5%, 8%, and 100%.

CONCLUSIONS

Hangings are a frequent cause of death in Los Angeles County. Patients typically have a psychiatric history and die almost exclusively from suicide. Hangings commonly occur at home, in public places, and in jail. Injuries were exceedingly rare and no patient sustained a Hangman's fracture, which may be related to the lack of significant suspension with modern hangings.

Near hangings: Epidemiology, injuries, and investigations

BACKGROUND

Near hangings are an infrequent cause of trauma, and the optimal workup for these patients is unclear. The study objectives were to define the epidemiology, injury patterns, and use of investigations, including computed tomographic angiography (CTA) neck, after near hangings.

METHODS

All patients presenting to LAC+USC Medical Center (2008-2015) after near hanging (International Classification of Diseases, Ninth Revision, code of E913.8, E953.0, E963, or E983.0) were screened for inclusion. Transferred patients were excluded. Patient demographics, clinical data, injury data, investigations performed, and outcomes were collected.

RESULTS

Over the study period, 71 patients were identified. Median age was 32 years (interquartile range [IQR], 24-44), and 85% (n=64) were male. Median Glasgow Coma Scale was 12 [IQR 5-15], and median Injury Severity Score was 1 [IQR 1-2]. Mortality rate was 14% (n = 10). The most common finding on physical examination was a ligature mark (n = 38, 54%). Cervical injuries after near hangings occurred infrequently (five injuries in four patients [6%]: 3 [4%] arterial injuries and 2 [3%] laryngotracheal injuries). Only one patient (1%) required surgical and/or endovascular intervention. Two (3%) arrived in cardiac arrest, underwent resuscitative thoracotomy, and were pronounced dead. All others (n = 69, 97%) underwent CTA of the neck. No patient in this series manifested signs or symptoms of cervical injury during hospitalization after a normal CTA neck on presentation.

CONCLUSION

Near hangings infrequently result in cervical injury, and intervention is rarely needed. When injuries are sustained, they occur to critical structures such as the larynx, trachea, and cervical vasculature. Therefore, effective injury screening is important. We recommend CTA of the neck as the optimal initial imaging investigation after near hangings.

LEVEL OF EVIDENCE

Epidemiologic, level IV; therapeutic/care management, level IV.

Evaluation of Nonfatal Strangulation in Alert Adults

STUDY OBJECTIVE

There is a paucity of evidence to guide the diagnostic evaluation of emergency department (ED) patients presenting after nonfatal strangulation (manual strangulation or near hanging). We seek to define the rate of serious injuries in alert strangled patients and determine which symptoms and examination findings, if any, predict such injuries.

METHODS

Using prospectively populated databases and electronic medical record review, we performed a retrospective analysis of alert strangled patients treated in the ED of an academic Level I trauma center. Exclusions were Glasgow Coma Scale (GCS) score less than 13, younger than 16 years, and interhospital transfers. Trained researchers used structured forms to abstract demographics, symptoms, examination findings, radiology and operative findings, and final diagnoses. Injuries requiring greater than 24 hours' observation or specific treatment (surgery, procedure, specific medication) were considered clinically important. The electronic medical record was searched for 30 days after presentation to identify missed injuries.

RESULTS

Advanced imaging (computed tomography or magnetic resonance maging) was obtained in 60%. Injuries were identified in 6 patients (1.7%, 95% CI, 0.7% to 3.6%). Two injuries were clinically important (0.6%, 95% CI, 0.1% to 2.0%). Both were cervical artery dissections with no neurologic deficits, treated with aspirin. No additional injuries were identified within 30 days or at next medical contact. Of 343 uninjured patients, 291 (85%) had documented medical follow up confirming the absence of any new diagnosis of injury or stroke. The small number of injuries precluded analyses of associations.

CONCLUSION

Alert, strangled patients had a low rate of injuries. All patients with neck injuries had concerning findings besides neck pain; specifically, GCS score less than 15 or dysphagia. Our findings suggest, but do not prove, that a selective imaging strategy is safe in alert patients after strangulation findings besides neck pain.

Neck-MRI experience for investigation of survived strangulation victims

For the medicolegal evaluation of victims of survived strangulation, a neck-magnetic resonance imaging (MRI) can be performed for assessing lesions in the inner soft tissues (fat, muscles or lymph nodes, for example). In our institute, such MRI examinations have been performed for a test period of 4 years with the aim of evaluating the use of this tool by forensic pathologists and identifying medicolegal indicators for the performance of neck-MRI in surviving victims of strangulation. We retrospectively reviewed medicolegal reports from all victims examined during the test period. We extracted objective lesions (e.g. petechiae, bruising and abrasions) and reported clinical symptoms (e.g. vision disorder, dysphasia) from the reports. These findings were compared to those reported from the neck-MRI. In total, 112 victims were clinically examined after suspected strangulation. Eleven of these victims underwent an MRI examination of the neck. Eighty-four of the victims presented objective lesions during the clinical examination, with eight showing signs of both petechiae and bruising. Neck-MRI was performed in four of these eight victims and three of them showed lesions visible in MRI. Of 76 victims with bruising as the only objective finding, 66 victims described clinical symptoms. Of those 66 victims, seven were examined by MRI and two demonstrated lesions in MRI. When MRI was performed, relevant findings were detected in 45% of the cases. This leads to the suspicion that many more findings could have been detected in the other victims, if an MRI had been performed in those cases. Our results lead us to the conclusion that an MRI examination of victims of suspected strangulation is useful, and strict indications for its application should be established.

Injury Patterns in Near-Hanging Patients: How Much Workup is Really Needed?

Survivors of near-hangings suffer anoxic brain injuries, but it remains uncertain whether the incidence of associated injuries warrants extensive workup or trauma activation. An 11-year retrospective review was conducted on adult patients with a hanging mechanism who underwent trauma workup and management. The majority of patients (n = 98) were white (88.8%) males (75.5%) with an average age of 30 ± 12.3 years. Two-hundred fifty-four CTand magnetic resonance scans were performed and eight injuries were uncovered: three thyroid cartilage/hyoid fractures; three vertebral injuries; and two cervical vascular injuries. Anoxic brain injury was diagnosed clinically in 35 patients (35.7%) and was present in all 19 patients (19.4%) who died. Only one patient had intra-abdominal injury requiring surgical intervention. Injuries were more likely in patients with abnormal Glasgow Coma Scale (GCS) versus normal GCS (55% vs 10.5%, respectively). Patients who present after near-hanging have a low incidence of associated injuries. Workup can be restricted to patients with abnormal GCS scores and for specific signs and symptoms or high-risk energy mechanisms. The trauma team can be activated for signs of trauma.

Neurological Outcomes Following Suicidal Hanging: A Prospective Study of 101 Patients

Context:

Survivors of suicidal hanging can have variable neurological outcomes – from complete recovery to irreversible brain damage. Literature on the neurological outcomes in these patients is confined to retrospective studies and case series. Hence, this prospective study was carried out.

Aims:

The aim is to study the neurological outcomes in suicidal hanging.

Settings and Design:

This was a prospective observational study carried out from July 2014 to July 2016.

Subjects and Methods:

Consecutive patients admitted to the emergency and medicine wards were included in the study. Details of the clinical and radiological findings, course in hospital and at 1 month postdischarge were analyzed.

Statistical Analysis Used:

Statistical analysis was performed using IBM SPSS advanced statistics 20.0 (SPSS Inc., Chicago, USA). Univariate analysis was performed using Chi-square test for significance and Odd's ratio was calculated.

Results:

Of the 101 patients, 6 died and 4 had residual neuro deficits. Cervical spine injury was seen in 3 patients. Interestingly, 39 patients could not remember the act of hanging (retrograde amnesia). Hypotension, pulmonary edema, Glasgow coma scale (GCS) score <8 at admission, need for mechanical ventilation, and cerebral edema on plain computed tomography were more in those with amnesia as compared to those with normal memory and these findings were statistically significant.

Conclusions:

Majority of patients recovered without any sequelae. Routine imaging of cervical spine may not be warranted in all patients, even in those with poor GCS. Retrograde amnesia might be more common than previously believed and further studies are needed to analyze this peculiar feature.