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Biffl WL, Moore EE, Kansagra AP, Flores BCCR, Weiss JS. Diagnosis and management of blunt cerebrovascular injuries: What you need to know. J Trauma Acute Care Surg 2024:01586154-990000000-00777. [PMID: 39093622 DOI: 10.1097/ta.0000000000004439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
ABSTRACT Blunt cerebrovascular injuries are not as rare as they were once thought to be-but they still have the same potential for disastrous outcomes. They may occur following any trauma, but more common with higher energy transfer mechanisms. If stroke occurs, prompt recognition and treatment offers the best chance for optimal outcome. Early diagnosis and provision of antithrombotic therapy may prevent strokes, so screening of asymptomatic patients is recommended. Herein we will present what you need to know to diagnose and manage blunt cerebrovascular injury.
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Affiliation(s)
- Walter L Biffl
- From the Division of Trauma/Acute Care Surgery (W.L.B.), Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California Department of Surgery/Trauma (E.E.M.), Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado; Division of Neuroradiology, Department of Radiology (A.P.K.), Santa Clara Valley Medical Center, San Jose, California; Section of Neurosurgery and Neurointerventional Radiology (B.C.C.R.F.), Scripps Memorial Hospital La Jolla; and Division of Vascular Surgery (J.S.W.), Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California
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Takefuji H, Komagamine J, Kurihara T. The prevalence of complicated cervical injuries in near-hanging patients without abnormal levels of consciousness or neck signs. Am J Emerg Med 2024; 84:45-49. [PMID: 39089142 DOI: 10.1016/j.ajem.2024.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 06/26/2024] [Accepted: 07/26/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND Cervical injuries are important complications of near-hanging, which is defined as self-injury by hanging if the patient survives at admission. Previous studies have reported that complicated cervical injuries due to near-hanging are uncommon. The primary aim of this study was to evaluate whether cervical imaging can be safely omitted for near-hanging patients who are alert and have no abnormal neck symptoms or signs. METHODS This was a retrospective observational study to investigate the prevalence of cervical injuries among hospitalized near-hanging patients between April 2014 and June 2023. The primary outcome was the prevalence of any complicated cervical injuries, which included laryngeal fractures, laryngeal deviations, spinal cord injuries, cervical spine fractures, and blunt cerebrovascular injuries. The primary aim of this study was to determine the primary outcome among near-hanging patients with normal levels of consciousness and no abnormal neck symptoms or signs. RESULTS During the study period, a total of 63 near-hanging patients were hospitalized. Of these, 11 patients (18%) with normal levels of consciousness and no neck symptoms or signs at admission were included. The median age of the patients was 37 years (IQR 27 to 53); 5 (45%) were women, and none had cardiac arrest at the scene. For the primary outcome, no complicated cervical injuries (0%; 95% CI, 0% to 27%) occurred among the small number of near-hanging patients who had normal levels of consciousness and no abnormal neck symptoms or signs at admission. CONCLUSIONS There were no cases of complicated cervical injuries among near-hanging patients with normal levels of consciousness and no abnormal neck symptoms or signs. Further prospective multicenter studies are warranted to investigate whether cervical imaging can be safely omitted in assessments of these patients.
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Affiliation(s)
- Hiro Takefuji
- Department of Emergency and Critical Care Medicine, NHO Tokyo Medical Center, Tokyo, Japan
| | - Junpei Komagamine
- Department of Emergency and Critical Care Medicine, NHO Tokyo Medical Center, Tokyo, Japan.
| | - Tomohiro Kurihara
- Department of Emergency and Critical Care Medicine, NHO Tokyo Medical Center, Tokyo, Japan
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Hopkins B, Wang A, McKendy K, Deckelbaum D, Fata P, Khwaja K, Jastaniah A, Razek T, Wong E, Clark G, Grushka JR. 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. Injury 2023; 54:110978. [PMID: 37599191 DOI: 10.1016/j.injury.2023.110978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/03/2023] [Accepted: 08/05/2023] [Indexed: 08/22/2023]
Abstract
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.
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Affiliation(s)
- Brent Hopkins
- Division of General Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada.
| | - Anna Wang
- Division of General Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Katherine McKendy
- Division of General Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Division of Trauma and Critical Care Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Dan Deckelbaum
- Division of General Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Division of Trauma and Critical Care Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Paola Fata
- Division of General Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Division of Trauma and Critical Care Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Kozar Khwaja
- Division of General Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Division of Trauma and Critical Care Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Atif Jastaniah
- Division of General Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Division of Trauma and Critical Care Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Tarek Razek
- Division of General Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Division of Trauma and Critical Care Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Evan Wong
- Division of General Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Division of Trauma and Critical Care Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Gregory Clark
- Department of Emergency Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Jeremy Richard Grushka
- Division of General Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Division of Trauma and Critical Care Medicine, McGill University Health Centre, Montreal, QC, Canada
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Etgen T, Stigloher M, Förstl H, Zwanzger P, Rentrop M. Systematic analysis of nonfatal suicide attempts and further diagnostic of secondary injury in strangulation survivors: A retrospective cross-sectional study. Health Sci Rep 2023; 6:e1572. [PMID: 37795312 PMCID: PMC10545888 DOI: 10.1002/hsr2.1572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/12/2023] [Accepted: 09/05/2023] [Indexed: 10/06/2023] Open
Abstract
Background and Aims Data on nonfatal suicide attempts in Germany are sparse. The study aimed to analyze data on nonfatal suicide attempts and consecutive diagnostic steps to identify secondary injuries after strangulation. Methods All admissions after nonfatal suicide attempt in a large Bavarian psychiatric hospital between 2014 and 2018 were reviewed and the methods were analyzed. Results A total of 2125 verified cases out of 2801 registered cases of nonfatal suicide attempts were included in further analysis. The most common methods were intoxication (n = 1101, 51.8%), cutting (n = 461, 21.7%), and strangulation (n = 183, 8.6%). Among survivors of strangulation with external neck compression (n = 99, 54.1%), no diagnostic steps were performed in 36 (36.4%) patients and insufficient imaging in 13 (20.6%) patients. Carotid artery dissection was detected in two (4.0%) of 50 patients with adequate neuroimaging. Conclusions This study provides details on nonfatal suicide attempts in Germany. Slightly more than half of the patients with strangulation underwent adequate diagnostic work-up, with 4.0% being diagnosed with dissection. Further studies with systematic screening for dissection after strangulation in psychiatric hospitals are recommended to reduce possible under-reporting.
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Affiliation(s)
- Thorleif Etgen
- Klinik und Poliklinik für Psychiatrie und PsychotherapieTechnische Universität MünchenMünchenGermany
- Klinik für Neurologie, KlinikumTraunsteinGermany
| | - Manuel Stigloher
- Klinik und Poliklinik für Psychiatrie und PsychotherapieTechnische Universität MünchenMünchenGermany
| | - Hans Förstl
- Institut für Geschichte und Ethik der MedizinTechnische Universität MünchenMünchenGermany
| | - Peter Zwanzger
- Department of PsychiatryLudwig Maximilian UniversityMünchenGermany
- kbo‐Inn‐Salzach‐Klinikum, Klinik für Psychiatrie, Psychotherapie und PsychosomatikWasserburg am InnGermany
| | - Michael Rentrop
- Klinik und Poliklinik für Psychiatrie und PsychotherapieTechnische Universität MünchenMünchenGermany
- kbo‐Inn‐Salzach‐Klinikum, Klinik für Psychiatrie, Psychotherapie und PsychosomatikWasserburg am InnGermany
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Salvetti M, Schnell G, Pichon N, Schenck M, Cronier P, Perbet S, Lascarrou JB, Guitton C, Lesieur O, Argaud L, Colin G, Cholley B, Quenot JP, Merdji H, Geeraerts T, Piagnerelli M, Jacq G, Paul M, Chelly J, de Charentenay L, Deye N, Danguy des Déserts M, Thiery G, Simon M, Das V, Jacobs F, Cerf C, Mayaux J, Beuret P, Ouchenir A, Lafarge A, Sauneuf B, Daubin C, Cariou A, Silva S, Legriel S. Epidemiology and outcome predictors in 450 patients with hanging-induced cardiac arrest: a retrospective study. Front Neurol 2023; 14:1240383. [PMID: 37818219 PMCID: PMC10560712 DOI: 10.3389/fneur.2023.1240383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/11/2023] [Indexed: 10/12/2023] Open
Abstract
Background Cardiac arrest is the most life-threatening complication of attempted suicide by hanging. However, data are scarce on its characteristics and outcome predictors. Methods This retrospective observational multicentre study in 31 hospitals included consecutive adults admitted after cardiac arrest induced by suicidal hanging. Factors associated with in-hospital mortality were identified by multivariate logistic regression with multiple imputations for missing data and adjusted to the temporal trends over the study period. Results Of 450 patients (350 men, median age, 43 [34-52] years), 305 (68%) had a psychiatric history, and 31 (6.9%) attempted hanging while hospitalized. The median time from unhanging to cardiopulmonary resuscitation was 0 [0-5] min, and the median time to return of spontaneous circulation (ROSC) was 20 [10-30] min. Seventy-nine (18%) patients survived to hospital discharge. Three variables were independently associated with higher in-hospital mortality: time from collapse or unhanging to ROSC>20 min (odds ratio [OR], 4.71; 95% confidence intervals [95%CIs], 2.02-10.96; p = 0.0004); glycaemia >1.4 g/L at admission (OR, 6.38; 95%CI, 2.60-15.66; p < 0.0001); and lactate >3.5 mmol/L at admission (OR, 6.08; 95%CI, 1.71-21.06; p = 0.005). A Glasgow Coma Scale (GCS) score of >5 at admission was associated with lower in-hospital mortality (OR, 0.009; 95%CI, 0.02-0.37; p = 0.0009). Conclusion In patients with hanging-induced cardiac arrest, time from collapse or unhanging to return of spontaneous circulation, glycaemia, arterial lactate, and coma depth at admission were independently associated with survival to hospital discharge. Knowledge of these risk factors may help guide treatment decisions in these patients at high risk of hospital mortality.
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Affiliation(s)
- Marie Salvetti
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | | | - Nicolas Pichon
- Medical-Surgical Intensive Care Unit, CHU de Limoges, Limoges, France
- AfterROSC, Paris, France
| | - Maleka Schenck
- Médecine Intensive Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Pierrick Cronier
- AfterROSC, Paris, France
- Intensive Care Unit, Sud-Francilien Hospital Center, Corbeil-Essonnes, France
| | - Sebastien Perbet
- Department of Perioperative Medicine, University Hospital of Clermont-Ferrand, 58 Rue Montalembert, Université Clermont Auvergne, CNRS, INSERM, GReD, Clermont-Ferrand, France
| | | | - Christophe Guitton
- Medical-Surgical Intensive Care Unit, Centre Hospitalier du Mans, Le Mans, France
| | - Olivier Lesieur
- AfterROSC, Paris, France
- Intensive Care Unit, Saint-Louis Hospital, La Rochelle, France
| | - Laurent Argaud
- AfterROSC, Paris, France
- Medical Intensive Care Unit, Hospices Civils de Lyon, Edouard Herriot Teaching Hospital, Lyon, France
| | - Gwenhael Colin
- AfterROSC, Paris, France
- Medical-Surgical Intensive Care Unit, La Roche-sur-Yon District Hospital Centre, La Roche-sur-Yon, France
| | - Bernard Cholley
- Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Cité et Service d'Anesthésie-Réanimation Médecine Péri Opératoire, Paris, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive-Réanimation, CHU Dijon Bourgogne, Dijon, France
| | - Hamid Merdji
- Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive Réanimation, Université de Strasbourg (UNISTRA), Strasbourg, France
- UMR 1260, Regenerative Nano Medicine, INSERM, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Thomas Geeraerts
- Department of Anaesthesiology, Critical Care and Perioperative Medicine, Toulouse University Hospital, Toulouse, France
| | - Michael Piagnerelli
- Intensive Care Unit, Marie-Curie Teaching Hospital, Université Libre de Bruxelles, Charleroi, Belgium
| | - Gwenaelle Jacq
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Marine Paul
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Jonathan Chelly
- AfterROSC, Paris, France
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Louise de Charentenay
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Nicolas Deye
- AfterROSC, Paris, France
- Medical Intensive Care Unit, Lariboisière University Hospital, APHP, Paris, France
- INSERM UMR-S 942, Lariboisière Hospital, Paris, France
| | | | - Guillaume Thiery
- Medical-Surgical Intensive Care Unit, Saint-Étienne University Hospital, Saint-Étienne, France
| | - Marc Simon
- Department of Intensive Care, Cliniques du Sud-Luxembourg of Arlon, Arlon, Belgium
| | - Vincent Das
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Intercommunal André Grégoire, Montreuil, France
| | - Frederic Jacobs
- Medical Intensive Care Unit, Beclère Teaching Hospital, Clamart, France
| | - Charles Cerf
- Department of Intensive Care, Foch Hospital, Suresnes, France
| | - Julien Mayaux
- Department of Pulmonology and Intensive Care, Pitié-Salpêtrière Teaching Hospital, Paris, France
| | - Pascal Beuret
- Department of Intensive and Continuous Care, Roanne Hospital, Roanne, France
| | | | - Antoine Lafarge
- Medical Intensive Care Unit, Saint Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bertrand Sauneuf
- AfterROSC, Paris, France
- General Intensive Care Unit, Cotentin Public Hospital Centre, Cherbourg-en-Cotentin, France
| | - Cedric Daubin
- AfterROSC, Paris, France
- Medical Intensive Care Unit, Caen Teaching Hospital, Caen, France
| | - Alain Cariou
- AfterROSC, Paris, France
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Paris, France
- INSERM U970, Paris Cardiovascular Research Centre, Paris, France
| | - Stein Silva
- AfterROSC, Paris, France
- Critical Care Unit, University Teaching Hospital of Purpan, Toulouse, France
| | - Stephane Legriel
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
- AfterROSC, Paris, France
- UVSQ, INSERM, CESP, PsyDev Team, Paris-Saclay University, Villejuif, France
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Coombs A, Ashton-Cleary D. Hanging and near-hanging. BJA Educ 2023; 23:358-363. [PMID: 37600213 PMCID: PMC10433290 DOI: 10.1016/j.bjae.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 08/22/2023] Open
Affiliation(s)
- A.E. Coombs
- University Hospitals Plymouth NHS Trust, Plymouth, UK
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Dorfman JD. Near Hanging: Evaluation and Management. Chest 2022; 163:855-860. [PMID: 36372303 PMCID: PMC9647002 DOI: 10.1016/j.chest.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 11/03/2022] [Indexed: 11/12/2022] Open
Abstract
Prior to the COVID-19 pandemic, the incidence of self-harm was already on the rise. Hanging/suffocation accounted for 50% of the increase in suicide attempts and remains the second leading cause of death from self-harm in the United States. Studies on the management of near-hanging patients are lacking, and most published literature is retrospective. Following airway and circulation assessment, clinical examination and imaging, namely CT angiography, remain the standard for identifying the injuries associated with near hanging: cervical spine fracture, blunt cerebrovascular injury, laryngeal injury, and injury to the trachea and oropharynx. These injuries, however, are uncommon, and each occur in < 5% of patients in most series. In a large series of critically ill near-hanging patients, > 50% survived to hospital discharge; however, cardiac arrest predicted a poor outcome. The management of asphyxia-related arrest remains controversial. Targeted temperature management has only been studied in a single large multicenter trial, which was retrospective. Given the significant selection bias of targeted temperature management in the treatment of the most ill patients, no firm recommendations can be made. Finally, for survivors, the underlying mental health issues must be addressed to avoid recurrent suicide attempts. Thirty percent of patients in a large near-hanging series were admitted for their second suicide attempt.
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Affiliation(s)
- Jon D Dorfman
- Division of Trauma and Surgical Critical Care, UMass Memorial, Worcester, MA.
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8
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Williamson F, Collins S, Dehn A, Doig S. Vascular injury is an infrequent finding following non-fatal strangulation in two Australian trauma centres. Emerg Med Australas 2021; 34:223-229. [PMID: 34505351 DOI: 10.1111/1742-6723.13863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 08/02/2021] [Accepted: 08/23/2021] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Frances Williamson
- Emergency and Trauma Centre and Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Jamieson Trauma Institute, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Sarah Collins
- Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Anja Dehn
- Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Shaela Doig
- Emergency and Trauma Centre and Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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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. Emerg Radiol 2021; 29:49-57. [PMID: 34414488 DOI: 10.1007/s10140-021-01979-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
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.
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10
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Schellenberg M, Hunt BL, Owattanapanich N, Jakob D, Lucas JR, Benjamin ER, Lewis M, Inaba K, Demetriades D. Hangings: Lessons Learned from the Coroner's Office. J Surg Res 2021; 264:158-162. [PMID: 33831602 DOI: 10.1016/j.jss.2021.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/10/2021] [Accepted: 02/27/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, California.
| | - Brice L Hunt
- Department of Medical Examiner-Coroner, Los Angeles County, Los Angeles, California
| | - Natthida Owattanapanich
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, California
| | - Dominik Jakob
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, California
| | - Jonathan R Lucas
- Department of Medical Examiner-Coroner, Los Angeles County, Los Angeles, California
| | - Elizabeth R Benjamin
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, California
| | - Meghan Lewis
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, California
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, California
| | - Demetrios Demetriades
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, California
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Schellenberg M. Near-Hanging Injuries. Chest 2020; 158:2243-2244. [DOI: 10.1016/j.chest.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/08/2020] [Indexed: 10/22/2022] Open
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de Charentenay L, Schnell G, Pichon N, Schenck M, Cronier P, Perbet S, Lascarrou JB, Rossignol T, Lesieur O, Argaud L, Colin G, Cholley B, Quenot JP, Merdji H, Silva S, Piagnerelli M, Chelly J, Salvetti M, Couraud S, Deye N, Danguy des Déserts M, Paul M, Thiery G, Simon M, Martin C, Vincent F, Das V, Jacq G, Jacobs F, Soummer A, Mayaux J, Beuret P, Ouchenir A, Durant C, Darmon M, Azoulay E, Sauneuf B, Daubin C, Mongardon N, Biard L, Cariou A, Geeraerts T, Legriel S. Outcomes in 886 Critically Ill Patients After Near-Hanging Injury. Chest 2020; 158:2404-2413. [PMID: 32758563 DOI: 10.1016/j.chest.2020.07.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 06/15/2020] [Accepted: 07/03/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Near-hanging experiences are life-threatening events about which few data are available. RESEARCH QUESTION What are the outcomes and early predictors of hospital mortality in critically ill patients who have undergone a near-hanging experience? STUDY DESIGN AND METHODS 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. RESULTS 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). INTERPRETATION 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. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT04096976; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Louise de Charentenay
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay, France
| | | | - Nicolas Pichon
- Medical-Surgical Intensive Care Unit, CHU de Limoges, Limoges, France; AfterROSC, Paris, France
| | - Maleka Schenck
- Medical Intensive Care Unit, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Pierrick Cronier
- AfterROSC, Paris, France; Intensive Care Unit, Sud-Francilien Hospital Center, Corbeil-Essonnes, France
| | - Sebastien Perbet
- Department of Perioperative Medicine, University Hospital of Clermont-Ferrand, Université Clermont Auvergne, CNRS, Inserm, GReD, Clermont-Ferrand, France
| | - Jean-Baptiste Lascarrou
- AfterROSC, Paris, France; INSERM U970, Paris Cardiovascular Research Center, Paris, France; Medicine Intensive Reanimation, University Hospital, Nantes, France
| | - Thomas Rossignol
- Medical-Surgical Intensive Care Unit, Centre Hospitalier du Mans, Le Mans, France
| | - Olivier Lesieur
- AfterROSC, Paris, France; Intensive Care Unit, Saint-Louis Hospital, La Rochelle, France
| | - Laurent Argaud
- AfterROSC, Paris, France; Medical Intensive Care Unit, Hospices Civils de Lyon, Edouard Herriot Teaching Hospital, Lyon, France
| | - Gwenhael Colin
- AfterROSC, Paris, France; Medical-Surgical Intensive Care Unit, La Roche-sur-Yon District Hospital Center, La Roche-sur-Yon, France
| | - Bernard Cholley
- Service de Réanimation Chirurgicale, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
| | | | - Hamid Merdji
- Service de Médecine Intensive Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France; Faculté de Médecine and Translationnelle de Strasbourg (FMTS), Université de Strasbourg (UNISTRA), Strasbourg, France; UMR 1260, Regenerative Nano Medecine, INSERM, Fédération de Médecine, Strasbourg, France
| | - Stein Silva
- AfterROSC, Paris, France; Réanimation Polyvalente, Hôpital Purpan, CHU Toulouse, Toulouse, France
| | | | - Jonathan Chelly
- AfterROSC, Paris, France; Intensive Care Unit, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Marie Salvetti
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay, France
| | - Segolene Couraud
- Medical-Surgical Intensive Care Unit, GH Le Havre, Le Havre, France
| | - Nicolas Deye
- AfterROSC, Paris, France; Medical Intensive Care Unit, Lariboisière Teaching Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | | | - Marine Paul
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay, France
| | - Guillaume Thiery
- Medical-Surgical Intensive Care Unit, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Marc Simon
- Intensive Care Department, Cliniques du Sud-Luxembourg of Arlon, Arlon, Belgium
| | - Charlotte Martin
- Anesthésie Réanimation, Hôpital Purpan, CHU Toulouse, Toulouse, France
| | - François Vincent
- Medical-Surgical Intensive Care Unit, Avicenne University Hospital, Bobigny, France
| | - Vincent Das
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Intercommunal André Grégoire, Montreuil, France
| | - Gwenaelle Jacq
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay, France
| | - Frederic Jacobs
- Medical Intensive Care Unit, Beclere Teaching Hospital, Clamart, France
| | - Alexis Soummer
- Department of Intensive Care Medecine, Foch Hospital, Suresnes, France
| | - Julien Mayaux
- Department of Pneumology and Intensive Care, Pitie Salpetriere Teaching Hospital, Paris, France
| | - Pascal Beuret
- Department of Intensive and Continuous Care, Roanne Hospital, Roanne, France
| | | | - Caroline Durant
- Intensive Care Unit, Marie-Curie Teaching Hospital, Charleroi, Belgium
| | - Mickael Darmon
- Medical Intensive Care Unit, Saint Louis Teaching Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint Louis Teaching Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Bertrand Sauneuf
- AfterROSC, Paris, France; General Intensive Care Unit, Cotentin Public Hospital Center, Cherbourg-en-Cotentin, France
| | - Cedric Daubin
- AfterROSC, Paris, France; Medical Intensive Care Unit, Caen Teaching Hospital, Caen, France
| | - Nicolas Mongardon
- AfterROSC, Paris, France; Department of Anesthesiology and Surgical Intensive Care Units, Henri Mondor Teaching Hospital, Créteil, France
| | - Lucie Biard
- Service de Biostatistique et Information Médicale, AP-HP Hôpital Saint Louis, Paris, France; Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments (ECSTRRA) Team, INSERM U1153 CRESS, Paris, France
| | - Alain Cariou
- AfterROSC, Paris, France; INSERM U970, Paris Cardiovascular Research Center, Paris, France; Medical Intensive Care Unit, Cochin Teaching Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Thomas Geeraerts
- Anesthésie Réanimation, Hôpital Purpan, CHU Toulouse, Toulouse, France
| | - Stephane Legriel
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay, France; AfterROSC, Paris, France; Team PsyDev, CESP, INSERM, UVSQ, University Paris-Saclay, Villejuif, France.
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Matusz EC, Schaffer JT, Bachmeier BA, Kirschner JM, Musey PI, Roumpf SK, Strachan CC, Hunter BR. Evaluation of Nonfatal Strangulation in Alert Adults. Ann Emerg Med 2019; 75:329-338. [PMID: 31591013 DOI: 10.1016/j.annemergmed.2019.07.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 07/05/2019] [Accepted: 07/10/2019] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Erin C Matusz
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Jason T Schaffer
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Barbra A Bachmeier
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Jonathan M Kirschner
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Paul I Musey
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Steven K Roumpf
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Christian C Strachan
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Benton R Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN.
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