Page 0: Page 1: COLLECTIVE REVIEW near-hanging; neck compression injuries; strangulation Strangulation: A Review of Ligature, Manual, and Postural Neck Compression Injuries [Iserson KV: Strangulation: A review of ligature, manual, and postural neck compression injuries. Ann Emerg Med March 1984;13:179-185.] INTRODUCTION Strangulation is produced by pressure on the neck, and can take four forms, depending on how the pressure is produced: hanging (the most common), ligature strangulation, manual strangulation, and postural strangulation. It can also be classified by the setting in which death occurs: suicide, accident, homicide, and judicial executions. There are approximately 3,500 deaths reported from suicidal strangulations and hangings in the United States each year,1 with strangulations of all types accounting for between 5% and 10% of criminally violent deaths in large urban areas, 2 and hangings responsible for approximately 5% of medicolegal autopsies.3 In both the United States and Australia the rate of suicide by hanging is constant, even with an increase in the total number of suicides during the past 15 years.l, 4 In continental Europe hanging is a frequent cause of suicidal mortality, s The United Kingdom, which has traditionally had a much lower incidence due to the societal stigma attached to hanging, is now showing an increase in this form of suicide.6, 7 In parts of the United Kingdom, where suicides by coal gas used to be common, 90% of suicides are now due to hanging.S Little data exist concerning types of patients involved in hangings. One limited series from New York City had a preponderance of foreign-born, white, elderly men and an unusually large number of young Puerto Rican and Oriental victims per population base. 4 A study from India had a preponderance of men in the 21- to 40-year-old category.3 Suicidal hangings usually occur at home or at work. 9 Of 106 sequential deaths by hanging in New York City, 4 79% occurred at home, 8% in the hospital (five of nine cases were schizophrenics), 6% at work, and fewer than 2% while visiting friends. In this series fewer than 4% occurred in jail, although penal institutions usually have a very high incidence of suicidal hangings3 o There are no accurate figures for accidental strangulations. DEFINITION OF TERMS Injuries from pressure on the neck are described in relation to how the pressure was applied, how much force was used, and for how long the force was maintained. These are the factors determining the length of time until death.u Hanging occurs when pressure is exerted on the neck by an external mechanism, and tightened by the weight of the victim's body 11 (RC Froede, medical examiner, Tucson, personal communication, September 1982). The body need not be suspended in a hanging. The term "complete hanging" is used when the feet do not touch the floor, and "incomplete" is used for all other positions. 12 Hanging can occur from virtually any position (Figure 1), with many nonjudicial hangings accomplished from suspension points below the individual's standing height.13-16 Placement of the ligature knot is important. The term "typical hanging" is Kenneth V Iserson, MD, FACEP Tucson, Arizona From the Section of Emergency Medicine, Department of Surgery, University of Arizona Health Sciences Center, Tucson, Arizona. Received for publication September 27, 1982. Revision received February 22, 1983. Accepted for publication March 15, 1983. Presented as a Trauma Research Paper at the American College of Emergency Physicians Annual Meeting in Atlanta, October 1983. Address for reprints: Kenneth V Iserson, MD, FACEE Section of Emergency Medicine, Department of Surgery, University of Arizona Health Sciences Center, Tucson, Arizona 85724. 13:3 March 1984 Annals of Emergency Medicine 179/63 Page 2: ;TRANGULATION serson Fig. 1. Various positions seen in im complete hanging (from Spitz et a113). ased when the point of suspension is ~laced centrally over the occiput. This position has the greatest liability for arterial occlusion. In an "atypical hanging" the point of suspension is in any other positionJ ¢ In ligature and manual strangulation, the constricting force is also external, but the weight of the body or head plays no part. Ligature strangulation can be suicidal, accidental, or homicidal. Postural strangulation occurs with the victim's neck placed over an object, with the weight of the body putting pressure on the neck. 9 This is seen frequently in infants and toddlers. JUDICIAL STRANGULATION A N D HANGING Hanging has been used since prehistoric times as a method of execution, but it is relatively rare now. More than 16,000 judicial hangings have occurred in the United States, the last in 1965~ (American Civil Liberties Union, personal communication, December 1983). In a classic judicial hanging, which is definitely not a strangulation injurg, the distance the victim dropped was directly proportional to his weight. As a rule, unless this drop was at least equal to the height of the victim, there was usually no injury to the cord, fracture of the spine, or fracture of the base of the skuU.9 When the knot was in the submental area or under the left jaw, there was an abrupt halt at the end of the drop, with a sudden backlash of the head. The objective was to cause a fracture without decapitation J3, ~4 In fact, judicial hangings are akin to decapitation injuries, with forceful distraction of the head from the torso, fracture of the upper cervical spine, and transection of the upper spinal cord. Is In the 1880s there was a great debate, which occurred partially in the medical literature, as to whether the submental, suboral, or suboccipital knot should be used in judicial hangings. A number of appliances that supposedly would have made hanging more efficacious also were suggested. 19 The classic "hangman's fracture" was a disruption of the transverse ligament of the atlas, with the odontoid 64/180 process of C-2 crushing the spinal cord and medullaAT,2o This rarely occurred. The most common spinal deficit was a significant distraction of C-2 from 0 3 , with bilateral fractures of the C-2 arch.6,17, 2°-22 Occasionally the distraction occurred between C-3 and C-4. The upper cervical cord was stretched or torn, with the medulla often tom at the border of the pons. This resulted in immediate unconsciousness, although cardiac and respiratory movements continued for up to 15 minutes. The pharynx was often injured, and the c o m m o n carotid arteries were partly or completely torn transverselyA ~ The vertebral arteries remained patent 2 In judicial hangings by the Nubian method, with the knot in the right suboral position, a fracture through the base of the skull was produced.6, 23 This m e t h o d was not c o m m o n in western civilization. Although sparsely used for judicial purposes, ligature strangulation was a method of legal execution in Spain, using a steel collar and screw (garotte), and in Turkey and other Eastern countries, using bow-string. 24 Annals of Emergency Medicine ACCIDENTAL STRANGULATION Accidental hangings can be divided into two distinct groups. Those in the first group occur without suicidal intent during play or work. Victims ind u d e children "playing at hanging" and, on rare occasions, adults giving demonstrations of hanging. Deaths have been reported in both circumstances.3 In the second group, the socalled "autoerotic" hangings, the victim dies while using hanging and/or self-strangulation to enhance sexual self-gratification. Although this results in only about 50 .deaths per year in the United States, it has been reported frequently because of its unusual features (Figure 2).2s,26 Virtually all the reported victims are men, ranging in age from the peri-pubescent to the elderly One possible case of autoerotic hanging in a woman was reported by Neugebauer in 1937Y Accidental ligature strangulation usually occurs in infants and young children, and is caused by the umbilical cord during birth or by clothing tightening around the neck w h e n caught on cribs or toys. A mother's 13:3 March 1984 Page 3: 1. An adolescent or young adult male. 2. Ropes, belts, or other binding material so arranged that compression of the neck may be produced and controlled voluntarily. 3. Protection of the neck by soft material interposed between the ligature and skin of the neck. 4. Evidence of masturbation. 5. Partial or complete nudity. 6. A solitary act (in those who survive, this is becoming a group activity). 7. Repetitive behavior. 8. No apparent wish to die (as determined at psychologic autopsy or interview). 9. The presence of erotic literature. 10. Binding of the body and/or the extremities and/or genitals with ropes, etc (rare). 11. Female attire may be present (rare). Autoerotic (eroticized repetitive) hanging syndrome (adapted from Resnik2S). Fig. 2. m a y be better developed in those whose occupation or sport involves frequent breath-holding, such as occurs in lifting or straining. But it is not clear whether this would alter the findings or course of nonjudicial hangings by changing venous drainage of the head. The hyoid bone and the thyroid and cricoid cartilages compose the anterior semi-rigid neck structures (Figure 3). The U-shape of the hyoid bone makes it vulnerable to fracture if the extremities of the greater comua are forced together. Ossification of this bone is extremely variable, and occasionally only one union is ossified. 36 The hyoid is the fulcrum of a muscular sling, and is highly mobile. In the thyroid cartilage the superior cornua are most liable to be injured. The degree of force needed to do this can be slight. Calcific rigidity of the thyroid cartilage occurs earlier in men than in women, and can be seen as early as the third decade, s The superior horn of the thyroid cartilage is attached strongly to the hyoid bone by the thyrohyoid ligament, which may be an important mechanical contribution to the production of fractures of the superior comua of the cartilage and to some fractures of the hyoid bone. 36 In children, cervical musculature is lax. A pseudosubluxation of 3.5 to 4 m m or more of C-2 on C-3 has been demonstrated in 15% of normal children.37 hair has also been implicated. 28 It can also occur in adults when clothing b e c o m e s e n t a n g l e d in m a c h i n ery.8,11,29,30 D e a t h s f r o m accidental p o s t u r a l strangulation have been reported in adults, but are more c o m m o n in children. C o m m o n causes of death include the neck being caught in a crib or window.9, 31 HOMICIDAL STRANGULATION Rare cases of homicidal hangings have b e e n recorded.9,32, 33 S i m i l a r events, mostly of interest to the forensic pathologist, include murder presenting as suicidal hanging and suicidal hanging simulating murder.9,3z, 33 H o m i c i d a l m a n u a l and l i g a t u r e s t r a n g u l a t i o n (throttling) are c o m monplace events in urban areas 2 (RC Froede, personal communication, September 1982). If the victim is female, rape is often a coexistent injury. 14 S U I C I D A L STRANGULATION Suicide is currently the most common setting in which strangulation occurs. And hanging is, by far, the most c o m m o n method. Although the ligature used takes many forms, commonly it is a rope or insulated electrical wire, as these are m o s t readily accessible. 18 Either a fixed or, more frequently, a running noose (ie, a slipknot) is used in suicidal hangings. Suicide by ligature strangulation involves significant mechanical difficulties.13, 34 A lever of some type usually must be used to produce a tourniquet effect on the neck. Suicide by such a 13:3 March 1984 means is possible but difficult.~6, 35 Suicidal and a c c i d e n t a l m a n u a l strangulations are thought to be impossible#l,13, 26 As soon as u n c o n sciousness develops, the grip will relax, permitting recovery. However, the possibility of m a n u a l c o m p r e s s i o n causing s t i m u l a t i o n of the carotid sinus and fatal cardiac a r r h y t h m i a s has been suggested as a mechanism of strangulation death. It is not k n o w n whether this actually occurs. 34,36 Victims of suicidal strangulation frequently will have other evidence of suicide attempts, including wrist lacerations, s e l f - s t a b b i n g or g u n s h o t wounds, and ingestion of toxins.8 RELEVANT ANATOMY The c o m m o n carotid arteries above the level of the cricoid cartilage are separated from the surface of the neck in the anterolateral direction by only the sternomastoid muscle, the deep cervical fascia, the platysma, and the skin. Posteriorly t h e y rest on the transverse processes of the fourth, fifth, and sixth cervical vertebrae, and the longissimus cervicis and capitis muscles. This makes the carotids liable to compression by direct pressure, especially where they cross the transverse process of C-6. 36 Vertebral artery flow p r o b a b l y is rarely affected by direct pressure, except when extremes of rotation and lateral flexion occur, as may happen in hanging. 36 The venous drainage of the head and neck is through both the jugular s y s t e m and a series of i n t e r c o m municating veins related to the spinal column. The vertebral venous plexus Annals of Emergency Medicine PHYSIOLOGY OF NONJUDICIAL STRANGULATION Death from strangulation may be caused in one of three ways: 1) by injury to the spinal cord and brain stem; 2) by mechanical constriction of the neck structures; or 3) by cardiac arrest, possibly facilitated by carotid sinus and pericarotid sympathetic and parasympathetic networks.l~, 38 Spinal cord, medullary, and bony spine injuries are extremely unusual events in nonjudicial hangings, in which most experimental work has been done. 9 Our current state of knowledge does not allow for a definitive statement on whether arterial occlusion, venous occlusion, or asphyxia plays the greatest part in nonjudicial hanging. Conclusions based on forensic data are con181/65 Page 4: STRANGULATION Iserson Fig. 3. The anatomy of neck structures affected by strangulation. Fig. 4. Pathophysiology of nonjudicial hanging. ,/ tradictory, and experimental findings axe not consistent. In an attempt to discover what actually causes death in nonjudicial hangings and ligature strangulations, investigators have examined the anatomical effects of progressive tensions of ligatures around the necks of cadavers. Only 2 kg of tension is needed to block the jugular veins; arterial occlusion may require as little as 2.3 kg or as much as 30 kg of tension.9,39,4o Few investigators have considered differences due to the knot position, the neck position, the type of ligature used, or the normal neck muscle tone in a living person. The elasticity of a ligature limits the force that can be applied to the neck.41 Asphyxia from obstruction of the airway has long been thought to be a major cause of death in suicidal hanging, 42 because the highly m o b i l e hyoid bone can easily be displaced posteriorly, carrying with it the base of the tongue. However, two findings suggest that obstruction of the airway may not be a prerequisite for death in nonjudicial hangings. The first is that in many autopsies after suicidal hanging, there was vomitus in the bronchi, i n d i c a t i n g t h a t the v i c t i m s w e r e breathing while they died. la The second is the successful suicide by hanging of a man who had previously had a tracheostomy. The ligature was above the tracheostomy site.43, 44 Venous compression, because of the low pressure required in any position, must be considered a factor in all nonjudicial hangings and ligature strangulations. The veins can be fully compressed while the arteries are not affected. The most likely pathophysiologic sequence in a nonjudicial hanging (Figure 4) is that low pressure on the neck causes venous obstruction and loss of consciousness. The body is then completely limp, muscle tone in the neck is decreased, and increased pressure on the neck may cause complete arterial occlusion and/or airway closure resultIng in death. Older people with atherosclerosis and carotid artery disease may die from "nervous apoplexy" or "reflex cardiac arrest" due to a marked cardiac slowing from increased vagal 66/182 / // / \4 ertebral A. ransverse Lig, of Atlas knt. Longitudinal Lig. ost. Longitudinal Lig. ertebral Venous Plexus Neck pressure (low) Venous obstruction (stagnant hypoxia) Loss of consciousness Decreased neck muscle tone Arterial occlusion? Airway obstruction? (Anoxic anoxia) Death tone following alterations in carotid sinus pressure.11A2,36 FORENSIC STUDIES Most series on suicidal hangings and other strangulations have been collected by forensic pathologists. While revealing in some aspects, their findings and conclusions must be susAnnals of Emergency Medicine pect in terms of the nearhanging or the patient who survives another form of strangulation. External marks from hanging usually include a parchment-like compression groove arotmd the neck, is, ~6 often duplicating the size and pattern of the ligature. It may be absent in victims who are discovered promptly 13:3 March 1984 Page 5: " Prehospital Fig. 5. Treatment of nonjudicial hangings and other strangulations. :1. Cut off ligature. A. Stabilize neck. B. Do not cut knot (needed for possible medicolegal investigation). 2. ABCs. A. Ventilate if no/poor spontaneous ventilation. B. If breathing spontaneously, position patient to prevent aspiration. C. Use EOA ® (EGTA) if no spontaneous ventilation. D. Cardiac monitor. 3. Start tV (D5 0.45 NS) at TKO and draw baseline blood. 4. Begin treatment for increased intracranial pressure/herniation (hyperventilation, diuretic) if signs are present. 5. Get any history about patient's position, knot placement, drop, and type of ligature. Emergency Department 1. Continue ventilation. A. Replace EOA ® with NT tube (blind, fiberoptic, or retrograde intubations), or cricothyrotomy. B. Use PEEP or CPAR 2. Check for other self-induced injuries (gunshot wounds, poisoning, lacerations). 3. Support systemic physiology. 4. Cross-table lateral C-spine film (probably negative). 5. Do not cease efforts to make prognosis on the basis of initial neurological findings. 6. Obtain photographs of any external neck injury. 7. Continue treatment of increased intracranial pressure. 8. Admit patient for observation, even with normal neurological and pulmonary status. Hospital ported as having any injury in nonjudicial hangings or ligature strangulations. In ligature strangulations, hyoid and laryngeal injury occurs in about 50% of the cases. Manual strangul a t i o n is m o s t o f t e n a s s o c i a t e d with fracture of the larynx, including the hyoid bone and thyroid cartilage.12,13,41 Cervical spine injury occurs in hangings only after a long drop, and never in ligature strangulation. 36 Forensic studies may be misleading due to the occasional postmortem cervical spine injuries. 36 In one series of 16 pediatric patients who died from strangulation, 12 had p u l m o n a r y congestion, seven had CNS edema and congestion, two had gastrointestinal bleeding, and four demonstrated airway swelling. There was no evidence of cervical fractures, dislocations, or laryngeal fracture. 31 Pulmonary edema and hemorrhage are frequent findings, with acute emphysematous changes occurring less commonly.45,46 N O N F O R E N S I C STUDIES The signs and symptoms found in a patient who arrives alive may not conform to what has been found in forensic studies. For example, hemorrhage may be significant in the area of the ligature. Within five to ten minutes after release of tension around the neck, blood returning to the area of the ligature causes hemorrhage where vessels have been injured by the ligature.9 Frequently a brownish groove is noted about the neck. 31 In patients who survive, the marks may remain visible for more than a week because there is considerably more small vessel trauma than is usually visible at autopsy. 9,47,48 If the patient is able to talk, severe hoarseness and stridor secondary to traumatic edema of the larynx and supraglottic tissue may occur, ls Victims of attempted strangulation or hanging show subconjunctival petechial hemorrhages after the event. 36 Fleschmann and Minovici, who performed hanging experiments on themselves, noted that they had significant pain on swallowing after the insult.47, 49 Minovici 47 described this as the most pronounced feature of an attempted hanging, and noted that aphonia was also often present. 183/67 1. Continue ventilatory support. 2. Continue treatment for increased intracranial pressure (? intracranial pressure monitor). 3. EEG at 48 hours or later. 4. Repeated neurological assessment. 5. Psychiatric referral and suicide precautions when extubated. 5 and "cut down. "14 The type of skin mark depends on the roughness of the ligature, its mode of application, and the degree of movement of the victim. It may be difficult to see, even at autopsy. Abrasions f r o m fingernails, bruising, or nail scratches might also be present if the victim attempted to free himself prior to death or unconsciousness. Manual strangulation may also cause fingernail marks on the neck.13 S i g n i f i c a n t injury to deep n e c k structures is not common in nonjudicial hangings and ligature strangulations.7,21, 41 The injuries that occur with ligature strangulation are more severe than those in nonjudicial hangings, but less severe than those produced by manual strangulation34 While frequently seen in judicial hangings, the transverse intimal tears 13:3 March 1984 at the bifurcation of the common carotid arteries are rare in nonjudicial hangings. Polson9 believed these are from friction of the opposite sides of the vessels. The traction injury, reported in about 5% of nonjudicial hangings, involves only slight bleeding into the walls of the carotid or a minimal tear in the intima at the level of the ligature.9 The presence of carotid injury in ligature strangulations and nonjudicial hangings may be related to the victim's age and severity of arteriosclerotic disease. 41 Fracture of the thyroid cartilage is found in almost 50% of nonjudicial hanging deaths. The hyoid bone is fractured in about 20% of patients over 40 years of age. 9 Virtually all are m i n i m a l fractures t h a t would be clinically insignificant. The cricoid cartilage is rarely reAnnals of Emergency Medicine Page 6: STRANGULATION Iserson Many near-fatal hangings and other strangulations require respiratory support. Most in-hospital deaths from near-fatal hangings are due to pulmonary edema or bronchopneumonia. 45 This may be from aspiration and/or a centrineurogenic cause. However, the pulmonary edema frequently responds well to positive-end-expiratory-pressure (PEEP).4s Studies suggest that the pulmonary complications can be managed successfully. Of 106 sequential deaths from hanging in M a n h a t t a n over a two-year period, only one patient died after several days of hospital care. 4 This patient appeared to have died from neurologic events> In a review of 233 cases of childhood strangulation, 31 no deaths were directly attributable to respiratory insufficiency. However, absent or agonal respirations in the emergency department (ED), absent heartbeat or the need for ventilatory assistance in the ED, a pH less than 7.2, or unsuccessful initial resuscitation in the field were found to have an extremely poor prognosis. 31 Although neurological sequelae are the m o s t s i g n i f i c a n t a f t e r m a t h of strangulation, initial neurological findings are not prognostically significant. Cerebral anoxia occurring during suspension m a y cause neurological damage that is not immediately assessable. Conversely, patients often will arrive with significant neurological deficits that resolve over a period of days. 5o Singh and Schlagenhauff 51 reported on two near-hanging victims who arrived in deep coma~ both had normal neurological examinations within three days after admission. Collins and Chatrian 52 reported on a 22-month-old who presented after accidental strangulation. He was initially apneic, cyanotic, unresponsive, and pulseless. After cardiopulmonary resuscitation (CPR) was performed, he had spontaneous shallow respirations, and was flaccid and unresponsive. On day 18, he was discharged from the hospital in normal neurological condition. At the time of discharge, his EEG appeared to be n o r m a l for his age. Kleppel and Parnitzke 53 reported on 16 patients who were followed with EEGs and neurologic examinations following strangulation. Twelve had EEGs within four hours of the event. All were abnormal, and most of the EEGs were flat. However, of the 16 patients w h o were s u b s e q u e n t l y followed, 13 had normal baseline activity 68/184 within 48 hours after the event. In the adults, asymmetry and focal findings subsided within a year. Only in juvenile patients with initially abnormal neurological findings and a progressive deterioration in neurological examinations did EEG findings persist over several years. These findings may be explained in part by the apparently different o u t c o m e s in primarily hypoxic, compared to ischemic, brain insults. 54 Peripheral neurological damage has been reported in two cases of injury to the spinal accessory nerve after suicidal hanging attemptsY Delayed neurological sequelae or death following a p p a r e n t improvement or recovery from strangulation is rare.9,3t, 55 Three patterns appear to be present. One is the comatose patient who, after minor neurologic improvement, dies. The second is the patient who appears to make an early neurological recovery, including awakening and appearing close to his neurological baseline, only to progress to an uncontrollable herniation syndrome leading to death or severe residua. Finally, and probably rarest of all, is the patient who appears to be completely normal neurologically and even may be discharged from the hospital, only to develop delayed encephalopathy and die. On autopsy, an llyear-old boy had extensive necrosis of nearly the entire caudate nucleus and putamen and part of the globus pallidus, with preservation of nerve cells and fibers throughout the cerebral cortex. 55 A s y m p t o m a t i c intervals m a y follow any period of c o m p r o m i s e d oxygenation and circulation to the central nervous system. usually critical to the patient's survival and m u s t take priority. Soft tissue films may aid in assessing hemorrhage and edema of the neck. 31 Aggressive respiratory management must be initiated immediately, including intubation and PEEP ventilation. Neurological support, including hyperventilation, osmotic diuresis and, possibly, intracranial pressure monitoring should be instituted as necessary to treat increasing intracranial pressure. Initial EEG assessment has been demonstrated to be of little prognostic significance. Finally, in the ambulatory patient arriving with the complaint of nears t r a n g u l a t i o n b u t w i t h few, if any, signs or s y m p t o m s , care m u s t be taken to evaluate the possibility that no strangulation had taken place.~l The author thanks Drs R Froede, M Kobernick, and D Lindsey, who helped review this manuscript, and Professor D Soren, N Soren, MA, and M Clarke, RN, who translated source material. REFERENCES 1. Statistical Abstract of the United States, ed 101. Washington, DC, US Bu- IMPLICATIONS FOR TREATMENT Aggressive treatment of strangulation victims should be instituted regardless of the initial n e u r o l o g i c a l findings (Figure 5). Even severe neurological findings are often reversible in these cases. 5o-53.On the other hand, patients appearing neurologically normal in the ED warrant a period of inhospital observation for both respiratory and CNS dysfunctions. Arrangem e n t s for a sequential neurological follow up must be made. The neck should be externally stabilized. Appropriate radiological evalu a t i o n of the n e c k s h o u l d be performed, but with the recognition that in near-strangulations, r e s p i r a t o r y / neurologic support and assessment are Annals of Emergency Medicine reau of the Census, 1980, p 178, 187. 2. Luke JL: Strangulation as a method of homicide. Arch Pathol 1967;83:64-70. 3. Sen Gupta BK: Studies on 101 cases of death due to hanging. J Indian Med Assoc 1965;45:135-140. 4. 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