Clinico-epidemiological study of near-hanging cases - An investigation from Nepal

Near-Hanging Injuries: Perspective for the Trauma and Emergency Surgeon

Introduction: Near-hanging injuries are a significant cause of morbidity and mortality worldwide. These injuries result in complex clinical presentations due to the combination of mechanical asphyxia and potential neck and cervical spine trauma. The primary objectives of this narrative review include assessing the incidence, sex distribution, pathophysiology, prognostic indicators, neurologic outcomes, and treatment strategies.Methods: Review performed using Medline in English from 1946 to 2023. Excluded: articles of accidental, sex-related, auto-asphyxiation, cancer-related, and pediatric near-hanging, review articles, and case reports.Results: 53 articles were first reviewed; 30 articles encompassing 4712 patients had complete demographic and neck injuries data. Sixteen articles reported the presence and absence of ligature markings in 1778 patients. Ligature markings were present in 1103 (73.5%). Median Age: 33 (29-38) 75.7% male distribution. Suicide attempt: 97.3%. Neck vascular injuries, aerodigestive, and neck bony injuries occurred in 83 (1.8%), 123 (2.6%), and 125 (2.7%), respectively. Cardiac arrest: 1195 (25.3%) and GCS<9-2125 (45%) were the major contributors to the mortality: 26.9%. Glasgow Outcome Score>3 or by a Cerebral Performance Category score of 1-2 was documented in 35.2% of patients. Hyperbaric oxygen treatment, hypothermia treatment, and targeted temperature management did not appear to be useful from the standpoint of survival in patients who suffered a cardiac arrest.Conclusions: Near-hanging as an attempt to suicide is more frequent in young male patients. The incidence of associated neck injuries is low; mortality is likely to occur in patients with cardiac arrest with an associated neurologic injury. There is insufficient evidence to support the use of hyperbaric oxygen treatment, hypothermia treatment, and targeted temperature management in patients who have suffered a cardiac arrest and severe neurologic injury after near-hanging.

Inpatient Suicides in Swedish Psychiatric Settings - A Retrospective Exploratory Study from a Nursing Perspective

In Sweden, approximately 1,200 individuals die by suicide annually. Inpatient suicide is considered rare, but death by suicide still occurs when admitted to a psychiatric hospital. This study was part of a national retrospective project covering data from all patients' medical records for the 2 years before death by suicide in 2015. In this study, 41 patients who died by suicide while being admitted to psychiatric care were identified. The aim was to retrospectively identify documentation of suicide risk, safety measures, and comparisons between those with and without suicide attempts for patients who died by suicide during psychiatric inpatient care. There was documentation of suicidal variables in 80% of the patients; 59% had a previous known suicide attempt, 63% were diagnosed with mood disorders, and 41% were assessed for elevated suicide risk. The most common suicide method was hanging, suffocation (68%), and 22% had died by suicide within 24 h after admission. Almost three-quarters were on voluntary care. No patients had constant professional supervision on a one-to-one basis, and 17% had 15-minute checks. One-third were on agreed leave at the time of the suicide. These results emphasise the lifesaving role of high-level supervision in the early stages of inpatient care.

Non-Fatal accidental strangulation in a stroke patient

Non-fatal strangulation poses a significant concern in clinical forensic medicine. Indeed, surviving victims often present a diverse array of signs and symptoms. In rare instances, acute pathological events that manifest with symptoms similar to those secondary to neck compression (e.g., stroke with subsequent neurological symptoms, etc.) can lead to loss of consciousness, inadvertently resulting in strangulation. Therefore, in this context, forensic investigation plays a crucial role in interpreting the signs and symptoms presented by the victim and determining whether they are the cause or consequence of neck compression. This report presents a case of a middle-aged previously healthy woman who was found by her husband on the bathroom floor and then brought to the medical attention exhibiting signs of neck compression in combination with neurological symptoms. Since a previous episode of domestic violence involving the husband has been recorded in the hospital database, a medico-legal investigation was initiated at the behest of the prosecutor. The integration of all clinical, radiological, forensic pathological findings and circumstantial data allowed the exclusion of homicidal strangulation by ligature perpetrated by the husband, as well as suicidal hanging; instead, it classified the case as an accidental hanging, with a stroke being the underlying cause of the accident. The case provides valuable insights into the complexity of interpreting injuries associated with neck compression and emphasizes the need for comprehensive investigative approach in such cases.

Intracerebral and subarachnoid hemorrhage after suicidal "near-hanging"

Hanging is one of the most common methods of attempting suicide with a fast occurring death and a high lethality rate. Depending on how fast the hanged individuals are found, they may be rescued, which is referred to as "near-hanging." Whilst hypoxic and ischemic brain damage are common findings in hanging, intracranial hemorrhages seem to be a rare occurrence. To the authors' knowledge, this is the first autopsy case report of an intracerebral and subarachnoid hemorrhage in a delayed death after incomplete hanging. We hypothesize that the combination of two mechanisms is involved in the development of such hemorrhages. First, the persistent venous hypertension during incomplete hanging causing endothelial damage resulting in vascular leakage. Second, the reperfusion of the brain due to recovery of venous blood return after the release form the rope. Whereas intracranial hemorrhage is not a common finding in daily autopsy cases of fatal hanging, it might be a severe complication in rescued cases.

Suicide by hanging: A scoping review

Suicide by hanging is increasing in many countries around the world and whilst efforts are being made to influence the prevention agenda to reduce the incidence, little is known regarding the contributing factors for choosing this method. The purpose of this scoping review is to summate understandings about how the epidemiology and prevention of suicide by hanging is recognised, described, and discussed in the literature, and critically appraise the extent to which the lived-experiences of survivors of suicide attempts are included. A scoping review was conducted implementing the appropriate framework and in accord with the PRIMSA-ScR extension. Three databases (CINAHL, PubMed, and PsycINFO) were searched along with the reference lists of eligible sources in January and February 2021. Thirty-six articles with a primary focus on hanging as a method of suicide and/or its prevention are included in this review, with brief thematic analysis used to summarise the featured studies. Three distinct themes emerging from the literature include: (i) Hanging suicide deaths in the community environment or person's usual place of residence, (ii) Hanging suicide deaths in controlled environments (including police cells, prisons, and inpatient units), and (iii) Medical management of near-lethal hangings. This review highlights the necessity for improving education and policy regarding the controlled environments frequently associated with hanging suicides and the medical management of near-lethal hangings, as well as the ongoing need for policy to guide and govern the responsible media portrayal of known suicides as well as fictional hangings. Finally, this review highlights the necessity for including those with lived-experiences of a suicide attempt by hanging to advance the current prevention agenda.

Hangings attended by emergency medical services: a scoping review

BACKGROUND

In the United Kingdom (UK) there were 6507 deaths by suicide in 2018, with hanging being the most common method. Hanging will normally result in emergency medical services (EMS) being called and may result in resuscitation being attempted. Trauma audits conducted by North East Ambulance Service NHS Foundation Trust have identified an increased trend in hanging cases, which were also reported in national data. The aim of this scoping review was to explore the literature around EMS attendance at hangings to inform further research and clinical practice.

METHODS

A five-stage scoping review method was used. Relevant studies were identified by searching MEDLINE, CINAHL, EMBASE and EMCARE with the help of the Library and Knowledge Service for NHS Ambulance Services in England. Grey literature and reference lists were also searched. Studies were included based on relevance to hangings attended by EMS. Data were tabulated and narratively synthesised.

RESULTS

Sixteen papers were included in the review. Australia was the most frequent source of studies (n = 5, 31%). Most studies (n = 11, 69%) were published in the past 10 years. The median sample size was 53 (IQR 41-988, range 10-3981). All papers included varying levels of patient characteristics, EMS input and patient outcomes.

CONCLUSION

Hanging is a highly lethal method of suicide that is increasingly used in the UK. This scoping review found that there is scarce literature focused on hangings attended by EMS. Treatment of the hanging patient in cardiac arrest is described in many of the papers included. Hanging patients may benefit from the presence of specialist resources who can deliver interventions such as sedation and advanced airway management. The psychological impact of attending, or witnessing, hanging patients is an area that needs further consideration. Further research is needed to describe and improve EMS treatment of hangings.

Factors Associated With Poor Outcome in Pediatric Near-Hanging Injuries

BACKGROUND

Hanging injury is the most common method of suicide among children 5 to 11 years of age and near-hangings commonly occur. Adult studies in near-hanging injury have shown that need for cardiopulmonary resuscitation, initial blood gas, and poor mental status are associated with poor prognosis. The literature for similar factors in children is lacking.

OBJECTIVES

This retrospective, single-center study was performed to identify the clinical factors associated with neurologic outcome in children after near-hanging.

METHODS

Inclusion criteria included <18 years of age and a diagnosis of near-hanging or strangulation. All physician documentation was reviewed, and incidences of respiratory complications, seizure, and multiorgan failure were noted. Pediatric cerebral performance category score was based on information at discharge and was defined as favorable (score of 1-4) or unfavorable (score of 5-6). Comparisons were made between outcome groups and suspected clinical factors.

RESULTS

The median age was 11.5 years with a median initial Glasgow Coma Scale (GCS) score of 10. Of all patients, 25% had a prehospital cardiac arrest, and 51% were admitted to the intensive care unit. Patients with unfavorable outcomes had a lower initial pH (6.9 vs. 7.3) and initial GCS score (3T vs. 14). Patients with an unfavorable outcome had significantly higher rates of intensive care unit admission, respiratory complications, anoxic brain injury, and multiorgan failure. No patient who presented with an initial GCS score of 3T and prehospital cardiac arrest had a favorable neurologic outcome.

CONCLUSIONS

This is the largest single-center study of children with near-hanging injury. An initial GCS score of 3T and prehospital cardiac arrest was uniformly associated with poor neurologic outcome.

Profile and Outcome of Near-hanging Patients Presenting to Emergency Department in a Tertiary Care Hospital in South India - A Retrospective Descriptive Study

BACKGROUND

Hanging is one of the common modes of deliberate self-harm presenting to emergency departments (EDs) across the world. Early intervention and aggressive resuscitation can decrease the morbidity and mortality associated with near-hanging. Our aim was to study the profile of patients presenting with near-hanging and their outcome to our adult ED.

MATERIALS AND METHODS

Medical records of patients with age more than 15 years presenting with near-hanging to the ED was reviewed retrospectively. The following profile data such as age, gender, marital status, material used for hanging, and type of hanging were collected. The information regarding the outcome of the patients from the hospital also analyzed. The data were analyzed to express the mean (±standard deviation) for the quantitative variables and frequency for the qualitative variables (±percent) using SPSS statistical software.

RESULTS

The analysis of 2 years data from August 2014 to July 2016 revealed 77 patients reached the ED with near-Hanging. The mean age of the patients - 31.1 years. Approximately, 43% were complete hanging, while rest were partial hanging. Majority of the patients used dressing materials for hanging themselves. Out of 77 patients, 64 were discharged alive while 2 patients died in the hospital and 11 were left against medical advice.

CONCLUSIONS

Hanging is still a major mode of deliberate self-harm in South India both among men and women. The outcome of near-hanging is positively influenced by early admission and active treatment.

Duret haemorrhage: An unusual finding in compression of neck structures

Hanging is one of the most lethal methods of suicide, where survival is an obvious rarity. Those who survive the initial act of hanging mostly suffer from hypoxic ischemic encephalopathy, and show some form of neurological damage. Intracranial haemorrhages are rarely associated with hanging. We report the first case of Duret haemorrhages in a 58 years old victim who survived for 8 days after the attempted hanging. Duret haemorrhage is mostly associated with fatal outcome. It is thus implied that cerebral edema should be brought under control at the earliest to prevent transtentorial herniation and subsequent Duret haemorrhages.

Hanging Deaths: A Retrospective Study Regarding 260 Cases

Hanging is a form of asphyxia caused by external pressure on the upper airways deriving from a band tightened by the gravitational weight of the body. During a 33-year period from 1983 to 2015, there were 260 hanging deaths examined at the Brescia Institute of Forensic Medicine (Northern Italy), which represented approximately 40% of all the asphyxial deaths recorded during this period. Almost all of the cases were represented by suicidal events, 1 case was a homicide event and there also was a case of sexual asphyxia. Eighty-two percent of the victims were men; 18% were women. There was an increasing tendency in the ages between 20 and 60 years, and the highest number of cases was observed in the 41- to 50-year age group (23% of the cases). The most common place chosen by the victim was the home setting followed by isolated outdoor places. The most common ligature material was a rope. The pathological findings were evaluated in all cases.