American Journal of Emergency Medicine 31 (2013) 1666–1670

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American Journal of Emergency Medicine

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Original Contribution

Outcomes of patients admitted for hanging injuries with decreased consciousnessbut without cardiac arrest☆

Jung Hee Wee, MD a,b, Jeong Ho Park, MD a,b, Seung Pill Choi, MD, PhD a,b, Kyu Nam Park, MD, PhD a,c,⁎a Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Koreab The Catholic University of Korea, Yeouido St Mary's Hospital, 10, Yuksam-ro, Seoul 150-713, Republic of Koreac The Catholic University of Korea, Seoul St Mary's Hospital 222, Banpo-daero, Seoul, Republic of Korea

a b s t r a c ta r t i c l e i n f o

☆ Funding sources/disclosures: None.⁎ Corresponding author. Department of Emergency M

The Catholic University of Korea, 222, Banpo-daeroHospital, Seoul 137-701, Republic of Korea. Tel.: +82

E-mail address: emsky@catholic.ac.kr (K.N. Park).

0735-6757/$ – see front matter © 2013 Elsevier Inc. Alhttp://dx.doi.org/10.1016/j.ajem.2013.08.061

Article history:

Received 26 June 2013Received in revised form 28 August 2013Accepted 28 August 2013

Objective: The objective of this study is to provide appropriate treatment of patients who showed decreasedmentality but did not suffer cardiac arrest (CA) from hanging injury, from reviewing the characteristics andanalyzing the outcomes in such patients.Methods: A retrospective review of victims with decreased mentality but without CA due to hangingpresenting to 2 tertiary general hospitals between January 2005 and August 2011 was performed. Treatments

and examinations were evaluated, and the outcomes were assessed by cerebral performance category athospital discharge.Results: A total of 21 patients were included, and their initial Glasgow Coma Scale scores were between 3 and11. No one received therapeutic hypothermia, but all regained consciousness spontaneously and weredischarged with cerebral performance category 1. They received only conservative treatment such asrespiratory care, fever control, and inotropic use. Computed tomography and magnetic resonance imagingstudies revealed no definite abnormality if the patient did not show abnormal symptom and sign.Conclusion: Unconscious patients without CA from hanging could recover consciousness through conservativetreatment.

© 2013 Elsevier Inc. All rights reserved.

1. Introduction

For many years, hanging has been used as a method of suicide,homicide, and capital punishment. More recently, however, hanginghas become more commonly used as a way to commit suicide. In fact,the average number of suicides per day in South Korea drasticallyincreased following the suicide of a celebrity by hanging [1]. Manypatients are admitted to the emergency department (ED) afterattempting suicide by hanging, and their symptoms range from mildwith an alert state of consciousness to severe with decreased mentalcapacity or even cardiac arrest (CA).

Cardiopulmonary resuscitation (CPR) is performed on patientswho are admitted with CA due to hanging. Patients who receivedrestoration of spontaneous circulation (ROSC) and those admittedwith decreased states of mental function without CA receive intensivecare. Many studies have been conducted to assess the effectivenessand predict the outcomes of such treatment. Therapeutic hypother-mia (TH) for hypoxic-ischemic encephalopathy caused by asphyxiahas been proven effective in experiments with animals and newborns

edicine, College of Medicine,, Seocho-gu, Seoul St Mary's011 82 018 379 4197.

l rights reserved.

[2,3], and the application of TH is recommended for patients whoachieved ROSC after an episode of CA [4]. Consequently, manyinstitutions perform TH on CA survivors with hanging injuries [5-9].As appropriate treatment guidelines are currently lacking for patientswith hanging injuries who are admittedwith a decreasedmental stateand without CA, the aim of the current study was to developguidelines for the proper treatment of such patients by studying theirclinical outcomes.

2. Materials and methods

Of the total number of patients older than 18 years who wereadmitted to the ED at the affiliated Seoul St Mary's Hospital andYeouido St Mary's Hospital between January 2005 and August 2011due to hanging injuries, we studied patients who were unresponsiveto verbal commands at the time of ED admission. Patients who had CAbefore or at the time of hospital admission or after were excluded.Both of the affiliated hospitals involved in the study are tertiaryuniversity hospitals in which approximately 30000 to 40000 patientsare admitted to the ED each year for treatment.

After obtaining institutional review board approval from bothhospitals, we retrospectively collected the data for this study byanalyzing the medical records and the emergency medical servicerecords of patients. We examined the sex, age, type of hanging, stateof consciousness at the time of admission, Glasgow Coma Scale (GCS)

Table 1Overview of unconscious patients after near-hanging injuries without CA

Case Sex Age (y) Suspensiontime (min)

Bystander CPR Mental statuson ED arrival

Hangingmethod

Intubation Mechanicalventilation

Therapeutichypothermia

Peak bodytemperature (°C)

1 F 23 b20 − Stupor Complete + + − 36.72 M 74 b5 − GCS 8 Complete + − − 37.03 M 80 Unknown − GCS 4 Unknown + + − 36.34 M 62 b50 − GCS 3 Complete + + − 36.55 F 42 b5 − GCS 8 Unknown − − − 36.96 M 66 Unknown − Stupor Unknown + + − 37.97 M 65 Unknown − GCS 7 Incomplete + + − 36.48 F 24 b20 − GCS 7 Complete + + − 37.99 M 48 b20 − GCS 11 Incomplete − − − 37.810 F 23 b10 − GCS 6 Incomplete − − − 36.711 F 40 b90 − GCS 13 Incomplete − − − 36.512 F 23 b30 − Semicoma Incomplete − − − 37.113 F 38 Unknown − GCS 4 Complete + + − 36.514 M 35 b10 − GCS 11 Complete − − − 36.615 M 81 b5 − Stupor Incomplete + + − 36.616 F 32 b20 − Coma Incomplete + + − 36.817 M 65 b25 − GCS 4 Incomplete + + − 36.418 F 46 b10 − GCS 5 Incomplete + + − 37.019 F 21 b35 − Stupor Complete − − − 36.720 F 38 b10 + Coma Unknown + + − 37.021 F 50 b3 − Drowsy unknown − − − 36.5

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score, presence of pupillary light reflex, whether CPR was performed,the use of intubation or ventilation, and the presence of a history ofpsychiatric disorders for each of the participants in the study. For theimaging studies, we examined the diagnosis of cerebral edema frombrain computed tomography (CT), abnormal findings in the brainmagnetic resonance imaging (MRI) scans, injuries to the cervical spineand soft tissues in the neck, damage to the carotid artery, and variouslaboratory data. In addition, we examined patient recovery ofconsciousness, recovery time, and complications that occurred duringhospitalization. Suspension time was estimated according to the mostrecent time the patient had been seen alive and the time of discovery.We classified the condition of the patients at the time of dischargefrom the hospital using the cerebral performance category (CPC)score, where CPC scores of 1 and 2 were considered to represent goodneurologic outcomes and CPC scores of 3 to 5 were considered torepresent poor neurologic outcomes.

The state of consciousness of the patients at the time of admissionwas recorded using the GCS based on the records made by the doctorsand nurses. However, for patient consciousness that was not recordedusing the GCS, such descriptive terms as alert, drowsy, stupor,semicoma, or coma were used.

The SPSS software (SPSS, Chicago, IL) was used for the statisticalanalysis, and the Kolmogorov-Smirnov test was used to determine thenormality of the continuous variables. Variables that followed anormal distribution were expressed as the mean and SD, whereas themedian and range were used to describe variables that did not followa normal distribution. P b .05 was defined as statistically significant.

3. Results

During the study period, 12 patients at Seoul St Mary's Hospitaland 9 patients at Yeouido St Mary's Hospital were admitted withdecreased consciousness but without CA due to hanging. Thus, a totalof 21 patients were included in the study. In reviewing the medicalrecord, we could find that any patients, who were decreasedconsciousness at the time of ED arrival, did not experience CA laterin the hospital. Of these patients, 12 (57.1%) were female, and theaverage age was 46.48 ± 19.69 years. All patients were admitted dueto suicide attempts; in addition, 7 patients (33.3%) were also sufferingfrom a major depression disorder, and 6 patients (28.6%) had alsomade previous suicide attempts. One patient had received bystander

CPR from a guardian, but none of the included patients demonstratedepisodes of CA, as confirmed by the medical staff. The mediansuspension time was 20 minutes (ranging from b3 minutes to b90minutes), although it was difficult to gauge the suspension time for 4patients. Regarding the type of hanging, 7 patients (33.3%) hadcommitted complete hanging, and 9 patients (42.9%) had committedincomplete hanging.

At the time of admission to the ED, all of the patients wereunresponsive to verbal commands, had GCS scores between 3 and 11,and exhibited mental states ranging from drowsy to coma. However,the patients' pupillary light reflexes remained intact, and no specificlateralizing signs were found. Endotracheal intubation was performedon 13 patients (61.9%), and mechanical ventilation was performed on12 patients (57.1%). During observation, some patients were sedatedwith drugs because of irritability, but all the patients (sedated ornonsedated) recovered their mentality after having been treated withconservative care (Table 1).

These target patients did not receive TH, and all patients weredischarged with a CPC score of 1. No one had body temperature below36.0°C after admission. In 3 instances, patients had fevers above37.5°C after admission, but the fevers did not exceed 38°C, due to theuse of such methods as the application of ice bags. It tookapproximately 9 hours and 15 minutes (ranging from 30 minutes to82 hours) from the time of discovery until the patient was in an alertstate of consciousness. Unsedated patients all regained consciousnesswithin 4 hours, but the recovery period for 14 patients (66.7%) wasextended as a result of intermittent sedation due to irritability. Theneurologic complications that occurred during hospitalization includ-ed seizure-like activities for 3 patients, delirium for 4 patients, andcerebral infarction accompanied by left-sided weakness for 1 patientwho subsequently received thrombolytic therapy. Respiratory com-plications, including pneumonia, spontaneous pneumomediastinum,and atelectasis, also occurred. Regarding circulatory complications, 2patients developed stress-induced cardiomyopathy and consequentlydeveloped elevated levels of cardiac enzymes and cardiogenic shock,although these symptoms improved with conservative care (Table 2).

Brain CT scans were performed on 15 patients, and no patientsdemonstrated evidence of cerebral edema according to the in-terpretations made by the radiology specialists. Brain MRI scanswere performed on 12 patients, and although acute abnormalitieswere not found in 10 of the patients, cerebral infarction was

Table 2The outcomes of hanging injury patients

Case Mental statuson ED arrival

PLR TH Interval time to alertmentality from detection (h)

Sedation Complications CPC at discharge

1 Stupor + − 14 + Delirium 12 GCS 8 + − 5 + Atelectasis, conjunctival hemorrhage 13 GCS 4 + − 8 unknown Seizure 14 GCS 3 + − unknown unknown Seizure, atelectasis 15 GCS 8 + − 16 + − 16 Stupor + − 1 + − 17 GCS 7 + − 16 + Pneumonia 18 GCS 7 + − 10.5 + Pneumomediastinum 19 GCS 11 + − 8 + − 110 GCS 6 + − 15 + Seizure 111 GCS 13 + − 1 − Delirium 112 Semicoma + − 14 + − 113 GCS 4 + − 4 − Recent memory loss 114 GCS 11 + − 12 + Corneal abrasion 115 Stupor + − 2 − Cerebral infarction, pneumonia 116 Coma + − 82 + Pulmonary edema, pneumonia, delirium 117 GCS 4 − 17 + − 118 GCS 5 − 3.2 + Stress induced cardiomyopathy, delirium 119 Stupor − 0.5 − − 120 Coma − 23.5 + − 121 Drowsy − 1 − Stress induced cardiomyopathy, conjunctival hemorrhage 1

Abbreviation: PLR, pupillary light reflex.

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discovered in 2 patients. According to the neck angiography analysis,which was conducted to observe the neck vessel abnormalities causedby strangulation, there were no abnormalities in the neck vessels,although a cerebral aneurysm was incidentally found in 1 case. C-spine lateral x-rays were taken on all patients, and no serious damagedue to the hanging injuries was found in the C-spine CT scans, whichwere conducted to evaluate the injuries further (Table 3).

4. Discussion

This study aimed to provide evidence for future treatmentguidelines by investigating patients who had been admitted to EDdue to injuries resulting from attempted hangings and whodemonstrated a decreased mental status but did not experience CA.In addition, the current findings were compared with those ofprevious studies.

Previous studies have considered the presence of CA and the GCSscore at the time of hospital admission as the prognostic factors forhanging injuries [10-13]. The 2010 American Heart Associationguidelines encourage considering the use of induced TH for patientswho achieved ROSC following an episode of CA but who were unableto follow commands [4]. Therefore, several institutions haveperformed TH and evaluated its effectiveness on patients whoachieved ROSC after CA episodes due to hanging attempts, andthese studies found the effects of TH to be modest [5,8,14]. Moreover,TH is also performed in patients who have not experienced CA butwho cannot follow commands, that is, those patients with reducedGCS scores or decreased levels of consciousness [5-8]. However,because it is not clear whether TH is indicated for these patients orwhether TH is effective, the implementation of TH is inconsistent,even within a single institution.

None of the 21 patients who were included in this study hadconfirmed episodes of CA, as assessed by the emergency medicalservice or ED, although these patients had decreased levels ofconsciousness before hospitalization in the ED. The Seoul St Mary'sHospital and the Yeouido St Mary's Hospital were the first hospitals toimplement the use of TH for CA patients in Korea, and both hospitalsuse the same TH protocol for these patients. However, because these 2hospitals only apply TH to patients with CA, the 21 patients examinedin the current study were excluded from this treatment option. As aresult, these 21 patients only received conservative care, including

airway management, because their state of consciousness haddecreased. Subsequently, all of these patients completely regainedconsciousness and were discharged with a CPC score of 1. Penny et al[11] reported that each of the hanging injury patients who wereadmitted between 1996 and 2001 with ROSC survived, but theapplication of TH on those patients is unknown. The study by Lee et al[8] also reported that among 9 unconscious patients who did notdemonstrate CA, TH was performed on only 4 patients, although all 9of these patients were discharged with a CPC score of 1.

Case number 15 involved an 82-year-old male patient who was ina stuporous mental state and was unresponsive to verbal commandsat the time of his arrival to the hospital. This patient fully regainedconsciousness 2 hours after the time of the initial discovery, whichwas within 1 hour and 30 minutes after arriving at the hospital.However, because left-sided weakness was observed, brain MRI scanswere performed, and an acute cerebral infarction was found. Then,within 3 hours of the most recent recorded instance in which thepatient was alive, the patient received thrombolytic therapy, and hissymptoms improved. However, if TH had been performed on thispatient, the neurologic abnormality would have been discovered longafterward, due to the effects of the continuously administeredsedatives and neuromuscular blocking agents during TH andrewarming period, and this patient may have also missed theappropriate time window for treatment.

The time that was required for the 21 patients completely to regainconsciousness varied from 30 minutes to 82 hours, and the cases withextended times were due to the use of sedatives for irritable patients.In 5 cases where sedatives were not used, the patients regainedconsciousness within 4 hours.

Thus, based on the results of this and previous studies, thefollowing treatment option is considerable for patients with hanginginjuries who show decreased consciousness but have not sufferedfrom documented CA: the sole administration of conservative care,including airway management and fever control, without theadministration of TH. However, further studies to support thisconclusion are necessary.

The brain CT scans, which were conducted to assess brain lesionsand evaluate the prognosis of patients with decreased consciousnessdue to hanging injuries, demonstrated normal findings and anabsence of cerebral edema. In contrast, the report by Lee et al [8]demonstrated cerebral edema in 73.3% of the patients who suffered

Table 3Overview of images done in unconscious patients after near-hanging injuries

Case C-spine CT Cerebral edemaon Brain CT

Brain MRI Carotidangiography

1 – – – –

2 – No Normal –

3 OPLL, spinal stenosis – Normal –

4 Normal – – –

5 Normal No Normal –

6 Normal No Normal Normal7 Spondylosis No Acute small

infarctionNormal

8 Normal No – Normal9 Spondylosis No – Normal10 Lordosis – Normal –

11 Normal No Normal Normal12 Straightening No – Normal13 – – Normal Normal14 Straightening No – Normal15 Spondylosis No Acute multifocal

infarctionNormal

16 – No Normal Normal17 – No – Normal18 Normal No Normal Normal19 Normal – – Normal20 Normal No Normal Normal21 Normal No – Aneurysm

Abbreviation: OPLL, ossification of posterior longitudinal ligament.

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from CA after attempted hangings. Based on the fact that hypoxiacould have occurred when the trachea and neck vessels werecompressed due to hanging (although arrest did not occur), webelieve that the amount of brain cell death in these patients wasrelatively small because the duration of hypoxia may not have beenlong enough to restrict blood flow [15,16]. Nevertheless, brainimaging such as brain CT or brain MRI is recommended if the patient'sneurologic symptoms change.

According to the neck angiography analysis conducted to assessneck vessel injuries, no acute damages caused by trauma wereobserved in the patients in this study. Although infrequent, injuries tothe common or internal carotid arteries have been reported, and fatalcarotid artery dissection can occur, as well. Therefore, it is importantto observe the patients' signs and symptoms carefully, performdetailed physical and neurologic examinations, and perform furtherevaluations when necessary [12,17–19].

As various cervical injuries can occur due to attempted hanging[12,13,17], C-spine lateral x-rays were taken for all patients todiagnose these injuries, and C-spine CT scans were performed forsome patients to evaluate further injuries. However, most CT resultsdemonstrated findings similar to those of the x-rays, and there wereno abnormalities discovered that required acute management. Incontrast, when CA occurred as a result of hanging injuries, the patientwas unable to verbalize his/her symptoms for long period. Thus, inthese CA patients, vertebral injuries could be revealed not onlythrough the use of x-rays but also using CT or MRI techniques [14].However, for patients without evidence of CA, we suggest that it maybe desirable to first screen for abnormalities using C-spine x-rays,observe treatment progress with C-spine protection, and conduct CTor MRI analyses in patients showing abnormal symptoms afterregaining consciousness.

Regarding the additional complications that developed, seizuresoccurred in 3 patients, although abnormalities were not observedfrom the brain imaging and electroencephalogram analyses, and therealso were no sequelae resulting from the seizures. Stress-inducedcardiomyopathy occurred in 2 patients who demonstrated a drop inblood pressure and elevated levels of cardiac enzymes, but thesepatients also made complete recoveries with the provision of onlyconservative care. However, we should not ignore the possibility that

TH could prevent these neurologic or cardiogenic complicationsbecause TH could be neuroportective or cardioprotective fromischemia-reperfusion injury [20,21]. Pneumomediastinum occurredin 1 case, but this condition improved with oxygen and antibiotictherapy. As previous studies have also reported high occurrences ofpneumomediastinum and cervical soft tissue emphysema in hanginginjury patients, these conditions should also be examined in futurestudies [22,23].

5. Conclusion

From this small, retrospective study, unconscious patients withoutCA from hanging could be expected that he or she will recoverconsciousness through the administration of conservative care, suchas airway management and fever control, rather than the adminis-tration of TH. Brain CT imaging does not offer a significant advantageto these patients if no lateralizing sign is observed. In addition,abnormalities can be screened for using C-spine lateral x-ray imaging,and additional analyses, such as CT or MRI scans, can be performed ifnecessary. As patients will recover consciousness within a few hoursunless they are sedated, further evaluation and treatment could beconsidered according to the symptoms or the complaint of discomfortthat are expressed after they regain consciousness.

6. Limitations

There are several study limitations. First, this study is retrospectivestudy, and therefore, some information, such as initial neurologicstatus and vital signs, may be missing and inaccurate. Second, thisstudy included a relatively small number of patients. Therefore,further studies including a large number of patients are needed todetermine and suggest the accurate outcomes.

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