Hanging is increasingly described in India as a method chosen by adults to attempt suicide. Hanging is defined as death due to external pressure on the neck when a ligature is applied to the neck of a wholly or partly suspended individual [1-2]. the term near hanging refers to patients who survive a hanging injury long enough to reach hospitals. The data on injury patterns, clinical aspects and management is also limited. Here, we shared our experience of managing such patient.

Case Report

14 year old female patient presented to emergency department with alleged history of hanging from wall ceiling on 17-04-2022 at around 5 pm as per information given by her mother. Initially they went to nearby hospital where IV fluids given and because of respiratory distress and poor GCS they referred. On examination, GCS was 7/15 and vitals HR = 104/min, RR = 36/min, spo2 = 86% on room air, BP = 118/64. On neurological examination, tone was increased so possibility of partial hanging with hypoxic injury kept and patient intubated in view of poor GCS and respiratory distress. ABG at that time shows pH = 7.389, pCO2 = 29.4, pO2 = 89.3, HCO3 = 19.8. 

Assisted controlled ventilation was provided with tidal volume 8ml/kg, RR 16/min, PEEP %cm of H2O and inspired fraction of oxygen(FiO2) 1, subsequently decreased to keep spo2 >94%. She was nursed in head up position (30-40 degree) maintain sedation with infusion of fentanyl and midazolam. Blood samples were sent for routine biochemical and haematological investigations. Patient remain in ventilator support for 36 hours after that she was extubated when she regained full consciousness and good spontaneous respiratory efforts; nebulization done with adrenalin and O2 continue along with IV fluids.

GCS initially after extubation was 11/15 and there was no sign of raised ICT. After 3 days of admission, patient was shifted to general ward that time her GCS was 14/15; On CNS examination tone was increased and DTR were brisk and plantar up, cranial nerve examination done in which 1,8,11,12 cannot be assessed other was normal. Day by day patient improved but verbally was not able to speak and developmentally was around age 4 year. Initially she was not able to move her upper limb but within 3 days slowly she started moving upper limb and power was equal in both upper and lower limb and power in distal muscle (muscle of hands) was decreased and attains normal power of distal muscle of hand at the end. Also she was not able to walk first but after 3 days she started walking with support and at the time of discharge she use to walk by her own. She initially understood command of her parents but gradually started following commands of hospital staff also. She was trying to speak but was not able to speak. ENT evaluation done for vocal cords that was normal. Neurology call done along with psychiatry call to rule out other possibility. 

Table 1:  Showing Serial Investigation of Patient

MRI was done to look for hypoxic changes which was suggestive of bilateral basal ganglia, left dorsolateral thalamus, bilateral frontal cortex, and subcortical WM T2/FLAIR hyperintensities with few diffusion restricted bilateral centrum semioval changes; Likely sequel of hypoxic ischemic injury. On examination abnormal movements was present in both upper and lower limb and her personality and behavior was also changed so involvement of area in MRI was well explained. As she was not able to speak so possibility of Broca’s aphasia kept as this area is present in inferior frontal gyrus. The patient was kept under observation for another 48 hours and was finally discharged from the hospital without any major neurological and pulmonary sequel.

In near hanging, which involves drop from a minimal height (< body height), injury occurs due to compression of neck structures. 

Complications Include

• Venous obstruction and cerebral hypoxia

• Laryngeal oedema and delayed airway obstruction (due to loss of neck muscle tone)

• Carotid sinus stimulation causing increased vagal tone

• Local injuries (thyroid cartilage/hyoid bone fracture/laryngeal rupture)

• Pulmonary complications (aspiration pneumonia, development of adult respiratory distress syndrome, pulmonary oedema secondary to negative intrathoracic pressure due to attempted inspiration in upper airway obstruction or centrally mediated sympathetic discharge leading to generalized vasoconstriction)

• Secondary cerebral injury (diffuse because of cerebral oedema and generalized cerebral hypoxia and/or focal because of arterial dissection or arterial spasm or subarachnoid haemorrhage)

• Other complications include hyperthermia, status epilepticus, bleeding into vessel wall or intima of carotid arteries or lower oesophageal rupture

While the overall survival rates described in patients with near hanging is optimistic and ranges from 70% to 100%, factors predicting clinical outcomes have been variably described and remain largely inconsistent, the most controversial of them being GCS score (1,3). A GCS score of 3 at presentation has been described as a predictor of poor clinical outcome. Considering that survival rates of up to 32% described even in patients with GCS scores of 3 at presentation, [3] aggressive resuscitation of all such patients, irrespective of their GCS score, is advocated. In the absence of a dedicated guideline for management of near-hanging patients, the approach largely described in the literature is on lines recommended by the advanced trauma life support guidelines, primarily including immobilization of neck, securing airway by endotracheal intubation, positive-pressure ventilation, maintenance of fluid, electrolyte balance, euglycemia and normocarbia (to control intracranial tension). However, in order to address cerebral oedema, fluids are largely restricted and diuretics, with or without mannitol or hypertonic saline, may be indicated [1-2]. Accordingly, all patients with suicidal near hanging, even those with severe initial neurological deficits and/or respiratory distress, must be aggressively managed as the recovery is often complete.

Source of Support

 Nil

Conflict of Interest

None declared

1. Adams N. "Near Hanging." Emerg Med, vol. 11, 1999pp. 17–21

2. McHugh T.P. and Stout M. "Near-Hanging Injury." Ann Emerg Med, vol. 12, 1983, pp. 774–776

3. Boots R.J. et al. "Near Hanging as Presenting to Hospitals in Queensland: Recommendations for Practice." Anaesth Intensive Care, vol. 34, 2006, pp. 736–745,