|Ahead of print publication
Successful management of a case of complete hanging: Life does not end by choice
Vishal Mangal1, Vivek Kumar2, Khushboo1, Kaminderbir Kaur3
1 Department of Internal Medicine, Military Hospital, Ambala, Haryana, India
2 Department of Anesthesiology and Critical Care, Command Hospital (WC), Chandimandir, Haryana, India
3 Department of Anesthesiology and Critical Care, Military Hospital, Ambala, Haryana, India
|Date of Submission||16-Nov-2022|
|Date of Decision||19-Dec-2022|
|Date of Acceptance||31-Dec-2022|
|Date of Web Publication||18-Feb-2023|
Department of Internal Medicine, Military Hospital, Ambala - 133 001, Haryana
Source of Support: None, Conflict of Interest: None
Suicide is an act of intentionally taking one's own life. In India, hanging remains the most common means of committing suicide. Complete hanging is when no body part touches the ground or any surface. Poor prognosis is associated with a Glasgow coma scale <8, systolic blood pressure <90 mmHg, head imaging consistent with anoxic brain injury, and hanging time longer than 5 min. In suicidal hanging, death is mainly due to hypoxia, asphyxia, or both. Currently, there are no standardized protocols for the management of hanging patients. We present a case of a 31-year-old female who was brought to our hospital after 20 min of bringing her down following complete hanging in a critical condition. She was successfully managed with mechanical ventilation, inotropes, and supportive care. She was discharged on the 7th day in walking condition without any neurological deficit.
Keywords: Case report, complete hanging, suicide
| Introduction|| |
In 2020, 153,052 suicides were reported in India, showing an increase of 10% compared to 2019. The male: female ratio of suicide victims was 7:3 in the year 2020. Among the females, more than 50% were homemakers. The most common means adopted to commit suicide in India are hanging (57.8%), consuming poison (25.0%), drowning (5.2%), and fire/self-immolation (3.0%). Complete hanging is when no body part touches the ground or any surface. Poor prognosis is associated with a Glasgow coma scale (GCS) <8, systolic blood pressure <90 mmHg, head computed tomography imaging consistent with anoxic brain injury, and hanging time longer than 5 min. Except in vagal stimulation, death is not immediate in cases of hanging. It is unlikely to occur before the end of 5 min and may take as long as 20 min. If there is no injury to the spinal cord and the stoppage of air is not complete, 5–8 min is the typical fatal period, but life may be restored after even half an hour of suspension. We present a case of a young female with suicidal complete hanging with a favorable outcome.
| Case Report|| |
A 31-year-old female with no prior comorbidities was brought by her neighbors as a case of suicidal hanging. Her children first saw the patient when they returned home after playing. The children called the neighbors. The patient was found hanging from the ceiling fan of her bedroom using a dupatta, her feet were unsupported, and a chair was found lying over the bed near her. The neighbors cut the dupatta and brought the patient down. It took them 20 min to reach the hospital. In the emergency department, the patient was unresponsive with a GCS of 3/15. Her heart rate was 58 beats/min, her blood pressure was 80/56 mmHg, and her saturation was 80% on room air. Her pupils were mid-dilated and sluggishly reacting to light. An oblique ligature mark was present over the neck extending from the right side of the midline above the larynx to the left side of the neck just below the angle of the left mandible [Figure 1].
|Figure 1: An oblique ligature mark is present over the neck extending from the right side of the midline above the larynx to the left side of the neck just below the angle of the left mandible|
Click here to view
The patient was ventilated with a Bains circuit with 100% oxygen and immediately intubated with a 7.5 mm internal diameter oral polyvinyl chloride cuffed endotracheal tube with premedication of 100 μg fentanyl. The patient was shifted to the intensive care unit. She was maintained on continuous mandatory ventilation mode with 450 ml tidal volume, peak end-expiratory pressure of 5 cm, and respiratory rate of 16/min on FiO2 100% initially, which was decreased subsequently to maintain saturation above 95%. She was sedated with an injection of fentanyl plus midazolam infusion at the rate of 5 ml/h. She was started on injection noradrenaline infusion to maintain mean arterial pressure (MAP) of more than 60 mmHg. Her initial laboratory parameters were within normal limits. Due to suspected airway inflammation, she was administered an injection of dexamethasone 8 mg intravenous twice a day along with empirical antibiotics and low-molecular-weight heparin. The next day patient remained sedated, and her pupils were 3 mm and sluggishly reacting to light. On day 3 of admission, the patient had a spontaneous eye-opening. She underwent magnetic resonance imaging of the brain to look for any evidence of hypoxic-ischemic encephalopathy. She was started on enteral feeds through a nasogastric tube. On the 4th day, the sedation was discontinued, and the patient was switched to adaptive support ventilation mode to start the spontaneous breathing trial. A cuff leak test was performed to check for airway edema. The patient was successfully extubated after 4 h and the enteral feeds were continued. Postextubation patient was talking with a very feeble voice and was crying incessantly. On day 5 of the admission, the patient was started on oral feeds and ambulated. On day 6 of the admission, glucocorticoids, antibiotics, and anticoagulants were stopped. Psychiatric consultation was taken, and she was started on the tablet mirtazapine 7.5 mg at bedtime. She was discharged on the 7th day.
| Discussion|| |
In suicidal hanging, death is mainly due to hypoxia, asphyxia, or both. The pressure required to compress the great vessels of the neck is 2–3 kg, compared to 15 kg for compression of the trachea. Hanging usually results in cerebral hypoxia and decreased muscle tone around the neck, causing a respiratory obstruction. Our patient was brought to the hospital after 20 min of bringing down her body; however, the exact time for which she was hanging is not known.
Currently, there are no standardized protocols for the management of near-hanging patients.
Bautz and Knottenbelt managed three cases of suicidal hanging with early intubation and mechanical ventilation along with supportive care. All the three patients had a favorable outcome. Similarly, Kodikara described a case of suicidal hanging in a 35-year-old male with successful management following early intubation, mechanical ventilation, and resuscitation.
Providers focus on following the Advanced Trauma Life Support protocol and maintaining the airway through intubation and positive-pressure ventilation. Resuscitation is managed through intravenous fluids. The cervical spine is often immobilized to prevent further injury to the spine. Frequent checking of random blood glucose is done to maintain normoglycemia and provide ventilator support when required. Tharmarajah et al. described an established protocol for early management based on the following three primary goals: (1) early emergency department intubation, (2) strict control of MAP 65 mmHg, and (3) targeted temperature management between 32 and 34°C. We managed our patient on similar lines except for targeted temperature management. The timely and vigorous efforts at resuscitation at the hospital resulted in the victim walking home without any neurological deficit. Although neurological injury determines the outcome following hanging, initial neurological presentation is of limited prognostic value: a poor initial condition does not exclude a good recovery.
Seizures, pulmonary edema, injury to the vertebral artery, status epilepticus, acute respiratory distress syndrome, cervical spinal cord injuries, and tracheal injuries are other rare complications of near-hanging reported in the past. Our patient did not have any of these complications.
| Conclusion|| |
Hanging is still the most common way of committing suicide. Despite the patient's initial condition, all efforts should be made to resuscitate the patient. This case highlights the fact that patients can have successful outcomes even after complete hanging depending on initial resuscitative measures.
The authors certify that patient consent was taken in writing for publication of this case report.
Our institute does not require ethical clearance for individual case reports.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kodikara S. Uneventful recovery from suicidal hanging: A case report. Med Sci Law 2006;46:89-91.
Tharmarajah M, Ijaz H, Vallabhai M, Jena NN, LeSaux M, Smith JP, et al.
Reducing mortality in near-hanging patients with a novel early management protocol. Am J Emerg Med 2018;36:2050-3.
Kodikara S. Attempted suicidal hanging: An uncomplicated recovery. Am J Forensic Med Pathol 2012;33:317-8.
ATLS Subcommittee, American College of Surgeons' Committee on Trauma, International ATLS Working Group. Advanced trauma life support (ATLS®): The ninth edition. J Trauma Acute Care Surg 2013;74:1363-6.
Bautz P, Knottenbelt JD. Successful resuscitation from suicidal hanging: Report of three cases. Injury 1994;25:111-2.
Davidson JA. Presentation of near-hanging to an emergency department in the Northern Territory. Emerg Med (Fremantle) 2003;15:28-31.
Ganesan P, Jegaraj MK, Kumar S, Yadav B, Selva B, Tharmaraj RG. Profile and outcome of near-hanging patients presenting to emergency department in a tertiary care hospital in South India – A retrospective descriptive study. Indian J Psychol Med 2018;40:205-9.
] [Full text]