Pediatric Strangulation
CASE
A 15 year-old girl is brought in as a trauma activation after being found by her father hanging from a tree after an apparent suicide attempt. The father cut her down and the emergency medical services (EMS) crew that responded brought her to the emergency department (ED) with a c-collar in place, using a bag-valve mask (BVM) to assist her respirations.
On arrival, she did not open her eyes to stimulation, had no vocalization, and was exhibiting decerebrate posturing, giving her a Glascow Coma Scale (GCS) of 4. She was intubated, and the remainder of her primary survey was normal. On secondary survey she was found to have a ligature mark around her neck, scattered abrasions across her legs, and old self-injury marks on her forearms. There were no step offs or deformity on spinal palpation.
Computed tomography (CT) imaging of her brain showed no injuries and preservation of grey-white matter differentiation. A CT of her c-spine also showed no injuries, and subsequent CT angiography of her neck showed a filling defect of the right internal carotid artery without evidence of dissection or contrast extravasation concerning for a blunt arterial injury.
DISCUSSION
Strangulation injuries are defined as any injury that results from a compressive force to the neck, leading to vascular and airway occlusion. Such forces might include hanging or strangulation (postural, ligature, or manual). Strangulation is implicated in 10% of violent deaths in the United States, while hanging is the second most common form of death by suicide.[1]
Mechanisms of Injury
The mechanism of strangulation can predict the type of injury one expects to see:
| Mechanism | Injury Pattern |
|---|---|
| Hanging | Intimal tear of common carotid artery |
| Ligature | Hyoid and laryngeal injury |
| Manual strangulation | Fracture of larynx, hyoid bone, and thyroid cartilage |
Traumatic Hanging
Hangings with a fall from a height greater than or equal to the victim’s height (as seen with judicial hangings) are considered “complete.” Hyperextension of the neck results in a traumatic fracture of C2, typically with severe spondylolisthesis. This classic “hangman’s fracture” (Figure 1) essentially causes internal decapitation and spinal cord transection.
Figure 1. “Hangman’s fracture” of C2. Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 32185.
Strangulation
Progressive cerebral hypoxia and ischemia is thought to be predominantly responsible for the morbidity and mortality associated with strangulation. Initially, external compression of the venous drainage system (internal/external jugular) results in loss of consciousness through stagnation hypoxia. This subsequently leads to a loss of neck muscle tone which permits the occlusion of the carotid artery and the arterial blood supply. Vagally mediated dysrhythmias through the carotid body reflex and airway obstruction are thought to be secondary mechanisms of injury. Fortunately, cervical spine injuries are rare in non-judicial hangings and strangulation injuries. [1-3]
Physical Examination
A careful physical exam is needed in patients who do not present with severe and obvious strangulation injuries. There is evidence that patients with strangulation may be “under evaluated” due to circumstances such as intoxication, hysteria, or minimization of symptoms/injury by victims of domestic abuse.[4]
Clinical findings will depend on the mechanism of strangulation, but generally include cough, stridor, muffled voice, and tenderness to palpation of the larynx. Subconjunctival hemorrhage, petechiae, and Tardieu spots (from ruptured capillaries; Figure 2) can be seen cephalad to the site of strangulation. Care must be taken not to dismiss subclinical airway edema and tachypnea, as hypoxia can be a late finding. Terrifyingly, half of strangulation victims have no signs of injury, and up to two thirds are asymptomatic.[5]
Figure 2. Tardieu spots result from the rupture of superficial capillaries. (Image from Medscape).
Prognosis
If a patient survives the initial hypoxic insult, in-hospital death is usually due to non-cardiogenic pulmonary edema (Figure 3). This neurogenic pulmonary edema is thought to result from a large sympathetic discharge related to brain injury. In terms of neurologic recovery, it can be incredibly difficult to prognosticate based on the initial presentation, as patients with apparently devastating neurologic injuries have been known to make full recoveries, whereas others progressively decline. Importantly, presenting GCS is not a good prognostic indicator. However, those who present in cardiac arrest have a universally grim prognosis.[1]
Figure 3. A chest x-ray of our patient on day 3 of hospitalization showed diffuse pulmonary infiltrates most consistent with acute respiratory distress syndrome.
Pediatric Considerations
Pediatric patients have unique anatomic and behavioral considerations in strangulation injuries. Younger children frequently suffer strangulation injuries from car windows, drapes, window shade cords, power cords, and high chairs. Teenagers are at increased risk from injury due to autoerotic asphyxiation and suicide by hanging.[6,7] Another interesting behavioral trend observed in children and adolescents is the “choking game” – a game in which they attempt to strangle each other in pursuit of the strange/euphoric sensations that occur just prior to passing out.[2]
Anatomically, the larynx is more superior in pediatric patients, which is protective and lessens the risk of injury in penetrating neck trauma.[8] However, children are generally at increased risk of presenting with significant airway compromise from strangulation injuries due to the smaller size of their larynx and the relative laxity of their soft tissues. Clinically, this means neck hematomas and tissue edema have the potential to expand more quickly and can have a more dramatic effect.[1]
Children often present as a result of clothesline-type injuries and falls onto handlebars. With this mechanism they can present in respiratory distress from tracheal injury rather than with the prolonged periods of hypoxia seen in circumferential strangulations. As one might expect, these injuries can further distort the already difficult pediatric anatomy. In terms of airway management, devices such as an intubating bronchoscope and even needle cricothyroidotomy can be helpful until a tracheostomy can be performed in the operating room.
The importance of close monitoring in pediatric strangulation injuries cannot be overstated as there are many cases of delayed rise in intracranial pressure which cause “late herniation” after the primary airway, pulmonary, and neurologic injuries have been stabilized.[9]
Emergency Department Management
Emergency treatment of strangulation injuries relies heavily on airway and respiratory management. These patients are at risk of developing severe edema of the uvula, epiglottis, larynx, and vocal cords, which may preclude delayed intubation. Given this, airway adjuncts and a good backup plan are essential when taking control of the patient’s airway. Beyond intubation, patients are at high risk of developing pneumonia and ARDS. Thus, fluids should be used judiciously and antibiotics considered. Care must be taken to decrease intracranial pressure (ICP) if there is evidence of neurologic compromise due to risk of herniation from cerebral edema, and this should be considered early in comatose patients. Finally, focal neurologic deficits may suggest cerebrovascular injury such as a carotid dissection or thrombus. CT imaging, including neck angiography can be very helpful in guiding management.
The outcomes in these patients, particularly pediatrics, are highly dependent on the effectiveness of emergency department resuscitation.[6] Thus, having a solid understanding of the pathophysiology and management of these injuries is essential.
CASE RESOLUTION
The patient was admitted to the pediatric intensive care unit for further management. She had a prolonged and complicated hospital course. The day following admission, she exhibited diffuse myoclonic jerking that was difficult to suppress with medications. On hospital day 2 she went into shock and then developed ARDS, which required aggressive ventilation maneuvers and vasopressors. For about a week she was too unstable to get a brain magnetic resonance imaging (MRI) to assess for anoxic injury, but during this time, bedside electroencephalogram (EEG) showed diffuse encephalopathy without seizure-like activity. Despite these EEG findings, she was able to open her eyes, track the examiner, and move her extremities. Her shock resolved during the second week of hospitalization, her ventilator settings were weaned, and she had an improving mental status. She was eventually extubated, had a near normal mental status, and was transitioned to the psychiatric unit for further management, where she underwent electroconvulsive therapy for severe depression.
TAKE-AWAYS
Cervical spine injuries are rare in non-judicial hangings; strangulations are more common.
Strangulation patients may be “under evaluated” due to circumstances such as intoxication, hysteria, or minimization of symptoms/injury by victims of domestic abuse.
Evaluate carefully for airway edema and tachypnea, because hypoxia can be a late finding.
The outcomes in strangulation are highly dependent on the effectiveness of emergency department resuscitation, so a solid understanding of pathophysiology and management is essential for any emergency medicine provider.
FACULTY REVIEWER
Dr. Jane Preotle
REFERENCES
Bean AS. Trauma to the Neck. Tintinalli’s Emergency Medicine – A Comprehensive Study Guide. 8e. 2016. Chapter 260 pp 1733-1740.
Kaki A, Crosby ET, Lui AC. Airway and respiratory management following non-lethal hanging. Can J Anaesth 1997 Apr;44(4):445-450.
Shumaker D, Kottamasu S, Preston G, et al. Acute pulmonary edema after near strangulation. Pediatr Radiol 1988;19(1):59-60.
McClane GE, Strack GB, Hawley D. A review of 300 at- tempted strangulation cases Part II: clinical evaluation of the surviving victim. J Emerg Med 2001 Oct;21(3):311-315.
https://emedicine.medscape.com/article/826704-overview.
Sabo RA, Hanigan WC, Flessner K, et al. Strangulation injuries in children. Part 1. Clinical analysis. J Trauma 1996 Jan;40(1):68-72.
Rauchschwalbe R, Mann NC. Pediatric window-cord strangulations in the United States, 1981-1995. JAMA 1997 Jun 4;277(21):1696-1698.
Balkany TJ, et al. The management of neck injuries. In: Zuidema GD, Rutherford RB, Ballinger WF, eds. The Management of Trauma. 4th ed. Philadelphia: W.B. Saunders, Co.; 1985.
Hanigan WC, Aldag J, Sabo RA, et al. Strangulation injuries in children. Part 2. Cerebrovascular hemodynamics J Trauma 1996 Jan;40(1):73-77.
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