Rosen & Barkin's 5-Minute Emergency Medicine Consult (471 page)

• 801.00 Closed fracture of base of skull without mention of intra cranial injury, unspecified state of consciousness
  
• 802.0 Closed fracture of nasal bones
  
• 920 Contusion of face, scalp, and neck except eye(s)
  

BASICS

• Strangulation:
  
  • Ligature: Material used to compress structures of neck
    
  • Manual: Physical force used to compress structures of neck
    
  • Postural: Airway obstruction from body weight (over an object) or position (typically in infants)
    
• Hanging is a form of strangulation:
  
  • Complete (judicial type): Victim’s entire body is suspended off the ground
    
  • Incomplete (nonjudicial): Some part of victim’s body contacts the ground
    
  • Typical: The point of suspension is placed centrally over the occiput.
    
  • Atypical: The point of suspension is in any position other than over the central occiput.
    
  • Intentional: Suicide, homicide, autoerotic, “the choking game”
    
  • Accidental: Often children or clothing caught in machinery
    
  • Near-hanging: Survival following nonjudicial hanging
    

• Hanging (judicial):
  
  • Victim is dropped a distance at least equal to his or her height
    
  • Forceful distraction of head from torso results in a decapitation type of injury (fracture of cervical spine and transection of spinal cord)
    
• Hanging (nonjudicial):
  
  • Typically occurs from a lower height
    
  • Injuries mimic nonjudicial strangulation
    
• Strangulation:
  
  • External neck pressure causes cerebral hypoxia secondary to venous and arterial obstruction.
    
  • Pressure on neck structures may cause airway, soft tissue, and vascular injuries.
    
  • Cervical spine injuries are uncommon except with judicial-type hanging.
    
• Death:
  
  • Secondary to mechanical closure of blood vessels or airway
    
  • Secondary to cardiac arrest from extreme bradycardia due to increased vagal tone from carotid sinus pressure
    
  • Secondary to direct neurologic injury to the spinal cord
    
  • Secondary to pulmonary complications in near-hanging victims
    
  • Secondary to cerebral hypoxia
    

• Cervical spine injury
  
• Hypoxic cerebral injury
  
• Arterial or venous dissection/thrombosis
  
• Hyoid bone fracture:
  
  • Typically seen in nonjudicial strangulation
    
• Cricoid cartilage disruption (rare)
  
• Thyroid cartilage disruption:
  
  • More common in nonjudicial strangulation deaths
    
• Phrenic nerve injury
  
• Airway edema
  
• Aspiration pneumonitis (may be late)
  
• Neurogenic pulmonary edema (may be late):
  
  • Due to massive central sympathetic discharge
    
• Postobstructive pulmonary edema (may be rapid onset):
  
  • Due to negative intrapleural pressure resulting from inspiration against an external airway obstruction
    
• Air embolism:
  
  • Consider when SC air and vascular injuries are present
    

DIAGNOSIS

• Airway disruption:
  
  • SC emphysema
    
  • Dyspnea
    
  • Dysphonia or stridor
    
  • Loss of normal cartilaginous landmarks
    
• Cervical spine injury:
  
  • Respiratory arrest
    
  • Paralysis
    
• Neurologic injury:
  
  • Hoarseness
    
  • Dysphagia
    
  • Altered mental status
    
  • Neurologic deficit
    
• Pulmonary sequelae:
  
  • Respiratory distress
    
  • Pulmonary edema, ARDS, pneumonia
    
• Soft tissue injury:
  
  • Abrasions, contusions, ecchymoses, ligature, or hand marks
    
• Vascular injuries:
  
  • Expanding hematoma
    
  • Pulse deficits or bruits
    
  • Evidence of cerebral infarction
    
  • Tardieu spots: Petechial hemorrhages of the skin, mucous membranes, and conjunctiva cephalad to the ligature marks
    

• Structures of neck are more cartilaginous and mobile than in adults
  
• More resistant to crush injuries and fractures
  
• Rapid airway compromise can occur with relatively little edema of soft tissues secondary to smaller airway diameter.
  

• Strangulation method:
  
  • Patient position:
    
    • To determine mechanism of strangulation
      
    • Predict potential injuries
      
  • Higher fall implies greater force:
    
    • Decapitation-type injury more common
      
  • Knot position:
    
    • Arterial occlusion more likely in typical hanging
      
  • Ligature material:
    
    • Elasticity limits force applied
      
    • Venous occlusion may still produce unconsciousness and death
      
• Circumstance:
  
  • Accidental, suicide/homicide, NAT, sexual, “choking game”
    

• ABCs:
  
  • Airway or respiratory compromise
    
  • C-spine precautions
    
• Disability:
  
  • Coma, AMS, neurologic deficit, paralysis
    
• Secondary survey:
  
  • Assess for traumatic injury to the neck:
    
    • Soft tissue, aero-digestive, vascular
      
  • Other traumatic injury due to fall, self-inflicted wounds (suicidal), injury sustained in conflict (homicidal/NAT)
    

• CT of the cervical spine through T1
  
• CT scan of the head:
  
  • For cerebral hemorrhage, subarachnoid hemorrhage, hematoma, edema, and evidence of hypoxic injury
    
• CT angiography of the neck:
  
  • For thrombosis and intimal dissection
    
• Plain radiography:
  
  • CXR to evaluate for SC emphysema, aspiration pneumonitis, and pulmonary edema
    
• Pulse oximetry
  
• Cardiac monitor
  

• ABG (may be considered):
  
  • Evaluate for evidence of hypoxia or respiratory compromise.
    
• Hematocrit for significant blood loss
  
• Type and cross-match in anticipation of transfusion for vascular injuries.
  
• Coagulation profile for significant blood loss or coagulopathy
  
• Toxicology studies (ASA/APAP/ETOH):
  
  • Consider for suicide-related ingestions
    

• MRI of the neck:
  
  • High sensitivity of MRI for soft tissue injury, bone and cartilaginous injury.
    
  • Superior to CT in diagnosis of soft tissue injury.
    
• Arteriography:
  
  • Definitive evaluation for potential vascular injuries
    

• Fiberoptic endoscopy:
  
  • Allows direct visualization for evaluation of aero-digestive injury
    
  • May aid in intubation
    
• Surgical exploration
  

Etiology of strangulation:

• Accidental, homicidal, suicidal, NAT, auto-erotic, choking game
  

TREATMENT

• ABCs
  
• Early and aggressive airway management: Oxygen, suction, intubation, as indicated:
  
  • Remove ligature.
    
• Cardiac monitor
  
• Cervical spine stabilization:
  
  • Patient position, strangulation method, drop involved, knot location, signs of foul play
    

• ABCs
  
• Aggressive airway management with cervical spine precautions is paramount:
  
  • Early intubation for respiratory compromise
    
  • Supplemental oxygen
    
  • Cricothyrotomy or tracheostomy may be required if severe maxillofacial injuries are present:
    
    • Avoid cricothyrotomy if hematoma over cricothyroid membrane or evidence of cricotracheal disruption is seen.
      
    • Arrange for emergent tracheostomy in above scenario (see Larynx Fracture).
      
• Control bleeding with application of direct pressure:
  
  • Do not explore in the ED
    

• IV access
  
• Consult otolaryngologist or trauma surgeon in management of neck soft tissue injuries.
  
• Consult vascular surgery in management of vascular injuries.
  
• Consult neurology for suspected cerebral ischemic insults (thrombosis, embolism, dissection).
  
• Supportive care for suspected elevated intracranial pressure/cerebral edema:
  
  • Elevate head of bed.
    
  • Ensure adequate oxygenation and cerebral perfusion.
    
  • Prevent secondary neurologic injury/insult.
    
  • Consult neurosurgery for intracranial pressure monitoring and surgery as indicated.
    
• Neck injury with SC emphysema:
  
  • Assume that mucosa of upper airway communicates with deep tissues of neck.
    
  • Administer antibiotics.
    
• Laryngeal edema:
  
  • Consider steroids.
    
• Evaluate for associated injuries or harm:
  
  • Consider ingestions in suicidal cases.
    
  • Report suspected nonaccidental injuries in children.