In this article, Dr Sujay Shanker shares his experience with a case of hanging that was presented at a primary care hospital in a remote location in India.

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Background

With its relatively small diameter, lack of bony shielding, and close association of the airway, spinal cord, and major vessels, the human neck is uniquely vulnerable to life-threatening injuries. Throughout recorded history, various methods of strangulation (disruption of normal blood and air passage in the neck) have been used by both assailants and penal systems to produce injury and death.

Hanging is a form of strangulation that involves suspension by the neck. Hangings can be classified as either complete or incomplete. When the whole body hangs off the ground and the entire weight of the victim is suspended at the neck, the hanging is said to be complete.

Incomplete hangings imply that some part of the body is touching the ground and that the weight of the victim is not fully supported by the neck. It may also be classified by intent

• Homicidal
• Suicidal
• Autoerotic
• Accidental

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Clinical presentation

At 9.00 pm on 10th May 2009, a 22-year-old man was brought to the hospital with a history of suicidal hanging. He had been hanging for approximately 15 minutes. Time taken to bring it to the hospital was 20 minutes. The patient was presented with the following findings:

• Patent airway
• Palpable and regular carotid pulse
• GCS: E2 V1 M2
• Generalised extensor spasms involving both upper and lower extremities and spine
• Ligature mark on the neck
• Frothing from mouth
• B/L conjunctival congestion
• Both pupils midsized with sluggish reaction to light
• Pulse 90/min
• BP 150/80
• Chest B/L rales

Facilities for the assessment of oxygen saturation and ABG were not available, and hence these parameters were not assessed. The nearest referral hospital with ICU facilities was a 4-hour drive on very bad roads, so it was not possible to shift the patient to a higher centre.

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Immediate treatment

Resuscitation was commenced immediately with oxygen inhalation, IV line with DNS was started. Injection Hydrocortisone 100mg IV bolus was administered. The patient responded to these measures and after approximately 15 minutes, the extensor spasms were replaced by belligerent behaviour, and the chest rales vanished.

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Further management and progress

20% mannitol 200 ml was then infused rapidly followed by slow iv DNS to keep the IV-line patent. A repeat injection of hydrocortisone was given at 10.00 pm. Gradually the patient settled down and went off to sleep. At 2.00 am he woke up, conversed with relatives, and asked for food and water. Mannitol 100 ml was infused at 5.30 am and the injection of hydrocortisone was then repeated at 6.00 am.

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Complete recovery

The next morning, the patient was fully conscious, alert and oriented during the examination. Vitals were stable with a pulse rate of 80/min and BP of 110/70. The chest was clear with B/L bronchovesicular breath sounds. There was no neck tenderness. No residual neurological deficit was apparent. The patient was subsequently discharged in excellent condition after 2 days.

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Discussion

The mode of death in cases of hanging is as follows:

• Coma
• Asphyxia
• Cerebral oedema due to venous congestion resulting from compression of jugular veins
• Shock due to vagal nerve compression
• Injury to the spinal column
• A combination of any of the above

Contrary to popular belief the common cause of death by hanging in most instances is compression of cervical vasculature and not asphyxia by airway obstruction.

Most experts agree that regardless of the events occurring in any given hanging or strangulation, death ultimately occurs from cerebral hypoxia and ischemic neuronal death.

In the present case, the patient’s symptoms were due to cerebral congestion and anoxia due to incomplete hanging. The venous return from the head was obstructed for some time leading to cerebral oedema. Treatment in the lines of cerebral oedema produced a dramatic change in the patient’s condition.

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Follow-up

As this was a medico-legal case police information was done after the stabilisation of the patient. A police enquiry was completed on the next morning, and further legal processes were initiated by the local police. The case was assessed from a social context. It seems, that the victim had married on his own and was living with his in-laws. Being unemployed, he was facing financial strain. Immediately preceding the incident, he had been berated by his mother-in-law for being unemployed and for getting married without being in a position to provide for his family.

Abject poverty and lack of employment opportunities is a significant social factor that contributes to suicides, and this is more common in rural areas. Lack of education and family support contributes to a low ability to cope with the stressors of everyday existence. In this particular case, social support was provided by the social outreach programme of the mining company that was running the hospital where he was treated.

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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Sujay Shanker is a general surgeon from Jamshedpur.