Hanging is one of the most common suicide methods in England and Wales (Office for National Statistics, 2011), with 51.7% of suicides (and deaths likely but not proven to be suicide) being by hanging. In 2010, over 4 200 people ended their lives by suicide in England (Department of Health, 2012), of which around 2 171 people hanged themselves. Gunnell et al (2005) propose that hanging is one of the most lethal forms of suicide attempt and estimate the fatality being around 70%.
Bennewith et al (2005) state that suicide by hanging in prison or psychiatric units account for only 6% of the total hanging suicides in the 6-month period and locations they studied. Thus, 94% of hanging suicides take place in the community, potentially in people's homes or workplaces. Bennewith et al (2005) further divide the locations, as can be seen in Table 1.
| Location | % |
|---|---|
| In their home | 65.4% |
| In public areas | 16.6% |
| Unaccounted for | 18% |
From: Bennewith et al, 2005
They also categorise the items used for the hanging (see Table 2); these items can clearly be identified by their commonplace availability and ease of access. The ease of access to these household items can make prevention difficult for the person regardless of whether the attempt is an impulsive one or a planned one.
| Item used | % |
|---|---|
| Rope or cord | 49.4% |
| Belt | 13.1% |
| Electrical cable | 11.9% |
| Other clothing (scarf, ties, dressing gown cord, shoelaces) | 10% |
From: Bennewith et al, 2005
In a retrospective analysis of 37 consecutive cases of suicidal hanging admitted to the intensive care unit of Manipal Hospital, Bangalore from July 1996 to December 2002, Karanth and Nayyar (2005) identified the gender split of hanging suicides as being almost equal: 19 males compared to 18 females. This is in contrast to overall suicide figures, where the Department of Health (2012) state ‘Men are at three times greater risk of suicide than women,’ and that ‘Men aged 35–49 are now the group with the highest suicide rate.’
The location of the majority of hanging suicides being at home and not in a medical institution (Bennewith et al, 2005), suggests that it is likely that ambulance crews will attend a number of these incidents within their careers. Thus, it is important for paramedics and indeed all ambulance staff to understand the nature of injuries and their management. There is limited research and evidence for the management of the hanged patient in the pre-hospital environment. This paper will draw from the available research to suggest the most appropriate course of action; however, it is recognised that more research is required to ensure best practice is found in the future.
Definition
Hanging can be categorised as judicial or non-judicial, with the former being a legal capital punishment, which usually follows a set procedure in order to cause death. Currently, it is argued that hanging is the most frequent form of judicial capital punishment, with approximately 60 countries ‘authorised’ to utilise, although may not practice, this form of capital punishment (Cornel Law School, 2012). Death from hanging (judicial or non-judicial) can be caused by a number of reasons: strangulation, carotid/vagal reflex or fracturing the cervical spine causing severe damage to the spinal cord (Capital Punishment UK, 2009). ‘Hanging’ by definition results in the death of the individual; however, ‘near hanging’ differs in that the individual survives to admission to hospital (Adams, 1999).
Context
Judicial hanging was abolished in the UK in 1969 (BBC, 2013), therefore the only hanging that UK ambulance crews should attend is suicide, murder or autoerotic asphyxiation. Suicide is the deliberate process of taking one's own life (NHS Choices, 2015), murder is defined as the unlawful killing of a human being by another, with malice aforethought (The Oxford English Dictionary, 1996), and autoerotic asphyxiation is the intentional production of a state of hypoxia or even anoxia to heighten sexual pleasure (Cowell, 2009). Anecdotally, the number of paediatric suicides and accidents by hanging has increased over the past 3–4 years, thus potentially, ambulance crews could attend such a case. Elnour and Harrison (2007) reported out-of-hospital hangings in Australia as having an 83% mortality.
Pathophysiology of hanging/near hanging
Strangulation
Asphyxiation is the cessation of gaseous exchange (National Association of Emergency Medical Technicians, 2010). In the case of hanging or near hanging, this could result from an increase in pressure on the trachea or fracture of the larynx, resulting in the compression of the larynx. It can also result from the backwards pressure of the tongue obstructing the airway. In essence, the patient has an airway obstruction from one source or another. Strangulation, however, is the closure of blood vessels and/or airways as a result of external pressure applied to the neck (Morild, 1996), therefore, strangulation incorporates some elements of asphyxiation.
Carotid/vagal reflex
Vagal stimulation has been shown to induce cardiac arrest, by initially inhibiting the action of the sinoatrial (SA) node in the heart (Vassalle et al, 1967). This then leads on to the suppression of any ventricular pacemakers, ceasing any electrical activity in the heart (Vassalle et al, 1967). This work has been supported by Vaseghi and Shivkumar (2008), who state ‘Substantial evidence links enhanced sympathetic activation with ventricular arrhythmias and sudden cardiac death.’
‘Death from hanging can be caused by a number of reasons: strangulation, carotid/vagal reflex or fracturing the cervical spine causing severe damage to the spinal cord’
Fracturing the cervical spine
The ‘hangman's fracture’ (traumatic spondylolisthesis of C2 (Xin-Feng et al, 2006)) is usually sustained as a direct result of distraction and hyperextension of the cervical spine region. It usually results in the movement of the vertebrae at C2. It is suggested that the ‘hangman's fracture’ occurs rarely in hanging, being more frequent in vehicular, diving and falling incidents (Fielding et al, 1989). However, rarely, does not mean it does not occur. Fielding et al (1989) suggest that it is most likely to occur where the knot (or joining of the loop is placed under the person's chin, forcing the head backwards. This is in support of Wood-Jones (1913), who suggests that should the knot be suboccipital (behind the head), it is most likely that the individual would be strangled. The movement and potential fracture of C2 can cause catastrophic damage to the spinal cord (Sköld, 1978) and therefore result in death.
The actual cause of death can be considered to be related to the type of hanging that occurs, as seen in Table 3. It can also been seen that the majority of suicides through hanging are unlikely to be ‘long drop’, therefore suggesting fracture to the cervical vertebrae/spinal cord experienced is likely to be uncommon.
|
Short drop
|
Cause of death is usually asphyxiation, or carotid/vagal reflex |
|
Suspension hanging
|
Cause of death is usually asphyxiation, or carotid/vagal reflex |
|
Standard drop
|
Cause of death can be asphyxiation, or carotid/vagal reflex OR fracture to the cervical vertebrae/spinal cord |
|
Long drop
|
Death is usually caused by fracture to the cervical vertebrae/spinal cord |
Adapted from: Capital Punishment UK, 2009
Pre-hospital management of the hanging/hanged patient in cardiac arrest
There are few guidelines presented for the pre-hospital management of the hanging/hanged patient, and most have been published some 20–30 years ago.
Many of these points could still be considered valid today. There is, however, no mention of circulatory support using cardiopulmonary resuscitation. It has been documented that even patients in a state of profound unconsciousness can have a positive outcome if they are managed correctly (Bautz and Knottenbelt, 1994).
More recent research (Mobbs et al, 2002) suggests that ridged cervical collar application can increase intercranial pressure in patients with brain trauma. It could be construed that in the hanging/hanged patient, hypoxia is a real risk, which can lead to brain injury (Arciniegas, 2012), thus the use of the rigid collar should be evaluated carefully. In cases of brain and cervical spine injury, Mobbs et al (2002) also suggest the use of sandbags either side of the patient's head taped to the bed, without the use of a collar.
Based upon the research within, it could be considered that a more effective management of the unconscious hanging victim could be:
Limitations
This paper has considered contemporary evidence where available; however, specific research would be beneficial in terms of identifying best practice with this groups of patients. Additionally, the paper does not consider the additional challenges that may be present in a conscious hanged patient.
Conclusions
This paper has examined the causes of death within hanging in the pre-hospital environment, with the most likely cause being asphyxiation. It is suggested that the majority of hanged patients attended by pre-hospital care staff in the UK will not have a cervical spine fracture. Therefore, careful consideration of the application of spinal immobilisation by cervical collar is recommended, comparing potential risks of spinal fracture, to those likely from cervical spine collar application. The use of immobilisation utilising head blocks or sandbags without cervical spine collar is a potential solution where possible if cervical spine fracture is highly suspected. Further research into this area of practice would be beneficial in the future.