Rosen & Barkin's 5-Minute Emergency Medicine Consult (472 page)

• Hypoxic brain injury:
  
  • Mannitol: 0.25–1 g/kg/dose IV (consider for elevated intracranial pressure; not routinely used in pediatric cases)
    
  • Hypertonic saline: Dosing regimens vary (consider for elevated intracranial pressure)
    
  • Phenytoin: 15–20 mg/kg IV (loading dose) as needed for seizures
    
• Neck injury with SC emphysema:
  
  • Ampicillin/sulbactam: 1.5–3 g (peds: 100–400 mg/kg/d) IV q6h
    
  • Clindamycin: 600 mg (peds: 25–40 mg/kg/d) IV q8h
    
• Airway edema:
  
  • Dexamethasone: 0.5–2 mg/kg/d (peds: 0.25–0.5 mg/kg) IV q6h
    

FOLLOW-UP

• Admit patients with strangulation or hanging-mechanism injuries to a monitored setting to observe for airway or neurologic compromise (may have delayed onset).
  
• Surgical correction of laryngeal, esophageal, or vascular neck injuries
  
• Altered level of consciousness, new neurologic deficit, coma
  
• Respiratory distress:
  
  • Supportive care for pulmonary edema, ARDS, pneumonia
    
• All patients with suspected suicidal or homicidal strangulation injury should have psychiatric or social work consultation.
  
• For pediatric patients:
  
  • Suspected nonaccidental trauma, concern for safety in the home
    

Only patients without strangulation or hanging injuries may be discharged after appropriate observation in the ED to ensure absence of airway compromise, vascular injury, neurologic deficit, and suicidal/homicidal ideation.

• Neuropsychiatric evaluation:
  
  • Consider in evaluation for hypoxic encephalopathy
    
• Psychiatry/psychology:
  
  • Suicidal or homicidal patients
    
  • Auto-erotic or “choking game” patients for medical/cognitive/behavioral therapy
    
• Surgical follow-up:
  
  • As indicated, based on injuries sustained
    

• Cervical spine injury is uncommon in nonjudicial hanging victims:
  
  • Cerebral hypoxia is the probable cause of death in the majority of victims.
    
• Aggressive airway management is paramount.
  
• Thoroughly evaluate for associated injuries.
  
• Consider admission for observation of all strangulation/hanging victims.
  
• Prognosis:
  
  • GCS on arrival does not predict prognosis.
    
  • Poor prognosis is suggested by:
    
    • Anoxic brain injury on head CT
      
    • Increased hanging time
      
    • Cardiac arrest at the scene AND on arrival to the ED
      

• Christe A, Oesterhelweg L, Ross S, et al. Can MRI of the neck compete with clinical findings in assessing danger to life for survivors of manual strangulation? A statistical analysis.
  Leg Med (Tokyo)
  . 2010;12(5):228–232.
  
• Christe A, Thoeny H, Ross S, et al. Life-threatening versus non-life-threatening manual strangulation: Are there appropriate criteria for MR imaging of the neck?
  Eur Radiol
  . 2009;19(8):1882–1889.
  
• Dundamadappa SK, Cauley KA. MR imaging of acute cervical spinal ligamentous and soft tissue trauma.
  Emerg Radiol
  . 2012;19(4):277–286.
  
• McClane GE, Strack GB, Hawley D. A review of 300 attempted strangulation cases Part II: Clinical evaluation of the surviving victim.
  J Emerg Med.
  2001;21:311–315.
  
• Nichols SD, McCarthy MC, Ekeh AP, et al. Outcome of cervical near-hanging injuries.
  J Trauma.
  2009;66:174–178.
  

CODES

994.7 Asphyxiation and strangulation

BASICS

• Blunt anterior neck trauma may result in various injuries to structures in the neck:
  
  • Vascular:
    
    • Carotid artery injury (internal, external, common carotid)
      
    • Vertebral artery injury
      
    • Intramural hematoma, intimal tear, thrombosis, and pseudoaneurysm
      
    • Hemorrhage or neck hematoma
      
  • Laryngotracheal:
    
    • Laryngeal injuries: Fracture of hyoid bone, thyroid cartilage, cricoid cartilage, cricotracheal separation
      
    • Vocal cord disruption
      
    • Dislocation of arytenoid cartilage
      
    • Tracheal injuries: Hematoma or transection
      
  • Pharyngoesophageal:
    
    • Pharynx: Hematoma, perforation
      
    • Esophagus: Hematoma, perforation
      
  • Nervous system:
    
    • Thoracic sympathetic chain wraps around carotid artery: Disruption can result in Horner's syndrome
      
    • Vagus nerve and recurrent laryngeal nerve
      
    • Cervical nerve roots and spinal cord
      
  • Cervical spine:
    
    • Fracture of vertebral body, transverse process, spinous process, etc.
      
    • Dislocation
      

• Motor vehicle accidents (most common cause):
  
  • Unrestrained occupants involved in frontal collisions may strike neck on dashboard or steering wheel: “Padded dash syndrome”
    
  • Shoulder harness (seatbelt) can also cause shearing injury to anterior neck.
    
• Assault: Blows to anterior neck from fists, kicks, or objects
  
• “Clothesline injury”:
  
  • Motorcycle, snowmobile, jet ski, or all-terrain vehicle (ATV)
    
  • Drivers strike neck on cord or wire suspended between 2 objects.
    
• Strangulation
  

• Head is proportionally larger in children, increasing risk of acceleration–deceleration injury to neck
  
• Intraoral blow to soft palate may cause carotid thrombosis (popsicle in mouth of child who falls, pushing the object into soft palate).
  

DIAGNOSIS

• Presentation varies depending on mechanism of injury and structures involved:
  
  • Vascular injury:
    
    • Hemorrhage, ecchymosis, edema
      
    • Carotid bruit or thrill (pathognomic for vascular injury)
      
    • Neurologic deficits (often delayed)
      
  • Laryngotracheal injury:
    
    • Voice changes, hoarseness, aphonia
      
    • Dyspnea, inspiratory stridor, labored breathing, “air hunger”
      
    • SC emphysema, tenderness to palpation
      
  • Pharyngoesophageal injury (rarely isolated):
    
    • Dysphagia, odynophagia, hematemesis, blood in saliva
      
    • Tenderness to palpation
      
    • Infection, sepsis (delayed presentation)
      
  • Neurologic injury:
    
    • Central or peripheral nervous system deficits
      

• Detailed history (if patient is able to provide) based on signs and symptoms:
  
  • Cover all structures of the neck, as well as structures outside the neck (neck trauma usually associated with injures to chest, head, etc.)
    

• Ensure airway protection and patency.
  
• Inspect neck for hemorrhage, hematoma, ecchymosis, edema, or distortion of anatomy.
  
• Auscultate for carotid bruits, stridor.
  
• Palpate to detect tenderness or SC emphysema.
  
• Neurologic exam to detect evidence of ischemic event, spinal cord injury, or peripheral nerve damage
  
• Complete physical exam to detect associated injuries to the chest, abdomen, etc.
  

Depends on history and physical exam findings

• Type and cross-match
  
• Baseline CBC
  
• BUN/creatinine may be needed prior to radiologic testing (contrast with CT or MRI)
  

• Cervical spine and lateral neck radiographs
  
• Limited value but may show subglottic narrowing, prevertebral soft tissue swelling, SC air, fractured calcified larynx
  
• CXR to rule out associated injury to thorax (pneumothorax, pneumomediastinum, etc.)
  
• Carotid duplex US is a noninvasive, rapid screening test for arterial injury:
  
  • Sensitivity as high as 92% in retrospective studies for dissection, operator-dependent, poor visualization above carotid bifurcation
    
• CT may be used in stable patients to evaluate laryngotracheal injury, cartilage disruption, or cervical spine injury.
  
• CT angiography:
  
  • Low sensitivity (50%) and high specificity (99%) on initial studies with early-generation CT scanner compared with angiography for carotid and vertebral artery injury, may have improved rates of detection with newer-generation CT scanners
    
• Magnetic resonance arteriography (MRA):
  
  • Low sensitivity (49%) and high specificity (99%) on initial studies with MRA compared with angiography for carotid and vertebral artery injury
    
  • 4-vessel angiography is considered gold standard for evaluation of arterial injury.
    
• Indications for angiography:
  
  • Presence of carotid bruit
    
  • Expanding neck hematoma
    
  • Neurologic deficit without intracranial pathology on CT
    
  • Horner's syndrome
    
  • Decreased level of consciousness