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Emergency and Acute Medicine – Neck Injury by Strangulation/Hanging
Neck injury from strangulation can occur through ligature strangulation (a material compressing the neck), manual strangulation (direct pressure using hands), or postural strangulation (airway obstruction from body weight over an object or positioning, most often in infants). Hanging is a form of strangulation and may be complete (judicial type), where the entire body is suspended, or incomplete (nonjudicial), where part of the body remains in contact with the ground. Typical hanging places the suspension point centrally over the occiput, while atypical hanging places it elsewhere. These events may be intentional (suicide, homicide, autoerotic activity, or “the choking game”) or accidental, especially in children. Near-hanging refers to survival following nonjudicial hanging.
In judicial hanging, the victim is dropped a distance at least equal to their height, producing forceful distraction of the head from the torso. This can cause severe cervical spine fracture and spinal cord transection. In nonjudicial hanging, the fall is usually from a lower height and injuries resemble those seen in strangulation. In strangulation, external neck pressure leads to cerebral hypoxia due to venous and arterial obstruction, and may also injure airway structures, soft tissues, and neck vessels. Cervical spine injuries are uncommon except with judicial-type hanging. Death may occur from mechanical closure of the airway or blood vessels, cardiac arrest caused by extreme bradycardia from carotid sinus stimulation, direct spinal cord injury, pulmonary complications in near-hanging victims, or cerebral hypoxia.
Commonly associated conditions include cervical spine injury, hypoxic brain injury, arterial or venous dissection or thrombosis, hyoid bone fracture (typically in nonjudicial strangulation), cricoid cartilage disruption (rare), and thyroid cartilage disruption (more common in nonjudicial strangulation deaths). Other complications include phrenic nerve injury, airway edema, aspiration pneumonitis (often delayed), neurogenic pulmonary edema (delayed, due to massive sympathetic discharge), postobstructive pulmonary edema (which may develop rapidly), and possible air embolism when subcutaneous air and vascular injury are present.
Symptoms and signs may involve multiple systems. Airway disruption can present with subcutaneous emphysema, dyspnea, dysphonia or stridor, and loss of normal neck cartilage landmarks. Cervical spine injury can cause respiratory arrest or paralysis. Neurologic injury may present with hoarseness, dysphagia, altered mental status, or focal neurologic deficits. Pulmonary sequelae can include respiratory distress, pulmonary edema, ARDS, or pneumonia. Soft tissue findings may include abrasions, contusions, ecchymoses, and ligature or hand marks. Vascular injuries may present with an expanding hematoma, pulse deficits, bruits, or evidence of cerebral infarction. Petechial hemorrhages above the ligature mark (Tardieu spots) may be seen on the skin, mucous membranes, or conjunctiva. In children, neck structures are more cartilaginous and mobile, making fractures less common, but airway compromise can occur quickly with relatively little edema because of the smaller airway diameter.
History should focus on the strangulation method and patient position to help predict injury patterns. A higher fall implies greater force and raises concern for decapitation-type injury. Knot position affects injury risk, with arterial occlusion more likely in typical hanging. Ligature material matters because elastic materials may limit peak force but venous obstruction can still cause unconsciousness and death. Circumstances should be clarified, including accidental injury, suicide/homicide, nonaccidental trauma, sexual context, or “choking game.” Physical examination should begin with ABCs and strict cervical spine precautions, followed by neurologic assessment for coma, altered mental status, paralysis, or focal deficits. A secondary survey should look for soft tissue injury, aero-digestive injury, and vascular trauma, as well as other trauma from falls, self-inflicted injuries, or assault.
Essential workup includes CT of the cervical spine through T1, CT of the head to assess for hemorrhage, edema, hematoma, subarachnoid hemorrhage, or hypoxic injury, and CT angiography of the neck to evaluate for thrombosis or intimal dissection. A chest radiograph helps detect subcutaneous emphysema, aspiration pneumonitis, and pulmonary edema. Continuous pulse oximetry and cardiac monitoring are required. Additional testing may include an ABG if respiratory compromise is suspected, hematocrit if significant blood loss is possible, type and cross-match if vascular injury is suspected, and coagulation studies for bleeding risk. Toxicology testing may be appropriate when intentional self-harm is suspected. MRI of the neck can be more sensitive than CT for soft tissue and cartilaginous injury, and arteriography remains a definitive test for vascular injury. Fiberoptic endoscopy can directly evaluate aero-digestive injury and may help with intubation decisions, while surgical exploration is reserved for indicated cases.
Prehospital care prioritizes rapid airway management with oxygen, suction, and intubation when indicated, while removing any ligature and maintaining cervical spine stabilization. In the emergency department, aggressive airway management with cervical spine precautions remains the priority, with early intubation for respiratory compromise and supplemental oxygen. Cricothyrotomy or tracheostomy may be required in severe facial trauma, but cricothyrotomy should be avoided if there is hematoma over the cricothyroid membrane or suspected cricotracheal disruption; emergent tracheostomy is preferred in that scenario. Bleeding should be controlled with direct pressure and the neck should not be explored in the ED.
Emergency treatment includes establishing IV access and consulting appropriate specialists: otolaryngology or trauma surgery for soft tissue and airway injuries, vascular surgery for suspected vascular injury, neurology for suspected ischemic insult, and neurosurgery if intracranial pressure monitoring or intervention is needed. Supportive care for suspected cerebral edema includes elevating the head of bed, maintaining oxygenation and cerebral perfusion, and preventing secondary neurologic injury. If subcutaneous emphysema is present, assume upper airway mucosal disruption communicating with deep tissues and administer antibiotics. Steroids may be considered for airway edema. Clinicians should also evaluate for associated harm such as co-ingestions in suicidal cases and must report suspected nonaccidental trauma in children.
Medications may include mannitol or hypertonic saline in selected cases of elevated intracranial pressure, and phenytoin for seizures when needed. For neck injury with subcutaneous emphysema, antibiotics such as ampicillin/sulbactam or clindamycin may be used. For airway edema, dexamethasone may be considered, with dosing adjusted for pediatric patients.
Disposition is typically admission to a monitored setting for all strangulation or hanging-mechanism injuries due to the risk of delayed airway compromise, pulmonary edema, or neurologic deterioration. Admission is required for altered consciousness, new neurologic deficits, coma, respiratory distress, or injuries requiring surgical correction, including laryngeal, esophageal, or vascular injuries. All suspected suicidal or homicidal cases require psychiatric or social work consultation, and pediatric cases with suspected nonaccidental trauma require safety evaluation. Discharge is appropriate only for patients without strangulation or hanging injuries after adequate ED observation confirms no airway compromise, vascular injury, neurologic deficit, or suicidal/homicidal risk.
Follow-up recommendations include neuropsychiatric evaluation when hypoxic encephalopathy is a concern, psychiatric follow-up for suicidal or homicidal patients, behavioral therapy for autoerotic or “choking game” cases, and surgical follow-up as indicated by the injuries. Key pitfalls include failing to recognize delayed airway or pulmonary complications, missing vascular injury or dissection, and underestimating severity in patients who initially appear stable. Cervical spine injury is uncommon in nonjudicial hanging, and cerebral hypoxia is the most common cause of death, so rapid airway control and full evaluation for associated injuries are essential.
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