Overview
Definition:
Near-hanging refers to an event where a child is suspended by a ligature around the neck, but is rescued before irreversible anoxic brain injury or death occurs
It represents a severe form of strangulation with significant potential for immediate and delayed morbidity, particularly affecting the airway and cervical spine.
Epidemiology:
While complete hanging leading to death is less common in children than adults, near-hanging incidents are a significant cause of pediatric injury and mortality
Accidental strangulation due to clothing cords, drawstrings, or climbing activities are common mechanisms
The incidence varies geographically and by age group, with younger children being more prone to accidental falls from heights with ligatures involved.
Clinical Significance:
Near-hanging is a medical emergency requiring rapid assessment and intervention
The primary concerns are compromise of the airway due to extrinsic compression or edema, and potential cervical spine injury from the trauma of suspension
Neurological deficits secondary to hypoxia can be devastating
Prompt recognition and management of these critical issues are paramount for improving patient outcomes and preventing long-term sequelae, making it a crucial topic for pediatric residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Altered level of consciousness, ranging from lethargy to unresponsiveness
Respiratory distress, characterized by stridor, grunting, retractions, or apneic episodes
Cyanosis or pallor
Seizures
Vomiting
Neck pain or tenderness
Evidence of external neck trauma, such as petechiae, ecchymosis, or ligature marks.
Signs:
Vital sign abnormalities including bradycardia, hypotension, or tachycardia
Hypoxia with decreased oxygen saturation
Palpable or visible signs of neck trauma, including ligature marks, abrasions, or lacerations
Neurological deficits, such as focal weakness, abnormal reflexes, or pupillary abnormalities
Signs of airway obstruction, including noisy breathing, hoarseness, or inability to vocalize.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the history of suspension and physical examination findings
There are no specific diagnostic criteria for near-hanging itself, but the presence of signs and symptoms of airway compromise or cervical spine injury necessitates aggressive evaluation and management according to established trauma and airway protocols.
Diagnostic Approach
History Taking:
Obtain a detailed history of the incident, including the duration of suspension, height of suspension, mechanism of suspension (accidental vs
intentional), and any resuscitative measures performed
Inquire about pre-existing medical conditions, allergies, and medications
Crucially, assess for the presence of vomiting or altered consciousness prior to or immediately after the event, which may suggest increased intracranial pressure.
Physical Examination:
A rapid primary survey (ABCDE approach) is essential
Focus on airway patency, breathing effectiveness, and circulation
Assess neurological status using GCS
Perform a detailed head-to-toe examination, paying close attention to the neck for external signs of injury and palpating for crepitus or tenderness
Assess for associated injuries that may have occurred during the incident
Secondary survey should include a thorough neurological examination.
Investigations:
Oxygen saturation monitoring and arterial blood gas analysis to assess oxygenation and ventilation
Complete blood count and electrolytes to assess for anemia or metabolic derangements
Imaging of the cervical spine (X-rays, CT scan) is indicated in all patients with significant neck trauma or neurological deficits to rule out fracture or dislocation
Flexible laryngoscopy or bronchoscopy may be required to directly visualize the airway for edema, contusions, or hematomas
Chest X-ray to assess for aspiration or pulmonary contusions
CT scan of the head may be indicated if there are signs of head trauma or altered mental status.
Differential Diagnosis:
Other causes of pediatric strangulation (e.g., manual strangulation, suffocation)
Accidental falls with associated head or neck trauma
Seizure disorders
Ingestion of foreign bodies causing airway obstruction
Near-drowning incidents
Differentiating from other causes of hypoxia and altered mental status is crucial for appropriate management.
Management
Initial Management:
Immediate ABCDE assessment and management
Secure the airway: This is the highest priority
If the airway is compromised, consider immediate endotracheal intubation
Maintain cervical spine precautions (immobilization with a rigid collar and sandbags or commercial device) during all airway manipulations until cervical spine injury is ruled out
Provide supplemental oxygen
Establish intravenous access
Treat hypotension with fluid resuscitation.
Airway Management:
In cases of significant airway edema or obstruction, immediate intubation is necessary
Use the smallest appropriate endotracheal tube to minimize trauma
If intubation is difficult, consider advanced airway adjuncts like a supraglottic airway or cricothyroidotomy
Monitor airway pressures closely
Extubation should only occur when the airway is deemed safe, typically after a period of observation and direct visualization if necessary
Pediatric residents must be proficient in rapid sequence intubation and recognizing signs of airway compromise.
Cervical Spine Precautions:
Maintain strict cervical spine immobilization throughout the initial assessment and management, especially during airway procedures
This includes a rigid cervical collar and manual in-line stabilization
Imaging of the cervical spine (plain radiographs, CT scan) is mandatory to rule out fractures or ligamentous injuries in the absence of contraindications or if there is any suspicion of injury
Pediatric trauma guidelines for cervical spine clearance should be followed meticulously.
Supportive Care:
Continuous cardiorespiratory monitoring
Strict neurological monitoring
Sedation and analgesia as needed, with caution to avoid respiratory depression
Prophylaxis against gastric stress ulcers
Nutritional support
Careful fluid management
Management of any seizures with appropriate anticonvulsant medications
Early involvement of pediatric surgery and pediatric intensive care unit (PICU) specialists is essential.
Complications
Early Complications:
Acute airway obstruction due to edema or hematoma formation
Hypoxic brain injury leading to neurological deficits
Pulmonary edema or aspiration pneumonia
Laryngeal or tracheal injury
Esophageal injury
Cervical spine fractures or dislocations
Cardiac dysrhythmias.
Late Complications:
Long-term neurological sequelae, including cognitive impairment, motor deficits, and developmental delay
Vocal cord paralysis or dysfunction
Tracheal stenosis
Psychological sequelae, including anxiety and post-traumatic stress disorder
Scarring or disfigurement of the neck.
Prevention Strategies:
Prevention of near-hanging incidents in children involves education of parents and caregivers on safe sleep practices, supervising children around cords and drawstrings, and creating a safe home environment
Prompt recognition and intervention are key to preventing severe complications during an actual event.
Prognosis
Factors Affecting Prognosis:
The duration of hypoxia, the degree of airway compromise, the presence and severity of cervical spine injury, and the promptness and efficacy of medical intervention are the most critical factors
Neurological outcome is strongly correlated with the duration of uncorrected hypoxia.
Outcomes:
Prognosis is variable and depends heavily on the severity of initial insult
Mild cases may recover fully with minimal sequelae
Severe cases can result in profound and permanent neurological disability or death
Early and aggressive management of the airway and cervical spine significantly improves the likelihood of a favorable outcome.
Follow Up:
Children who have experienced near-hanging require close follow-up, particularly for neurological development, respiratory function, and psychological well-being
Regular assessments by pediatric neurologists, pulmonologists, and developmental pediatricians may be necessary
Long-term monitoring for laryngeal or tracheal issues is also important.
Key Points
Exam Focus:
Prioritize airway management and cervical spine precautions in any pediatric near-hanging scenario
Recognize signs of hypoxia and neurological compromise
Understand the indications for laryngoscopy/bronchoscopy and cervical spine imaging
DNB and NEET SS often test critical decision-making in emergency situations.
Clinical Pearls:
Always assume cervical spine injury in near-hanging until proven otherwise
Be prepared for rapid sequence intubation and advanced airway techniques
Do not underestimate the potential for airway edema to worsen hours after the initial insult
A multidisciplinary approach involving PICU, ENT, and Neurosurgery is often required.
Common Mistakes:
Failure to maintain cervical spine precautions during airway management
Delaying definitive airway management when there are signs of compromise
Inadequate neurological assessment and monitoring
Underestimating the risk of delayed airway complications or neurological sequelae
Not consulting specialist services early enough.