Case Report

Beneficial response to mild therapeutic hypothermia for comatose survivors of near-hanging

Abstract

Therapeutic hypothermia has been shown to clearly benefit comatose survivors of cardiac arrest. It is reason- able to postulate that if therapeutic hypothermia is beneficial for the neurological injury of cardiac arrest, then it may have a role in the treatment of near-hanging suffocation injuries. We report a retrospective series of 2 patients who received mild therapeutic hypothermia for their comatose state after a near-hanging injury. The exclusionary criteria and protocols that we use for comatose survivors of cardiac arrest were used. After at least 24 hours of mild therapeutic hypothermia, both patients had a complete return of neurological function, with Glasgow Coma Scale scores of 15 at the time of discharge from the hospital. These data, taken with other case series, suggest that therapeutic hypothermia may be beneficial for comatose survivors of near-hanging.

Death from suffocation is commonly associated with near-hanging and has become even more prevalent with an increasing number of choking games and autoerotica asphyxia among adolescents and young men, respectively [1-3]. In 2005, suffocation was the second leading cause of death from suicide in the United States, accounting for 22.5% of the 33 300 suicide-related deaths [4].

Near-hanging is defined as an unsuccessful attempt at nonjudicial hanging resulting in strangulation rather than a fatal cervical spine injury [5]. Depending on the time of suspension, the patient may experience Cerebral hypoxia and ischemia and arrive at the hospital comatose [6]. Once in the emergency department (ED), there is no specific treatment for a near-hanging comatose injury besides general Intensive care supportive treatment [7].

Therapeutic hypothermia has been shown to clearly benefit comatose survivors of cardiac arrest [8,9]. It is therefore reasonable to postulate that if TH is beneficial for the neurological injury of cardiac arrest, then it may have a role in the global anoxic injury associated with suffocation- type injuries like near-hanging. Despite this, the literature lacks evidence of treating near-hanging patients with induced hypothermia.

We report a retrospective case series of 2 patients in which mild TH was performed for comatose survivors of near- hanging. The patients were treated with the exclusionary criteria and protocols that we use for comatose survivors of cardiac arrest.

A 20-year-old white woman with a history of depression and prior suicide attempts was found by her boyfriend suspended by fabric in her closet with her feet almost touching the floor. The suspension time was unknown; however, she had not been seen for 50 to 60 minutes. After the boyfriend cut the fabric and placed her on the floor, he found her with a weak pulse despite the fact that she was not breathing. Cardiopulmonary resuscitation was initiated and emergency medical service (EMS) was called.

According to the EMS, the patient was in respiratory arrest when they arrived and was subsequently placed in c-collar and intubated on scene. Upon arrival to the hospital, she had a Glasgow Coma Scale score of 6, dilated pupils with sluggish constriction to light, no corneal reflex, and no gag reflex. A computed tomogra- phy (CT) scan of her neck showed no acute Vascular abnormalities and no evidence of cervical fractures or subluxations. A CT scan of her head revealed diffuse cerebral edema, and a chest x-ray showed pulmonary congestion bilaterally.

Initially, the patient was treated with high-dose dexa- methasone, mannitol, prophylactic diphenylhydantoin, and ventilation. After obtaining informed consent, the TH protocol was begun. The patient was sedated with high- dose propofol and paralyzed with vecuronium. Ice bags were immediately applied, an Arterial line and a right subclavian central line were placed, and 2 L of 4?C normal saline was rapidly infused. To achieve and maintain a core temperature of 33?C, an external cooling system (Gaymar) was used. She was transferred to the intensive care unit with the continuation of TH.

After 24 hours from the time cooling was started, rewarming was initiated. The patient tolerated the treatment both hemodynamically and clinically throughout its dura- tion. Seventeen days later, the patient was extubated; shortly thereafter, she began to show improvements in alertness and was deemed stable.

Her neurological recovery began slowly, with evidence of hemiparesis on the right side of the body and limited

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390.e2 Case Report

concentration. However, as time progressed, she showed increased movement of the right side of her body and her concentration improved. At follow-up 4 months later, she had made full neurological recovery, with only a small amount of short-term memory loss.

A 45-year-old white man with a history of depression, anxiety, and suicide attempts was found hanging unrespon- sive by his wife. A suspension time of 20 minutes was estimated from the last time he was seen. After the wife cut him down, the EMS was called. Upon EMS arrival, the patient was found to have a tactile blood pressure and normal sinus rhythm. The EMS therefore transported the patient to the nearest community hospital.

Once in the ED, the patient was found to be severely hypoxic and unresponsive, with a GCS score of 7; subsequently, he was intubated and transferred to a hospital with a higher level of care.

Upon arrival to the level 1 trauma center, the patient underwent a trauma workup. A CT scan of his neck showed no acute vascular abnormalities and no evidence of cervical fractures or subluxations. A head CT scan displayed no acute abnormalities, and his chest x-ray was negative. A central line was placed and diphenylhydantoin was administered.

The patient was transferred to the medical intensive care unit, where TH was initiated and carried out under the same protocols as those for the patient in case 1. The patient tolerated the TH treatment both clinically and hemodynam- ically during the treatment. Four days after arrival to the ED, the patient was extubated, with a GCS score of 15. At the time of discharge from the medical service to psychiatry, he had made full neurological recovery.

The mechanism of strangulation can involve a Manual compression of the neck or a ligature tied around the neck, as in our patients. It can be accidental, suicidal, homicidal, or judicial. In any event, prolonged strangulation leads to death. Venous obstruction results from compression of the neck, causing cerebral hypoxia and loss of consciousness. The pressure in the neck is further increased as muscle tone is lost, resulting in additional Arterial occlusion and airway collapse [10,11]. Death shortly ensues. It is important to note that in near-hanging patients, death is not a result of cervical dislocation [5].

For nearly 20 years, TH in treating cardiac arrest has been studied and shown to be beneficial in multiple animal studies [12-17]. These studies were followed by more recent human clinical trials, in which TH proved beneficial for the neurological outcome in patients with not only cardiac arrest but also near-drowning, peripartum hypoxia-ische- mia, and stroke [9,18-20]. In one study of patients with cardiac arrest treated with mild TH, it was found that 55% of the patients treated with hypothermia had a good neurological outcome, whereas only 39% of those not treated with hypothermia had a good neurological outcome [9]. In another similar study, Bernard et al [20] found that moderate TH improved outcomes in 49% of the comatose

patients after resuscitation from out-of-hospital cardiac arrest, whereas only 26% of the comatose patients who did not receive TH had improved outcomes.

In a case report of twin toddlers who experienced near-drowning together, in which one was treated with Mild hypothermia and one was not, the patient treated with the mild hypothermia recovered with no Neurological deficits, whereas the other toddler developed apallic syndrome [18]. In newborns with hypoxic ischemic encephalopathy, TH has been shown to reduce mortality without increasing major disability [21]. Lastly, in a study treating massive hemispheric infarctions, it was found that moderate hypothermia is feasible in treating acute strokes [19].

The question of when to induce TH has caused further research. Preliminary animal data suggest that induction of TH during resuscitation as opposed to after the return of spontaneous circulation provides greater clinical benefit [22,23]. Inducing TH during resuscitation obviously would not have been applicable with our patients because neither had cardiac arrest. However, it seems reasonable from these results that comatose survivors of near-hanging may benefit from earlier TH.

The literature is limited in the use of TH specifically in treating near-hanging victims. In one study available, a literature review was conducted examining a 4-year period for cases of near-hanging treated with TH [7]. Of 8 near- hanging patients receiving mild TH, 6 had a good outcome, whereas of the 5 not receiving TH, only 3 had good outcome. It is important to note that their data were split into 2 groups: those who hung and had cardiac arrest and those who hung and did not have cardiac arrest. All patients in the cardiac arrest group received induced hypothermia [7]. The limitations of this review are the small number of patients and the inclusion of cardiac arrest patients only in the TH group.

The difference between mild and moderate TH is the target temperature for treatment. Several studies have varying definitions, but the most consistent definition found is 30?C for moderate hypothermia and 34?C for mild hypothermia [13,14]. In our patient, mild hypothermia was induced by the same protocols that we currently use for cardiac arrest patients.

After inclusion and exclusion criteria are met and consent is obtained, ice packs are placed on the head, neck, axilla, and groin. Arterial and Central lines are placed, followed by a Bolus infusion of a refrigerated (4?C) solution of normal saline at 100 mL/min with a maximum of 2 L. Proper analgesics, sedatives, Neuromuscular blocking agents, Deep venous thrombosis prophylaxics, and stress ulcer prophylaxics are given and vitals are monitored. The goal of treatment is to reduce the patient’s core temperature to between 32?C and 34?C within 6 hours of onset and keep the temperature at 34?C for 24 hours from onset of cooling. To maintain this core temperature, we use a Gaymar external cooling device. Rewarming at 0.17?C/h begins after 24 hours

Case Report 390.e3

until a temperature of 36?C is reached to prevent overshoot. Passive rewarming follows.

Despite the positive outcome of near-hanging patients treated with TH, some studies have concluded that even patients with a low GCS score who make it to the hospital still recover completely with only supportive treatment [5].A randomized control trial would be helpful to clarify the role of TH in near-hanging patients.

Mild TH applied in our patients and in a previous study has been shown to be beneficial for the neurological outcome of near-hanging patients. Despite the small number of near- hanging patients in the literature and our 2 patients who have been treated, it seems reasonable to treat comatose survivors of near-hanging with mild TH.

Dietrich Jehle MD Department of Emergency Medicine Erie County Medical Center

Buffalo, NY, USA SUNY at Buffalo School of Medicine and

Biomedical Sciences Buffalo, NY, USA

E-mail address: [email protected]

Michael Meyer MD Department of Neurology Erie County Medical Center

Buffalo, NY, USA SUNY at Buffalo School of Medicine and

Biomedical Sciences Buffalo, NY, USA

Seth Gemme BA

SUNY at Buffalo School of Medicine and

Biomedical Sciences Buffalo, NY, USA

E-mail address: [email protected] doi:10.1016/j.ajem.2009.07.022

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