American Journal of Emergency Medicine (2012) 30, 690-694

Original Contribution

Outcome analysis of cardiac arrest due to hanging injury

Jung Hee Wee MD, Kyu Nam Park MD?, Sang Hoon Oh MD, Chun Song Youn MD, Han Joon Kim MD, Seung Pill Choi MD

Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

Received 12 January 2011; revised 14 March 2011; accepted 15 March 2011

Abstract

Objective: The aim of this study was to review patient characteristics and analyze the outcomes in patients who have had cardiac arrest from hanging injuries.

Methods: A retrospective review was performed that examined the victims of out-of-hospital cardiac arrest (OHCA) due to hanging who presented to a tertiary general hospital from January 2000 to December 2009. Utstein style variables were evaluated, and patient outcomes were assessed at the time of hospital discharge using the Cerebral Performance Category scale.

Results: Fifty-two patients with OHCA due to hanging were enrolled in this study from the aforementioned 10-year inclusion period. resuscitation attempts were performed in 31 patients (60%), and 21 patients were pronounced dead. In all cases, the first monitored cardiac rhythms were either asystole or Pulseless electrical activity and were therefore nonShockable rhythms. Of the patients for whom resuscitation was attempted, 13 (42%) experienced a return of spontaneous circulation and 1 revealed cervical spine fracture. Of the 13 return-of-spontaneous-circulation patients, 5 survived to be discharged. The mean age of these 5 surviving patients was 36 years. All 5 patients were graded as cerebral performance category 4 at discharge.

Conclusion: The first monitored cardiac rhythms of patients presenting with OHCA due to hanging were nonshockable rhythms wherein the survival rate of these patients was 9.6%. All of the survivors were relatively young and demonstrated Poor neurologic outcomes at discharge. Physicians must consider cervical spine fracture in patients who had cardiac arrest from hanging.

(C) 2012

Introduction

The number of suicide has doubled over the past 10 years; and South Korea has the highest suicide rate in the world, with 31 per 100 000 people ending their own lives, compared with 15 per 100 000 in 1999 [1]. Hanging is a leading method of suicide rivaling with poisoning and falling. hanging patients are usually transferred to the emergency

* Corresponding author. Department of Emergency Medicine, Seoul St Mary’s Hospital, 505 Banpo-Dong, Seocho-Gu, Seoul, 137-701, Republic of Korea. Tel.: +82 2 2258 1987; fax: +82 2 2258 1997.

E-mail address: [email protected] (K.N. Park).

department (ED), some are in comatose state, and some need cardiopulmonary resuscitation (CPR).

A recent and growing interest in cardiac arrest has resulted in several studies that have investigated its epidemiology and etiology as well as ways to improve outcome prediction and methods for outcome improvement. Furthermore, hanging induces a unique injury mechanism [2], which suggests that the resulting cardiac arrest may be unique in characteristics and outcome. Several studies have investigated near hanging injuries, although none has analyzed cardiac arrest due to hanging.

Thus, the aim of this study was to describe the characteristics and outcomes of hanging-induced cardiac arrest victims presented to ED.

0735-6757/$ - see front matter (C) 2012 doi:10.1016/j.ajem.2011.03.013

Methods

Patients and settings

We got the approval of the institutional review board. All patients who presented to our department with out-of- hospital cardiac arrest (OHCA) due to hanging over the course of a 10-year period, from January 2000 to December 2009, were included in this study. We excluded patients who had been dead for an extended period.

Our department is part of a Tertiary EDucational hospital that is located in the center of Seoul, South Korea. We provide emergency medical services (EMSs) to approxi- mately 48 000 people per year and administer OHCA CPR to approximately 200 patients per year.

Data acquisition

Patient data were collected from the cardiopulmonary cerebral resuscitation registry wherein patient information is registered whenever advanced cardiac life support is provided in our ED. Patient medical charts, cardiopulmonary cerebral resuscitation registries, and EMS records were reviewed and analyzed for Utstein style variables.

Outcome

All of the patients who survived until hospital admission were prospectively followed up to ascertain their outcomes. The neurologic status of each survivor at the time of hospital admission was assessed based on the return of spontaneous circulation (ROSC), using the Glasgow Coma Score at the time of hospital discharge using the cerebral performance category scale. Cerebral Performance Categories 1 and 2 were classified as a Favorable neurologic outcome, whereas CPC 3, 4, and 5 were regarded as an unfavorable outcome.

Results

Victim information

A total of 52 patients with OHCA due to hanging presented during the study inclusion period (Fig. 1). All patients studied here were in arrest at the scene and at the time of hospital arrival. All of these hanging arrests were suicide attempts, except for 1 victim who was hanged by an elevator door accidentally. Bystander CPR was performed in 5 patients (9.6%), prehospital EMS CPR was done in 34 cases (65.4%), and in-hospital resuscitation was attempted in 31 cases (60%). Patient ages ranged from 21 to 88 years (mean, 48.8 +- 21.5 years). No patients were children, and 30 patients (58%) were female. Eighteen were dangling above the ground or floor, and 15 were in contact with the floor; 19 were unknown. Sixteen patients (30%) had a Depressive disorder, whereas 9

(17%) had previously attempted suicide. Drug and/or alcohol ingestion was not reported in most cases. Forty-five hanging victims (86.6%) were founded in house, 3 (5.8%) were at public place, and 2 (3.8%) were in another hospital (Table 1). Only 2 types of first-monitored rhythms were observed in this study, wherein 47 cases (90.4%) demonstrated asystole and 5 (9.6%) demonstrated pulseless electrical activity .

Hanging time was difficult to determine because the times at which the patients were last seen were recorded in only 37% of all of the investigated patients.

Return-of-spontaneous-circulation patients

Of the 31 attempted resuscitations, 13 (42%) resulted in ROSC. The mean age of the recovered patients was 38.5 +- 14.2 years, wherein 9 of these patients (69.2%) were women. Of these cases, 3 (23%) received bystander CPR. Eight (61.5%) and 5 patients (38.5%) demonstrated asystole and PEA, respectively, as their first monitored rhythm. Therapeutic hypothermia was performed in 10 patients (76.9%); and of these, 6 patients died. Of these 13 ROSC patients, 6 (46.2%) showed seizure movement. Lateral cervical spine radiograph was performed for all patients who achieved an ROSC, and cervical spine computed tomography was checked in 1 patient, which showed a cervical spine fracture (Table 2).

Patients surviving to discharge

The 5 surviving patients were discharged, which represented a 9.6% survival rate for all of the investigated 52 cardiac arrest patients and a 38.5% survival rate for the 13 patients who experienced an ROSC. Of these 13 ROSC patients, 8 (61.5%) died of multiorgan failure or brain death and died after an average of 12.3 +- 10.6 days. The mean age of the surviving patients was 36.0 +- 14.2 years. Of these patients, 4 (80%) were younger than 35 years (Table 3).

At the time of discharge, the neurologic status of each of the 5 surviving patients was categorized as CPC 4. Four patients were discharged to nursing homes, and 1 was transferred to another hospital.

Discussion

Several studies have investigated OHCA and have observed that OHCA can be caused by several different factors. Utstein style guidelines for cardiac arrest can be used to categorize the etiologies of cardiac arrest into several groups including presumed cardiac, trauma, submersion, respiratory, other noncardiac, and unknown [3]. Hanging is typically included in the traumatic category, although it leads to cardiac arrest via a unique mechanism. Today, hanging injuries most often result from suicide attempts and substantially differ from judicial hanging injuries. For this reason, an awareness of the types of injuries and outcomes

Absence of signs of circulation and/or considered for resuscitation N = 52

Resuscitation not attempted All cases n = 21

DNAR? n = 0

Considered futile n = 21

Resuscitation attempted

All cases n = 31

Any defibrillation n = 3 Chest compressions n = 31 Assisted ventilation n = 31

Shockable	n = 0
VF+	n = 0
VT?	n = 0
Non-shockable	n = 31
Asystole	n = 25
PEA	n = 6
NSR?	n = 0
Unknown	n = 0

Asystole

N = 25

ROSC = 8

Survival to discharge = 3 Neurologic outcome at discharge

CPC 1 or 2 n = 0

CPC 3 or 4 n = 3

CPC 5 n = 22

PEA

N = 6

ROSC = 5

Survival to discharge = 2 Neurologic outcome at discharge

CPC 1 or 2 n = 0

CPC 3 or 4 n = 2

CPC 5 n = 4

Fig. 1 Template for OHCA due to hanging. * DNAR; do not attempt resuscitation, + VF; ventricular fibrillation, ? VT; ventricular tachycardia, ? NSR; normal sinus rhythm.

observed in these patients, especially for those having cardiac arrest, is important to the physicians who are required to make medical decisions concerning their treatment.

First monitored rhythm

suicidal hanging injuries pathologically differ from judicial hanging injuries in several ways. Many studies have reported that nonjudicial hangings rarely result in Cervical spine injuries [4-6]. For example, 1 study observed that there were no cervical vertebral fractures or dislocations in 101 autopsies performed on victims of suicidal hangings [7]. In our

study, cervical radiographs were only performed on the 13 patients who experienced an ROSC and only on 1 case examined by cervical spine computed tomography wherein a C2 dense fracture was observed. This suggests that there might be more spine problems. Other studies have observed thoracic spine fractures, laryngeal fractures, and tracheal fractures in patients with near-hanging injuries who did not experience cardiac arrest. However, in our study, because we did not investigate other types of patient injuries because of their poor

Variable	n = 5 (%)
Age, y (mean +- SD)	36 +- 14.2
b35	4 (80)
Discharge destination
Nursing home	4 (80)
Other hospital	1 (20)

Table 3 Analysis of survived patients from hanging arrest

Neurologic status at discharge CPC 1-3

CPC 4

0 (0)

5 (100)

condition, physicians must suspect another types of injury other than cervical spine fracture [8,9]. Therefore, we suggest that, even if the risk of cervical spine injury is small, hanging arrest victims should be treated with the full cervical spine immobilization they are radiologically cleared.

Table 1 Characteristics of patients with cardiac arrest due to hanging

Variable

Age, y (mean +- SD) Age group, y

21-55

N55

Female Witnessed Bystander CPR Suicide attempt Yes

No Location

Place of residence Public place Other hospital Other

Previous suicide attempt Previous psychiatric history Resuscitation attempted ROSC

First monitored rhythm Asystole

PEA VF/VT

N = 52 (%)

48.8 +- 21.5

34 (86)

18 (14)

30 (58)

1 (2)

5 (9.6)

51 (98)

1 (2)

45 (86.6)

3 (5.8)

2 (3.8)

2 (3.8)

9 (17)

16 (30)

31 (59.6)

13 (41.9)

47 (90.4)

5 (9.6)

0 (0)

In South Korea, EMS providers provide only basic life support for cardiac arrest patients and usually check their cardiac rhythms. All victims included here did not have ROSC before ED arrival and were in persistent cardiac arrest. We reviewed the both rhythms obtained in the field (if they

Table 2 Analysis of ROSC patients from hanging arrest

Variable n = 13 (%)

Age, y (mean +- SD) 38.5 +- 14.2 Female 9 (69.2) Resuscitation before EMS arrival 3 (23) Total BLS time, min (mean +- SD) 16.5 +- 6.0 ACLS time, min (mean +- SD) 5.5 +- 4.4 Total arrest time, min (mean +- SD) 27.8 +- 9.9 First monitored rhythm Asystole 8 (61.5) PEA 5 (38.5) C-spine fracture 1 (7.6) Therapeutic hypothermia 10 (76.9) Seizure 6 (46.2) Survival to discharge 5 (38.5) Duration of survival before death, d (mean +- SD) 12.3 +- 10.6

ACLS indicates advanced cardiac life support. BLS indicates basic life support.

existed) and in the ED. There were only 27 field rhythms, and these were the same as the initial ED rhythms. Therefore, the first cardiac rhythm can be either field rhythm or ED rhythm, which was first checked. The first cardiac rhythms observed in the hanging arrest patients examined in this study were all nonshockable rhythms that consisted of either asystole (90.4%) or PEA (9.6%). This differs from the typical initial rhythms of patients with cardiac arrest of a cardiac etiology, which typically includes both shockable and nonshockable rhythms wherein shockable rhythms occupies the significant proportion [10,11]. Cardiac arrest due to hanging also differs from cardiac arrest due to drowning, wherein shockable rhythms are observed [12,13]. This result may be because of the unique mechanism by which hanging causes cardiac arrest from complete airway/Arterial occlusion and secondary to carotid sinus stimulation and increased Vagal tone [14,15] or to the fact that arrests due to hangings are rarely witnessed, so have longer anoxic time. In this result, ROSC occurred in 5 of the 6 patients who demonstrated PEA as the first monitored rhythm. In contrast, of the 25 patients who demonstrated asystole as the first monitored rhythm, only 8 recovered circulation. Because PEA has been associated with better outcomes than asystole in cardiac arrest [16,17], hanging patients who demonstrate PEA must receive aggressive resuscitation efforts to maximize their chances of survival.

To improve patient neurologic outcomes after resuscita- tion from cardiac arrest, physicians often induce therapeutic hypothermia [18]. We performed therapeutic hypothermia in 10 of the 13 patients who experienced an ROSC, wherein 6 of these patients died of brain death and multiorgan failure; and the neurologic outcomes for those who survived were poor. One case of complete Neurologic recovery has been reported in the literature for a patient treated with therapeutic hypothermia who had cardiac arrest due to hanging [19]. In this case, the estimated hanging time was short, paramedics arrived and performed CPR quickly, spontaneous circulation was restored, and the patient was hemodynamically stabilized within 5 minutes. Although the results reported herein are not encouraging, aggressive treatment, including therapeutic hypothermia, should be applied to hanging arrest patients whose presumed arrest time is short because Good neurologic outcomes are possible in these patients.

Most (86%) of the hanging arrest victims reported herein were younger than 55 years, which is consistent with what

has been reported in the literature [8,14]. In addition, 80% of the surviving patients were younger than 35 years old; and unfortunately, they were all categorized as CPC 4 at discharge. This suggests that hanging occurs most frequently in relatively Young people, at an age when social activity is often high and the results are most devastating. Therefore, large efforts should be made to prevent hanging; and accurate tools must be developed to predict neurologic outcomes early in the treatment period.

Unfortunately, the neurologic outcomes of the surviving ROSC patients examined herein were universally poor; and it may seem futile to look for or discuss positive prognostic factors.

Conclusion

This is, to our knowledge, the largest report that has investigated hanging arrest victims. The victims examined herein all exhibited nonshockable rhythms at the time that the heart rhythms were first monitored. Most patients were young, and the occurrence of a spinal fracture in 1 patient suggests that physicians must consider cervical spine fracture in the treatment of hanging arrest patients. The overall survival rate was 9.6%, and the neurologic outcomes in the surviving patients were universally poor. Therefore, new and innovative treatments along with early predictors of outcome must be developed to treat this unique causes of cardiac arrest. Ultimately, these results demonstrate the need for increased efforts to prevent suicidal hanging.

We think this study showed grave results, but this will help the emergency physicians to expect the neurologic outcomes of cardiac arrest patient due to hanging.

Limitations

There are several study limitations. First, this study is retrospective; and therefore, some information may be missing and inaccurate. Second, prehospital data were almost missing to predict another prognostic factor.

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